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Shin TY, Han H, Min HS, Cho H, Kim S, Park SY, Kim HJ, Kim JH, Lee YS. Prediction of Postoperative Creatinine Levels by Artificial Intelligence after Partial Nephrectomy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1402. [PMID: 37629692 PMCID: PMC10456500 DOI: 10.3390/medicina59081402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/20/2023] [Accepted: 07/28/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: Multiple factors are associated with postoperative functional outcomes, such as acute kidney injury (AKI), following partial nephrectomy (PN). The pre-, peri-, and postoperative factors are heavily intertwined and change dynamically, making it difficult to predict postoperative renal function. Therefore, we aimed to build an artificial intelligence (AI) model that utilizes perioperative factors to predict residual renal function and incidence of AKI following PN. Methods and Materials: This retrospective study included 785 patients (training set 706, test set 79) from six tertiary referral centers who underwent open or robotic PN. Forty-four perioperative features were used as inputs to train the AI prediction model. XG-Boost and genetic algorithms were used for the final model selection and to determine feature importance. The primary outcome measure was immediate postoperative serum creatinine (Cr) level. The secondary outcome was the incidence of AKI (estimated glomerular filtration rate (eGFR) < 60 mL/h). The average difference between the true and predicted serum Cr levels was considered the mean absolute error (MAE) and was used as a model evaluation parameter. Results: An AI model for predicting immediate postoperative serum Cr levels was selected from 2000 candidates by providing the lowest MAE (0.03 mg/dL). The model-predicted immediate postoperative serum Cr levels correlated closely with the measured values (R2 = 0.9669). The sensitivity and specificity of the model for predicting AKI were 85.5% and 99.7% in the training set, and 100.0% and 100.0% in the test set, respectively. The limitations of this study included its retrospective design. Conclusions: Our AI model successfully predicted accurate serum Cr levels and the likelihood of AKI. The accuracy of our model suggests that personalized guidelines to optimize multidisciplinary plans involving pre- and postoperative care need to be developed.
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Affiliation(s)
- Tae Young Shin
- Synergy A.I. Co., Ltd., Seoul 07985, Republic of Korea;
- Department of Urology, College of Medicine, Hallym University, Chuncheon 24253, Republic of Korea;
- Department of Urology, College of Medicine, Ewha Womans University, Seoul 07985, Republic of Korea
| | - Hyunho Han
- Department of Urology, College of Medicine, Yonsei University, Seoul 03722, Republic of Korea;
| | - Hyun-Seok Min
- Tomocube, Inc., Daejeon 34109, Republic of Korea; (H.-S.M.); (H.C.)
| | - Hyungjoo Cho
- Tomocube, Inc., Daejeon 34109, Republic of Korea; (H.-S.M.); (H.C.)
| | - Seonggyun Kim
- Department of Urology, College of Medicine, Hallym University, Chuncheon 24253, Republic of Korea;
| | - Sung Yul Park
- Department of Urology, College of Medicine, Hanyang University, Seoul 04763, Republic of Korea;
| | - Hyung Joon Kim
- Department of Urology, College of Medicine, Konyang University, Daejeon 35365, Republic of Korea;
| | - Jung Hoon Kim
- Department of Urology, Chung-Ang University Gwangmyeong Hospital, College of Medicine, Chung-Ang University, Gwangmyeong 14353, Republic of Korea;
| | - Yong Seong Lee
- Department of Urology, Chung-Ang University Gwangmyeong Hospital, College of Medicine, Chung-Ang University, Gwangmyeong 14353, Republic of Korea;
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Ishiyama Y, Kondo T, Tachibana H, Yoshida K, Iizuka J, Tanabe K, Takagi T. Impact of Warm Ischemia on Acute Kidney Injury After Robotic Partial Nephrectomy Stratified by Baseline Kidney Function. J Endourol 2023; 37:286-296. [PMID: 36352821 DOI: 10.1089/end.2022.0493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives: To evaluate the differences in baseline chronic kidney disease (CKD) status in correlations between warm ischemic time (WIT) and acute kidney injury (AKI) or acute/chronic renal function change after robot-assisted partial nephrectomy (RAPN). Methods: This study retrospectively recruited 1290 patients from a multi-institutional RAPN database. The patients were grouped into four preoperative CKD categories: CKD Group 1 (CKDG1), CKD Group 2 (CKDG2), CKD Group 3a (CKDG3a), and CKD Group 3b (CKDG3b). The correlation between WIT and the probability of AKI was assessed according to the baseline CKD grade, together with changes in serum creatinine (sCr) at the postoperative maximum and chronic renal function. Results: AKI was not observed in the CKDG1 group. The probability of AKI at WIT = 30 minutes was 5.6% for CKDG2, 8.5% for CKDG3a, and 11.6% for CKDG3b (all p < 0.05). WIT was an independent predictor of AKI occurrence in the multivariate model for these three CKD groups. Significant weak correlations were observed between WIT and sCr change for all four groups, with R2 = 0.22 for CKDG1, R2 = 0.16 for CKDG2, R2 = 0.03 for CKDG3a, and R2 = 0.09 for ≥CKDG3b. For chronic renal function, correlations were significant in CKDG2, CKDG3a, and ≥CKDG3b, yet R2 was considered small in all cases (<0.1). Conclusions: The association between extended WIT and the probability of AKI increased in patients with more severe baseline CKD. The correlation between WIT and renal function was significant, yet clinically modest.
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Affiliation(s)
- Yudai Ishiyama
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan.,Department of Urology, Tokyo Women's Medical University Adachi Medical Center, Tokyo, Japan
| | - Tsunenori Kondo
- Department of Urology, Tokyo Women's Medical University Adachi Medical Center, Tokyo, Japan
| | | | - Kazuhiko Yoshida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Junpei Iizuka
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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Ishiyama Y, Kondo T, Tachibana H, Yoshida K, Takagi T, Iizuka J, Tanabe K. Limited impact of warm ischemic threshold for partial nephrectomy in the robotic surgery era: A propensity score matching study. Int J Urol 2021; 28:1219-1225. [PMID: 34472136 DOI: 10.1111/iju.14674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/25/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the association between extended (≥30 min) warm ischemic time and renal function in patients undergoing robot-assisted partial nephrectomy. METHODS This multi-institutional study retrospectively recruited 1131 patients who underwent robot-assisted partial nephrectomy. Patients were classified into shorter (<30 min; n = 1038) and longer (≥30 min; n = 92) groups based on the ischemic time required, and 1:2 propensity score matching was used to minimize selection bias. The perioperative outcomes, including acute kidney injury and trifecta attainment, and mid/long-term renal function were assessed before and after matching. RESULTS Patients in the longer group had tumors with a significantly larger diameter and RENAL nephrometry score. The decline in the nadir of the estimated glomerular filtration rate was significantly greater in the longer than the shorter group in the unmatched and matched cohorts (-16.2 vs -5.5%, P < 0.001; 15.5 vs -9.5%, P = 0.003, respectively). A higher incidence of acute kidney injury (9.8 vs 2.6%, P = 0.002) was observed in the longer group before matching, whereas the difference was comparable after matching. Before matching, the decline in estimated glomerular filtration rate at 6 months postoperatively was greater (-8.2 vs -5.1%, P = 0.005) and trifecta attainment was lower (50.0 vs 63.5%, P < 0.001) in the longer group. However, the differences were comparable for both the parameters between the groups in the matched cohort. CONCLUSIONS While extended warm ischemia during robot-assisted partial nephrectomy can be demanded in case of large and complex tumors, its impact on postoperative renal function is limited.
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Affiliation(s)
- Yudai Ishiyama
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan.,Department of Urology, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Tsunenori Kondo
- Department of Urology, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Hidekazu Tachibana
- Department of Urology, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Kazuhiko Yoshida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Junpei Iizuka
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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Yasuda Y, Saito K, Tanaka H, Uehara S, Kijima T, Yoshida S, Yokoyama M, Matsuoka Y, Kihara K, Fujii Y. Outcomes of gasless laparoendoscopic single-port partial nephrectomy in 356 consecutive patients: Feasibility of a clampless and sutureless technique. Int J Urol 2020; 28:302-307. [PMID: 33300187 DOI: 10.1111/iju.14452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/08/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To investigate the outcomes and feasibilities of gasless laparoendoscopic single-port clampless sutureless partial nephrectomy. METHODS We reviewed 356 consecutive patients with primary unilateral non-metastatic renal masses who underwent gasless laparoendoscopic single-port partial nephrectomy (2011-2018), which was performed retroperitoneally using a three-dimensional flexible endoscope, without vascular clamping or renorrhaphy in principle. RESULTS The median tumor size was 2.5 cm, and 213 (60%), 105 (29%), and 38 (11%) patients had peripheral, central, and hilar tumors, respectively. Clampless and sutureless partial nephrectomy was accomplished in 337 patients (95%), while eight (2%) and 16 (4%) patients required vascular clamping and renorrhaphy, respectively. The median operative time and blood loss were 220 min and 266 mL, respectively; eight patients (2%) received blood transfusion. Clavien-Dindo grade 3a complications occurred in 27 patients (8%); all these patients had urinary leakage treated with ureteral stent placement, one of whom also developed a postoperative pseudoaneurysm. Among 324 patients diagnosed with renal cell carcinoma, six (2%) had positive surgical margins, and one (0.3%) and seven (2%) developed metastatic and local recurrences, respectively. During a median follow-up of 54 months, no patient died from kidney cancer. The median percent decrease in estimated glomerular filtration rate at 3 months after surgery was 5.7%. No patient experienced postoperative acute renal failure, while one patient with preexisting renal impairment started dialysis at 70 months after surgery. CONCLUSIONS Clampless and sutureless partial nephrectomy can be safely accomplished in most patients undergoing gasless laparoendoscopic single-port surgery, yielding favorable oncological and functional outcomes.
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Affiliation(s)
- Yosuke Yasuda
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazutaka Saito
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hajime Tanaka
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Sho Uehara
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshiki Kijima
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Soichiro Yoshida
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Minato Yokoyama
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoh Matsuoka
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazunori Kihara
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
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Tachibana H, Kondo T, Yoshida K, Takagi T, Tanabe K. Lower Incidence of Postoperative Acute Kidney Injury in Robot-Assisted Partial Nephrectomy Than in Open Partial Nephrectomy: A Propensity Score-Matched Study. J Endourol 2020; 34:754-762. [PMID: 32368924 DOI: 10.1089/end.2019.0622] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Acute kidney injury (AKI) after partial nephrectomy is attributed to parenchymal reduction and ischemia, but the extent of its effect remains unclear. This study aimed to compare the incidence of postoperative AKI among surgical modalities, robot-assisted partial nephrectomy (RAPN), laparoscopic partial nephrectomy (LPN), and open partial nephrectomy (OPN), and to evaluate the validity of RAPN by comparing it with LPN and OPN in terms of postoperative AKI, perioperative complications, and long-term renal function. Patients and Methods: Patients who underwent RAPN, LPN, and OPN for renal tumors at our institutions between 2004 and 2018 were retrospectively analyzed. RAPN and LPN were performed under warm ischemia and OPN under cold ischemia. En bloc hilar clamping was employed for LPN and OPN and arterial clamping for RAPN. AKI was defined as % decrease in estimated glomerular filtration rate (eGFR) >25% from preoperative eGFR to postoperative nadir eGFR. Multivariate regression analysis was used to test associations of AKI with perioperative factors. Then, we compared the incidence of AKI with two propensity score-matched cohorts: RAPN vs OPN and RAPN vs LPN. Results: This study included 1762 cases (RAPN: 959, LPN: 215, and OPN: 588). After matching, 147 cases each from RAPN and LPN groups and 368 cases each from RAPN and OPN groups were selected. RAPN had shorter warm ischemia time than LPN, lower incidence of AKI, and lower % decrease in eGFR after 6 months. RAPN had a shorter ischemia time and a lower incidence of AKI than OPN, although the % decrease in eGFR after 6 months did not differ significantly. Conclusions: AKI incidence was lower in RAPN than in LPN or OPN, which may be due to the shorter ischemia time or clamping of only arteries in RAPN. Although long-term renal outcomes did not differ between RAPN and OPN, RAPN can help prevent AKI. This supports the validity of RAPN for patients with chronic kidney disease.
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Affiliation(s)
- Hidekazu Tachibana
- Department of Urology, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Tsunenori Kondo
- Department of Urology, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Kazuhiko Yoshida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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Abstract
Renal cell cancer is nowadays predominantly diagnosed in early stages due to the widespread use of sectional imaging for unrelated symptoms. Small renal masses (<4 cm) feature a largely indolent biology with a very low risk for metastasis or even a benign biology in up to 30% of the cases. Consequently, there is a need for less invasive therapeutic alternatives to nephron-sparing surgery. Meanwhile, there is a broad portfolio of local ablation techniques to treat small renal tumors. These include the extensively studied radiofrequency ablation and cryoablation techniques as well as newer modalities like microwave ablation and irreversible electroporation as more experimental techniques. Tumor ablation can be performed percutaneously under image guidance or laparoscopically. In particular, the percutaneous approach is a less invasive alternative to nephron-sparing surgery with lower risk for complications. Comparative studies and meta-analyses report a higher risk for local recurrence after renal tumor ablation compared to surgery. However, long-term oncological results after treatment of small renal masses are promising and do not seem to differ from partial nephrectomy. The possibility for salvage therapy in case of recurrence also accounts for this finding. Especially old patients with an increased risk of surgical and anesthesiological complications as well as patients with recurrent and multiple hereditary renal cell carcinomas may benefit from tumor ablation. Tumor biopsy prior to intervention is associated with very low morbidity rates and is oncologically safe. It can help to assess the biology of the renal mass and prevent therapy of benign lesions.
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Kawamura N, Yokoyama M, Tanaka H, Nakayama T, Yasuda Y, Kijima T, Yoshida S, Ishioka J, Matsuoka Y, Saito K, Kihara K, Fujii Y. Acute kidney injury and intermediate-term renal function after clampless partial nephrectomy. Int J Urol 2018; 26:113-118. [PMID: 30253449 DOI: 10.1111/iju.13799] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/02/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the incidence and predictors of acute kidney injury after clampless partial nephrectomy, and its impact on intermediate-term renal function. METHODS The incidence and severity of acute kidney injury were assessed for 262 patients undergoing clampless partial nephrectomy between 2010 and 2015. The association between perioperative covariates and acute kidney injury was evaluated using multivariate logistic regression analysis. An annual change in estimated glomerular filtration rate from 1 year after surgery was calculated according to the presence or absence of acute kidney injury. An impact of acute kidney injury on postoperative renal impairment, defined as a ≥25% estimated glomerular filtration rate decrease, was evaluated. RESULTS Overall, 21 (8.0%) patients experienced grade 1 acute kidney injury after clampless partial nephrectomy, and grade ≥2 acute kidney injury was not observed. High tumor complexity was the only independent predictor of acute kidney injury. Estimated glomerular filtration rate in patients with acute kidney injury improved within 1 year, and annual estimated glomerular filtration rate changes were similar among patients with or without acute kidney injury. Ultimately, 13 (5.0%) patients showed postoperative renal impairment during the median follow-up period of 37 months. Advanced age and diabetes mellitus were independent risk factors for renal impairment, but acute kidney injury was not. CONCLUSIONS The incidence and severity of acute kidney injury after clampless partial nephrectomy are low. Low-grade acute kidney injury after clampless partial nephrectomy does not seem to affect intermediate-term renal function.
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Affiliation(s)
- Naoko Kawamura
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan.,Department of Urology, JA Toride Medical Center, Toride, Japan
| | - Minato Yokoyama
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Hajime Tanaka
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Takayuki Nakayama
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Yosuke Yasuda
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Toshiki Kijima
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Soichiro Yoshida
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Junichiro Ishioka
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Yoh Matsuoka
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Kazutaka Saito
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Kazunori Kihara
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
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Delto JC, Paulucci D, Helbig MW, Badani KK, Eun D, Porter J, Abaza R, Hemal AK, Bhandari A. Robot-assisted partial nephrectomy for large renal masses: a multi-institutional series. BJU Int 2018; 121:908-915. [DOI: 10.1111/bju.14139] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
| | | | - Michael W. Helbig
- Florida International University Herbert Wertheim College of Medicine; Miami FL USA
| | | | - Daniel Eun
- Lewis Katz School of Medicine at Temple University; Philadelphia PA USA
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Liu B, Zhan Y, Chen X, Xie Q, Wu B. Laparoscopic ultrasonography: The wave of the future in renal cell carcinoma? Endosc Ultrasound 2018; 7:161-167. [PMID: 29941724 PMCID: PMC6032702 DOI: 10.4103/eus.eus_27_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Laparoscopic or robotic surgery is the main method of treating renal cell carcinoma (RCC). Laparoscopic surgery can accurately target lesions and shorten patient recovery time. Renal endogenous tumors or inferior vena cava tumor thrombi are very difficult to remove using the laparoscopic approach. The emergence of laparoscopic ultrasonography (LUS) has solved this problem. LUS can assist in the detection of tumor boundaries and the extent of tumor thrombi. The lack of tactile feedback may hinder the development of laparoscopic surgery for the treatment of renal cancer. LUS has become an important tool that has improved the rates of successful surgery. LUS is applied in not only early and locally advanced RCC treatment but also in monitoring ablation therapy, testing renal blood perfusion, and exposing renal pedicles. Sonographic techniques used for LUS include initial B-mode, Doppler, and contrast-enhanced ultrasound (CEUS). Contrast agents applied for CEUS do not induce nephrotoxicity and can display renal perfusion more accurately than the regular color Doppler ultrasound. According to current literature, LUS is a promising technique for the treatment of RCC, especially for endogenous RCC or RCC with thrombosis, and for monitoring the effectiveness of radiofrequency ablation, although further well-designed studies are warranted.
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Affiliation(s)
- Bitian Liu
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yunhong Zhan
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Xiaonan Chen
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Qingpeng Xie
- Department of Urology, Cancer Hospital of China Medial University, Liaoning Cancer Hospital, Shenyang, Liaoning Province, China
| | - Bin Wu
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
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