Avoiding "Needless" nephrectomy: What is the role of small renal mass biopsy in 2024?

Current guidelines do not mandate routine preoperative renal mass biopsy (RMB) for small renal masses (SRMs), which results in a considerable rate (18%-26%) of needless nephrectomy/partial nephrectomy for benign renal tumors. In light of this ongoing practice, a narrative review was conducted to examine the role of routine RMB for SRM. First, arguments justifying the current non-biopsy approach to SRM are critically reviewed and contested. Second, as a standalone procedure, RMB is critically assessed; RMB was found to have higher sensitivity, specificity, and an equal or lower complication rate when compared with other commonly preoperatively biopsied solid organ tumors (e.g., breast, prostate, lung, pancreas, thyroid, and liver). Based on the foregoing information, we propose a paradigm shift in SRM management, advocating for an updated policy in which partial nephrectomy or nephrectomy for SRM invariably occurs only after a preoperative biopsy confirms that a SRM is indeed malignant.

Surgical Force: Initial Study and Clinical Implications in the Assessment of Ureteral Access Sheath Induced Injury.

Purpose: Ureteral access sheaths (UAS) pose the risk of severe ureteral injury. Our prior studies revealed forces ≤6 Newtons (N) prevent ureteral injury. Accordingly, we sought to define the force urologists and residents in training typically use when placing a UAS. Materials and Methods: Among urologists and urology residents attending two annual urological conferences in 2022, 121 individuals were recruited for the study. Participants inserted 12F, 14F, and 16F UAS into a male genitourinary model containing a concealed force sensor; they also provided demographic information. Analysis was completed using t-tests and Chi-square tests to identify group differences when passing a 16F sheath UAS. Participant traits associated with surpassing or remaining below a minimal force threshold were also explored through polychotomous logistic regression. Results: Participant force distributions were as follows: ≤4N (29%), >6N (45%), and >8N (32%). More years of practice were significantly associated with exerting >6N relative to forces between 4N and 6N; results for >8N relative to 4N and 8N were similar. Compared to high-volume ureteroscopists (those performing >20 ureteroscopies/month), physicians performing ≤20 ureteroscopies/month were significantly less likely to exert forces ≤4N (p = 0.017 and p = 0.041). Of those surpassing 6N and 8N, 15% and 18%, respectively, were high-volume ureteroscopists. Conclusions: Despite years of practice or volume of monthly ureteroscopic cases performed, most urologists failed to pass 16F access sheaths within the ideal range of 4N to 6N (74% of participants) or within a predefined safe range of 4N to 8N (61% of participants).

Evaluation of Renal Function and Stent Durability Following Resonance Stent Placement for Benign Disease.

Introduction: The metal-based Resonance stent (RS) has traditionally been placed in patients with malignant ureteral obstruction; as such, the long-term utility of RS among patients with benign ureteral obstruction (BUO) remains underinvestigated. Methods: We retrospectively reviewed our database for patients with BUO who underwent RS placement between 2010 and 2020. The impact of chronic RS placement on renal function was evaluated by estimated serum creatinine-based glomerular filtration rate (eGFR), furosemide renal scan, and CT-based renal parenchymal volume measurement. The number of and reason for RS stent exchanges during the follow-up period, incidence of encrustation, and the average indwell time were recorded. A cost analysis of placing the RS vs a polymeric stent was performed. Results: Among 43 RS patients with BUO, at a mean follow-up of 26 months, there was no change in eGFR (p = 0.99), parenchymal volume (p = 0.44), or split renal function of the stent-bearing side on renal scan (p = 0.48). The mean RS indwell time was 9.7 months. Eleven patients (26%) underwent premature stent replacement (6 cases) or removal (5 cases). Stents in 9 patients (32%) were encrusted, of which 4 (44%) required laser lithotripsy. Overall, 25 patients (58%) and 12 patients (28%) had a mean stent indwell time of ≥6 months and ≥12 months, respectively. Placing an RS resulted in a 52%, 37%, and 5.6% cost reduction compared with a regular polymeric stent placement, where it was exchanged every 6, 4, or 3 months, respectively. Conclusions: RS deployment in the patient with a BUO results in cost-effective maintenance of renal function and of renal parenchymal volume at a mean follow-up of 2 years; however, only 28% of patients fulfilled the 1-year criterion for RS indwell time.