Surgical Approach for Partial Nephrectomy in the Management of Small Renal Masses: A Systematic Review and Network Meta-Analysis.

Background: A variety of surgical and nonsurgical management options for small renal masses (SRMs) now exist. Surgery in the form of partial nephrectomy (PN) has three different approaches. It is unclear which PN approach, if any, offers superior clinical outcomes. Aim: The aim of this study is to compare outcomes in patients with SRMs <4 cm undergoing PN through the open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), or robotic partial nephrectomy (RPN) approach and to establish the advantages and disadvantages of the various approaches. Methods: A systematic literature search was conducted for studies comparing at least two of the above techniques. Eighteen studies and 17,013 patients were included in our study. A network meta-analysis with a frequentist framework was performed. OPN was used as the baseline comparator. The prespecified primary outcome was R0 resection rates. Secondary outcomes included operating time, ischemia time, blood loss, transfusion rates, urine leak rates, significant morbidity, length of stay, and recurrence. Results: There was no significant difference between the techniques in terms of R0 rates, tumor recurrence, urine leak rates, renal function, and >3a Clavien-Dindo complications. LPN had a longer ischemic time and operating time. OPN had a longer length of stay and higher average intraoperative blood loss. RPN had lower blood transfusion rates. Discussion: All approaches are acceptable from an oncological perspective. The minimally invasive approaches (i.e., RPN and LPN) offer advantages in terms of morbidity; however, LPN may increase ischemic time and operative duration. Variations between perioperative outcomes may influence the choice of approach on a case-by-case and institutional basis.

Predicting Adherent Perinephric Fat Using Preoperative Clinical and Radiological Factors in Patients Undergoing Partial Nephrectomy.

BACKGROUND: The decision to perform a partial nephrectomy (PN) relies largely upon the complexity of the renal mass and its surrounding anatomy. The presence of adherent perinephric fat (APF) can increase surgical complexity and extend operative times. The accurate prediction of APF may improve surgical planning and aid in decision making for the surgical approach. OBJECTIVE: We sought to develop and externally validate a score that predicts APF based on preoperative clinical and radiological prognostic factors. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively analyzed 495 consecutive patients who underwent open or minimally invasive PN. APF was defined as the presence of "dense," "adherent," or "sticky" perinephric fat at the time of dissection by the surgeon, and this did not require subcapsular dissection. Additionally, we analyzed an independent cohort of 285 patients for external validation. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: A score model was developed using multivariate logistic regression analysis. Calibration of the fitted model was assessed graphically with a plot of the predicted versus the actual probability of APF, and discrimination was assessed by calculating the area under the receiver operating characteristic curve. RESULTS AND LIMITATIONS: Of the 495 patients, 95 (19%) had APF. Patients with APF had longer operative (p=0.02) and arterial clamp (p=0.01) times than non-APF patients. On multivariate analyses, diabetes mellitus (p=0.009), posterior perinephric fat thickness (p<0.001), and perinephric stranding (p<0.001) were predictors of encountering APF in PN. A risk score ranging from 0 to 4 was developed based on these three variables to predict APF. The scoring system demonstrated good discrimination of 0.82 and 0.84 for the development and external validation cohorts, respectively. CONCLUSIONS: The APF score can accurately predict the presence of APF in patients with a small renal mass who are planning to undergo PN. This score could aid in pre- and intraoperative planning and impact the surgical approach. PATIENT SUMMARY: The presence of "sticky" fat surrounding the kidney in patients undergoing partial nephrectomy has previously been linked to longer operative times, intraoperative complications, and surgical conversion. In our study, we found that this feature is more often presented in patients with diabetes mellitus, and thicker and more inflammatory fat on renal imaging. Based on these findings, we developed a risk score that can accurately predict this feature before surgery, in order to improve surgical planning and better counsel the patients.

Urological service provision during the COVID-19 period: the experience from an Irish tertiary centre.

PURPOSE: Urological service provision has changed dramatically with the advent of the SARS-CoV-2, necessitating restructuring and reorganization. The aim of this study was to review the reorganization of our unit, map the change in volume of departmental activities and discuss potential solutions. METHODS: Departmental activities over the months of April and May 2020 and 2019 were analysed. Details of admissions, operations, diagnostic procedures, outpatient reviews, morbidities and mortalities were recorded. Operations were performed on two sites, with elective operation transferred to an offsite, COVID-free hospital. RESULTS: Seventy-four emergency operations were performed onsite, with 85 elective operations outsourced. A total of 159 operations were performed, compared with 280 in the same period in 2019. Five (5.0%) of 101 admitted patients to the COVID hospital contracted COVID-19. No patients outsourced to the COVID-free hospital were infected there. Outpatient referrals to urology service decreased from 928 to 481. There was a 66% decrease in new cancer diagnoses. A virtual review clinic was established, with remaining outpatients reviewed through a telephone clinic platform. CONCLUSION: Compared with 2019, we performed fewer operations and outpatient procedures, had fewer admissions and diagnosed fewer patients with new cancers. However, outsourcing elective operation to designated non-COVID hospitals prevented the infection of any patient with COVID-19 in the post-operative period. The use of virtual clinic and telephone clinic has had some success in replacing traditional outpatient visits. The overall significant decrease in operative volume will likely precipitate a mismatch between demand and service provision in the coming months, unless capacity is increased.

Implementation of a nurse-led lower urinary tract symptoms (LUTS) clinic reduces general urology clinic workload in a Model 4 Hospital: a pilot study in Tallaght University Hospital.

BACKGROUND: With among the lowest urologist per population ratios in Europe, the demand for urology specialist review in Ireland far exceeds supply. Lower urinary tract symptoms (LUTS) account for a significant number of referrals. The traditional paradigm of every patient being reviewed in a consultant-led clinic is unsustainable. New models of care with nurse-led clinics represent an opportunity to optimise limited resources. METHODS: Existing long-waiting male LUTS referrals were triaged to a specialist nurse-led LUTS clinic. After urology CNS assessment, charts were reviewed by a consultant urologist and a plan formulated. Relevant data were prospectively collected and analysed. RESULTS: Fifty-eight new male patients with LUTS were seen over a 6-month period with an average waiting time of 15.8 months. Patients were assessed with uroflowmetry, IPSS and DRE. Mean age was 64, IPSS 14.5, Qmax 18.3 ml/s and PVR 89 ml. Thirty patients (52%) were discharged directly with lifestyle modification and medical therapy. Twenty-eight patients (48%) required one or more further investigations and subsequent review; 11 had flexible cystoscopy, 4 had urodynamics, 5 had prostate MRI, and 2 patients were listed for surgery (TURP and circumcision). The remaining 10 patients were for review post trial of lifestyle modifications and/or medical treatment. After review/investigations, 4 more patients were discharged. A total of 32 patients (55%) were discharged or listed for surgery after initial assessment. This total increased to 62% after a second review/investigations. CONCLUSION: Introduction of a CNS-led LUTS clinic has significantly reduced the number of patients requiring follow-up in general urology clinics, representing a quality improvement in service provision.

Intraoperative and early postoperative complications in postchemotherapy retroperitoneal lymphadenectomy among patients with germ cell tumors using validated grading classifications.

BACKGROUND: Postchemotherapy retroperitoneal lymphadenectomy (PC-RPLND) is an essential, yet potentially morbid, therapy for the management of patients with advanced germ cell tumors. In the current study, the authors sought to define the complication profile of PC-RPLND using validated grading systems for intraoperative adverse events (iAEs) and early postoperative complications. METHODS: Between 2000 and 2018, all patients who underwent PC-RPLND were analyzed for iAEs and early postoperative complications using the Kaafarani and Clavien-Dindo classifications, respectively. Logistic regression models were conducted to assess patient and tumor factors associated with iAEs and postoperative complications. RESULTS: Of the 453 patients identified, 115 patients (25%) and 252 patients (56%), respectively, experienced an iAE and postoperative complication. Major iAEs (grade ≥3) were observed in 15 patients (3%) and major postoperative complications (grade ≥3) were noted in 80 patients (18%). The most common iAE was vascular injury (112 of 132 events; 85%), which occurred in 92 patients (20%), and the most frequent postoperative complication was ileus, which occurred in 121 patients (27%). Original and postchemotherapy retroperitoneal mass size, nonretroperitoneal metastases, intermediate and/or poor International Germ Cell Cancer Collaborative Group classification, previous RPLND, elevated tumor markers at the time of RPLND, and anticipated adjuvant surgical procedures increased the risk of both iAEs and postoperative complications. Patients who experienced an iAE were significantly more likely to experience a postoperative complication (odds ratio, 2.50; 95% confidence interval, 1.58-3.97 [P < .001]). CONCLUSIONS: In what to the authors' knowledge is the first analysis of PC-RPLND using validated classifications for both iAEs and postoperative complications, advanced disease and surgical complexity significantly increased the risks of major iAEs and postoperative complications. Standardized reporting of adverse perioperative events allows providers and patients to appreciate the consequences of PC-RPLND during counseling and decision making.

The utility of stent on strings in clinical practice.

INTRODUCTION: Various types of ureteric stents are used in the management of ureteric stones. Stents on strings (SOS) are an attractive option as they may be removed without the need for instrumentation. There is some hesitation using SOS due to perceived complications and the risk of premature dislodgement. The aim of this study was to evaluate the utility of SOS compared with the conventional stent (CS). METHODS: A retrospective review was performed on all ureteric stents removed in the urology department over a 7-month period. Only stents inserted during the endoscopic management of ureteric stones were included in analysis. Patients were contacted to identify the incidence of those seeking medical attention while the stent was in situ or within 2 weeks of stent removal. A basic cost analysis was performed. RESULTS: One hundred and sixty cases were identified (98 CS, 62 SOS). No SOS was dislodged prematurely. One SOS was removed cystoscopically due to a broken string. There was no significant difference in the number of patients with SOS seeking medical attention following stent placement compared with those with CS (38.1% (12/51) vs 25.6% (22/86), p = 0.48). There was an estimated cost saving of €23,790 associated with the use of SOS during the study period (€390/case). The use of SOS created additional capacity which was utilised for diagnostic cystoscopy. CONCLUSION: The SOS appeared to be well tolerated and showed similar complication rates as the CS. The use of SOS resulted in a significant cost saving and increased the availability of cystoscopy for other indications.

Implications of faecal ESBL carriers undergoing TRUS-guided prostate biopsy (TRUSPB): role of screening prior to TRUSPB.

INTRODUCTION: Modification of antibiotic prophylaxis prior to transrectal ultrasound-guided prostate biopsy (TRUSPB) based on pre-procedure rectal culture results is effective for prevention of infection from fluoroquinolone (FQ)-resistant and extended-spectrum beta-lactamase (ESBL) Escherichia coli strains. This has several implications for service delivery and cost. Our aim was to audit sepsis rates after introduction of ESBL screening and to identify risk factors for FQ resistance in ESBL strains and factors for sepsis risk. METHODS: This was a prospective cohort study from 2013 to 2016. TRUSPB patients underwent pre-procedure rectal swabs. ESBL-positive patients received amikacin in addition to ciprofloxacin prophylaxis. Patients filled a formal risk assessment questionnaire prior to biopsy. RESULTS: Sepsis rate after introduction of targeted prophylaxis reduced from 3.1% (2009-2012) to 1.4% (2013-2016). Of 38 ESBL patients, n = 5 (13%) developed severe post-TRUSPB sepsis. Among the FQ-resistant ESBL producers, the sepsis rate was 24%. Predictive factor for FQ resistance in ESBL producers included-antibiotic use in the last 3 months (OR 15). The logistic regression analysis did not identify any significant factor for post-TRUSPB sepsis in ESBL-positive patients once they had received additional prophylaxis. CONCLUSION: In the face of rising TRUSPB sepsis and higher sepsis rates with ESBL carriers despite additional prophylaxis, introduction of a targeted antibiotic prophylaxis prior to TRUSPB sepsis prostate biopsies based on rectal swabs or urine cultures may reduce sepsis rates or clinicians may find themselves leaning towards increasingly performing transperineal biopsies with lower sepsis rates supporting the 'trexit' initiative.

Urinary catheters in the emergency department: a prospective audit to improve quality control.

INTRODUCTION: The best way to prevent urinary catheter related complications is to avoid unnecessary insertions of catheters and removing the catheters when they are no longer necessary. Previous studies have shown 47% documentation rate of urinary catheter (UC) insertion in the Emergency Department (ED) and have found one-sixth of patients in the ED have no indication for UC insertion. The aim of this audit was to record the indications and documentation of UC insertion in the ED and to propose an intervention to improve the quality of these processes. MATERIAL AND METHODS: A prospective audit was conducted in a tertiary university teaching hospital in Ireland over an eight-week period. A week-long intervention was conducted in the ED to educate staff, an ED doctor was involved in directly communicating this to the staff thereafter and concise labels were introduced to document relevant details about each UC insertion. The pre-intervention and post-intervention data was compared using Chi-Square tests. RESULTS: A total of 103 (50 pre-intervention and 53 post-intervention) consecutive age and gender matched patients were recruited in the audit over 8 weeks. The documentation for UC insertion improved by 22% (8% to 30%, (p <0.001, chi-square) while the non-indication for UC insertion reduced by 6% (36% to 30%, p = 0.53, chi-square). CONCLUSIONS: A simple intervention achieved significantly improved documentation of UC insertion and a trend toward increased appropriateness of UC insertion. This audit serves as an example to improve quality control around UC insertion which could be adopted in other institutions.

Primitive neuroectodermal tumour with synchronous ipsilateral clear cell carcinoma of the kidney.

We report the first case of a synchronous ipsilateral primitive neuroectodermal tumour (PNET) and clear cell renal cell carcinoma of the kidney. A 37-year-old man presented to the emergency department with a 24-hour history of colicky abdominal pain and visible haematuria. He had no relevant surgical or medical history. Physical examination was unremarkable apart from mild left flank tenderness. Triphasic CT of the abdomen and pelvis showed two solid lesions in the left kidney. Further staging CT of the chest showed no evidence of local or distal metastasis. He subsequently underwent laparoscopic radical nephrectomy. Pathological analysis of the kidney showed two synchronous renal tumours, a clear cell carcinoma and PNET of the kidney. The patient received adjuvant chemotherapy according to Ewing's sarcoma chemotherapy protocol. Surveillance CT scans at 3, 6 and 12 months showed no evidence of disease recurrence or metastasis.

Paratesticular myositis ossificans of the spermatic cord.

A 56-year-old man presented with a painless scrotal lump, enlarging over the preceding 1 month. The lump was roughly 1 cm in size, and located in his left hemiscrotum and separate from the testis. An ultrasound revealed an echogenic focus with dystrophic tissue calcification. Subsequent surgical excision and histopathological analysis revealed it to be late-stage myositis ossificans, a benign, extraosseous formation of the bone or cartilage. We report of only the second described case of myositis ossificans of the spermatic cord in the literature to date.

Quantitative Analysis of Technological Innovation in Urology.

OBJECTIVE: To assess major areas of technological innovation in urology in the last 20 years using patent and publication data. METHODS: Patent and MEDLINE databases were searched between 1980 and 2012 electronically using the terms urology OR urological OR urologist AND "surgeon" OR "surgical" OR "surgery". The patent codes obtained were grouped in technology clusters, further analyzed with individual searches, and growth curves were plotted. Growth rates and patterns were analyzed, and patents were correlated with publications as a measure of scientific support and of clinical adoption. RESULTS: The initial search revealed 417 patents and 20,314 publications. The top 5 technology clusters in descending order were surgical instruments including urinary catheters, minimally invasive surgery (MIS), lasers, robotic surgery, and image guidance. MIS and robotic surgery were the most emergent clusters in the last 5 years. Publication and patent growth rates were closely correlated (Pearson coefficient 0.78, P <.01), but publication growth rate remained constantly higher than patent growth, suggesting validated scientific support for urologic innovation and adoption into clinical practice. CONCLUSION: Patent metrics identify emergent technological innovations and such trends are valuable to understand progress in the field of urology. New surgical technologies like robotic surgery and MIS showed exponential growth in the last decade with good scientific vigilance.

Incidence of Visible Hematuria Among Antithrombotic Agents: A Systematic Review of Over 175,000 Patients.

OBJECTIVE: To determine the probability of visible hematuria with antithrombotic agents and to evaluate association of urologic etiology in antithrombotic-related hematuria. METHODS: Preferred Reporting Items in Systematic Reviews and Meta-Analyses guidelines were followed to conduct a systematic review using search engines PUBMED and SCOPUS with the terms "(hematuria) OR (haematuria) OR urinary bleeding)) AND ((anticoagulants) OR anticoagulation) OR noac) OR novel anticoagulants) OR antiplatelet) OR dabigatran) OR rivaroxaban) OR apixaban) OR warfarin) OR aspirin) OR heparin) OR dipyridamole)." Raw data were used to perform a pooled analysis. Chi-square and logistic regression analysis were used for statistical analyses. RESULTS: Twenty-two studies describing 175,114 patients met inclusion criteria. Odds ratio of hematuria with warfarin to rivoraxaban was 33 and warfarin to dabigatran was 16. The odds ratio of hematuria for oral anticoagulant (26.7%) to prophylactic parenteral anticoagulant (1.1%) agents was 9.6. Antiplatelet agents are 76 times less likely to cause hematuria compared to anticoagulants. Odds of hematuria with aspirin were 6.7 times the odds with clopidogrel and 3.5 times the odds with ticagrelor. Dabigatran was 198 times more likely to cause major hematuria compared to warfarin, whereas clopidogrel is 1.2 times more likely to cause major hematuria compared to aspirin. Urologic pathology was identified in 44% (234/532) of cases, malignancy in 24%. CONCLUSION: Warfarin use poses the greatest risk for hematuria but is unlikely to cause major hematuria, whereas novel antithrombotic agents are more commonly associated with major hematuria. This review further characterizes the risk profile of antithrombotic agents and associated hematuria to equip clinicians with knowledge to choose an appropriate antithrombotic agent in patients with high-risk hematuria.

The Role of Metastasectomy in Patients with Renal Cell Carcinoma with Sarcomatoid Dedifferentiation: A Matched Controlled Analysis.

PURPOSE: Management of metastatic renal cell carcinoma with sarcomatoid dedifferentiation remains a therapeutic challenge with no standard treatment strategies. We evaluated whether metastasectomy has any survival benefit in patients with metastatic sarcomatoid dedifferentiation treated with radical nephrectomy. MATERIALS AND METHODS: From an institutional database of 273 patients with sarcomatoid dedifferentiation treated with nephrectomy we matched 80 with synchronous and asynchronous metastases for age, ECOG (Eastern Cooperative Oncology Group) performance status, histology and lymph node status. Matched pairs were then retained only if patients who did not undergo metastasectomy were alive at metastasectomy comparable to matched surgical patients to decrease the bias of survival outcomes. Overall survival from nephrectomy was studied using univariable and multivariable proportional hazards regression. RESULTS: Median overall survival was 8.3 (95% CI 6.5-10.5) and 18.5 months (95% CI 11.5-42.9) in patients with synchronous and asynchronous metastases, respectively. Overall survival in patients who underwent metastasectomy for synchronous metastasis compared to nonsurgical patients was 8.4 and 8.0 months (p = 0.35), respectively. Similarly, overall survival in patients with asynchronous metastases treated with metastasectomy compared to the nonsurgical group was 36.2 and 13.7 months, respectively (p = 0.29). On multivariable analysis positive lymph nodes at nephrectomy were associated with an increased risk of death in the synchronous and asynchronous patient subgroups (HR 2.1, 95% CI 1.1-4.0, p = 0.03 and HR 3.3, 95% CI 1.2-9.2, p = 0.02, respectively). CONCLUSIONS: In the current study there was no clear evidence of benefit in patients with sarcomatoid dedifferentiation who underwent metastasectomy after nephrectomy. Particularly, the group of patients with pathological lymph node positive disease at nephrectomy had considerably worse survival.

The role of neoadjuvant therapy in the management of locally advanced renal cell carcinoma.

In the past decade, the armamentarium of targeted therapy agents for the treatment of metastatic renal cell carcinoma (RCC) has significantly increased. Improvements in response rates and survival, with more manageable side effects compared with interleukin 2/interferon immunotherapy, have been reported with the use of targeted therapy agents, including vascular endothelial growth factor (VEGF) receptor tyrosine kinase inhibitors (sunitinib, sorafenib, pazopanib, axitinib), mammalian target of rapamycin (mTOR) inhibitors (everolimus and temsirolimus) and VEGF receptor antibodies (bevacizumab). Current guidelines reflect these new therapeutic approaches with treatments based on risk category, histology and line of therapy in the metastatic setting. However, while radical nephrectomy remains the standard of care for locally advanced RCC, the migration and use of these agents from salvage to the neoadjuvant setting for large unresectable masses, high-level venous tumor thrombus involvement, and patients with imperative indications for nephron sparing has been increasingly described in the literature. Several trials have recently been published and some are still recruiting patients in the neoadjuvant setting. While the results of these trials will inform and guide the use of these agents in the neoadjuvant setting, there still remains a considerable lack of consensus in the literature regarding the effectiveness, safety and clinical utility of neoadjuvant therapy. The goal of this review is to shed light on the current body of evidence with regards to the use of neoadjuvant treatments in the setting of locally advanced RCC.

Prediction of Pulmonary Metastasis in Renal Cell Carcinoma Patients with Indeterminate Pulmonary Nodules.

BACKGROUND: Indeterminate pulmonary nodules (IPN) are of uncertain significance in patients with renal cell carcinoma. OBJECTIVE: We sought to determine predictors of IPN progression to pulmonary metastasis and develop a tool for individualized risk stratification of patients who present with IPN on preoperative chest imaging in the setting of localized or locally advanced renal cell carcinoma. DESIGN, SETTING, AND PARTICIPANTS: We reviewed all patients who had radical nephrectomy with no evidence of distant metastases at a single institution from 2005-2009 who had ≥1 IPN on chest computed tomography that measured <2 cm. All chest computed tomographies were rereviewed by a radiologist who was blinded to outcomes, to independently determine number, size, and location of nodules. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary objective of the study was to develop a prognostic model to predict pulmonary metastases among radical nephrectomy patients who present with IPN based on readily available preoperative imaging and postoperative pathological criteria. Univariable and multivariable Cox regression models were used to assess the predictive factors for development of pulmonary metastasis. We developed a nomogram that predicted the 3-yr and 5-yr lung metastasis-free survival (LMFS), with assessment of discrimination and internal validation. RESULTS AND LIMITATIONS: Among 251 patients with IPN who underwent nephrectomy, 72 (29%) developed pulmonary metastases. Median follow-up for the cohort was 36.6 mo. Three-yr and 5-yr probability of LMFS for the overall cohort was 71% (95% confidence interval 65-77%) and 65% (95% confidence interval 57-72%), respectively. The nomogram developed included number and size of IPN along with postoperative pathological variables, and showed calibration with a concordance index (c-index) of 0.81 and a bootstrap corrected c-index of 0.78. Limitations include retrospective study with no external validation. CONCLUSIONS: We developed a nomogram to predict the individualized risk LMFS for patients who underwent nephrectomy for localized or locally advanced renal cell carcinoma. PATIENT SUMMARY: We reviewed outcomes among kidney cancer patients who presented with small lung nodules and developed a clinical tool to predict risk of developing lung metastases.

Prognosticators and outcomes of patients with renal cell carcinoma and adjacent organ invasion treated with radical nephrectomy.

OBJECTIVE: To study the natural history, prognosticators, and outcomes in patients with renal cell carcinoma (RCC) with extension of tumor beyond Gerota׳s fascia or invading contiguously into the adrenal gland (pT4) or both. PATIENTS AND METHODS: From 1992 to 2012, we identified 61 patients who underwent radical nephrectomy and were found to have pT4 disease. Clinicopathologic variables were queried using univariate analysis to identify relevant prognostic variables. Cox proportional hazards model was used for multivariate analysis of predictors of cancer-specific survival. Survival plots were estimated using Kaplan-Meier method and survival analysis using log-rank test. RESULTS: Median age was 56 years (interquartile range: 49-64) and 49 (81.7%) patients had Eastern Cooperative Oncology Group Performance Status 0 or 1. At diagnosis, 22 (36.1%) patients showed nonmetastatic and 39 (63.9%) patients showed metastatic RCC. Overall, 49 (80.3%) patients had clear cell RCC, 24 (39.3%) patients had sarcomatoid features, and 39 (69.6%) patients had Fuhrman grade 3 to 4. There were 26 (42.6%) patients with pN0, 16 (26.2%) patients with pN1, and 19 (31.1%) patients with pNx. Median cancer-specific survival was 37 months for patients with nonmetastatic and 8 months for patients with metastatic RCC. On multivariate analysis, preoperative lactate dehydrogenase and alkaline phosphatase, M stage, pN stage, and sarcomatoid dedifferentiation were significantly associated with survival. CONCLUSIONS: Survival in patients with pT4 remains poor. The pT4 disease is associated with a locally and regionally invasive biology that requires specific attention and warrants careful study. Understanding the drivers of this unique phenotype would generate therapeutic interventions that can change the behavior of these uniquely aggressive tumors.

Management of the Incidental Adrenal Mass.

CONTEXT: Incidentally discovered adrenal masses are becoming more common in clinical practice. OBJECTIVE: To review the management of the incidental adrenal mass, including initial evaluation, surveillance, medical therapy, and surgical therapy. EVIDENCE ACQUISITION: A literature search of English-language publications that included the keywords adrenal incidentaloma and incidental adrenal mass was performed through July 2015 using PubMed. Relevant original articles and guidelines on the management of the incidental adrenal mass were ultimately selected for analysis, with the consensus of all authors. EVIDENCE SYNTHESIS: Data from the manuscripts included in this review were synthesized, and findings were categorized into metabolic evaluation, imaging, biopsy, surgical considerations, and follow-up recommendations. CONCLUSIONS: Ideally, management of patients with adrenal incidentalomas should involve a multidisciplinary approach with experienced surgeons, radiologists, and endocrinologists to determine whether such lesions are benign or malignant and functional or nonfunctional and/or whether they require surgical resection. PATIENT SUMMARY: Management of patients with adrenal incidentalomas should involve a multidisciplinary approach with surgeons, radiologists, and endocrinologists to determine whether such lesions are benign or malignant and functional or nonfunctional and/or whether they require surgical resection.

Surgical considerations for patients with metastatic renal cell carcinoma.

Among patients with renal cell carcinoma (RCC), 25-30% present with metastatic disease at the time of initial diagnosis. Despite the ever-increasing array of treatment options available for these patients, surgery remains one of the cornerstones of therapy. Proper patient selection for cytoreductive surgery is paramount to its effective use in the management of patients with metastatic RCC despite the decrease in reported morbidity rates. We explore the evolving role cytoreductive surgery in metastatic RCC spanning the immunotherapy era to the targeted therapy era. Despite significant advances in the management of patients with metastatic RCC, further evidence on the definitive role of cytoreductive surgery in the targeted therapy era is awaited through large randomized trials.

Role of metastasectomy in metastatic renal cell carcinoma.

PURPOSE OF REVIEW: Management of patients with metastatic renal cell carcinoma is challenging and continues to be delivered in a multidisciplinary context. Even with the advent of systemic targeted therapy, complete remission with these new agents is rare using systemic therapy alone. Surgical resection of the primary tumor and metastatic deposits continues to play an important role in managing patients with metastatic renal cell carcinoma when aiming for complete remissions. To date, despite the lack of level 1 evidence, metastasectomy appears to prolong survival and achieve long-term cure in carefully selected patients. This review examines current evidence for the role of metastasectomy in renal cell carcinoma. RECENT FINDINGS: Studies continue to consistently support a benefit of complete metastasectomy for overall and cancer-specific survival at most sites for resection, with the exception of brain and bone, which tend to perform for symptomatic relief and palliation. Metastasectomy has not yet been examined in a randomized setting. The debate of survival benefit because of selection bias of patients or differences in tumor biology is relevant and has yet to be resolved in the literature. Clearly, careful patient selection remains paramount in optimizing survival benefit from metastasectomy. SUMMARY: Patients with isolated surgically resectable metastatic disease, with long disease-free intervals, and with good performance status are likely to benefit the most from metastasectomy.