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Arteriovenous malformations (AVMs) secondary to renal-cell carcinoma (RCC) are well-described in the literature. Independently, renal vein and inferior vena cava tumor thrombi can be detected in locally-advanced RCC. A 67-year-old gentleman presented with a cT1b renal mass detected on workup for elevated creatinine. Multiphase CT imaging obtained for partial nephrectomy surgical-planning revealed an initially-missed renal cortical AVM. This drastically changed the plan for intervention, including use of an open approach with AVM embolization by interventional radiology prior and avoidance of a nephron-sparing approach. Final pathology confirmed the AVM and a subclinical renal vein thrombus masked by arterial flow on CT imaging, making this the first concurrent case described in the literature. Herein, we describe avoidance of catastrophic intraoperative hemorrhage by careful review of preoperative imaging and provide a literature review of imaging modalities for both renal surgical-planning and detection of tumor thrombi in RCC.

INTRODUCTION: Immune checkpoint blockade (ICB) is a rapidly emerging field of oncology that has revolutionized the metastatic renal cell carcinoma (mRCC) treatment. Four recent treatment regimens Nivolumab-Ipilimumab, Pembrolizumab-Axitinib, Nivolumab-Cabozantinib, and Pembrolizumab-Lenvatinib—have demonstrated improved clinical endpoints compared to standard of care and are endorsed by NCCN (2021). However, data on patient-reported outcomes (PROs) for patients receiving these regimens are limited. We conducted a comparative assessment of the quality and standardization of PROs endpoints and data reported for these randomized controlled trials (RCTs). PATIENTS AND METHODS: We systematically identified all RCTs evaluating combination ICB for ccRCC. PROs-specific data were abstracted from the final version of 4 RCT protocols, as well as clinical and PROs specific manuscripts published between April 2018 and April 2021. We used 3 previously published guides standardizing PROs research to objectively score the data: i) 24-point PROEAS; ii) 12-point SPIRIT-PRO; and iii) 14-point CONSORT-PRO. RESULTS: The CheckMate 214, KEYNOTE 426, CheckMate 9ER, and CLEAR studies had PROEAS scores of 88% (21/24), 37% (9/24), 83% (20/24), and 16% (4/24), respectively, and SPIRIT-PRO scores of 50% (6/12), 75% (9/12), 66% (8/12), and 41% (5/12) respectively. The CONSORT-PRO scores were 86% (12/14) for CheckMate 214 and 43% (6/14) for CheckMate 9ER, but scores were not available for the CLEAR and KEYNOTE 426 studies because of a lack of sufficient data. The average SPIRIT-PRO score across the 4 RCTs was 58%, indicating a reasonable adoption of PROs research in data management and analysis. The CheckMate 214 trial had the longest follow-up and most comprehensive published PROs data. CONCLUSION: Our analysis identified the limitations of current PROs data in combination ICB approved for mRCC. This analysis will enable clinicians to better interpret the current PROs results and emphasize the importance of better incorporation of PROs endpoints in future mRCC trial design.

Zachary Werner,1 Ahmad Haffar,2 Emma Bacharach,1 Jennifer Knight-Davis,3 Ali Hajiran,1 Adam Luchey1 1Department of Urology, West Virginia University, Morgantown, WV, USA; 2School of Medicine, West Virginia University, Morgantown, WV, USA; 3Department of Surgery, West Virginia University, Morgantown, WV, USACorrespondence: Ahmad Haffar, School of Medicine, West Virginia University, Suite 6300 Health Sciences Center Morgantown, Morgantown, WV, 26505, USA, Tel +304 993-2237, Fax +304 293-2807, Email aihaffar@mix.wvu.eduObjective: Current urologic renal trauma guidelines favor conservative management. In 2012, we implemented an institution-wide renal trauma protocol to standardize management. This protocol details initiation of DVT (deep vein thrombosis) prophylaxis, cessation of bed rest, and frequency of laboratory studies. We hypothesized that low-grade injuries (grade I–III) could be managed without urologic consultation and that our chemical DVT prophylaxis regimen would not pose an increased risk of hemorrhage requiring transfusion.Methods: We performed a cross-sectional analysis of a prospectively maintained database containing all renal trauma at our institution from 2009 to 2019. We segregated injuries based on grade, presence of multi-organ trauma, and evaluated the presence and types of intervention, initiation of chemical DVT prophylaxis, and post-DVT prophylaxis hemorrhage requiring transfusion.Results: We identified 295 cases of renal trauma, of which 62 were isolated injuries. Forty-three of the isolated renal injuries were transferred from outside facilities, 70% of which were classified as low-grade injuries. There were 220 low-grade lacerations and 75 high-grade lacerations. No grade I or II lacerations required any interventions. Two (2.5%) grade III lacerations required IR embolization. Twenty-five (41%) grade IV lacerations required intervention, of which five were nephrectomy. Seven (54%) grade V lacerations required intervention, of which 5 were nephrectomies. Upon review of our protocol with early ambulation and DVT prophylaxis, there were no cases of isolated renal injury where initiation of either treatment resulted in delayed hemorrhage requiring transfusion or surgical intervention.Conclusion: Only 2/220 low-grade renal lacerations required intervention. Our data suggest that grade I and II renal lacerations can be managed safely without urologic consultation. Consultation is warranted for grade III injuries given the possibility of initial understaging. Furthermore, we believe our renal laceration protocol in our admittedly small, isolated sample has shown our DVT prophylaxis initiation to not pose increased risk.Keywords: renal, trauma, review, protocol, thromboembolic

Because the optimal number of cycles of neoadjuvant gemcitabine and cisplatin chemotherapy (GC) is unclear, we aimed to compare disease response and survival outcomes of patients receiving either 3 or 4 cycles of neoadjuvant GC for muscle-invasive bladder cancer (MIBC).A total of 166 patients who were treated with neoadjuvant GC and radical cystectomy for clinical stage T2-4N0M0 were identified. Response and effectiveness of different cycle counts were assessed using downstaging (complete pathologic and partial pathologic response), cancer-specific survival (CSS), and overall survival (OS). Response and survival outcomes were examined with adjusted logistic regression and Cox regression models. Statistical significance was defined as P0.05.Of 166 patients who received neoadjuvant GC, 107 (64.5%) received 3 cycles and 59 (35.5%) received 4 cycles. Age, insurance, comorbidity, tumor histology (pure urothelial carcinoma, urothelial with divergent differentiation, variant histology), and tumor stage were similar between the 2 treatment groups. Rates of complete response or any downstaging were similar between groups (21.5% and 40.2% in the 3-cycle group and 20.3% and 44.1% in the 4-cycle group, respectively). While disease response was similar (OR 1.03, 95% CI 0.43-2.45), both cancer-specific survival (HR 1.69, 95% CI 0.87-3.26) and overall survival (HR:1.88, 95% CI:1.02-3.48) were more favorable among patients managed with 4 cycles of neoadjuvant chemotherapy compared to those who received 3 cycles in adjusted models.Our analysis demonstrated that survival outcomes tended to be better among patients who received 4 cycle of neoadjuvant GC compared to those treated with 3 cycles. Although potential benefits of omission of fourth cycle may include expedited time to surgery, reduced chemotherapy-associated toxicity, and lower treatment costs, continuation of treatment with a fourth cycle of neoadjuvant GC chemotherapy may benefit patients with muscle-invasive bladder cancer and further improve disease outcomes.