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Living donor nephrectomy is a high-stake procedure involving healthy individuals, therefore every effort should be made to define each patient’s individualized risk and improve potential donors’ information. The aim of this study was to evaluate the interest of the Mayo adhesive probability (MAP) score, an imaging-based score initially designed to estimate the risk of adherent perinephric fat in partial nephrectomy, to predict intra- and postoperative complications of living donor nephrectomy. We retrospectively reviewed the imaging, clinical, and follow-up data of 452 kidney donors who underwent laparoscopic donor nephrectomy in two academic centers. Imaging and follow-up data were available for 307 kidney donors, among which 44 (14%) had a high MAP score (≥ 3). Intraoperative difficulties were encountered in 50 patients (16%), including difficult dissection (n = 35) and bleeding (n = 17). Conversion to open surgery was required for 13 patients (4.2%). On multivariate analysis, a MAP score ≥ 3 was significantly associated with the risk of intraoperative difficulty [OR 14.12 (5.58–35.7), p

Background The 2 main objectives regarding living kidney transplant are to provide optimal graft function and to ensure the safety of donation. Our study hypothesized that the glomerular filtration rate of a single kidney (skGFR), when transplanted, might predict graft function and that the skGFR of the remaining kidney could predict donor functional gain. Methods A prospective monocentric study was conducted at Grenoble-Alpes University Hospital. Twenty couples of donors and recipients were included. Dimercaptosuccinic acid renal scintigraphy and 51Cr-ethylene-diamine tetra-acetic acid clearance were evaluated predonation to calculate skGFR. All patients had renal function according to 51Cr-ethylene-diamine tetra-acetic acid clearance at 1 year post transplant to assess graft function and donor functional gain. All donors had normal renal function predonation. Results At 1 year post transplant, median glomerular filtration rate of the graft was 50 mL/min/1.73 m2 (range, 46-56 mL/min/1.73 m2) and donor median glomerular filtration rate was 59 mL/min/1.73 m2 (range, 55-74 mL/min/1.73 m2). Median functional gain was 20 mL/min/1.73 m2 (range, 12-22 mL/min/1.73 m2). No statistical correlation was found between skGFR of the transplanted kidney and graft function at 1 year (R2 = 0.096, P = .7). For the donor, functional gain was not associated with predonation skGFR of the remaining kidney (R2 = 0.17, P = .5). A statistical difference was found between donor functional gain (18 [SD, 10] mL/min) and recipient gain (delta between skGFR before and after transplant, 7 [SD, 16] mL/min; P = .02). Conclusion Predonation skGFR of the transplanted kidney had no influence on renal allograft function at 1 year post transplant. Similarly, there was no association between measured skGFR of the remaining kidney and donor functional gain at 1 year.

International audience; BACKGROUND:Results of the conservative treatment of renal cell carcinomas arising in functional renal transplants are unknown compared to transplant nephrectomy. Only small series or case reports have been reported.METHODS:Data were collected from 32 transplantation centers nationwide on cases of de novo tumors in functional renal transplants presumed to be malignant between January 1988 and December 2013.RESULTS:Among 116 de novo transplant tumors, 62 were treated conservatively including: 48 by partial nephrectomy (PN) and 14 by thermal ablation (TA). These patients were compared to 30 other patients who were treated by transplant nephrectomy. The median age of the transplanted kidneys at the time of diagnosis was 43.5 years old as calculated from the donor's age. Tumors treated by transplant nephrectomy presented more often with symptoms (pain, fever, impaired condition, hematuria) than tumors treated conservatively (P = .019). After PN, final histology showed 27 (47.5%) papillary carcinomas, 19 (32.2%) clear cell carcinomas, 1 mixed carcinoma, and 2 oncocytomas. The median tumor size treated by PN was 24 mm with no difference in comparison to the TA group. Nine patients treated by PN had postoperative complications (21%), including 4 requiring operative intervention (Clavien IIIb). None of the patients treated by TA had complications. Specific survival was 100% at the time of last follow-up (median time after treatment 37 months) for patients treated by PN or TA.CONCLUSION:PN proved to be efficient in the treatment of small tumors of transplanted kidneys with good long-term functional and oncologic outcomes, including avoiding return to dialysis. TA seems to be an alternative therapy with good results in selected patients.

Study Type – Therapy (outcomes) Level of Evidence 2b What's known on the subject? and What does the study add? High-grade renal trauma seems to be eligible for conservative management. Ureteric stent placement raises issues about its usefulness and its timing. Predictive factors of post-trauma function and surgery need to be known. Urinary extravasation is not associated with poor functional outcome. Ureteric stenting is needed only in case of sepsis and ureteric clot retention. The only independent predictor of long-term renal function is the importance of devascularised renal fragments. OBJECTIVE • To predict the outcomes of a non-operative approach to managing urinary extravasation after blunt renal trauma. PATIENTS AND METHODS • A prospective observational study was conducted between January 2004 and October 2011. First-line non-operative management was proposed for 99 patients presenting with a grade IV blunt renal injury according to the revised American Association for the Surgery of Trauma (AAST) classification. Among them, 72 patients presented with a urinary extravasation. • Management and outcomes were recorded and compared between patients presenting and those who did not present with urinary leakage. Relative postoperative renal function was assessed 6 months after the trauma using dimercapto-succinic acid renal scintigraphy. • Predictors of the need for endoscopic or surgical management and long-term renal function were evaluated on multivariate analysis. RESULTS • Among patients with urinary leakage, endoscopic ureteric stent placement and open surgery were required in 37% and 15%, respectively. • On multivariate analysis, fever of >38.5 °C and ureteric clot obstruction were independent predictors of the need for ureteric stent placement. The only predictor of open surgery was the percentage of devitalised parenchyma. • Long-term renal function loss was correlated to the percentage of devitalised parenchyma and associated visceral lesions. Urinary extravasation did not predict surgical intervention or long-term renal function loss. CONCLUSIONS • Urinary extravasation after blunt renal trauma can be successfully managed conservatively and does not predict long-term decreased renal function or surgery requirement. • A devascularised parenchyma volume of >25% predicts a higher rate of surgery and poorer renal function.

What's known on the subject? and What does the study add? Using a standardized classification for renal tumours is a major step towards an objective comparison of the indications and expected outcomes of partial nephrectomy (PN). Several scores have been described, including the RENAL nephrectomy score (RNS), to evaluate the anatomical features of a renal tumour and predict the surgical challenges with particular regard to PN. Previous studies show discrepancies with regard to the effectiveness of using the RNS to predict postoperative outcomes. Although we showed that conversion to radical nephrectomy was predicted by the RNS, the occurence of complications was more difficult to predict. Objective To evaluate the RENAL nephrometry score (RNS) as a predictor of the perioperative outcomes of a partial nephrectomy. Patients and Methods A retrospective review of 177 consecutive patients who were candidates for an open partial nephrectomy (OPN, n = 159) or a laparoscopic partial nephrectomy (LPN, n = 18) from August 2008 to January 2011 was undertaken. Tumour complexity was stratified into three categories: low (4–6), moderate (7–9) and high (10–12) complexity. Complications, and surgical and renal outcomes were recorded and analysed. Predictors of conversion to radical nephrectomy (RN) and complications were assessed using univariate and multivariate logistic regression. Multiple linear regression was used to evaluate the prediction of postoperative estimated glomerular filtration rate (eGFR) and warm ischaemia time (WIT). Results The median RNS was 7 (interquartile range 6–9). Tumour complexity was assessed as low in 72 (40.6%), moderate in 87 (49.2%) and high in 18 patients (10.2%). There were no significant differences among the three groups with respect to demographic characteristics, operating time, estimated blood loss, transfusion, length of stay, complications and positive surgical margins. Conversion to RN occurred in 29 patients (16.3%). RNS was significantly associated with an increased risk of conversion to RN (odds ratio [OR] = 3.5, P = 0.01 and OR = 6.7, P = 0.005, respectively, for moderate vs low, and high vs low complexity groups). On multivariate analysis, RNS was the only independent predictor of WIT (P = 0.03) and conversion to RN (P = 0.008), but failed to predict postoperative eGFR (P = 0.84) and the occurrence of major complications (P = 0.91). Conclusions In the present series, RNS predicted an increased risk of conversion to RN and prolonged WIT. RNS was not a predictor of complications and postoperative renal function.

UNLABELLED What's known on the subject? and What does the study add? Patients with end-stage renal disease (ESRD) have an increased risk of developing RCC in their native kidneys. The prevalence of RCC is 3-4% in cases of ESRD in dialyzed and/or transplanted patients, which corresponds to a rate 100-times higher than that in the general population. This is the first study, to our knowledge, comparing the characteristics of kidney cancer in the ESRD population according to their dialysis or transplantation status at the time of diagnosis. The differences in stage and survival we observed may be due to differences in surveillance strategies between transplanted and not transplanted patients, nevertheless, the differences in pathological subtypes suggest they could also be due to differences in the tumorigenesis process. OBJECTIVE • To compare clinical, pathological and outcome features of renal cell carcinomas (RCCs) arising in patients with chronic renal failure (CRF) with or without renal transplantation. PATIENTS AND METHODS • In all, 24 French University Departments of Urology and Kidney Transplantation participated in this retrospective study comparing RCCs arising in patients with CRF according to their dialysis or transplantation status at the time of diagnosis. • Information about age, sex, symptoms, duration of CRF, mode and duration of dialysis, renal transplantation, tumour staging and grading, histological subtype and outcome were recorded in a unique database. • Qualitative and quantitative variables were compared by using chi-square and Student statistical analysis. Survival was assessed by Kaplan-Meier and Cox methods. RESULTS • Data on 303 RCC cases diagnosed between 1985 and 2009 were identified in 206 men (76.3%) and 64 women (23.7%). • Transplanted and not transplanted patients accounted for 213 (70.3%) and 90 cases (29.7%), respectively. • In transplant recipients, RCC was diagnosed at a younger age [mean (sd) 53 (11) vs 61 (14) years, P < 0.001), the mean tumour size was smaller [3.4 (2.3) vs 4.2 (3.1) cm, P= 0.02), pT1a stage (75 vs 60%, P= 0.009) and papillary histological subtype (44 vs 22%, P < 0.001) were more frequent than in their dialysis-only counterparts. • Nodal (1 vs 6%, P= 0.03) and distant metastases rates (0 vs 5%, P < 0.001) were significantly increased in patients who had not had a transplant. However, Furhman grading, symptoms, tumour multifocality or bilaterality, presence of acquired cystic kidney disease, were not significantly different between the groups. • Estimated 5-year survival rates were 97% and 77% for transplanted and not transplanted patients, respectively (P < 0.001). In univariate analysis, presence of symptoms (P= 0.008), poor performance status (P= 0.04), large tumour size, advanced TNM stage (P < 0.001), high Fuhrman grade (P= 0.005) and absence of transplantation (P < 0.001) were all adverse prognostic factors. In multivariate analysis, only T stage remained an independent predictor for cancer-related death (P < 0.001). CONCLUSION • RCC arising in native kidneys of transplant patients seems to exhibit many favourable clinical, pathological and outcome features compared with those diagnosed in dialysis-only patients. Further research is needed to determine whether it is due to particular molecular pathways or to biases in relation to mode of diagnosis.

International audience; PURPOSE:The management of major renal trauma has shifted in the last decade in favor of a nonoperative approach. Our level 1 trauma center promotes this approach with the objective of renal function preservation. However, certain situations still require surgery. In this study we analyze predictors of surgery and long-term outcomes after conservative management.MATERIALS AND METHODS:From January 2004 to March 2015 we prospectively collected data from all patients admitted to our institution for high grade blunt renal trauma (grades IV and V). Nonoperative management was considered successful when patients did not undergo surgical exploration, regardless of angioembolization or endoscopic treatment.RESULTS:Of 306 patients with renal trauma 151 presented with major injuries, including 124 grade IV and 27 grade V. Nonoperative management was successful in 110 (89%) cases of grade IV and 14 (52%) cases of grade V lesions. Deceleration mechanism (p=0.03), associated lesions (p=0.001), percentage of devitalized parenchyma (p=0.012), angioembolization (p

International audience; Nephron sparing surgery (NSS) results in the transplanted population remain unknown because they are only presented in small series or case reports. Our objective was to study renal sparing surgery for kidney graft renal cell carcinomas (RCC) in a multicenter cohort. Data were collected from 32 French transplantation centers. Cases of renal graft de novo tumors treated as RCC since the beginning of their transplantation activity were included. Seventy-nine allograft kidney de novo tumors were diagnosed. Forty-three patients (54.4%) underwent renal sparing surgery. Mean age of grafted kidneys at the time of diagnosis was 47.5 years old (26.1-72.6). The mean time between transplantation and tumor diagnosis was 142.6 months (12.2-300). Fifteen tumors were clear cell carcinomas (34.9%), and 25 (58.1%) were papillary carcinomas. Respectively, 10 (24.4%), 24 (58.3%) and 8 (19.5%) tumors were Fuhrman grade 1, 2 and 3. Nine patients had postoperative complications (20.9%) including four requiring surgery (Clavien IIIb). At the last follow-up, 41 patients had a functional kidney graft, without dialysis and no long-term complications. NSS is safe and appropriate for all small tumors of transplanted kidneys with good long-term functional and oncological outcomes, which prevent patients from returning to dialysis.

INTRODUCTION AND OBJECTIVES: To compare RENal and PADUA scores to predict major complications (Clavien 3-4), conversion to radical nephrectomy and warm ischemia time in patients undergoing partial nephrectomy for renal tumor. METHODS: We retrospectively reviewed the files of 177 patients scheduled in our center for a partial nephrectomy for a single renal tumor. Surgical outcomes, including perioperative complications, as well as renal and oncological outcomes were analyzed by Wilcoxon rank sum and Chi-square test, as appropiate. Then, ROC curves were constructed to compare the predictive accuracy of both scores for major complications, conversion to radical nephrectomy and warm ischemia time. RESULTS: Among the 177 patients, 55 were female and median age was 55.0 /12.8 (range 23 80). Median scores were 7 (4-11) for RENaL and 8 (6-13) for PADUA. In multivariate analysis both RENaL and PADUA scores were predictor conversion to radical nephrectomy (n 29 ; p 0.006 for RENaL and p 0.013 for PADUA) and warm ischemia time more than 20 minutes (n 62 ; p 0.005 for RENaL and p 0.013 for PADUA). But RENaL and PADUA score failed to predict major complications (n 21 ; p 0.91 for RENaL and p 0.93 for PADUA). By comparing ROC curves, PADUA and RENaL scores were comparable to predict the occurence of conversion to radical nephrectomy (p 0.70) a warm ischemia time more than 20 minutes (p 0.68) and major complications (p 0.63). CONCLUSIONS: In our series, RENaL score and PADUA score are comparable to predict the risk of conversion to radical nephrectomy, major complications or a long warm ischemia time. These results must be confirmed by a prospective study.

The management of high grade blunt renal injury has evolved with time to become increasingly conservative with the ultimate objective of renal preservation. We evaluated relative renal function with dimercapto-succinic acid renal scintigraphy 6 months after major renal trauma (grade IV or V).This prospective observational study was done between January 2004 and April 2010. All patients who presented with grade IV or V renal trauma and were treated conservatively were included in analysis. Patient and trauma characteristics, and initial management were recorded. Relative renal function was evaluated by dimercapto-succinic acid renal scintigraphy 6 months after trauma.A total of 88 patients were included in the study. Conservative management was possible in 79 patients (90%), including 69 and 10 with grade IV and V trauma, respectively. Dimercapto-succinic acid renal scintigraphy was done at 6 months for 22 patients (28%). Mean relative renal function for grade IV and V injuries was 39% and 11%, respectively (p=0.0041). The percent of devascularized parenchyma (p=0.0033) and the vascular subtype of grade IV injuries (p=0.0194) also correlated with decreased renal function. No complication or de novo arterial hypertension was noted.Conservative treatment achieves the objective of renal function preservation for grade IV lesions. Grade V and specific subtypes of grade IV injury have a poor functional outcome. Further study must be performed to determine which patients will benefit from conservative treatment vs early nephrectomy to avoid a longer hospital stay and useless procedures.

International audience; BACKGROUND: Patients with end-stage renal disease (ESRD) are at risk of developing renal tumours. OBJECTIVE: Compare clinical, pathologic, and outcome features of renal cell carcinomas (RCCs) in ESRD patients and in patients from the general population. DESIGN, SETTING, AND PARTICIPANTS: Twenty-four French university departments of urology participated in this retrospective study. INTERVENTION: All patients were treated according to current European Association of Urology guidelines. MEASUREMENTS: Age, sex, symptoms, tumour staging and grading, histologic subtype, and outcome were recorded in a unique database. Categoric and continuous variables were compared by using chi-square and student statistical analyses. Cancer-specific survival (CSS) was assessed by Kaplan-Meier and Cox methods. RESULTS AND LIMITATIONS: The study included 1250 RCC patients: 303 with ESRD and 947 from the general population. In the ESRD patients, age at diagnosis was younger (55 ± 12 yr vs 62 ± 12 yr); mean tumour size was smaller (3.7 ± 2.6 cm vs 7.3 ± 3.8 cm); asymptomatic (87% vs 44%), low-grade (68% vs 42%), and papillary tumours were more frequent (37% vs 7%); and poor performance status (PS; 24% vs 37%) and advanced T categories (≥ 3) were more rare (10% vs 42%). Consistently, nodal invasion (3% vs 12%) and distant metastases (2% vs 15%) occurred less frequently in ESRD patients. After a median follow-up of 33 mo (range: 1-299 mo), 13 ESRD patients (4.3%), and 261 general population patients (27.6%) had died from cancer. In univariate analysis, histologic subtype, symptoms at diagnosis, poor PS, advanced TNM stage, high Fuhrman grade, large tumour size, and non-ESRD diagnosis context were adverse predictors for survival. However, only PS, TNM stage, and Fuhrman grade remained independent CSS predictors in multivariate analysis. The limitation of this study is related to the retrospective design. CONCLUSIONS: RCC arising in native kidneys of ESRD patients seems to exhibit many favourable clinical, pathologic, and outcome features compared with those diagnosed in patients from the general population.

INTRODUCTION AND OBJECTIVES: A prospective multi-center study was set up to evaluate the results and relative renal function 6 months after conservative treatment for severe blunt renal trauma (grades IV or V). METHODS: From January 2004 to april 2010, 88 patients were admitted to a center of the French Alps with a grade IV or V blunt renal trauma (confirmed on CT scan). Conservative treatment was allowed in 79 cases (90%). Mean age was 27 (10–70). The lesions were classified according to the AAST classification, grade IV in 69 cases (including 51 with urinary extravasation), and grade V in 10 cases. Their management required endoscopic drainage in 21 cases, selective arterial embolization in 10 cases, 3 attempted endovascular revascularisation (angioplasty / stenting), and a mean transfusion rate of 1 red blood cell unit (0–10). RESULTS: An evaluation of the relative renal function with renal scintigraphy was available in 22 patients (28%), 4 grades V and 18 grades IV. The mean relative function of the traumatized kidney was 34%, and 39% in grades IV (15–50%). Considering grade V traumas, 2 kidneys showed no remaining function, the other 2 had a relative function of 20% and 25%. No arterial hypertension was noted during follow-up. Mean hospital stay was 16 days. The mean hospital stay of grade V traumas treated conservatively (14 days) was significantly shorter when compared to the nephrectomy group (24 days, p 0,032). CONCLUSIONS: Our attitude of first-line conservative treatment for grade IV blunt renal trauma provides excellent results at 6 months. On the other hand, conservative treatment of grade V trauma provides mixed results regarding renal function, but a major benefit in terms of hospital stay, without clinical consequences at 6 months.

De novo tumors in renal allografts are rare and their prevalence is underestimated. We therefore analyzed renal cell carcinomas arising in renal allografts through a retrospective French renal transplant cohort. We performed a retrospective, multicentric survey by sending questionnaires to all French kidney transplantation centers. All graft tumors diagnosed after transplantation were considered as de novo tumors. Thirty-two centers participated in this study. Seventy-nine tumors were identified among 41 806 recipients (Incidence 0.19%). Patients were 54 men and 25 women with a mean age of 47 years old at the time of diagnosis. Mean tumor size was 27.8 mm. Seventy-four (93.6%), 53 (67%) and 44 tumors (55.6%) were organ confined (T1-2), low grade (G1-2) and papillary carcinomas, respectively. Four patients died of renal cell carcinomas (5%). The mean time lapse between transplantation and RCC diagnosis was 131.7 months. Thirty-five patients underwent conservative surgery by partial nephrectomy (n = 35, 44.3%) or radiofrequency (n = 5; 6.3%). The estimated 5 years cancer specific survival rate was 94%. Most of these tumors were small and incidental. Most tumors were papillary carcinoma, low stage and low grade carcinomas. Conservative treatment has been preferred each time it was feasible in order to avoid a return to dialysis.

As Teleflex Medical contraindicates the use of Hem-O-Lok clips in laparoscopic living donor nephrectomy (LLDN), we report the feasibility of a simple surgical artifice that aims to preserve the advantages of lockable clips with increased safety while respecting the manufacturer's legal recommendations. Since January 2009, a polyglactin-0 tie was placed on the renal artery in addition to the two usual Hem-O-Lok clips in LLDN at our institution (n = 10) using a pre-tied loop suture (Endoloop ligature, Ethicon) placed on the artery stump, proximally to the aorta, after kidney removal. This artifice increased operating time of 65 seconds (range, 35-85 seconds) with no modification of warm ischemia time and led to visually decreased aortic pulsation transmitted to the clips. Without evidence of increased safety, we assume that this ruse may protect surgeons from prosecution in cases of clip displacement. It certainly decreases the risk of clip slippage and should be considered as a cheap, easy artifice to reduce the already low-risk of hemorrhage in LLDN.

International audience; OBJECTIVES: To evaluate the morbidity and surgical complications of retropubic radical prostatectomy (RRP) in renal transplant recipients (RTRs) and compare these results with the observed morbidity in a control group of nontransplanted patients. METHODS: We conducted a multicenter retrospective study and reviewed the charts and records of 20 RTRs who had undergone RRP for localized prostate cancer at four French renal transplant centers belonging to the Renal Transplantation Committee of the French Urological Association from April 1996 to April 2007. A total of 40 patients who had undergone RRP at the same centers, by the same surgeons, were analyzed as the case-control population. RESULTS: The mean operating time (163 +/- 41 vs 160 +/- 66 minutes), blood loss (516 +/- 279 vs 566 +/- 449 mL), transfusion rate (20% vs 22.5%), and hospital stay (11.9 +/- 5.44 vs 9.45 +/- 2.8 days) were similar in the RTR and case-control populations. No graft loss or graft injury was reported in the RTRs, except for two ureteral injuries that were immediately repaired during RRP. No decrease in the kidney graft function was observed after RRP. The rate of medical complication (deep venous thrombosis, pulmonary embolism, urinary tract infection) was similar in both groups, except for the rate of bacterial systemic infection, which was significantly greater in the RTRs than in the controls (15% vs 2.5%, P = .01). CONCLUSIONS: In our study, RRP was a safe procedure to treat localized prostate cancer in RTRs. RRP resulted in the same morbidity in RTRs as in the case-control population.

International audience; BACKGROUND: We conducted a retrospective multi-centre study to determine the characteristics of prostate cancer in renal transplant recipients (RTR) and to analyse the relation with immunosuppressive maintenance therapies. METHODS: Patients from 19 French transplant centres diagnosed with prostate cancer at least 1 year after kidney transplantation were included in this study. Data regarding demographics, kidney transplantation, prostate cancer and immunosuppressive treatment were analysed. RESULTS: Sixty-two patients met the eligibility criteria for this study. Thirty-eight patients (61.3%) received calcineurin inhibitors (CNI) and azathioprine (AZA) with or without steroids, twenty received CNI with or without steroids (32.2%) and four received CNI and mycophenolate mofetil (6.5%). Patients with CNI and AZA immunosuppressive therapy presented more high-stage cancer (T3 and T4) when compared to patients receiving CNI alone (47.5% versus 15%, respectively, P = 0.03). A non-significant increase in lymph node invasion was found in patients receiving CNI and AZA compared to patients receiving CNI alone (21% versus 5%, P = 0.16). In the multivariate analysis, the immunosuppressive regimen with CNI and AZA was the only independent risk factor for locally advanced disease (P = 0.007). CONCLUSION: Our results showed that RTR are at risk for early occurrence and for locally advanced prostate cancer, especially when they received a CNI and AZA maintenance immunosuppressive therapy.