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Objectives: To understand the facilitators and barriers to the implementation of renal tumour biopsy (RTB) in the diagnostic pathway for renal tumours in England. Patients and Methods: Participants consisted of patients who had a renal tumour diagnosed and/or treated at one of five tertiary centres in England, healthcare professionals involved in the direct care of patients diagnosed with renal tumours, and clinical service managers and commissioners. The study employed a mixed‐methods research methodology consisting of individual interviews and an on‐line survey that explored the types of facilitators and barriers individuals perceived and experienced and the frequency in which these were reported. A public dissemination event took place following the completion of data collection; to facilitate discussion of potential solutions to implementing RTB. Results: There were 50 participant interviews (23 patients, 22 clinicians, and five health service commissioners/operations managers). The patient on‐line survey received 52 responses, and the clinician survey received 22 responses. Patients most frequently reported influences in choosing whether to undergo RTB pertained to wanting to know the diagnosis of their kidney mass (40%), the advice or information provided by healthcare professionals (40%), and not wishing to delay treatment (23%). Clinicians most frequently reported barriers to recommending RTB related to their uncertainty of diagnostic accuracy (56%), availability of appointments or hospital beds (52%), concerns of risk of bleeding (44%), risk of seeding (41%), and delays in meeting national cancer pathway targets (41%). The dissemination event was attended by 18 participants (seven patients and 11 clinicians). Suggestions to improve implementation included reducing variation and promotion of standardisation of practice by a consensus statement, increasing the evidence base (clinicians) and improved communication by developing better patient aids such as videos and diagrams (patients and clinicians). Conclusion: Implementation of RTB may be dependent on the quality of information provided, its format and perceived reliability of the information. Increased utilisation of RTB may be improved by development of a consensus statement on the role of biopsy, with patients expressing a preference for alternative information aids such as patient videos. [ABSTRACT FROM AUTHOR]

Objective: We assessed the safety and feasibility of minimally invasive robot-assisted surgery for horseshoe kidney (HSK). Method: A prospectively maintained data set for consecutive patients undergoing robotic kidney surgery was reviewed for patients with HSK. Cases were performed by experienced robotic surgeons, across two high-volume centres between 2016 and 2020. Results: Seven patients underwent robotic surgery for HSK, comprising three partial nephrectomies for renal masses, one nephroureterectomy and three benign nephrectomies for non-functioning kidneys. The median age was 53 (interquartile range (IQR) = 47–60) years and median body mass index (BMI) was 25 (IQR = 25–26.5). Median console time was 120 (IQR = 118–215) minutes and median estimated blood loss was 150 (IQR = 125–250) mL. The median pre- and post-operative estimated glomerular filtration rate (eGFR) was 76 (IQR = 72–90) and 71 (IQR = 60–81), respectively. There were no higher-grade complications (Clavien–Dindo III–IV) and one Clavien–Dindo grade II complication (wound infection treated with IV antibiotics). Median length of stay (LOS) was 2 days and there were no 30-day readmissions. Negative margins were achieved in 75% of tumour resections. Conclusion: We report one the largest series of robot-assisted surgery on HSK. Robotic surgery is safe and feasible for HSK in centralised high-volume centres with acceptable perioperative outcomes. Established benefits of minimally invasive surgery, such as reduced LOS and low complication rates, were demonstrated. Level of evidence: 4 [ABSTRACT FROM AUTHOR]

Objectives: Simple nephrectomies can be challenging with significant morbidity. To prove the hypothesis of "not‐so‐simple" nephrectomy, we compared demographics, perioperative outcomes, and complications between simple and radical nephrectomy in a tertiary referral center. Methods: We analyzed 473 consecutive radical nephrectomies (January 2018–October 2020) and simple nephrectomies (January 2016–October 2020). Univariate and multivariate analysis of perioperative outcomes utilized the Mann–Whitney U test, Chi‐squared test, Mantel–Haenszel test of trend, and multiple linear regression. Radical nephrectomies were classified in cT1, cT2a, and cT2b‐T3 subgroups and compared to simple nephrectomies. Minimally invasive and open techniques were compared between the two groups. Infected versus non‐infected simple nephrectomies were compared. Results: A total of 344 radical and 129 simple nephrectomies were included. Simple nephrectomy was an independent predictor of increased operative time (p = 0.001), length of stay (p = 0.049), and postoperative complications (p < 0.001). Simple nephrectomies had higher operative time (p < 0.001), length of stay (p = 0.014), and postoperative morbidity (p < 0.001) than cT1 radical nephrectomies and significantly more Clavien 1–2 complications than cT2a radical nephrectomies (p = 0.001). The trend was similar in minimally invasive operations. However, conversion to open rates was not significantly different. Infected simple nephrectomies had increased operative time (p < 0.001), length of stay (p = 0.005), blood loss (p = 0.016), and intensive care stay (p = 0.019). Conclusions: Patients undergoing simple nephrectomy experienced increased operative time and morbidity. Simple nephrectomy carries higher morbidity than radical nephrectomy in tumors ≤10 cm. Robotic simple nephrectomies may reduce open conversion rates. Postoperative intensive care and enhanced recovery may be essential in simple nephrectomy planning with infected pathology. [ABSTRACT FROM AUTHOR]

Objective: Renal fusion anomalies are rare and usually present as horseshoe kidneys or crossed fusion ectopia. The complex renal anatomy seen in patients with these anomalies can present a challenge. Pre-operative planning is therefore paramount in the surgical management of these cases. Herein we report the use of interactive virtual three-dimensional (3D) reconstruction to aid renal surgery in patients with fusion anomalies of the kidney. Materials and Methods: A total of seven cases were performed between May 2016 and October 2020. 3D reconstruction was rendered by Innersight Labs using pre-operative computed tomography (CT) scans. Results: Five patients had malignant disease and two patients had benign pathology. Robotic and open operations were performed in four and three patients, respectively. Conclusion: The use of 3D reconstruction in the cases reported in this series allowed for the identification of variations in renal vasculature, and this informed the choice of operative approach. Oxford Centre for Evidence-Based Medicine Evidence Level: 4 [ABSTRACT FROM AUTHOR]

Objective: Surgical planning for robotic-assisted partial nephrectomy is widely performed using two-dimensional computed tomography images. It is unclear to what extent two-dimensional images fully simulate surgical anatomy and case complexity. To overcome these limitations, software has been developed to reconstruct three-dimensional models from computed tomography data. We present the results of a feasibility study, to explore the role and practicality of virtual three-dimensional modelling (by Innersight Labs) in the context of surgical utility for preoperative and intraoperative use, as well as improving patient involvement. Methods: A prospective study was conducted on patients undergoing robotic-assisted partial nephrectomy at our high volume kidney cancer centre. Approval from a research ethics committee was obtained. Patient demographics and tumour characteristics were collected. Surgical outcome measures were recorded. The value of the three-dimensional model to the surgeon and patient was assessed using a survey. The prospective cohort was compared against a retrospective cohort and cases were individually matched using RENAL (radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior, location relative to polar lines) scores. Results: This study included 22 patients. Three-dimensional modelling was found to be safe for this prospective cohort and resulted in good surgical outcome measures. The mean (standard deviation) console time was 158.6 (35) min and warm ischaemia time was 17.3 (6.3) min. The median (interquartile range) estimated blood loss was 125 (50–237.5) ml. Two procedures were converted to radical nephrectomy due to the risk of positive margins during resection. The median (interquartile range) length of stay was 2 (2–3) days. No postoperative complications were noted and all patients had negative surgical margins. Patients reported improved understanding of their procedure using the three-dimensional model. Conclusion: This study shows the potential benefit of three-dimensional modelling technology with positive uptake from surgeons and patients. Benefits are improved perception of vascular anatomy and resection approach, and procedure understanding by patients. A randomised controlled trial is needed to evaluate the technology further. Level of evidence: 2b [ABSTRACT FROM AUTHOR]