Search

Introduction: How renal mass biopsy (RMB) impacts patient management with T1 renal masses (T1RM) is unclear. We explore the association between RMB and utilization of active surveillance (AS), nephron-sparing interventions (NSI), and radical nephrectomy (RN)., Methods: Data were analyzed retrospectively using the MUSIC-KIDNEY registry. Treatment received was analyzed using a fitted mixed-effects multinomial logistic-regression model., Results: Of 4062 patients, 19.6% underwent RMB. Factors associated with RMB included younger age, higher Charlson comorbidity score, tumor size > 2.0 cm and higher complexity tumors. AS was selected by 88%, 68%, and 27% of patients with benign, indeterminate, and malignant RMB findings. Non-malignant pathology at surgery was significantly ( P < .0001) more common without RMB (vs after RMB): 14.8% vs 7.2% of PN and 10.2% vs 1.7% of RN. Patients with T1bRM managed without or with RMB, AS was chosen by 22% vs 34%, NSI by 31% vs 35%, and RN by 47% vs 32% ( P = .0027). An interaction between tumor stage (T1a vs T1b) and RMB remained in multivariable analyses accounting for practice-level variation and other confounding variables. The risk-adjusted RN rate for T1bRM was 41.4% without RMB vs 27.8% with RMB; 7.4 RMB are needed to avoid one RN (number needed to treat) for benign or indolent disease., Conclusions: Treatments received by T1RM patients undergoing RMB are different than when RMB is omitted, based on RMB results and several confounders. T1RM patients benefit from reduction in intervention for non-malignant disease, particularly when RN is planned. For every 7 biopsies of T1bRM performed, one RN was avoided.

Introduction: Postoperative length of stay (LOS) after robot-assisted radical prostatectomy (RARP) is a potentially modifiable aspect of prostate cancer care. Our objective was to evaluate the use of same-day discharge (SDD) RARP and compare pre- and perioperative characteristics of these men with those who underwent hospitalization postoperatively., Methods: Perioperative outcomes for patients undergoing RARP were evaluated from the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry. Men were classified by hospital LOS: SDD, 1 day, and 2 days. Practice and surgeon-level variation of SDD and the change in SDD use over time were assessed. The primary outcome was 30-day readmission after RARP., Results: We identified 10,249 men undergoing RARP in MUSIC from 2018 to 2022. Most patients had 1-day LOS (79.6%), with 2.8% undergoing SDD. The proportion of patients undergoing RARPs with SDD rose from 0.6% in 2018 to 1.2% in 2019 and 4.4% for 2020 to 2022. At least one SDD was performed in 12 of 28 MUSIC practices (42.9%) and by 52 of 138 urologists (37.7%). In multivariable analysis, odds of 30-day readmission were not significantly different between patients .undergoing SDD and LOS 1 day (OR: 1.72, 95% CI: 0.92-3.22, P = .090). Limitations include retrospective, registry-based observational study with nonuniform utilization of SDD., Conclusions: Although more patients have undergone SDD after RARP beginning in 2018, rates across Michigan have remained < 5% annually. Importantly, patients undergoing SDD RARP did not experience significantly more readmissions compared to hospitalized patients. SDD appears safe and feasible for select patients who are motivated by this approach.

Objective: Life expectancy models are useful tools to support clinical decision-making. Prior models have not been used widely in clinical practice for patients with renal masses. We sought to develop and validate a model to predict life expectancy following the detection of a localized renal mass suspicious for renal cell carcinoma., Materials and Methods: Using retrospective data from 2 large centers, we identified patients diagnosed with clinically localized renal parenchymal masses from 1998 to 2018. After 2:1 random sampling into a derivation and validation cohort stratified by site, we used age, sex, log-transformed tumor size, simplified cardiovascular index and planned treatment to fit a Cox regression model to predict all-cause mortality from the time of diagnosis. The model's discrimination was evaluated using a C-statistic, and calibration was evaluated visually at 1, 5, and 10 years., Results: We identified 2,667 patients (1,386 at Corewell Health and 1,281 at Johns Hopkins) with renal masses. Of these, 420 (16%) died with a median follow-up of 5.2 years (interquartile range 2.2-8.3). Statistically significant predictors in the multivariable Cox regression model were age (hazard ratio [HR] 1.04; 95% confidence interval [CI] 1.03-1.05); male sex (HR 1.40; 95% CI 1.08-1.81); log-transformed tumor size (HR 1.71; 95% CI 1.30-2.24); cardiovascular index (HR 1.48; 95% CI 1.32-1.67), and planned treatment (HR: 0.10, 95% CI: 0.06-0.18 for kidney-sparing intervention and HR: 0.20, 95% CI: 0.11-0.35 for radical nephrectomy vs. no intervention). The model achieved a C-statistic of 0.74 in the derivation cohort and 0.73 in the validation cohort. The model was well-calibrated at 1, 5, and 10 years of follow-up., Conclusions: For patients with localized renal masses, accurate determination of life expectancy is essential for decision-making regarding intervention vs. active surveillance as a primary treatment modality. We have made available a simple tool for this purpose., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: KS's institution receives grant funding from the National Institute of Diabetes and Digestive and Kidney Diseases, Blue Cross Blue Shield of Michigan, and Teva Pharmaceuticals for unrelated work. KS previously served on a scientific advisory board for Flatiron Health. All other authors have no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Understanding the relationship between comorbidities and life expectancy is important in cancer patients who carry risks of cancer and noncancer-related mortality. Comorbidity indices (CI) are tools to provide an objective measure of competing risks of death. We sought to determine which CI might be best incorporated into clinical practice for patients with suspected renal cancer., Materials and Methods: 1572 patients diagnosed with renal masses (stage I-IV) between 1998 and 2016 were analyzed for this study. Patient data were gathered from a community-based health center. Comorbidities were evaluated individually, and with 1 of 4 CI: Charlson (CCI), updated CCI (uCCI), age-adjusted CCI (aCCI), and simplified cardiovascular index (CVI). Cox-proportional hazard analysis of all-cause mortality was performed using the four CI, adjusting for the 4 CI, adjusting for age, gender, race, tumor size, and tumor stage., Results: Univariable analyses revealed the four CI were significant predictors of mortality (P < 0.05), as were age, gender, tumor size, and stage. Comorbid conditions at diagnosis included hypertension (47.8%), diabetes mellitus (47.2%), coronary artery disease (41.1%), chronic kidney disease (31.8%), peripheral vascular disease (8.0%), congestive heart failure (5.7%), chronic obstructive pulmonary disease (5.7%), and cerebrovascular disease (2.0%). When analyzing the 4 CI in multivariable survival analyses accounting for factors available at diagnosis, and analyses incorporating pathologic and recurrence data, only CVI score and uCCI remained statistically significant (P < 0.05). Limitations of this work are the retrospective nature of data collection and data from a single institution, limiting the generalizability., Conclusion: Increasing comorbidity, age, tumor size, and cM stage are predictors of ACM for suspected renal cancer patients. CVI appears to provide comparable information to various iterations of CCI (uCCI, aCCI) while being the simplest to use. Utilization of CVI may assist clinicians and patients when considering between interventional and noninterventional approaches for suspected renal cancer., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To create and validate 2 models called RENSAFE (RENalSAFEty) to predict postoperative acute kidney injury (AKI) and development of chronic kidney disease (CKD) stage 3b in patients undergoing partial (PN) or radical nephrectomy (RN) for kidney cancer., Methods: Primary objective was to develop a predictive model for AKI (reduction >25% of preoperative eGFR) and de novo CKD≥3b (<45 ml/min/1.73m 2 ), through stepwise logistic regression. Secondary outcomes include elucidation of the relationship between AKI and de novo CKD≥3a (<60 ml/min/1.73m 2 ). Accuracy was tested with receiver operator characteristic area under the curve (AUC)., Results: AKI occurred in 452/1,517 patients (29.8%) and CKD≥3b in 116/903 patients (12.8%). Logistic regression demonstrated male sex (OR = 1.3, P = 0.02), ASA score (OR = 1.3, P < 0.01), hypertension (OR = 1.6, P < 0.001), R.E.N.A.L. score (OR = 1.2, P < 0.001), preoperative eGFR<60 (OR = 1.8, P = 0.009), and RN (OR = 10.4, P < 0.0001) as predictors for AKI. Age (OR 1.0, P < 0.001), diabetes mellitus (OR 2.5, P < 0.001), preoperative eGFR <60 (OR 3.6, P < 0.001) and RN (OR 2.2, P < 0.01) were predictors for CKD≥3b. AUC for RENSAFE AKI was 0.80 and 0.76 for CKD≥3b. AKI was predictive for CKD≥3a (OR = 2.2, P < 0.001), but not CKD≥3b (P = 0.1). Using 21% threshold probability for AKI achieved sensitivity: 80.3%, specificity: 61.7% and negative predictive value (NPV): 88.1%. Using 8% cutoff for CKD≥3b achieved sensitivity: 75%, specificity: 65.7%, and NPV: 96%., Conclusion: RENSAFE models utilizing perioperative variables that can predict AKI and CKD may help guide shared decision making. Impact of postsurgical AKI was limited to less severe CKD (eGFR<60 ml/min 71.73m 2 ). Confirmatory studies are requisite., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Inc.)

Purpose: We sought to determine whether clinical risk factors and morphometric features on preoperative imaging can be utilized to identify those patients with cT1 tumors who are at higher risk of upstaging (pT3a)., Materials and Methods: We performed a retrospective international case-control study of consecutive patients treated surgically with radical or partial nephrectomy for nonmetastatic renal cell carcinoma (cT1 N0) conducted between January 2010 and December 2018. Multivariable logistic regression models were used to study associations of preoperative risk factors on pT3a pathological upstaging among all patients, as well as subsets with those with preoperative tumors ≤4 cm, renal nephrometry scores, tumors ≤4 cm with nephrometry scores, and clear cell histology. We also examined association with pT3a subsets (renal vein, sinus fat, perinephric fat)., Results: Among the 4,092 partial nephrectomy and 2,056 radical nephrectomy patients, pathological upstaging occurred in 4.9% and 23.3%, respectively. Among each group independent factors associated with pT3a upstaging were increasing preoperative tumor size, increasing age, and the presence of diabetes. Specifically, among partial nephrectomy subjects diabetes (OR=1.65; 95% CI 1.17, 2.29), male sex (OR=1.62; 95% CI 1.14, 2.33), and increasing BMI (OR=1.03; 95% CI 1.00, 1.05 per 1 unit BMI) were statistically associated with upstaging. Subset analyses identified hilar tumors as more likely to be upstaged (partial nephrectomy OR=1.91; 95% CI 1.12, 3.16; radical nephrectomy OR=2.16; 95% CI 1.44, 3.25)., Conclusions: Diabetes and higher BMI were associated with pathological upstaging, as were preoperative tumor size, increased age, and male sex. Similarly, hilar tumors were frequently upstaged.

Background: Paraneoplastic syndromes (PNS) are defined as the signs and symptoms attributed to cytokines or hormones released from a tumor or a patient's immune system. PNS have been reported with many cancers for decades and data supporting their relevance in renal cell carcinoma (RCC) are largely historical. The widespread use of electronic medical record (EMR) systems provides a more robust method to capture data. The objective of this study was to establish contemporary data regarding the incidence and relevance of PNS in patients undergoing nephrectomy for suspected RCC., Methods: In this retrospective single-institution study, 851 patients undergoing nephrectomy for suspected RCC between 2011 and 2018 were assessed for the presence or absence of PNS as defined by laboratory abnormalities. Factors associated with PNS and with all-cause mortality were examined., Results: The incidence of PNS was 33.1% among 851 patients prior to nephrectomy. The most prevalent PNS were anemia (22.4%), thrombocytosis (7.5%), and elevated C-reactive protein (CRP) (7.4%). PNS were more common in women (39.2% vs. 29.4%, p = 0.0032) and higher stage RCC (31.1% of stage I vs. 54.2% of stage IV, p = 0.0036). Factors associated with the presence of PNS in multivariable analysis included female gender, high comorbidity, and stage IV RCC. Prenephrectomy PNS were associated with poorer survival in multivariable analysis (HR: 2.12, p = 0.0002). Resolution of PNS occurred in 52.1% of patients after nephrectomy, including 55.2% with stage I to III and 38.5% with stage IV RCC (p = 0.10)., Conclusions: Using EMR data, laboratory evidence of PNS was present in one-third of a contemporary cohort of patients undergoing nephrectomy, with >50% of PNS resolving after surgery. Consistent with prior reports, PNS are more common in higher-stage RCC and are associated with poorer survival in RCC patients., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest., (Copyright © 2023. Published by Elsevier Inc.)

Introduction: Multidisciplinary tumor board meetings are useful sources of insight and collaboration when establishing treatment approaches for oncologic cases. However, such meetings can be time intensive and inconvenient. We implemented a virtual tumor board within the Michigan Urological Surgery Improvement Collaborative to discuss and improve the management of complicated renal masses., Methods: Urologists were invited to discuss decision-making for renal masses through voluntary engagement. Communication was performed exclusively through email. Case details were collected and responses were tabulated. All participants were surveyed about their perceptions of the virtual tumor board., Results: Fifty renal mass cases were reviewed in a virtual tumor board that included 53 urologists. Patients ranged from 20-90 years old and 94% had localized renal mass. The cases generated 355 messages, ranging from 2-16 (median 7) per case; 144 responses (40.6%) were sent via smartphone. All urologists (100%) who submitted to the virtual tumor board had their questions answered. The virtual tumor board provided suggestions to those with no stated treatment plan in 42% of cases, confirmed the physician's initial approach to their case in 36%, and offered alternative approaches in 16% of cases. Eighty-three percent of survey respondents felt the experience was "Beneficial" or "Very Beneficial," and 93% stated increased confidence in their case management., Conclusions: Michigan Urological Surgery Improvement Collaborative's initial experience with a virtual tumor board showed good engagement. The format reduced barriers to multi-institutional and multi-disciplinary discussions and improved the quality of care for selected patients with complex renal masses.

Purpose: Renal masses can be characterized as "indeterminate" due to lack of differentiating imaging characteristics. Optimal management of indeterminate renal lesions remains nebulous and poorly defined. We assess management of indeterminate renal lesions within the MUSIC-KIDNEY (Michigan Urological Surgery Improvement Collaborative-Kidney mass: Identifying and Defining Necessary Evaluation and therapY) collaborative., Materials and Methods: Each renal mass is classified as suspicious, benign, or indeterminate based on radiologist and urologist assessment. Objectives were to assess initial management of indeterminate renal lesions and the impact of additional imaging and biopsy on characterization prior to treatment., Results: Of 2,109 patients, 444 (21.1%) had indeterminate renal lesions on their initial imaging, which included CT without contrast (36.2%), CT with contrast (54.1%), and MRI (9.7%). Eighty-nine patients (20.0%) underwent additional imaging within 90 days, 8.3% (37/444) underwent renal mass biopsy, and 3.6% (16/444) had reimaging and renal mass biopsy. Additional imaging reclassified 58.1% (61/105) of indeterminate renal lesions as suspicious and 21.0% (22/105) as benign, with only 20.9% (22/105) remaining indeterminate. Renal mass biopsy yielded a definitive diagnosis for 87%. Treatment was performed for 149 indeterminate renal lesions (33.6%), including 117 without reimaging and 123 without renal mass biopsy. At surgery for indeterminate renal lesions, benign pathology was more common in patients who did not have repeat imaging (9.9%) than in those who did (6.7%); for ≤4 cm indeterminate renal lesions, these rates were 11.8% and 4.3%., Conclusions: About 33% of patients diagnosed with an indeterminate renal lesion underwent immediate treatment without subsequent imaging or renal mass biopsy, with a 10% rate of nonmalignant pathology. This highlights a quality improvement opportunity for patients with cT1 renal masses: confirmation that the lesion is suspicious for renal cell carcinoma based on high-quality, multiphase, cross-sectional imaging and/or histopathological features prior to surgery, even if obtaining subsequent follow-up imaging and/or renal mass biopsy is necessary. When performed, these steps lead to reclassification in 79% and 87% of indeterminate renal lesions, respectively.

Objective: To investigate renal functional outcomes of surveillance, embolization, and surgery for angiomyolipomas (AML)., Methods: Longitudinal data regarding patients with AML were analyzed retrospectively in this 2-center study. Demographic, radiographic, and functional data were tabulated according to treatment type. Primary outcome was change in renal function from diagnosis to within 6 months postdiagnosis (interim) and to latest glomerular filtration rate (GFR) assessment., Results: 318 patients were diagnosed with AMLs; mean follow-up was 6.2 years. 184 patients (57.9%) were managed with surveillance, 30 (9.4%) underwent embolization, and 103 (32.4%) underwent surgery (91 partial nephrectomy; 12 radical nephrectomy). Baseline characteristics, including tumor size, age, and race differed between the 3 groups (P<.05). Surveilled AMLs were smaller (P<.001) than the intervention groups: 1.9 cm vs 5.4 cm (embolization) and 4.9 cm (surgery). Greater interim decreases in GFR were observed following intervention with embolization (-14.0%) or surgery (-11.8%), when compared with surveillance (-4.1%); however, this was not statistically significant (P=.19). Latest GFR was also reduced more (P=.02) with embolization (-14.1%) and surgery (-14.7%) when compared to surveillance (-6.0%). At latest determination, chronic kidney disease progression by at least one stage occurred in 37.8% overall, including 33.7% of surveilled patients, and was not statistically different across the three cohorts (P=.074)., Conclusion: Within the study limitations, surveillance appears to be appropriate for most AML patients; embolization and surgical intervention should be reserved for selected patients with large and/or symptomatic AML. Renal functional deterioration is common in patients with AML, whether managed with surveillance, embolization, or surgery. Long-term monitoring of renal function should be obligatory for all AML patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To examine practice-level variation in the management of magnetic resonance imaging (MRI) Prostate Imaging-Reporting and Data System (PI-RADS) 3 lesions in men with favorable-risk prostate cancer (FRPC) considering or on active surveillance (AS)., Patients and Methods: We reviewed the Michigan Urological Surgery Improvement Collaborative registry for FRPC men (GG1 and low-volume GG2) undergoing MRI from January 2013 to March 2020. The primary outcome was to assess practice-level variation in time from MRI to biopsy and MRI to treatment for PI-RADS 3 lesions. Both MRIs obtained after the diagnostic biopsy and while on AS were included. The Kaplan-Meier method was used to estimate biopsy-free survival for time from MRI to surveillance biopsy and multivariable Cox proportional hazards models identified clinical and demographic factors associated with time obtaining a biopsy after finding PI-RADS 3 lesions., Results: We identified 3172 FRPC men with a MRI, of whom 473 had a PI-RADS 3. There was significant practice-level variation in biopsy rates among patients with PI-RADS 3 MRI results (log-rank test, P <.001), with biopsy-free probability at 6 months ranging from 28% to 69% (median: 59%). We were unable to identify factors with significant associations with time to biopsy. Conversely, there was less variation in time from PI-RADS 3 to treatment (log-rank test, P = .2), while several clinical factors had statistically-significant associations: age (P = .018), Prostate Specific Antigen-Density 0.1-0.2 (P = .035), ISUP-GG 2 (P = .002), and number of positive cores (P <.001), as expected., Conclusion: Urology practice, rather than GG or extent of biopsy positivity, is the largest factor affecting the decision for biopsy of PI-RADS 3 lesions in FRPC men considering or on AS. Future work to assist with decision-making and reduce variability is needed., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: To compare patient-reported side effects and tolerability of full-dose Bacillus Calmette-Guérin (BCG), reduced-dose BCG, and gemcitabine one week after administration., Methods: All patients from July 2019 to November 2020 receiving intravesical therapy (IVT) for non-muscle invasive bladder cancer (NMIBC) at our institution were surveyed before repeat instillation. Survey questions recorded IVT retention times and the duration and severity of the following side effects: bladder symptoms, fatigue, body aches, hematuria, fever, chills, and other. All responses were collected and quantified in a de-identified, password-protected database. Statistical analysis was performed using SAS JMP 13., Results: Of 592 surveys completed, symptoms of any kind were reported on 463 surveys (78%) with the most common symptoms including bladder symptoms (59%), fatigue (52%), body aches (26%), and hematuria (18%). Patients were able to hold full-dose BCG, reduced-dose BCG, and gemcitabine for the protocol-specified duration 87%, 95%, and 71% of the time (P <0.05). The prevalence, severity, and duration of body aches were highest with gemcitabine (P <0.05) while the prevalence and duration of hematuria were higher with BCG (P <0.05). Reduced-dose BCG had the lowest prevalence, severity, and duration of fatigue (P <0.05)., Conclusion: Significant differences in the side effects and tolerability of full-dose BCG, reduced-dose BCG, and gemcitabine were demonstrated using this novel survey, and these differences are of value for informing IVT selection. Evaluation of IVTs other than gemcitabine and BCG will further inform selection of therapies for NMIBC., Competing Interests: Competing interests The authors have no conflicts of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: While surgical excision remains the principal management strategy for clinical T1 renal masses (cT1RMs), the rates of noninterventional approaches are not well known. Most single-institution and population-based series suggest rates below 10%., Objective: To evaluate the use of observation for newly diagnosed cT1RM patients in academic and community-based practices across a statewide collaborative., Design Setting and Participants: The Michigan Urological Surgery Improvement Collaborative-Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) commenced data collection in September 2017 by recording clinical, radiographic, pathologic, and short-term follow-up data for cT1RM patients at 13 diverse practices. Patients with complete data were assessed at >90 d after initial evaluation as to whether observation or treatment was performed., Outcome Measurements and Statistical Analysis: Relationships with outcomes were analyzed using multivariable logistic regression, chi-square test, and Wilcoxon rank-sum test., Results and Limitations: Out of 965 patients, observation was employed in 48% ( n  = 459), with practice-level rates ranging from 0% to 68%. Patients managed with observation (vs treatment) were significantly older (71.2 vs 62.8 yr, p  <  0.0001) and had smaller tumors (2.3 vs 3.4 cm, p  <  0.0001). Observation was used for 53.5% of cT1a renal masses, for 29.9% of cT1b renal masses, and for 42.5%, 53.7%, and 63.9% of radiographically solid, Bosniak III-IV cystic, and indeterminate cT1RMs, respectively. Factors significantly associated with observation in multivariable analysis included lesion type (Bosniak III-IV vs solid, p  =  0.017), tumor stage (cT1a vs cT1b, p  <  0.001), and higher age ( p  <  0.001). A short duration of follow-up limits the assessment of longer-term patient management., Conclusions: Noninterventional management of cT1RMs is common across the MUSIC-KIDNEY collaborative, with wide variability across practices. Factors associated with observation were advanced age, smaller tumor size, and cystic tumor type. Durability of the initial decision for observation (delayed intervention vs active surveillance vs less active surveillance) will be a focus of subsequent study., Patient Summary: The Michigan Urological Surgery Improvement Collaborative: Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) quality improvement collaborative assessed the current utilization of initial observation of a renal mass ≤7 cm across a diverse group of urology practices and found it to be used in 48% of patients. We found that the factors predicting observation were advanced age, smaller tumor size, and cystic tumor type., (© 2020 The Authors.)

Purpose: Nonmalignant pathology has been reported in 15% to 20% of surgeries for cT1 renal masses. We seek to identify opportunities for improvement in avoiding surgery for nonmalignant pathology., Materials and Methods: MUSIC-KIDNEY started collecting data in 2017. All patients with cT1 renal masses who had partial or radical nephrectomy for nonmalignant pathology were identified. Category for improvement (none-0, minor-1, moderate-2 or major-3) was independently assigned to each case by 5 experienced kidney surgeons. Specific strategies to decrease nonmalignant pathology were identified., Results: Of 1,392 patients with cT1 renal masses 653 underwent surgery and 74 had nonmalignant pathology (11%). Of these, 23 (31%) cases were cT1b. Radical nephrectomy was performed in 17 (22.9%) patients for 5 cT1a and 12 cT1b lesions. Only 6 patients had a biopsy prior to surgery (5 oncocytoma, 1 unclassified renal cell carcinoma). Review identified 25 cases with minor (34%), 26 with moderate (35%) and 10 with major (14%) quality improvement opportunities. Overall 17% of cases had no quality improvement opportunities identified (12 partial nephrectomy, 1 radical nephrectomy)., Conclusions: Review of patients with cT1 renal masses who underwent surgery for nonmalignant pathology revealed a significant number of cases in which this outcome may have been avoided. Approximately half of cases had moderate or major quality improvement opportunities, with radical nephrectomy for nonmalignant pathology being the most common reason. Our data indicate a lowest achievable and acceptable rate of nonmalignant pathology to be 1.9% and 5.4%, respectively. Avoiding interventions for nonmalignant pathology, particularly radical nephrectomy, is an important focus of quality improvement efforts. Strategies to decrease unnecessary interventions for nonmalignant pathology include greater use of repeat imaging, renal mass biopsy and surveillance.

Background: Partial nephrectomy (PN) is the gold standard for the treatment of small renal masses. Urinary biomarkers (UBMs) may serve as early indicators of acute kidney injury (AKI) following PN., Objective: To evaluate the timing, specificity, and sensitivity of several candidate UBMs after PN to determine the most promising UBMs in this setting. We hypothesize that some UBMs will have utility as early markers of AKI., Design, Setting, and Participants: Twenty-two patients undergoing on-clamp robotic or open PN underwent paired urine collection via ureteral catheterization of the affected kidney and Foley catheterization for the unaffected kidney obtained preoperatively, after anesthesia, and at several points in time after renovascular occlusion., Outcome Measurements and Statistical Analysis: Measured UBMs included albumin, α-glutathione S-transferase, B2M, calbindin, clusterin, cystatin C, epidermal growth hormone, kidney injury molecule 1, neutrophil gelatinase-associated lipocalin, osteoactivin, osteopontin, total protein, trefoil factor 3, uromodulin, and vascular endothelial growth factor., Results and Limitations: The largest fold changes in UBM levels were observed between the baseline values and just prior to vascular occlusion (time "0"). Albumin, clusterin, and calbindin were among the most consistently and significantly increased UBMs. After vascular occlusion and subsequent reperfusion, some UBMs, most notably albumin, calbindin, and total protein, continued to increase in the affected kidney, peaking at 60-90min, followed by decrease to time "0" measurements after 1 d and to baseline levels 14-42 d after surgery. No striking association of UBMs with parameters such as duration of surgery, ischemia time, and tumor complexity was observed., Conclusions: The most significant UBM increases were observed when comparing samples obtained at preoperative visit and after anesthesia, but before clamp time. Albumin, clusterin, and calbindin were the most consistently and significantly altered UBMs; further investigation will be necessary to determine whether UBMs can identify AKI earlier in nephrectomy patients., Patient Summary: Factors (biomarkers) measured in the blood or urine can indicate the presence and amount of kidney injury. We evaluated 15 different biomarkers at several points in time prior to, during, and after surgery for kidney cancer. We found that three of these biomarkers were most consistently elevated in patients undergoing partial nephrectomy. Interestingly, the largest increases were observed when comparing samples obtained prior to surgery with those obtained just after anesthesia., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: Chronic kidney disease (CKD) is classified according to cause, glomerular filtration rate, and proteinuria. Identification of proteinuria with urinalysis (UA) is less accurate than quantification via other methods. We investigated factors leading to discordant UA findings when compared against paired albumin-to-creatinine ratio (ACR) testing., Methods: Four thousand three hundred and twenty-three UAs were grouped by proteinuria level (A1-A3); concordance with ACR was examined. Classification of UA with confounding factors (UA+CF) or without (UA-CF) was based on CF that resulted in >10% increase in false-positive proteinuria readings. The presence of ≥3+ blood, ≥3+ leukocyte esterase, any ketonuria, specific gravity ≥1.020, ≥1+ urobilinogen, ≥2+ bilirubin, ≥2+ bacteria, ≥3 RBC/hpf (high powered field), ≥10 WBC/hpf, and/or ≥6 epithelial cells/hpf led to UA+CF classification., Results: Proteinuria was determined to be present in 14.1% by UA dipstick and 24.9% by ACR. Using ACR as the standard, overall concordance was 80.4%, with 17.2% false-negatives and 2.3% false-positives by UA. UA+CF represented 55.6% of UA overall (n = 2404), and 98.0% of those false-positive for proteinuria. High specific gravity and hematuria are the strongest predictors of false positives. For A2 proteinuria (30-300 mg/g, 1+,2+,3+ on UA) UA-CF had a higher negative predictive value (NPV) (99.8%) than UA+CF (77.6%); NPV for A3 proteinuria (>300 mg/g, 4+ on UA) was 100% for UA-CF and UA+CF., Conclusion: Additional abnormalities were noted in >50% of outpatient UAs indicating proteinuria. Given the significant proportion of patients having a false-positive UA for proteinuria when these CFs were present, we recommend that such patients undergo ACR confirmatory testing, according to a clinical algorithm for the incorporation of UA results into the management of CKD., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: We describe the establishment of the Michigan Urological Surgery Improvement Collaborative-Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) to improve the quality of care that patients in Michigan receive for localized, 7 cm or smaller (T1) renal masses., Methods: The MUSIC-KIDNEY collaborative is comprised of 45 urologists from 8 group practices. From June 2017 to November 2018 surgeons collected data for 821 patients with newly diagnosed T1 renal masses. Goals are to reduce the overall burden of treatment for T1 renal masses specifically by avoiding treatment when a noninterventional approach is appropriate, reducing the treatment of benign renal masses, preventing radical nephrectomy when a kidney sparing approach is appropriate, and decreasing length of hospitalization and readmission rates., Results: Median age at diagnosis was 66 years, 56.8% of patients were male and 83.8% were Caucasian. The patient populations differed across practice sites for age (p <0.001), tumor size (p=0.002), race (p <0.001), Charlson comorbidity index and insurance type (p <0.001). Tumor complexity was infrequently reported (35.1%). Initial management included surveillance/repeat imaging (45.1%), biopsy (15.4%), intervention (39.1%) and second opinion (0.6%). No treatment at initial presentation (0% to 74.5%) and nephron sparing treatment (0% to 100%) varied significantly among practices (p <0.001). Of 133 patients with T1 renal masses who underwent radical nephrectomy (39.8%) 53 had tumors smaller than 4 cm and/or surgical findings without malignancy. Readmission or emergency department visit within 30 days after renal surgery occurred in 7.6%., Conclusions: Initial findings of MUSIC-KIDNEY indicate practice level variation and several quality improvement opportunities. Focusing on these goals may optimize practice patterns and surgical outcomes across Michigan.

Objectives: Prostate cancer (CaP) staging traditionally includes computed tomography (CT) and technetium-99m bone scintigraphy (BS) for assessment of lymph node (LN) and bone metastases, respectively. In recent years, multiparametric magnetic resonance imaging (mpMRI) has been used in diagnostic assessment of CaP. We sought to compare the accuracy of mpMRI to CT and BS for pretreatment staging., Materials and Methods: Using the Michigan Urological Surgery Improvement Collaborative registry, we identified men undergoing pretreatment mpMRI in addition to CT and/or BS in 2012 to 2018. Imaging reports were classified as positive, negative, or equivocal for detection of LN and bone metastases. A best value comparator (BVC) was used to adjudicate metastatic status in the absence of pathologic data. mpMRI accuracy was calculated using pessimistic (equivocal=positive) and optimistic (equivocal = negative) interpretations. We compared the diagnostic performance of mpMRI, CT, and BS in detecting metastases., Results: In total, 364 men underwent CT and mpMRI, and 646 underwent BS and mpMRI. Based on the BVC, 52 men (14%) harbored LN metastases and 38 (5.9%) harbored bone metastases. Sensitivity of mpMRI for LN metastases was significantly higher than CT (65-73% vs 38%, P < 0.005), and specificity of mpMRI and CT were 97% to 99% and 99% (P = 0.2-0.4), respectively. For bone metastases, BS sensitivity was 68% as compared to 42% to 71% (P = 0.02-0.83) for mpMRI. Specificity for bone metastases was 95% to 99% across all modalities., Conclusions: Using statewide data, mpMRI appears superior to CT and comparable to BS for detection of LN and bone metastases, respectively. Pretreatment mpMRI may obviate the need for additional staging imaging., (Copyright © 2020. Published by Elsevier Inc.)

Renal cell carcinoma (RCC) has an undisputed genetic component and a stable 2:1 male to female sex ratio in its incidence across populations, suggesting possible sexual dimorphism in its genetic susceptibility. We conducted the first sex-specific genome-wide association analysis of RCC for men (3227 cases, 4916 controls) and women (1992 cases, 3095 controls) of European ancestry from two RCC genome-wide scans and replicated the top findings using an additional series of men (2261 cases, 5852 controls) and women (1399 cases, 1575 controls) from two independent cohorts of European origin. Our study confirmed sex-specific associations for two known RCC risk loci at 14q24.2 (DPF3) and 2p21(EPAS1). We also identified two additional suggestive male-specific loci at 6q24.3 (SAMD5, male odds ratio (OR male ) = 0.83 [95% CI = 0.78-0.89], P male  = 1.71 × 10 -8 compared with female odds ratio (OR female ) = 0.98 [95% CI = 0.90-1.07], P female  = 0.68) and 12q23.3 (intergenic, OR male  = 0.75 [95% CI = 0.68-0.83], P male  = 1.59 × 10 -8 compared with OR female  = 0.93 [95% CI = 0.82-1.06], P female  = 0.21) that attained genome-wide significance in the joint meta-analysis. Herein, we provide evidence of sex-specific associations in RCC genetic susceptibility and advocate the necessity of larger genetic and genomic studies to unravel the endogenous causes of sex bias in sexually dimorphic traits and diseases like RCC.

Background: Chronic kidney disease (CKD) staging is improved by adding proteinuria to glomerular filtration rate (GFR). While proteinuria independently predicts CKD progression and mortality, the clinical setting of proteinuria determination has not been well-studied previously. The objective of our study is to determine whether clinical setting differentially impacts survival outcomes., Methods: Kaplan-Meier and Cox proportional hazards analyses of overall survival were performed retrospectively for cohorts of outpatients (n = 22,918), emergency patients (n = 16,861), and inpatients (n = 12,304) subjected to urinalysis (UA) at a single health system in 2010. GFR (G1-G5) and proteinuria (A1:<30 mg, A2:30-300 mg, A3:>300 mg) were classified under Kidney Disease: Improving Global Outcomes (KDIGO) guidelines., Results: GFR and proteinuria levels varied more in inpatients than in emergency and outpatients. For each clinical population, survival significantly decreased with increasing proteinuria (A1>A2>A3, p < 0.05 for each comparison). The effect of proteinuria on survival differed by clinical setting, with statistical differences in all categories other than A3 in outpatients and emergency patients (p = 0.98). The strongest predictors of mortality were cancer diagnosis (HR: 3.07, p < 0.0001) and very-high KDIGO classification (HR: 2.01, p < 0.0001). Limitations include the retrospective observational study design and single health system analysis., Conclusions: The value of UA to screen for proteinuria in each clinical setting is evident, but the impact of A2 and A3 level proteinuria on survival varies depending on the clinical scenario in which the determination was made. The clinical setting of proteinuria measurement should be factored into both patient care and clinical research activities.

Objective: To evaluate the accuracy of radius, exophytic/endophytic, nearness to collecting system/sinus, anterior/posterior, and location relative to polar lines (RENAL), preoperative aspects and dimensions used for anatomical classification (PADUA), contact surface area (CSA), and preoperative assessment of volume preservation (PAVP) nephrometry scores in predicting postoperative renal functional outcomes after partial nephrectomy (PN). Few studies have compared the accuracy of tumor complexity systems directly in the same set of PN patients., Materials and Methods: Patients treated with robotic, laparoscopic, or open PN having available imaging (n = 344) were examined. The ability of 4 systems to predict nadir estimated glomerular filtration rate (eGFR [median postoperative day 1]) and new baseline eGFR (median: 0.95 year) was analyzed using univariable and multivariable models., Results: Median preoperative, nadir, and new baseline eGFR were 79 (interquartile range [IQR]: 63-97), 65 (IQR: 47-85), and 80 (IQR: 63-99) mL/min/1.73 m 2 . Multivariable models incorporating RENAL, PADUA, CSA, or PAVP were similarly predictive of postoperative renal function (nadir eGFR: R 2  = 0.683-0.688, new baseline eGFR: R 2  = 0.775). In univariable analysis, all 4 complexity systems were predictors of nadir GFR (each P < .05), with RENAL (P = .045), CSA (P = .027), and PAVP (P = .012) also significantly predicting nadir eGFR in multivariable models. No complexity system was significantly associated with new baseline eGFR in multivariable analysis, with only RENAL (P = .023) and PAVP (P = .049) having a statistically significant association in univariable analysis., Conclusion: RENAL, PADUA, CSA, and PAVP are all predictors of early postoperative renal function. RENAL and PAVP provided the greatest predictive ability for later renal functional outcomes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Several obesity-related factors have been associated with renal cell carcinoma (RCC), but it is unclear which individual factors directly influence risk. We addressed this question using genetic markers as proxies for putative risk factors and evaluated their relation to RCC risk in a mendelian randomization (MR) framework. This methodology limits bias due to confounding and is not affected by reverse causation., Methods and Findings: Genetic markers associated with obesity measures, blood pressure, lipids, type 2 diabetes, insulin, and glucose were initially identified as instrumental variables, and their association with RCC risk was subsequently evaluated in a genome-wide association study (GWAS) of 10,784 RCC patients and 20,406 control participants in a 2-sample MR framework. The effect on RCC risk was estimated by calculating odds ratios (ORSD) for a standard deviation (SD) increment in each risk factor. The MR analysis indicated that higher body mass index increases the risk of RCC (ORSD: 1.56, 95% confidence interval [CI] 1.44-1.70), with comparable results for waist-to-hip ratio (ORSD: 1.63, 95% CI 1.40-1.90) and body fat percentage (ORSD: 1.66, 95% CI 1.44-1.90). This analysis further indicated that higher fasting insulin (ORSD: 1.82, 95% CI 1.30-2.55) and diastolic blood pressure (DBP; ORSD: 1.28, 95% CI 1.11-1.47), but not systolic blood pressure (ORSD: 0.98, 95% CI 0.84-1.14), increase the risk for RCC. No association with RCC risk was seen for lipids, overall type 2 diabetes, or fasting glucose., Conclusions: This study provides novel evidence for an etiological role of insulin in RCC, as well as confirmatory evidence that obesity and DBP influence RCC risk., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: TE declared employment, research support, and stock in AstraZeneca and research support from Bayer and Pfizer. PCH is a population health fellow of Cancer Research UK. GDS is a member of the Editorial Board of PLOS Medicine.

Rationale and Objectives: Prostate volume (PV) determination provides important clinical information. We compared PVs determined by digital rectal examination (DRE), transrectal ultrasound (TRUS), magnetic resonance imaging (MRI) with or without three-dimensional (3D) segmentation software, and surgical prostatectomy weight (SPW) and volume (SPV)., Materials and Methods: This retrospective review from 2010 to 2016 included patients who underwent radical prostatectomy ≤1 year after multiparametric prostate MRI. PVs from DRE and TRUS were obtained from urology clinic notes. MRI-based PVs were calculated using bullet and ellipsoid formulas, automated 3D segmentation software (MRI-A3D), manual segmentation by a radiologist (MRI-R3D), and a third-year medical student (MRI-S3D). SPW and SPV were derived from pathology reports. Intraclass correlation coefficients compared the relative accuracy of each volume measurement., Results: Ninety-nine patients were analyzed. Median PVs were DRE 35 mL, TRUS 35 mL, MRI-bullet 49 mL, MRI-ellipsoid 39 mL, MRI-A3D 37 mL, MRI-R3D 36 mL, MRI-S3D 36 mL, SPW 54 mL, SPV-bullet 47 mL, and SPV-ellipsoid 37 mL. SPW and bullet formulas had consistently large PV, and formula-based PV had a wider spread than PV based on segmentation. Compared to MRI-R3D, the intraclass correlation coefficient was 0.91 for MRI-S3D, 0.90 for MRI-ellipsoid, 0.73 for SPV-ellipsoid, 0.72 for MRI-bullet, 0.71 for TRUS, 0.70 for SPW, 0.66 for SPV-bullet, 0.38 for MRI-A3D, and 0.33 for DRE., Conclusions: With MRI-R3D measurement as the reference, the most reliable methods for PV estimation were MRI-S3D and MRI-ellipsoid formula. Automated segmentations must be individually assessed for accuracy, as they are not always truly representative of the prostate anatomy. Manual segmentation of the prostate does not require expert training., (Copyright © 2018 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the integration of 3T nonendorectal coil multiparametric prostate magnetic resonance imaging (mpMRI) at 2 high-volume practices that routinely use mpMRI in the setting of active surveillance., Materials and Methods: This was an institutional review board-approved, Health Insurance Portability and Accountability Act-compliant, and dual-institution retrospective cohort study. Subjects undergoing 3T mpMRI without endorectal coil at either study institution over a 13-month period (August 1, 2015-August 31, 2016) were selected based on predefined criteria: clinical T1/T2 Gleason 6 prostate cancer, prostate-specific antigen <15 ng/mL, ≥40 years old, mpMRI within 2 years of prostate biopsy, and Prostate Imaging Reporting and Data System (PI-RADS) v2 score assigned. Subjects surveilled for Gleason ≥3 + 4 prostate cancer were excluded. The primary outcome was detection of Gleason ≥3 + 4 prostate cancer on magnetic resonance-ultrasound fusion biopsy, standard biopsy, or prostatectomy within 6 months following mpMRI. Positive predictive values (PPVs) were calculated., Results: A total of 286 subjects (N = 193 from institution 1, N = 93 from institution 2) met the criteria. Most (87% [90 of 104]) with maximum PI-RADS v2 scores of 1-2 did not receive immediate biopsy or treatment and remained on active surveillance. Incidence and PPVs for PI-RADS v2 scores of ≥3 were the following: PI-RADS 3 (n = 57 [20%], PPV 21% [6 of 29]), PI-RADS 4 (n = 96 [34%], PPV 51% [39 of 77]), and PI-RADS 5 (n = 29 [13%], PPV 71% [20 of 28]). No Gleason ≥4 + 3 prostate cancer was identified for PI-RADS v2 scores of 1-3 (0 of 43 with histology). Following mpMRI and subsequent biopsy, 21% (61 of 286) of subjects were removed from active surveillance and underwent definitive therapy., Conclusion: The 3T nonendorectal coil mpMRI has been integrated into the care of patients on active surveillance and effectively stratifies risk of Gleason ≥3 + 4 prostate cancer in this population., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Magnetic resonance imaging of the prostate is increasingly being performed at academic centers but implementation in community based health systems has lagged and literature regarding clinical impact in this setting is limited. We describe our experience developing a community based prostate magnetic resonance imaging program, including the evolution of interpretation and reporting methods, and the resulting clinical impact during a period of more than 5 years (August 2010 to December 2015)., Methods: Data collected for prostate magnetic resonance imaging included demographic, clinical, scanning, pathology and treatment/management information. Suspicion level on prostate magnetic resonance imaging was correlated with pathology results when available. Outcomes were compared across 3 reporting eras, ie early, mid and Prostate Imaging Reporting and Data System, version 2., Results: A total of 537 prostate magnetic resonance images were obtained for diagnosed prostate cancer (60%) or screening (37%). During the study period the number of scans and ordering physicians increased. The proportion of patients with suspected extraprostatic extension (17.5%), lymph node metastasis (6.9%) and bone/other metastasis (4.3%) on prostate magnetic resonance imaging remained relatively constant. When stratified by era, there was a significant increase in low suspicion studies (p = 0.0002) and a trend toward a significant increase in cancer detection at biopsy (p = 0.09), reflecting increased specificity in the Prostate Imaging Reporting and Data System, version 2 era., Conclusions: While staging information with prostate magnetic resonance imaging was accurate early in the implementation of the program, lesion characterization improved with use of Prostate Imaging Reporting and Data System, version 2 criteria and standardized reporting. Regular multidisciplinary participation in community based prostate magnetic resonance imaging programs may maximize clinical impact.

Purpose: We sought to confirm the findings from a previous single institution study of 572 patients from Memorial Sloan Kettering Cancer Center in which we found that 49% of patients recovered to the preoperative estimated glomerular filtration rate within 2 years following radical nephrectomy for renal cell carcinoma., Materials and Methods: A multicenter retrospective study was performed in 1,928 patients using data contributed from 3 independent centers. The outcome of interest was postoperative recovery to the preoperative estimated glomerular filtration rate. Data were analyzed using cumulative incidence and competing risks regression with death from any cause treated as a competing event., Results: This study demonstrated that 45% of patients had recovered to the preoperative estimated glomerular filtration rate by 2 years following radical nephrectomy. Furthermore, this study confirmed that recovery of renal function differed according to preoperative renal function such that patients with a lower preoperative estimated glomerular filtration rate had an increased chance of recovery. This study also suggested that larger tumor size and female gender were significantly associated with an increased chance of renal function recovery., Conclusions: In this multicenter retrospective study we confirmed that in the long term a large proportion of patients recover to preoperative renal function following radical nephrectomy for kidney tumors. Recovery is more likely among those with a lower preoperative estimated glomerular filtration rate., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Relative telomere length in peripheral blood leukocytes has been evaluated as a potential biomarker for renal cell carcinoma (RCC) risk in several studies, with conflicting findings., Objective: We performed an analysis of genetic variants associated with leukocyte telomere length to assess the relationship between telomere length and RCC risk using Mendelian randomization, an approach unaffected by biases from temporal variability and reverse causation that might have affected earlier investigations., Design, Setting, and Participants: Genotypes from nine telomere length-associated variants for 10 784 cases and 20 406 cancer-free controls from six genome-wide association studies (GWAS) of RCC were aggregated into a weighted genetic risk score (GRS) predictive of leukocyte telomere length., Outcome Measurements and Statistical Analysis: Odds ratios (ORs) relating the GRS and RCC risk were computed in individual GWAS datasets and combined by meta-analysis., Results and Limitations: Longer genetically inferred telomere length was associated with an increased risk of RCC (OR=2.07 per predicted kilobase increase, 95% confidence interval [CI]:=1.70-2.53, p<0.0001). As a sensitivity analysis, we excluded two telomere length variants in linkage disequilibrium (R 2 >0.5) with GWAS-identified RCC risk variants (rs10936599 and rs9420907) from the telomere length GRS; despite this exclusion, a statistically significant association between the GRS and RCC risk persisted (OR=1.73, 95% CI=1.36-2.21, p<0.0001). Exploratory analyses for individual histologic subtypes suggested comparable associations with the telomere length GRS for clear cell (N=5573, OR=1.93, 95% CI=1.50-2.49, p<0.0001), papillary (N=573, OR=1.96, 95% CI=1.01-3.81, p=0.046), and chromophobe RCC (N=203, OR=2.37, 95% CI=0.78-7.17, p=0.13)., Conclusions: Our investigation adds to the growing body of evidence indicating some aspect of longer telomere length is important for RCC risk., Patient Summary: Telomeres are segments of DNA at chromosome ends that maintain chromosomal stability. Our study investigated the relationship between genetic variants associated with telomere length and renal cell carcinoma risk. We found evidence suggesting individuals with inherited predisposition to longer telomere length are at increased risk of developing renal cell carcinoma., (Published by Elsevier B.V.)

Objective: To retrospectively evaluate clinical predictors of chronic kidney disease (CKD) in renal cell carcinoma (RCC) patients to identify associations between patient- and tumor-specific factors with poorer renal function. CKD and RCC are interrelated, with 26%-44% of RCC patients having concomitant CKD at diagnosis., Patients and Methods: Institutional registries from Spectrum Health and University of California, San Diego, were queried for preoperative glomerular filtration rate and proteinuria status before radical or partial nephrectomy. Preoperative clinical and tumor factors were recorded; proteinuria was classified as A1 (<30 mg), A2 (30-300 mg), and A3 (>300 mg). CKD was grouped by Kidney Disease Improving Global Outcomes classification (low, moderately increased, high, very high)., Results: We evaluated 1569 patients undergoing surgery for renal cortical tumors. CKD status was low risk in 860 (55%), moderately increased in 381 (24%), high in 194 (12%), and very high in 134 (9%) patients. Increased radius, exophytic or endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior or posterior, location relative to polar lines score, tumor size, and clinical tumor stage were strongly associated with increased CKD risk at baseline. Clinical stage T3/T4 disease had more at-risk patients than stages T2 and T1 disease (39.5% vs 22% and 19%, P = .0001). Clinical tumor stage and gender were the only predictors of proteinuria, lower glomerular filtration rate, and higher CKD risk group in both univariate and multivariate analyses., Conclusion: Forty-five percent of patients with RCC had moderate or higher CKD before treatment. A positive correlation between pretreatment CKD and locally advanced RCC (cT3/T4) was present. This likely relates to increased loss of functional parenchyma with increasing tumor size or stage, with important implications in patient management., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Previous genome-wide association studies (GWAS) have identified six risk loci for renal cell carcinoma (RCC). We conducted a meta-analysis of two new scans of 5,198 cases and 7,331 controls together with four existing scans, totalling 10,784 cases and 20,406 controls of European ancestry. Twenty-four loci were tested in an additional 3,182 cases and 6,301 controls. We confirm the six known RCC risk loci and identify seven new loci at 1p32.3 (rs4381241, P=3.1 × 10 -10 ), 3p22.1 (rs67311347, P=2.5 × 10 -8 ), 3q26.2 (rs10936602, P=8.8 × 10 -9 ), 8p21.3 (rs2241261, P=5.8 × 10 -9 ), 10q24.33-q25.1 (rs11813268, P=3.9 × 10 -8 ), 11q22.3 (rs74911261, P=2.1 × 10 -10 ) and 14q24.2 (rs4903064, P=2.2 × 10 -24 ). Expression quantitative trait analyses suggest plausible candidate genes at these regions that may contribute to RCC susceptibility.

Neoadjuvant targeted molecular therapy may benefit select patients with metastatic renal cell carcinoma. The primary use of this therapy in patients with metastatic disease is to reduce tumor burden, prevent distant metastasis, and increase overall survival. Neoadjuvant therapy may reduce tumor size and tumor complexity, facilitate partial nephrectomy rather than radical nephrectomy, downstage tumor thrombus facilitating thrombectomy, and make unresectable tumors resectable when applied to selected patients. These potential benefits of neoadjuvant therapy require further clinical trials to better define the renal function and oncological and survival outcomes in patients receiving each active agent., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To compare the prevalence of proteinuria in the urology clinic with other outpatient settings. Chronic kidney disease is classified according to cause, glomerular filtration rate, and proteinuria. Proteinuria may be more prevalent in patients with known chronic kidney disease, renal disorders (benign or malignant), or after urologic surgery., Methods: A cross-sectional study of 3 populations undergoing urinalysis (UA) testing was carried out: general outpatients (n = 20,334), urology outpatients (n = 5023), and kidney cancer patients (n = 1016). Proteinuria was classified under Kidney Disease: Improving Global Outcomes guidelines: A1 (<30 mg), A2 (30-300 mg), and A3 (>300 mg)., Results: Proteinuria was detected throughout a community-based health system in 8.6% of UA (8.2%: A2; 0.4%: A3). In comparison, 18.6% of urology office-performed UA had proteinuria (16.0%: A2, 2.5%: A3) (P < .0001 vs non-urology). Kidney cancer patients were more likely to have proteinuria (17.9%: A2, 3.8%: A3). The proportion with A3 was significantly higher in urology and kidney cancer patients when compared with other outpatients (each P < .0001), and in the kidney cancer subgroup compared with all urology patients (P < .0001). Additional abnormalities were frequently present on microscopic analysis of UA in the urology clinic, including hematuria (20.9%), pyuria (21.8%), and bacteriuria (3.1%)., Conclusion: The value of UA in the urology clinic as a screening test for proteinuria and other conditions appears high, with >56% having at least 1 abnormality. The population risk of proteinuria in the urology clinic is 18.5%, which is higher than that observed in non-urology clinics. Patients with kidney cancer appear more likely to have proteinuria than the average urology patient. We recommend evaluation of urology patients with UA to identify proteinuria., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Prostate-specific antigen (PSA) screening may reduce death due to prostate cancer but leads to the overdiagnosis of many cases of indolent cancer. Targeted use of PSA screening may reduce overdiagnosis. Multimarker genomic testing shows promise for risk assessment and could be used to target PSA screening., Methods: To test whether counseling based on the family history (FH) and counseling based on a genetic risk score (GRS) plus FH would differentially affect subsequent PSA screening at 3 months (primary outcome), a randomized trial of FH versus GRS plus FH was conducted with 700 whites aged 40 to 49 years without prior PSA screening. Secondary outcomes included anxiety, recall, physician discussion at 3 months, and PSA screening at 3 years. Pictographs versus numeric presentations of genetic risk were also evaluated., Results: At 3 months, no significant differences were observed in the rates of PSA screening between the FH arm (2.1%) and the GRS-FH arm (4.5% with GRS-FH vs. 2.1% with FH: χ 2 = 3.13, P = .077); however, PSA screening rates at 3 months significantly increased with given risk in the GRS-FH arm (P = .013). Similar results were observed for discussions with physicians at 3 months and PSA screening at 3 years. Average anxiety levels decreased after the individual cancer risk was provided (P = .0007), with no differences between groups. Visual presentation by pictographs did not significantly alter comprehension or anxiety., Conclusions: This is likely the first randomized trial of multimarker genomic testing to report genomic targeting of cancer screening. This study found little evidence of concern about excess anxiety or overuse/underuse of PSA screening when multimarker genetic risks were provided to patients. Cancer 2016;122:3564-3575. © 2016 American Cancer Society., (© 2016 American Cancer Society.)

Purpose: We determined the functional life of various configurations of partial nephrectomy closure systems., Materials and Methods: Sutures were prepared using standard techniques for sutured renorrhaphy during partial nephrectomy. Tested systems included knot/Hem-o-Lok®, Lapra-Ty®/Hem-o-Lok and Hem-o-Lok/Hem-o-Lok combinations. The saline filled tank was maintained at 37C. Vicryl®, Stratafix™ polyglycolic acid-polycaprolactone or V-Loc™ 180 sutures were suspended at 4 or 2 N. Suture material breakage or slippage was considered failure., Results: At 4 N 20% of sutures terminated with knot/Hem-o-Lok failed by 3 weeks compared to 56% and 100% terminated with Lapra-Ty/Hem-o-Lok and Hem-o-Lok/Hem-o-Lok, respectively (p <0.0001). The 55% and 100% of failures with Lapra-Ty/Hem-o-Lok and Hem-o-Lok/Hem-o-Lok, respectively, were generally due to slippage vs 11% with knot/Hem-o-Lok (p <0.0001). Overall failure rates with Lapra-Ty/Hem-o-Lok for zero to 4-zero sutures were 41% with Vicryl, 82% with polyglycolic acid-polycaprolactone and 24% with V-Loc 180 (p <0.0001). The only sutures without failure at 4 N with Lapra-Ty/Hem-o-Lok and knot/Hem-o-Lok closure systems were Vicryl zero, and V-Loc 2-zero and 3-zero. At 2 N Lapra-Ty/Hem-o-Lok failure (17.5% vs 0%, p = 0.039) and Hem-o-Lok/Hem-o-Lok failure (39% vs 16%, p = 0.074) were more common with polyglycolic acid-polycaprolactone than with V-Loc sutures., Conclusion: Hem-o-Lok/Hem-o-Lok and Lapra-Ty/Hem-o-Lok combinations resulted in more frequent failures at 3 weeks or greater than knot/Hem-o-Lok. For all sutures tested knots were superior to Lapra-Tys to backstop Hem-o-Loks at 4 N. Preferably, Vicryl zero or V-Loc 2-zero/3-zero sutures should be used in combination with knots or Lapra-Tys at 4 N. Under these experimental conditions the Lapra-Ty/Hem-o-Lok combination did not reliably suspend the other sutures tested for 3 weeks. If Lapra-Ty/Hem-o-Lok or Hem-o-Lok/Hem-o-Lok combinations are used, we recommend closure at lesser tension and/or the use of appropriate sutures., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Although it is commonly staged according to glomerular filtration rate, an international work group recommended classifying chronic kidney disease by cause, glomerular filtration rate and albuminuria. Data on nonsurgical patients with chronic kidney disease indicate proteinuria to be an independent predictor of renal function decrease and mortality. We evaluated whether preoperative proteinuria impacted survival in patients undergoing nephrectomy., Materials and Methods: An institutional registry was queried for information regarding preoperative creatinine/glomerular filtration rate and urinalysis in 900 patients, including 362 and 538 treated with partial and radical nephrectomy, respectively. Patients were grouped according to glomerular filtration rate level (G1 to G5), proteinuria level (A1 to A3) and chronic kidney disease risk classification (low to very high). Kaplan-Meier and Cox proportional hazards analyses of overall survival were performed., Results: The preoperative glomerular filtration rate was less than 60 ml/minute/1.73 m(2) in 30% of patients (median 73, IQR 56-91) and 20% of patients had baseline proteinuria. According to the KDIGO (Kidney Disease Improving Global Outcomes) classification 23% of patients were at moderately increased, 11% were at high and 8% were at very high risk for chronic kidney disease progression. Kaplan-Meier analysis revealed that the preoperative glomerular filtration rate, proteinuria and chronic kidney disease risk group were associated with poor overall survival. In Cox proportional hazard models accounting for age, gender, race, tumor size, clinical stage and surgery type the glomerular filtration rate, proteinuria and chronic kidney disease risk group were highly significant predictors of overall survival (p <0.0001)., Conclusions: Preoperative proteinuria is a significant predictor of overall survival in patients who undergo nephrectomy. Classification according to preoperative glomerular filtration rate and proteinuria more accurately predicts survival than using the glomerular filtration rate alone after accounting for cancer stage. This information supports routine evaluation of proteinuria in patients with kidney cancer., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Next-generation sequencing (NGS) capabilities can affect therapeutic decisions in patients with complex, advanced, or refractory cancer. We report the feasibility of a tumor sequencing advisory board at a regional cancer center. Specimens were analyzed for approximately 2800 mutations in 50 genes. Outcomes of interest included tumor sequencing advisory board function and processes, timely discussion of results, and proportion of reports having potentially actionable mutations. NGS results were successfully generated for 15 patients, with median time from tissue processing to reporting of 11.6 days (range, 5 to 21 days), and presented at a biweekly multidisciplinary tumor sequencing advisory board. Attendance averaged 19 participants (range, 12 to 24) at 20 days after patient enrollment (range, 10 to 30 days). Twenty-seven (range, 1 to 4 per patient) potentially actionable mutations were detected in 11 of 15 patients: TP53 (n = 6), KRAS (n = 4), MET (n = 3), APC (n = 3), CDKN2A (n = 2), PTEN (n = 2), PIK3CA, FLT3, NRAS, VHL, BRAF, SMAD4, and ATM. The Hotspot Panel is now offered as a clinically available test at our institution. NGS results can be obtained by in-house high-throughput sequencing and reviewed in a multidisciplinary tumor sequencing advisory board in a clinically relevant manner. The essential components of a center for personalized cancer care can support clinical decisions outside the university., (Copyright © 2015 American Society for Investigative Pathology and the Association for Molecular Pathology. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the outcomes of patients undergoing robot-assisted radical prostatectomy (RARP) with urinary drainage using a modified technique for suprapubic catheter (SPC) placement with those undergoing a previously described technique for SPC placement and those with urethral catheter (UC) alone., Materials and Methods: We reviewed the records of 225 consecutive patients who underwent RARP by a single surgeon. The most recent patients were contacted via a telephone survey with 86 responses (69%) received., Results: After RARP, 174 patients had only UC placement (77%) and 51 had an SPC placed (23%). Twelve patients had SPC placement with a 4-mL balloon (SPC-4), with catheter-related complications occurring in four patients (33%). The technique was modified to use SPC with a 10-mL balloon (SPC-10). Only 2 of 39 SPC-10 patients (5%) had catheter-related complications (P = .03 vs SPC-4). Continence rates at 6 weeks were 83% and 82% for UC and SPC, respectively. Based on postoperative survey results using a 10-point scale, overall experience with RARP was rated 8.9 ± 1.7 and 8.7 ± 2.3 for UC and SPC, respectively (P = .63). Mean catheter bother was rated 5.1 ± 3.0 and 4.6 ± 2.9 for UC and SPC, respectively (P = .45)., Conclusion: SPC provides a safe option for patients who would prefer not to have UC following RARP, with equivalent perioperative outcomes. Modification of the published technique to place a standard 16F catheter results in fewer catheter-related complications., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The preoperative distinction between benign and malignant renal masses is a well-known radiographic diagnostic challenge. With angiomyolipoma (AML) and renal cell carcinoma (RCC) representing the most common benign and malignant renal parenchymal lesions, respectively, differentiating these two entities is especially important due to their vastly different treatments and prognoses. Renal AML is typically composed of smooth muscle cells, dysmorphic blood vessels, and varying amounts of adipose tissue. In most cases, "typical" AML can be diagnosed by identifying macroscopic fat with ultrasound, computed tomography, or magnetic resonance imaging. However, approximately 4-5 % of AML tumors have fat that is grossly undetectable by conventional techniques, precluding a straightforward diagnosis. The overlapping radiographic features between "atypical" or "fat-poor" AML and RCC, especially in smaller (<3-4 cm) lesions, lead many patients with benign AML to undergo unnecessary surgery for suspected RCC when the diagnosis is not established beforehand. This review presents the most recent studies and developments in preoperative evaluation of fat-poor AML.