==inizio objective==

Laparoscopic partial nephrectomy is indicated for the treatment of small renal tumors due to its miniinvasiveness and good results in matter of nephron sparing using “zero-ischemia” technique, with the aim of completely eliminate surgical renal ischemia (1-2)
Aim of the study is evaluating the incidence of blood transfusion in comparing laparoscopic radical versus partial nephrectomy, in order to propose the technical feasibility and safety of partial procedures

==fine objective==

==inizio methodsresults==

Clampless laparoscopic partial nephrectomy (cl-LPN) technique was performed with no selective branch micro-dissection of renal artery/vein, and no calibrated and timed intraoperative controlled hypotension . No intraoperative controlled hypotension was performed during laparoscopic radical nephrectomy (LRN). Match analysis between surgical and transfusional data was performed . We evaluated retrospectively 147 clampless laparoscopic partial nephrectomies (cl-LPN) versus 247 laparocopic radical nephrectomies (LRN ) performed from genuary 2008 till december 2016 Patients aged 23 – 87 and 31 – 91 years for cl-LPN and LRN respectively

==fine methodsresults==

==inizio results==

13 pat out of 147 clampless laparoscopic partial nephrectomies (8,8 %) versus 27 pat out of 247 (10,9%) LRN needed blood transfusions during hospitalization : 4 out of 13 (30 %) transfusion of the cl-LPN were performed after the early 12 hours postsurgery versus 6 /27 (22 %) of the radical nephrectomies: no statistically significant difference was noted between the two groups . Otherwise a statistically significant difference was noted in the need of blood transfusion between cl-LPN undergone before 2010 versus those after 2010 : 7/36 (19.4 %) versus 6 /111 (5.4 %) respectively (p< 0.05) ==fine results== ==inizio discussions== Clampless laparoscopic partial nephrectomy had the same incidence of transfusion as the radical ones. Our data underlined that there is no increased risk of bleeding using laparoscopic partial technique versus laparoscopic radical technique. Technical approach is very different and quite opposite: in radical procedures first of all renal vessels were identificated isolated clamped and cut ; in the partial technique first of all the renal lesion is identificated isolated and enucleated: no preventive dissection of the renal hilum was usually performed , unless in case of renal lesion located near the hilum itself. As paradox, manteining an adequate blodd pressure during surgery permits a better evaluation of blood loss in order to perform the best coagulation with bi-polar forceps, after the cold enucleation of the lesion by the scissors . Furthermore we had to consider that 30 % of the cl-LPN and 22 % of LRN were delayied transfusion 12 hours after surgery, demonstrating only a mild vascular leakage without the need of a surgical second look If LRN can be considered a relatively “blood sparing” safe procedure, the same we can affirm for clampless laparoscopic partial nephrectomy . A progressive decrease of the need of transfusion was noted during the observed period : this can be due both to the increasing ability of the surgeon and in the use of different hemostatic agent ==fine discussions== ==inizio conclusion== Clampless laparoscopic partial nephrectomy is a feasible technique in neprhon sparing and even in “blood sparing” purpose , avoiding renal functional damage due to ischemia ==fine conclusion== ==inizio reference== 1) Clampless laparoscopic partial nephrectomy: a step towards a harmless nephron-sparing surgery? F. Porpiglia; R. Bertolo; I. Morra; C. Fiori Int. braz j urol. vol.38 no.4 Rio de Janeiro July/Aug. 2012 2) Indications, Techniques, Outcomes, and Limitations for Minimally Ischemic and Off-clamp Partial Nephrectomy: A Systematic Review of the Literature G. Simone , I. S. Gill , A. Mottrie, A. Kutikov , J. J. Patard , A. Alcaraz , C. G. Rogers EUR UROL 6 8 ( 2 0 1 5 ) 6 3 2 – 6 4 0 ==fine reference==

==inizio objective==

Robotic Assisted Partial Nephrectomy (RAPN) is preferred to radical nephrectomy because it guarantees superior functional outcomes in patients with small renal masses (RMs). Only a few studies so far have evaluated the feasibility of RAPN for the treatment of RMs ≥ 4 cm (1).
The aim of this study is to evaluate the safety and feasibility of RAPN based on a comparison of trifecta and pentafecta rates for RMs ≥ 4 cm.

==fine objective==

==inizio methodsresults==

We retrospectively analyzed prospective collected data from an institutional database of patients undergoing RAPN from September 2013 to November 2016. Demographic and perioperative data were collected and statistically analyzed. Pentafecta is defined as achievement of trifecta (negative surgical margins, no postoperative complications and warm ischemia time ≤ 25 min) with the addition of two other variables, namely, over 90% estimated Glomerular Filtration Rate (eGFR) preservation and no chronic kidney disease stage progression 1 year after surgery.

==fine methodsresults==

==inizio results==

Overall, 123 patients underwent RAPN. Of those,38 (30.9%) had RMs ≥4 cm. These patients were more frequently symptomatic at diagnosis (23.7 vs 8.2%, p=0.03) and had high PADUA scores (13.2 vs 3.5%, p=0.02). As expected, patients with RMs≥4 cm had longer OT (133.4 vs 105.9 minutes, p<0.01), higher EBL (287.4 vs 166.3 ml, p<0.01),and more frequently showed WIT >25 min(0% vs. 26.3 %, p<0.01). Mean pathologic tumor size was 2.4 cm in patients with RMs smaller than 4 cm and 4.8 in those with RMs larger than 4 cm. . In our study, no significant differences in post-operative complications were found between these two groups. Overall, trifecta and pentafecta were achieved in 64.2% and 19.5% of cases, respectively.. When patients were stratified according to tumor size, trifecta was achieved in 72.9% of those with RMs <4 cm and in 44.7 of those withRMs≥4 cm, whereas achievement rates for pentafecta were 23.5% and 10.5%, respectively. In logistic regression models, patients with RMs≥4 cm were less likely to achieve trifecta (p<0.01);however, RMs≥4 cm were not associated with lower pentafecta rates (p=0.08). On multivariable regression analysis, no significant predictive factors were found in connection with trifecta, whereas with regard to pentafecta the only significant predictor was age(OR: 0.91; 95%CI 0.85-0,98; p = 0.01). ==fine results== ==inizio discussions== We hypothesized that RAPN would be a safe and reliable procedure even in patients with RMs larger than 4 cm. We also hypothesized that achievement of trifecta and pentafecta, as surrogate markers of surgical success as well as of short- and long-term functional outcomes, would be similar for RMs smaller or larger than 4 cm treated with RAPN. Our data overlap favorably with data available in the literature. As regards perioperative complications after RAPN for larger RMs, data from the literature are controversial. Patel and Ficarra reported higher complications rates for tumors>4 cm, than for tumors<4 cm (26.6 vs 8.9% and 26.5 vs 9.4%, respectively (2-3). In a multicenter study, Petros et al. analized data of 445 patients, 83 of whom had RMs >4 cm, and found no increased risk of perioperative complications after RAPN (4). In our study, patients with RMs smaller or larger than 4 cm had similar perioperative complication rates, again with no significant differences(p=0.37). Likewise, no significant differences were recorded in connection with post-operative 90% eGFR preservation in RMs<4 or ≥4 cm (p=0.38). To the best of our knowledge, only Kim et al examined differences in trifecta and pentafecta rates in patients with pT1a and pT1b tumors. In their study,65.3% of pT1a patients and 43.3% of pT1b patients achieved trifecta, while pentafecta was achieved by38.3% of pT1a patients and by26.7% of pT1b patients (1). Our results corroborate data from the literature, with overall trifecta and pentafecta rates being achieved in 64.2% and 19.5% of cases, respectively. ==fine discussions== ==inizio conclusion== RAPN is a feasible and safe procedure with good long-term renal outcomes even for patients with large renal masses (≥4cm). Trifecta and pentafecta are important tools for evaluating both short-and long-term perioperative and functional renal outcomes. ==fine conclusion== ==inizio reference== 1) Kim DK, Kim LHC, Raheem AA, Shin TY, Alabdulaali I, Yoon YE, et al. Comparison of Trifecta and Pentafecta Outcomes between T1a and T1b Renal Masses following Robot-Assisted Partial Nephrectomy (RAPN) with Minimum One Year Follow Up: Can RAPN for T1b Renal Masses Be Feasible? PloS One. Mar 2016;11(3):e0151738. 2) Patel MN, Krane LS, Bhandari A, Laungani RG, Shrivastava A, Siddiqui SA, et al. Robotic partial nephrectomy for renal tumors larger than 4 cm. Eur Urol. Feb2010;57(2):310–6. 3) Ficarra V, Bhayani S, Porter J, Buffi N, Lee R, Cestari A, et al. Robot-assisted partial nephrectomy for renal tumors larger than 4 cm: results of a multicenter, international series. World J Urol. Oct 2012;30(5):665–70. 4) Petros F, Sukumar S, Haber G-P, Dulabon L, Bhayani S, Stifelman M, et al. Multi-institutional analysis of robot-assisted partial nephrectomy for renal tumors >4 cm versus ≤ 4 cm in 445 consecutive patients. J Endourol. Jun 2012;26(6):642–6.

==fine reference==

==inizio objective==

Nephron sparing surgery (NSS) is now reference standard for many T1 renal tumors. To reduce renal damage several technique have been proposed; cold ischemia, artery clamping, selective artery clamping, zero ischemia. We retrospectively compared perioperative results of clamp vs no clamp procedure in patients affected by T1 renal cancer.

==fine objective==

==inizio methodsresults==

From database of our institution we reviewed patients affected by single, clinical T1 tumor who underwent a laparoscopic partial nephrectomy (LPN). A transperitoneal approach was performed in all patients. In Clamp LPN group renal artery was clamped using laparoscopic Bull dog. In off-clamp group, a controlled hypotension, to carefully lower the mean arterial pressure (MAP) while maintaining excellent systemic perfusion, was maintened at approximately 60 mmHg. To induce hypotension, the doses of inhalational isoflurane was increased. The renal lesion was excised using cold endoshears. Parenchyma was repaired with Vicryl™ sutures arrested with absorbable clips and Hem-O-lok™. In clamp group bulld dog was removed while in the off –clamp group blood pressure was restored to preoperative levels. Biologic hemostatic agents and Surgicel™ were applied to the resection bed when appropriated.

==fine methodsresults==

==inizio results==

We identified 59 patients in the clamp group and 67 in off-clamp group; baseline characteristic of the two groups are described in table 1. Patients of off clamp group presented significant less operative time, blood loss and transfusion rate than clamp group. Hospitalization and suture time were shorter for off-clamp group, also [table 2]. No significant differences were observed in terms of histological evaluation [table 3]. Postoperative complication were rare [table 4].
Table 1. Baseline characteristics
Clamp group Off clamp group p value
pts n 59 67
Age (y) y 59.8 ± 13.6 58.4 ±12.4 0.57
BMI 28.5 ±4.6 27.8 ±5.3 0.56
cTumor size mm 40.5 11.7 42.7 ±15.4 0.41
pTumor size mm 44.7 ±16.4 41.3 ±16.0 0.40
ASA (%) I 6.1 5.9 0.56
II 39.4 47.1
III 51.5 45.1
IV 3.0 1.9
RENAL (%) Low 17.0 20,3
Medium 57.6 72,5
High 25.4 7,2

Table 2. operative outcomes
Clamp group Off clamp group p value
Operative time min. 214.5 ±56.6 147.6 ±54.7 0.001
Resection time min. 6.9 ± 2.9 8.5 ±4.6 0.46
Suture time min. 16.3 ±7.3 9.6 ±6.4 0.006
Blood loss min. 747.4 ±706.3 357.1 ±340.4 0.001
Hb drop gr/dl 2.3 ±1.7 2.1 ±1.1 0.51
Transfusion (n) 0 33 58 0.002
1 13 3
2 5 5
3 8 0
Hospitalization Days 10.2 7.4 0.03

Table 3. Histological outcomes
Clamp group Off clamp group p value
Type
RCC 38 34
Cromophobe 1 5
Papillary 6 12
unclassificable 1 1
Oncocytoma 6 9
aml 3 3
Benign 4 3
Stage
T1a 26 (56.5) 25 (48.1) 0.87
T1b 15 (32.6) 20 (38.5)
T2 1 (2.2) 2 (3.8)
T3a 4 (8.7) 5 (9.6)
+ve surgical margins 1 (1.7%) 0

Tab 4. Perioperative complications
Clamp group Off clamp group
haemorrage 2 (3.4%) 0
Diaphragmatic lesion 2 (3.4%) 1 (1.5%)
Urine leakage 3 (5.1%) 2 (3.0%)
Pnx 1 (1.7%) 0
fever 2 (3.4%) 5 (7.5%)

==fine results==

==inizio discussions==

==fine discussions==

==inizio conclusion==

Clamp and off-clamp laparoscopic partial nephrectomy are equally safe and reproducible technique in terms of perioperative outcomes and complications. However the appropriate procedure should be selected taking into account tumor complexity, patient comorbidity and surgeon experience.

==fine conclusion==

==inizio reference==

==fine reference==

==inizio objective==

we present our experience with six cases of persistent iatrogenic urinary fistulas where minimally
invasive endoscopic treatment with fibrin sealant was employed, in an attempt to spare further challenging surgery in patients that had been already operated on recently.

==fine objective==

==inizio methodsresults==

During the period 2010-2017 a cohort of 6 patients were hospitalized for the treatment of iatrogenic fistulas which failed to resolve after conventional urine drainage. There were 6 calyceal fistulas (4 upper calix and 2 inferior calix) occurring after laparoscopic enucleoresection for pT1/PT2 renal cell carcinomas. Following documentation of urine leak though the drainage tube, the initial treatment had consisted in all in endoscopic placement of a double J stent and gravity drainage of the bladder via an indwelling Foley catheter, but after a median period of 7/10 days urine leak persisted. Under fluoroscopic guidance the double J stents were endoscopically removed and an open-end 8 F ureteral catheter was advanced over an hydrophilic guide wire in the upper calyx in 4 cases while was advance in the inferior calyx in 2 patient, placing the tip close to the fistula site. An amount of fibrin sealant (between 10 and 20 cc ) (Tisseel , Baxter, Deerfield, IL, United States of America) was injected and the ureteral catheter was rapidly withdrawn. After a few minutes a new open-end ureteral catheter was advanced in the renal pelvis, and a control retrograde pyelography was performed . Finally a new double J or mono J ureteral stent was placed and the bladder was drained with a Foley catheter.

==fine methodsresults==

==inizio results==

In four cases there was immediate resolution of urine leak through the lumbar drainage, which was removed after 5 days. In two patient with persisting drainage, following evidence at uro-CT scan of contrast medium outside the kidney, we perfomed an flexible ureterorenoscopy to identify caliceal lesion and was repeated the procedure as described aboce with success

==fine results==

==inizio discussions==

Iatrogenic urinary tract fistulas may present as early complications following urological procedures, and their incidence is likely to increase due to the diffusion of laparoscopic and robotic surgery, where inadvertent thermal damage to the kidney by different energy sources may cause urine leak(1). Their conventional management consists in appropriate urinary drainage, which can be sufficient for tissue healing and fistula closure, provided that the amount of leakage is not excessive and the tissue damage is limited. The open fistula repair may be technically challenging and a decreased renal function is to be considered as the final result. In particular calyceal fistulas for adequate repair often require partial or total nephrectomy(1) .In the early postoperative period therefore there is room for attempts at fistula closure using minimally invasive techniques, and fibrin sealants offer a possibility in this field. Until now there are few single case reports , which obviously had all a favorable outcome documenting a success rate of about 85%(2).

==fine discussions==

==inizio conclusion==

In our experience a fibrin sealant, originally proposed like emostatic agent , was also suitable for occlusion of urinary fistulas using endoscopic approaches. Since this treatment is well tolerated, without major complications and minimally invasive. In our opinion it is worthwhile to consider it relatively early when conventional urinary drainage measures fail

==fine conclusion==

==inizio reference==

(1)Bhaskar V, Sinha RJ, Purkait B, Singh V. Renal fistulae: different aetiologies, similar management. BMJ Case Rep 2017. 14. doi:10.1136/bcr-2017-219678
(2)Evans LA, Ferguson KH, Foley JP, Rozanski TA, Morey AF.Fibrin sealant for the management
of genitourinary injuries, fistulas and surgical complications. J Urol 2003.169:1360–1362

==fine reference==

==inizio objective==

Nephron sparing surgery is now reference standard for many T1 renal tumors. Although hilar clamping creates bloodless operative field, it necessarily imposes kidney ischemic injury. ”Zero ischemia” partial nephrectomy allows to eliminate ischemia during nephron sparing surgery.We report our preliminary experience of “zero ischemia” laparoscopic partial nephrectomy realized by controlled hypotension.

==fine objective==

==inizio methodsresults==

Patients with a single, clinical T1 tumor were candidates for “zero ischemia” laparoscopic partial nephrectomy. High-risk patients with severe, preexisting, cardiopulmonary, cerebrovascular, or hepatorenal dysfunction were not eligible. The preoperative work-up comprised medical history, physical examination, routine laboratory tests and CT scan or MRI.A transperitoneal approach was performed in all patients; four or five laparoscopic ports are inserted. The hilar vessels are prepared in event that bulldog clamping may subsequently be needed.Intraoperative monitoring includes electrocardiogram, central venous pressure (CVP), electroencephalographic bispectral (BIS) index (BIS monitor™), NICOM (non invasive cardiac output monitoring), urinary Foley catheter. A controlled hypotension, to carefully lower the mean arterial pressure (MAP) while maintaining excellent systemic perfusion, is maintened at approximately 60 mmHg. To induce hypotension, the doses of inhalational isoflurane is increased. The renal lesion is excised using cold endoshears. Upon completion of tumor excision, blood pressure is restored to preoperative levels. Parenchyma is repaired withVicryl™ sutures arrested with absorbable clips and Hem-O-lok™. Biologic hemostatic agents and Surgicel™ are applied to the resection bed.

==fine methodsresults==

==inizio results==

85 patients affected by renal tumor underwent zero ischemia LPN. Mean age and mean BMI were 58.2 (±12.2) years and 27.8 (±5.3). ASA score was 1, 2 and 3 in 5, 47 and 48 patients, respectively. Charlson comorbidity index was 3.2±1.6. Renal score was low (4-6) in 20,5%, moderate (7-9) in 71,8% and high (10-12) in 7,75 or the patients.
Mean tumor size was 42.9 mm (±15.4). Operative time, blood loss, ∆Hb were 148.7 min (±54.9), 374.2 ml (±365.5), 2.1 gr/dl (±1.2), respectively. Hilar vessels were isolated in 44.2%. In all cases the procedure was performed without clamping. Resection, first and scond suture times were 7.9 (±3.9), 9.6 (±6.4) and 7.3 (±3.2) minutes, respectively. Hospital stay was 6.5 (±5.6) days. Postoperative complications were: 5 fever (Clavien I), 1 fever (Clavien II), 3 urine leakage managed conservatively (Clavien IIIa). Histological evaluation revealed benign lesion in 4 pts, Oncocytoma in 10 pts, AML in 4 pts, complex cyst in 1 pts, Papillary RCC in 14 pts, Cromophobe RCC in 5 pts, clear cell RCC in 47 pts [pT1a (31 pts), pT1b (25 pts), T2 (2 pts), T3a (7 pts)]. Preoperative and postoperative serum Creatinine was 0.8 ±0.24 and 0.9 ±0.22, respectively (Δ0.05±0.08; Δ% -6.2); Preoperative and postoperative GFR was 96.43 ±33.03 and 88.03 ±26.35, respectively (Δ-8.41 ±12.97 Δ% -8.7).

==fine results==

==inizio discussions==

==fine discussions==

==inizio conclusion==

Zero ischemia LPN represents a safe and reproducible technique that allow to sparing renal parenchyma and preserve renal function. However long-term results are needed.

==fine conclusion==

==inizio reference==

==fine reference==

==inizio objective==

Partial nephrectomy for endophytic renal tumors is a challenging surgical procedure. The use of intraoperative ultrasound allows the surgeon to localize the tumor and to score the resection margins, without any data about the deep part of resection. We describe a novel technique to mark endophytic renal tumors with transarterial superselective delivery of indocyanine green (ICG)-lipiodol mixture, in patients selected for purely off clamp (OC) robotic partial nephrectomy (RPN).

==fine objective==

==inizio methodsresults==

Between September 2017 and October 2017, 10 consecutive patients with predominantly or totally endophytic renal masses underwent superselective transarterial tumor ICG marking and bland embolization immediately before OC-RPN. Preoperative transarterial bland embolization was performed with superselective delivery of lipiodol-ICG mixture (1 to 2 by volume, mixing 1.5 millilitres of ICG with 3 millilitres of lipiodol) into tertiary order arteries feeding the tumor. Purely OC-RPN was performed. Near infrared fluorescence imaging was used to early identify the tumor (Fig. 1A), to score resection margins (Fig. 1B) and to obtain an image guided control of resection margins (Fig. 1C).Baseline, clinical, perioperative and pathologic data were reported.

==fine methodsresults==

==inizio results==

Median tumor size was 3 cm (IQR 2.3-3.8). Median PADUA nephrometry score was 10 (IQR 9-11) Median operative time was 75 minutes (IQR 65-85), median estimated blood loss was 250 mL (IQR 200-350). Bland embolization was uneventful in all patients. Hilar clamp was not necessary in any case, as well as no conversion to radical nephectomy was needed. Perioperative course was uneventful for all patients and median hospital stay was 3 days (IQR 2-3). At discharge, median Hgb and percent eGFR drop down were -3.3 g/dL (IQR 2.1-3.3) and -11% (IQR 10-20), respectively. Surgical margins were negative in all cases. Eight (80%) patients had renal cell carcinoma histology at final pathology.

==fine results==

==inizio discussions==

We previously reported our experience with off-clamp partial nephrectomy with preoperative superselected transarterial embolization [1]. We describe a novel technique to simplify challenging RPNs based on ICG-lipiodol tumor marking with preoperative superselective bland embolization. Key benefits of this technique include a quick identification of the mass, avoiding any use of intraoperative ultrasound imaging, and a real time control of resection margins thanks to an improved visualization of tumor.

==fine discussions==

==inizio conclusion==

The technique we described may simplify challenging RPNs, thanks to a quick identification of the mass, avoiding any use of intraoperative ultrasound imaging, and a real time control of resection margins thanks to an improved visualization of tumor.

==fine conclusion==

==inizio reference==

1. Zero ischemia laparoscopic partial nephrectomy after superselective transarterial tumor embolization for tumors with moderate nephrometry score: long-term results of a single-center experience.
Simone G, Papalia R, Guaglianone S, Carpanese L, Gallucci M.
J Endourol. 2011 Sep;25(9):1443-6. doi: 10.1089/end.2010.0684. Epub 2011 Jul 28.

==fine reference==

==inizio objective==

Papillary renal cell carcinoma (PRCC) is the second most commonly encountered morphotype of renal cell carcinoma (RCC). PRCC is a malignant tumour derived from renal tubular epithelium: traditionally classified into type 1 and type 2 (1,2). Recently, an oncocytic variant of PRCC has been described (3). We describe a rare case of OPRCC recently underwent our observation.

==fine objective==

==inizio methodsresults==

83 years old caucasian man with incidental solid left renal mass, as showed from abdomen US and CT scan, underwent our observation wit LUTS without gross hematuria. Particular, CT scan showed a esophitic 47×36 mm upper pole vascularized renal mass. We performed a surgical enucleoresection with nephron sparing approach of the mass.

==fine methodsresults==

==inizio results==

We have performed a lombotomic left antero-lateral approach to go to a neprhon sparing enucleoresection of the mass with hot ischemia by a selective closure of the upper pole arterial branch of the major renal artery. Total operating time has been 120 minutes with no significative blood loss. Not evidence disease at six months after surgery.
Specimen was fixed in 10% formalin buffer solution for 48 hours, then grossly sectioned and slices embedded in paraffin. Slides were stain with Hematoxylin/eosin. Immunohistochemistry was performed of the instrument Dako Omnis (Agilent Technologies, Santa Clara, US) with CD 10 (clone 56C6), Vimentin (clone V9), CD 177 (policlonal), Cytokeratin 7 (clone OV-TL12/30) and P504S/AMACR (clone 13H4) antibodies. Histologically, the tumor showed a papillary pattern; the papillary folds was formed by thin fibrovascular stalk, occasionally contain foamy macrophages, lined by single layer of epithelial cells with abundant granular eosinophilic cytoplasms and round nuclei, grade 2 sec. Vancouver classification. There were hemorrhagic spots and hemosiderothic histiocytes between papillae. No vascular invasion was seen. At periphery, the tumoral cells pushed a subtle fibrous capsula to perinephric fat without true invasion of adipose tissue. Tumoral cells were immunoreactive for CD 10, Vimentin and p504S/AMACR and negative for CD 177 and Cytokeratin 7.

==fine results==

==inizio discussions==

Papillary renal cell carcinomas (PRCC) is a well-established subtype of RCC with characteristic gross and histological features and is further subdivided into 2 subtypes, type 1 and 2, for its distinct morphological feature and prognostic implications. Type 1 PRCC consist of small cells with low nuclear grade and a scant amount of cytoplasm arranged in a single layer, whereas type 2 PRCC tumor cells are larger, with abundant eosinophilic cytoplasm, higher nuclear grade, and nuclear pseudostratification. The two types of PRCC also demonstrate different clinical behavior. Patients with type 2 have a poorer prognosis than those with type 1. Therefore, accurate subtyping of PRCC is important for prognosis and proper patient management. Recently, a new histopathologic variant of PRCC named oncocytic PRCC (OPRCC) has been described. It was first reported by Lefevre et al. in 2005 that 10 cases of RCC with the features of prominent papillary architecture, abundant granular eosinophilic cytoplasm and low-grade non overlapping nuclei (3-4).
The majority of patients OPRCC were identified by medical examination and the remaining presented with macroscopic hematuria or lumbar pain. Grossly, tumors were well demarcated and varied from 1.5 to 9 cm in diameter. Microscopically, typical OPRCC has fine papillary structures with delicate fibrovascular cores, lined with a single layer cell with large, deeply eosinophilic granular cytoplasm and round or polygonal-shaped nucleus exhibiting low nuclear grade in 10 cases (WHO/ISUP grade I-II). Most cases possessed hemosiderin-laden and foam-like cells. Focal necrosis presented. Immunohistochemically, the majority of tumors presented high expression rates of alpha-methylacylCoA racemase (AMACR), CD10 and vimentin, which were similar to type 2 PRCC. The immune markers including cytokeratin-7 (CK7), KSP-cadherin and EMA exhibited variable positive immunostaining. Genetically, FISH analysis demonstrated trisomy of chromosome 7 and trisomy of chromosome 17 in OPRCCs (5).

==fine discussions==

==inizio conclusion==

OPRCC is a PRCC variant with type 1 and type 2 histological patterns (1). Literature review shows only one case of disease related dead (3). A slow malignancy profile. It represents, otherwise, an important differential diagnosis element in urological clinical practice (2).

==fine conclusion==

==inizio reference==

1. WHO Classification of Tumours of the Urinary System and male Genital Organs. 4th Edition. Moch H, Humphrey PA, Ulbright TM, Reuter VE. International Agency for Research on Cancer (IARC). Lyon,2016.
2. Morphologic, Molecular, and Taxonomic Evolution of Renal Cell Carcinoma: A Conceptual Perspective With Emphasis on Updates to the 2016 World Health Organization Classification. Udager AM, Mehra R. Arch Pathol Lab Med. 2016 Oct;140(10):1026-37. Review.
3. Oncocytic papillary renal cell carcinoma: a clinicopathological study emphasizing distinct morphology, extended immunohistochemical profile and cytogenetic features. Xia QY1, Rao Q, Shen Q, Shi SS, Li L, Liu B, Zhang J, Wang YF, Shi QL, Wang JD, Ma HH, Lu ZF, Yu B, Zhang RS, Zhou XJ. Int J Clin Exp Pathol. 2013 Jun 15;6(7):1392-9.
4. Two Cases of Oncocytic Papillary Renal Cell Carcinoma. Matsuoka T, Ichikawa C, Fukunaga A, Yano T, Sugino Y, Okada T, Imai Y, Kawakita M. Hinyokika Kiyo. 2016 Apr;62(4):187-91. Japanese.
5. Oncocytic papillary renal cell carcinoma: A clinicopathological and genetic analysis and indolent clinical course in 14 cases. Han G, Yu W, Chu J, Liu Y, Jiang Y, Li Y, Zhang W. Pathol Res Pract. 2017 Jan;213(1):1-6. Epub 2016 Apr 28.

==fine reference==

==inizio objective==

Radical nephrectomy with Inferior vena cava (IVC) thrombectomy for renal cancer is one of the most challenging urologic surgical procedures. We describe surgical technique and present perioperative and oncologic outcomes of 23 consecutive cases of completely intracorporeal robot-assisted radical nephrectomy with IVC level I (17,9%) II (30%) and III (52,1%) tumor thrombectomy.

==fine objective==

==inizio methodsresults==

Twenty-three consecutive patients with renal tumor and IVC thrombus were treated between July 2011 and September 2017. Baseline, perioperative and follow-up data were collected into prospectively maintained IRB approved databases. Surgical technique has been previously described. We report perioperative and oncologic outcomes of 23 consecutive patients treated in a tertiary referral center.

==fine methodsresults==

==inizio results==

All procedures were successfully completed; open conversion wasn’t necessary. Median operative time was 300 minutes. Eleven patients (47.8%) did not experience any complication. Ten patients (43,4%) required blood transfusion (Clavien grade 2); one patient (4,3%) had a Clavien grade 3a complication (gastroscopy); one patients (4,3%) had Clavien grade 3b complication (reintervention due to bleeding from adrenal gland); Two patients (8,6%) required ICU admission (Clavien 4a), for PRESS syndrome and atrial fibrillation, respectively. Out of 8 patients who underwent cytoreductive nephrectomy and IVC thrombectomy, at a median follow-up of 19 months (IQR 6-31), 2-yr cancer specific and overall survival rates were 50%. Fifteen patients received surgery with curative intent and 7 of these experienced disease recurrence. three patients died of disease progression; 2-yr disease-free and cancer specific survival rates were 42.1% and 71.5%, respectively.

==fine results==

==inizio discussions==

Robotic IVC tumor thrombectomy is feasible for level II-III thrombi [1]. To maximize intraoperative safety and chances of success, a thorough understanding of applied anatomy and altered vascular collateral flow channels, careful patient selection, meticulous cross-sectional imaging, and a highly experienced robotic team are essential.

==fine discussions==

==inizio conclusion==

Robotic IVC tumor thrombectomy has demonstrated to be a feasible and safe surgical procedure in tertiary referral centers. Favorable perioperative outcomes represent a rational base to expand indications also in the cytoreductive setting.

==fine conclusion==

==inizio reference==

1. Robot-assisted Level II-III Inferior Vena Cava Tumor Thrombectomy: Step-by-Step Technique and 1-Year Outcomes.
Chopra S, Simone G, Metcalfe C, de Castro Abreu AL, Nabhani J, Ferriero M, Bove AM, Sotelo R, Aron M, Desai MM, Gallucci M, Gill IS.
Eur Urol. 2017 Aug;72(2):267-274. doi: 10.1016/j.eururo.2016.08.066. Epub 2016 Sep 20.

==fine reference==

==inizio objective==

Renal cancer represents 3% of all cancers and in 1-2% of cases it is bilateral. Bilateral outset may be a sign of the presence of genetic syndromes predisposing to this cancer, such as Von Hippel-Lindau syndrome, Cowden syndrome, family renal carcinoma syndrome, Birth-Hogg-Dubè syndrome, renal hereditary papillary carcinoma syndrome, Tuberous Sclerosis (1).
Today, the treatment of bilateral renal cancers is a challenge that aims to cure oncologic disease while preserving renal function as much as possible, using nephron-sparing techniques and non-surgical ablation (thermoablation, cryotherapy, radiofrequency), to “extreme kidney surgery” (2,3,4,5). We report our experience in the surgical treatment of 2 patients who have come to our attention with synchronous bilateral renal cancers, in light of recent articles published in the literature.

==fine objective==

==inizio methodsresults==

Between July and September 2017 we treated 2 patients with synchronous bilateral renal cancers. Patient M.R., age 51, was affected by left kidney cancer measuring 14 cm in diameter and by right kidney cancer measuring 9 cm in diameter, with suspected pulmonary metastasis. We have chosen to treat cancers in two times: in order to avoid dialysis, first enucleoresection of right renal tumor was performed (without warm ischemia time and controlled hypotension) and then, after approximately one month, left radical nephrectomy was performed. The second Patient, P.G. was affected by left kidney cancer measuring 8,5 x 7 cm in diameter and by two right kidney cancers measuring 3 cm and 5,7 cm in diameter (in addition to multiple cysts). Again, the treatment was performed in two times, to minimize the risk of impaired renal function. We started with enucleoresection of left kidney cancer, a single neoplasm with lower risk of intra and post-operative bleeding (without warm ischemia time and controlled hypotension). After 1 month, we proceeded with the enucleoresection of the double right renal cancers (again without warm ischemia time and controlled hypotension).

==fine methodsresults==

==inizio results==

Histological examinations in the first patient revealed clear cell carcinoma pT2a (enucleoresection of right renal carcinoma) and clear cell carcinoma pT2b (left radical nephrectomy). In the second patient histological examinations revealed papillary renal carcinoma type I, pT2a (enucleoresection of single left kidney cancer) and papillary renal carcinoma type I on both right kidney cancers treated by enucleoresection, pT1a the smallest and pT1b the largest. None of two patients needed to be treated with intra or postoperative blood transfusion. None of the two patients required postoperative dialysis. The patient subjected to enucleoresection of right kidney cancer and left radical nephrectomy showed a moderate renal function impairment. We currently have a very limited oncological follow-up for both patients.

==fine results==

==inizio discussions==

The occurrence of synchronous bilateral renal cancer is rare, but not exceptional. The main goal of treatment is certainly the radical cure for oncologic disease, but another important target is preservation of renal function to avoid dialysis (6). Recent retrospective works about treatment of patients with synchronous bilateral renal cancer exist, but there are no clear guidelines on the type of intervention to be performed and the timing of the interventions themselves in case of two-times interventions.

==fine discussions==

==inizio conclusion==

In case of bilateral renal cancer, treatment planning should take into account size, number and location of the tumours as well as the patient’s performance status. If enucleoresection of tumour lesions is executable, nephron-sparing surgery should be considered as a valid therapeutic option even in case of voluminous cancers, in order to avoid postoperative renal function impairment requiring definitive dialysis. If two times treatment is planned, it is advisable to perform conservative surgery on the “best” kidney first, ensuring an adequate post-operative recovery period before treating the contralateral kidney, without delaying too much second intervention. In case of cancers deriving from suspected hereditary syndromes, patients should be advised to have a oncological genetic examination with personalized follow-up. It would be appropriate to create guidelines for treatment of these types of cancer, in order to ensure more standardized and effective treatment.

==fine conclusion==

==inizio reference==

1) Inherited renal carcinomas.
Kawashima A, Young SW, Takahashi N, King BF, Atwell TD.
Abdom Radiol (NY). 2016 Jun;41(6):1066-78. doi: 10.1007/s00261-016-0743-6.

2) A Combination Therapy of Partial Nephrectomy and Cryoablation Achieved Good Cancer Control and Renal Function in Bilateral Synchronous Renal Cell Carcinoma.
Takamoto A, Araki M, Wada K, Sugimoto M, Kobayashi Y, Sasaki K, Watanabe T, Nasu Y.
Acta Med Okayama. 2017 Apr;71(2):187-190. doi: 10.18926/AMO/54989.

3) Hereditary Kidney Cancer Syndromes and Surgical Management of the Small Renal Mass.
Nguyen KA, Syed JS, Shuch B.
Urol Clin North Am. 2017 May;44(2):155-167. doi: 10.1016/j.ucl.2016.12.002. Epub 2017 Mar 14.

4) Surgical strategy of bilateral synchronous sporadic renal cell carcinoma-experience of a Chinese university hospital.
Hu XY, Xu L, Guo JM, Wang H.
World J Surg Oncol. 2017 Feb 28;15(1):53. doi: 10.1186/s12957-016-1071-6.

5) Bilateral Synchronous Sporadic Renal Cell Carcinoma: Retroperitoneoscopic Strategies and Intermediate Outcomes of 60 Patients.
Wang B, Gong H, Zhang X, Li H, Ma X, Song E, Gao J, Dong J.
PLoS One. 2016 May 2;11(5):e0154578. doi: 10.1371/journal.pone.0154578. eCollection 2016.

6) Bilateral renal cancers: oncological and functional outcomes.
Berczi C, Thomas B, Bacso Z, Flasko T.
Int Urol Nephrol. 2016 Oct;48(10):1617-22. doi: 10.1007/s11255-016-1354-4. Epub 2016 Jul 5.

==fine reference==

==inizio objective==

Minimally invasive (MI) Off-Clamp partial nephrectomy (OC-PN) is a challenging surgical procedure. Training
programs in this specific surgical field are difficult to realize due to the significant risks of intraoperative bleeding with potential impact on achieving negative
surgical margins. The aim of this study was to compare perioperative outcomes of patients treated with MI-OC-PN by either a training or an expert surgeon in the
same Institution.

==fine objective==

==inizio methodsresults==

The prospectively maintained “renal cancer” database was queried for “off-clamp, minimally invasive, partial nephrectomy”. Overall, data of 372 patients treated between January 2015 and September 2017 were collected. A 1:2 propensity score matched (PSM) analysis was used to generate two populations homogeneous for the following variables: patient demographics (age, gender, BMI); ASA score; tumor size; PADUA nephrometry score; preoperative hemoglobin, preoperative eGFR. Exclusion criteria for propensity score analysis included multiple tumors (17), preoperative estimated glomerular filtration rate (eGFR) <30 ml/min (14), lacking PADUA score (26), single setting multiple surgeries (9), leaving 286 control cases in the expert cohort available for selection. Perioperative outcomes of first 20 patients treated by the training surgeon were compared against 40 PSM selected patients treated by an expert surgeon who have previously performed more than 1000 OC-PN. The training surgeon had previously performed more than 200 minimally invasive prostatectomies and 45 laparoscopic radical nephrectomies. ==fine methodsresults== ==inizio results== Patients treated by the expert surgeon had significantly larger tumors (4.1 vs 2.9, p=0.007), lower incidence of low (≤7) PADUA nephrometry scores (30.1% vs 60%, p=0.029) and higher incidence of comorbidities (ASA score 3-4 27.3% vs 5%, p=0.03). After applying the PSM, the two cohorts were homogeneous for all preoperative variables (all p>0.18, Table 1). Patients treated by training surgeon had higher hemoglobin at discharge (12.4 vs 11.4 g/dL, p= 0.03) and significantly lower incidence of transfusion rates (0 vs 10%) but comparable incidence of hospital stay (4.9 vs 4.6 d, p=0.71), severe complications according to Clavien classification system (5% vs 5%), positive surgical margins (0% vs 2.5%, p=0.47) and eGFR at discharge (78.6 vs 73.4 mL/min, p=0.49, Table 2). Hilar clamping was never necessary in both selected cohorts (0% vs 0%, p=1.00)

==fine results==

==inizio discussions==

Minimally invasive (MI) Off-Clamp partial nephrectomy (OC-PN) is a challenging surgical procedure, with concerns about surgical training [1]. The impact of learning curve on outcomes of MI-OC-PN is negligible after completion of a proper training in minimally invasive surgery.

==fine discussions==

==inizio conclusion==

The impact of learning curve on outcomes of MI-OC-PN is negligible after completion of a proper training in minimally invasive surgery.

==fine conclusion==

==inizio reference==

1. Does training of fellows affect peri-operative outcomes of robot-assisted partial nephrectomy?
Khene ZE, Peyronnet B, Bosquet E, Pradère B, Robert C, Fardoun T, Kammerer-Jacquet SF, Verhoest G, Rioux-Leclercq N, Mathieu R, Bensalah K.
BJU Int. 2017 May 2. doi: 10.1111/bju.13901

==fine reference==