A rare case of a well-differentiated neuroendocrine tumor of the kidney in a young patient: a diagnostic challenge and surgical management

==inizio objective==

Neuroendocrine tumors (NETs) are uncommon tumors that exhibit a wide range of differentiation and biological behavior. NETs can arise from any tissue or organ, including organs that do not normally contain neuroendocrine cells.[1] NETs embrace a large spectrum of diseases rarely originating from the kidney (2); they include well-differentiated NET (carcinoid), well-differentiated neuroendocrine carcinoma, poorly differentiated neuroendocrine carcinoma and small cell carcinoma. Renal carcinoids are typically slow-growing tumors with a variable clinical course. We herein report a rare case of well-differentiated NET (carcinoid) in a 17-year-old male along with the immunohistochemical features and a review of the literature.

==fine objective==

==inizio methodsresults==

A 18-year-old male presented with dull pain in the left flank since 9 months. The abdominal examination revealed a big palpable mass in the left abdomen; CT scan showed a huge cystic tumor occupying the entire left part of the abdominal cavity arising from the left kidney with maximum diameter > 30 cm without regional node involvement and distant metastasis.

==fine methodsresults==

==inizio results==

US-guided percutaneous biopsy of the neoplasm was inconclusive and the patient underwent surgical removal of a large renal tumor displacing all the surrounding organs in absence of infiltrative growth pattern. The mass was excised by blunt dissection from the kidney allowing to preserve a large amount of healthy renal parenchyma.
Gross examination revealed a brown coloured cystic mass with large haemorragic areas, apparently surrounded by a fibrous capsule.
On microscopic examination there was absence of necrosis and mitotic figures were scant (<2/10 HPF). Immunohistochemically, these tumor cells were diffusely positive for chromogranin, synaptophysin, vimentine, CK8/18 and negative for GFAP, pS100, RCC, PAX-8, WT-1 and CK-7. Ki-67 index was nearly 2%. Thus, a diagnosis of well-differentiated NET was given.

==fine results==

==inizio discussions==

NETs are most commonly seen in the gastrointestinal tract, less frequently in the respiratory system and sporadically in parenchymal organs such as the liver. Primary NETs of the kidney are extremely rare.[2] They can occur in both the renal parenchyma and the renal pelvis.[3]
The pathogenesis of primary NETs of the kidney is still controversial. Neuroendocrine cells have been identified in the renal pelvis but not in the normal renal parenchyma.[4] Different theories support the fact that NETs arise from primitive totipotential stem cells that subsequently differentiate in a neuroendocrine direction. Several mechanisms have been used to explain the origin of such tumors, including metastasis from an occult primary tumor site to the kidney, activation of aberrant gene sequences in a totipotential stem cell line that differentiates into aberrant NET cells, and concurrent renal congenital abnormalities. Some authors think that the tumors arise from neuroendocrine cells occurring in the mucosa of the renal pelvis in intestinal metaplasia.[5]
In 2010, the WHO has proposed a classification system for renal carcinoid tumors that is similar to that of the carcinoid tumors of other organs.[6] They classified neuroendocrine neoplasms into NET-well differentiated grade 1, NET-well differentiated grade 2, NEC-poorly differentiated grade 3 (small and large cell type), mixed adenoneuroendocrine carcinoma, hyperplastic, and preneoplastic lesions. This classification differentiates between NETs and neuroendocrine carcinomas. The proliferation index (Ki-67, MIB-1), angioinvasion, and mitoses are important factors in this classification.
Well-differentiated NET (carcinoid) of the kidney are rare with 4 cm. This could be due to the vacuous nature of the retroperitoneal space as kidneys are essentially retroperitoneal organs.
There is no clear correlation between the histologic features of the disease and prognosis and tumor necrosis is not a predictor of prognosis. Metastatic workup must always be done to rule out the possibility of metastasis from an occult tumor elsewhere when a clinical diagnosis of renal carcinoid is made. Long-term follow-up care is essential because of the prolonged course of disease despite metastasis. The clinical course of renal carcinoid is difficult to predict because of the rarity of the condition; however, it is largely believed to have an indolent course

==fine discussions==

==inizio conclusion==

The current recommended management for primary renal carcinoid tumors includes radical nephrectomy with surveillance and surgical removal of any subsequent metastases.[6] Even partial nephrectomy is recommended. The average follow-up time is 20 months with 73.1% of patients without evidence of disease after surgical treatment which suggests that surgical treatment is curative.[8],[9] Liver metastasis can be treated with open resection or with minimally invasive ablative procedures. Metastatic renal carcinoid has been noted to be resistant to chemotherapy.

==fine conclusion==

==inizio reference==

1.
DeLellis RA, Osamura RY. Neuroendocrine tumors: An overview. Pathol Case Rev 2006;11:229-34.

2.
Lane BR, Jour G, Zhou M. Renal neuroendocrine tumors. Indian J Urol 2009;25:155-60.
3.
Kuroda N, Katto K, Tamura M, Shiotsu T, Hes O, Michal M, et al. Carcinoid tumor of the renal pelvis: Consideration on the histogenesis. Pathol Int 2008;58:51-4.

4.
el-Naggar AK, Troncoso P, Ordonez NG. Primary renal carcinoid tumor with molecular abnormality characteristic of conventional renal cell neoplasms. Diagn Mol Pathol 1995;4:48-53.

5.
Romero FR, Rais-Bahrami S, Permpongkosol S, Fine SW, Kohanim S, Jarrett TW. Primary carcinoid tumors of the kidney. J Urol 2006;176 (6 Pt 1):2359-66.

6.
Eble JN, Sauter G, Epstein JL. World Health Organization Classification of Tumours. Pathology and Genetics of Tumors of the Urinary System and Male Genital Organs. Lyon: IARC Press; 2004. p. 81-2.

7.
Omiyale AO, Venyo AK. Primary carcinoid tumour of the kidney: A review of the literature. Adv Urol 2013;2013:579396.

8.
Raslan WF, Ro JY, Ordonez NG, Amin MB, Troncoso P, Sella A, et al. Primary carcinoid of the kidney. Immunohistochemical and ultrastructural studies of five patients. Cancer 1993;72:2660-6.

9.
Cabral Ribeiro J, Sousa L, Ribeiro Santos A. Primary neuroendocrine tumor of the kidney. Actas Urol Esp 2010;34:907-9.

==fine reference==

PREDICTIVE FACTORS OF RENAL FUNCTION IMPAIRMENT AFTER 18 MONTHS IN PATIENTS UNDERGOING LAPAROSCOPIC PARTIAL NEPHRECTOMY

==inizio objective==

Currently there are no indications about nephrologic consult in patients undergoing partial nephrectomy (PN) at risk of chronic kidney disease. The present study has the purpose of identifying the predictive factors of significant fall in eGFR below 60 mL/min after 18 months (eGFR18) in patients undergoing laparoscopic partial nephrectomy. The analyzed variables are: preoperative creatinine, age at the time of surgery, Padua score, RENAL nephrometry score, gender and the percentage change in perioperative creatinine (from before the surgery to 72h after).

==fine objective==

==inizio methodsresults==

==fine methodsresults==

==inizio results==

==fine results==

==inizio discussions==

According to EAU guidelines, the choice therapy for T1a and T2b tumors is PN due to the lower morbidity compared to radical nephrectomy (RN)1,2. Despite the fact that PN preserve renal function more than RN, the former procedure still exposes the patient to the risk of renal filtration’s fall. In fact, many studies in the last years had the purpose of disclosing the risk factors for renal function impairment after PN3–8.
Preoperative creatinine, as said before, was found not significant at univariate analysis (p=0,0792) but, at multivariate, using 0,95 mg/dl as threshold it was the only significant variable (p=0,0205, OR=18,2). We speculated that because creatinine values, in our sample, were not pathological as one inclusive criterion was preoperative eGFR>=60 mL/min, it was necessary to split our population to better perform the multivariate analysis. The creatinine threshold was found building the ROC curve, comparing creatinine values to eGFR18, and it resulted that creatinine >0,95 mg/dl had sensitivity of 66,7% and specificity of 73% to identify patients at risk of eGFR18<60 mL/min. The analysis demonstrates that creatinine level is a prominent risk factor for significant renal function impairment also in normal functioning kidneys. We believe that this result is important and reliable, since our population preoperative eGFR is above 60 mL/min and thus with normal renal function. Padua score demonstrated significant at univariate (p=0,0242) but not significant at multivariate (p=0,404, OR=1,52). RENAL proved to be not significant to both univariate (p=0,0942) and multivariate (p=0,6653, OR=1,21). Despite the results we believe that both scores are important, and the small population played a major role for the outcome as other papers showed a correlation between nephrometric scores and late eGFR9,8. In support of our hypothesis, we highlight that group 1 had higher values in both mean and median for both scores. Gender proved to be a risk factor at multivariate but without statistical significance, nevertheless it agrees with literature 7,8(p=0,1779, OR=5,85). Age did not demonstrate any correlation with eGFR18, neither at univariate nor at multivariate analysis (p=0,6831, OR=1,01). Even if group 1 had higher mean and median age the values between the groups were too close to identify any significant difference, and this is likely to be the reason for the result as other studies had a different outcome3,4,8. Percentage change in creatinine from pre-surgery to 72h after-surgery was not associated with eGFR18 (p=0,6855; OR=1,01). This is still a relevant result because, as said previously, we incurred in only 5 AKI stage 1, and therefore the role of AKI in our sample can be considered marginal. For this reason, we speculated that variation in perioperative creatinine, in the absence of AKI, doesn’t represent a risk factor and should not alarm the physician, but other investigation should be performed. ==fine discussions== ==inizio conclusion== The present study, despite the small sample and therefore the lack of significance in most statistical analysis, still highlights preoperative creatinine, Padua score, RENAL score and gender as risk factors for significant eGFR18 fall. Furthermore, it seems that percentage change in perioperative eGFR in the absence of AKI is not a risk factor and therefore should not alarm the physician. The age between the two groups is comparable so it was not possible to find any correlation with eGFR18. ==fine conclusion== ==inizio reference== 1. Klatte T, Ficarra V, Gratzke C, et al. A Literature Review of Renal Surgical Anatomy and Surgical Strategies for Partial Nephrectomy. Eur Urol. 2015. doi:10.1016/j.eururo.2015.04.010 2. Weight CJ, Larson BT, Fergany AF, et al. Nephrectomy Induced Chronic Renal Insufficiency is Associated With Increased Risk of Cardiovascular Death and Death From Any Cause in Patients With Localized cT1b Renal Masses. J Urol. 2010. doi:10.1016/j.juro.2009.12.030 3. Choi YS, Park YH, Kim YJ, Kang SH, Byun SS, Hong SH. Predictive factors for the development of chronic renal insufficiency after renal surgery: A multicenter study. Int Urol Nephrol. 2014. doi:10.1007/s11255-013-0534-8 4. Lee KS, Kim DK, Kim KH, et al. Predictive factors for the development of renal insufficiency following partial nephrectomy and subsequent renal function recovery: A multicenter retrospective study. Medicine (Baltimore). 2019. doi:10.1097/MD.0000000000015516 5. Mukkamala A, He C, Weizer AZ, et al. Long-term renal functional outcomes of minimally invasive partial nephrectomy for renal cell carcinoma. Urol Oncol Semin Orig Investig. 2014. doi:10.1016/j.urolonc.2014.04.012 6. Barlow LJ, Korets R, Laudano M, Benson M, McKiernan J. Predicting renal functional outcomes after surgery for renal cortical tumours: A multifactorial analysis. BJU Int. 2010. doi:10.1111/j.1464-410X.2009.09147.x 7. Lane BR, Babineau DC, Poggio ED, et al. Factors Predicting Renal Functional Outcome After Partial Nephrectomy. J Urol. 2008. doi:10.1016/j.juro.2008.08.036 8. Martini A, Cumarasamy S, Beksac AT, et al. A Nomogram to Predict Significant Estimated Glomerular Filtration Rate Reduction After Robotic Partial Nephrectomy. Eur Urol. 2018. doi:10.1016/j.eururo.2018.08.037 9. Marconi L, Desai MM, Ficarra V, Porpiglia F, Van Poppel H. Renal Preservation and Partial Nephrectomy: Patient and Surgical Factors. Eur Urol Focus. 2016. doi:10.1016/j.euf.2017.02.012 ==fine reference==

NEFRECTOMIA DESTRA LAPAROSCOPICA RETROPERITONEALE CON CAVOTOMIA

==inizio abstract==

Il video descrive il trattamento laparoscopico di una voluminosa neoformazione renale destra in paziente ZD di anni 55, che ha eseguito follow-up per pregresso Ca mammario, con riscontro TC di lesione espansiva di 8 cm al III medio inferiore del rene destro, determinante infiltrazione del sistema collettore ed espansione della vena renale per estesa colonizzazione di tessuto neoformato che protrude leggermente nel lume cavale.
TC torace negativa.
Il video mostra la preparazione dello spazio di lavoro retroperitoneale destro, isolamento e trattamento dell’arteria renale destra, clippaggio della vena surrenalica e dell’uretere destro; preparazione della cava ed isolamento della vena renale destra, imbottita dal trombo neoplastico. Viene descritto il posizionamento di Satinsky sulla cava, cavotomia, asportazione del trombo cavale, doppia sutura in prolene 3-0: declampaggio cavale, completamento dell’isolamento del rene ed asportazione in endobag attraverso minilaparotomia di servizio.
I tempi operatori sono stati di 100 minuti, le perdite ematiche intraoperatorie 400 ml.
Gli esami di laboratorio hanno evidenziato un calo dell’emoglobina in prima giornata postoperatoria: 13.1 g/dl (da 15.1 preoperatoria), mentre la creatininemia postoperatoria è stata 1.0 (preoperatoria 0.9).
Il drenaggio lombare è stato rimosso in II giornata post-operatoria, mentre la paziente è stata dimessa in IV giornata.

==fine abstract==

CLAMPLESS LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR HILAR COMPLEX TUMORS

==inizio abstract==

Nephron sparing surgery is now reference standard for many T1 renal tumors. ”Zero ischemia” partial nephrectomy allows to eliminate ischemia during nephron sparing surgery. It is possible to realize a clampless LPN also for the treatment of hilar tumors. The video shows 3 cases of complex renal turmors.
The first case shows a transperitoneal clampless left PN for hilar tumor.Hilar vessels are prepared in event that bulldog clamping may subsequently be needed. Intreoperative laparoscopic ultrasound is performed to identify tumor borders. To induce hypotension, the doses of inhalational isoflurane is increased. The renal lesion is excised using Ligasure. Calyceal suture was performed with Monocryl. Renal parenchyma was repaired with Vicryl™ sutures arrested with absorbable clips. Hemopatch and Floseal were applied to resection bed. The second case is represented by a right hilar tumor; Padua score is 9h and C index 1.4. The renal artery and vein are isolated on vessel loop. We proceed with resection of tumor using Ligasure. The third tumor is a left hilar tumor with Padua score is 10h, C index 0.4; renal artery is isolated on vessel loop. In this case we proceed with selective clamping of tumor artery during resection of the lesion. After removing bulldog clamp, renorraphy is completed.

==fine abstract==

Nefrectomia parziale laparoscopia transperitoneale 3D per neoplasie renali complesse

==inizio abstract==

In questo video vogliamo esporre il nostro approccio chirurgico abituale per le neoplasie renali T1b complesse.
Riteniamo infatti che la tecnica lapariscopica transperitoneale tridimensionale, possa essere un approccio standard per l’aggressione di masse renali voluminose, localizzate soprattutto sulla faccia anteriore e al polo superiore dell’organo.
Il video si compone di 2 casi clinici similari:
Caso 1: una Paziente di 37 anni normopeso che non presentava nessuna comorbidità di rilievo, ha avuto una diagnosi accidentale TC durante ricovero in ambiente internistico per polmonite, di neoformazione allocata al polo superiore del rene destro delle dimensioni di 71×46 cm, in stretta contiguità alla faccia inferiore del surrene omolaterale.
Caso 2: una Paziente di 66 anni obesa e con lievi comorbidità, ha avuto una diagnosi accidentale ecografica (successivamente approfondita con indagine TC) di neoformazione renale allocata alla faccia anteriore del rene sinistro, sul terzo medio-superiore verso il labbro mediale, del diametro di 3,9 cm.
Secondo la nostra esperienza, l’approccio chirurgico laparoscopico tridimensionale transperitoneale, risulta ideale nella gestione delle neoformazioni renali (fino a T1b) localizzate alla faccia anteriore del rene, di natura anche complessa e parzialmente endofitica. Tale evidenza corrobora inoltre le indicazioni delle linee guida EAU a tal riguardo.

==fine abstract==

3D CLAMPLESS LAPAROSCOPIC PARTIAL NEPHRECTOMY

==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==

101 patients affected by renal tumor underwent zero ischemia LPN. Mean age and mean BMI were 59.9 (±11.7) years and 28.0 (±4.9). ASA score was 1, 2 and 3 in 6.9%, 42.5%, 43.7% and 6.9%, respectively. Renal score was low (4-6) in 28.7%, moderate (7-9) in 61.4% and high (10-12) in 9.9% of the patients.
Mean tumor size was 43.7 mm (±15.8). Operative time, blood loss, ∆Hb were 149.6 min (±52.4), 371.2 ml (±328.8), 2.8 gr/dl (±1.5), respectively. In all cases the procedure was performed without clamping. Resection, first and second suture times were 8.3 (±5.7), 9.4 (±6.3) and 6.7 (±2.3) minutes, respectively. Hospital stay was 6.7 (±3.9) 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==

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.

==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==

SURGICAL OUTCOMES AND PERIOPERATIVE MORBIDITY OF CLAMP vs OFF-CLAMP LAPAROSCOPIC PARTIAL NEPHRECTOMY

==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 65 patients in the clamp group and 101 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].

==fine results==

==inizio discussions==

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.

==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==

Clamp-Less partial robotic nephrectomy (RPN): surgical feasibility, percentage of positive margins and intra- and post-operative complications

==inizio objective==

Robotic partial nephrectomy (RPN) has emerged as an attractive minimally invasive nephron-sparing surgical option. However, on-going concerns about RPN include: prolonged ischaemia time with potential implications on renal functional outcomes(1-2). We detail the technique and present perioperative outcomes of our technique of zero-ischaemia RPN for renal tumours (Clamp-less Robotic surgery)(3).

==fine objective==

==inizio methodsresults==

From January 2011 to September 2019 181 patients underwent PN Clamp-Less Robotic Assisted Care. RPN was offered to all patients with even partially exotic lesions, regardless of renal-vascular anatomy, contralateral kidney characteristics or renal function. 5/181 had dual unilateral tumours. 7/181 had monorene.
The mean diameter of the neoplasms was 3.9 cm (2.5 – 5.5 cm), the lesions were localized: 101 right kidney, 80 left kidney, 47 upper polar, 53 middle, 80 lower.
The operating technique involved the use of 3 robotic doors (camera + scissors and Prograsp) + 1 accessory door. After isolation of the kidney and the lesion, hot enucle/tumorectomy was performed with subsequent diathermocoagulation of the enucleoresezine bed with positioning of fibrin glue and haemostatic material

==fine methodsresults==

==inizio results==

The RPN Zero-ischemia has been successful in all cases without the need for hilar clamping. The size of the median tumor (range) was 3.9 (2.5-5,5) cm. The time of warm ischemia was zero in all cases. The mean operating time was 60 (45-100) min, the estimated blood loss was 120 (50-300) ml. The average hospital stay was 4 (3-6) days. There were no intraoperative complications; 4/181 (0.02%) patients presented a post-operative haemorrhage that required a decisive laparotomy. None of the 4 patients had bleeding from the resection margins. 2 patients was bleeding from kidney fat and 2 from a robotic port. All tumour samples had negative surgical margins. The absolute median decrease in serum creatinine and the estimated glomerular filtration rate at discharge were 0 (0.2-0.7) mg / dL (P = 0.4) and 5 (-16-29) mL / min for 1.73 m (2) (P = 0.8), respectively.

==fine results==

==inizio discussions==

Zero-ischemic RPN for kidney cancer is safe and feasible. The elimination of hot ischemia can optimally preserve renal function.

==fine discussions==

==inizio conclusion==

Randomized prospective studies are required to confirm any renal functional advantages of RPN without clamping.

==fine conclusion==

==inizio reference==

1. Zero-ischaemia robotic partial nephrectomy (RPN) for hilar tumours.
Abreu AL, Gill IS, Desai MM.
BJU Int. 2011 Sep;108(6 Pt 2):948-54
2. Off-clamp robot-assisted partial nephrectomy does not benefit short-term renal function: a matched cohort analysis.
Anderson BG, Potretzke AM, Du K, Vetter J, Figenshau RS.
J Robot Surg. 2018 Sep;12(3):401-407. doi: 10.1007/s11701-017-0745-6. Epub 2017 Aug 31
3. On-clamp versus off-clamp robotic partial nephrectomy: A systematic review and meta-analysis.
Antonelli A, Veccia A, Francavilla S, Bertolo R, Bove P, Hampton LJ, Mari A, Palumbo C, Simeone C, Minervini A, Autorino R.
Urologia. 2019 May;86(2):52-62.

==fine reference==

A single institute retrospective analysis between laparoscopic partial nephrectomy and open partial nephrectomy for the treatment of highly complex renal tumors with PADUA score ≥10

==inizio objective==

Partial nephrectomy(PN) is considered the standard of care in patients with T1 tumours for whom a PN is feasible by any approach, including open (1). PN achieves equivalent oncological outcomes with those of radical nephrectomy(RN) also in patient with RCC ≥4cm (2). The indications for (nephron sparing surgery) NSS are expanding with the use of minimal invasive techniques. Studies comparing laparoscopic and open PN found no difference in PFS and OS in centers with laparoscopic expertise (3). Anatomical classification systems, such as the PADUA score, help the surgeon to evaluate the complexity of the tumor. We considered complex renal tumors as Preoperative Aspects and Dimensions Used for an anatomical (PADUA) ≥10 (4). We report our experience in conservative treatment of highly complex renal tumors with PADUA score ≥10.

==fine objective==

==inizio methodsresults==

We retrospectively evaluated all the patients treated in our department from January 2015 to September 2019. All procedures were performed by a single surgical team. 21 patient underwent an open partial nephrectomy (OPN) (Group A) and 72 underwent a laparoscopic partial nephrectomy (LPN) (Group B). All OPN were performed with a retroperitoneal approach and all LPN were performed with a transperitoneal approach. Postoperative complications have been classified according to the Clavien-Dindo system. Only the complications with a score ≥3 were considered in the analyses. Mean values with standard deviations(±SD) were computed and reported for all items. Statistical significance was achieved if p-value was ≤0.05(two-sides). Statistical analyses were conducted using SAS version 9.3 software(SAS Institute, Inc., NC)

==fine methodsresults==

==inizio results==

The two groups showed no difference in terms of patients’ demographics as well as tumour characteristics in all variables (p>0.05) [age, BMI, weight, height, comorbidity according to Charlson Comorbidity Index, Clinical Stage, PADUA score, left and right side]. Table 1 summarizes the operative data and grade ≥3 post-operative complications according to Clavien-Dindo classification. Group A was found to be similar to group B in terms of operation time (p=0.0877) , conversion to radical nephrectomy (p=0.3485) and positive surgical margin (p=0.0626) while estimated blood loss (p=0.0205), intraoperative (p=0.0104) and post-operative (p=0.0081) transfusion rate, drains time (p=0.0012), pain score at post-operative day one ( 10. Our study has some limitation, first of all the size of our cohort. While we were able to identify statistically significant differences between the treatment modalities, the study is not adequately powered to detect more subtle differences. In recent time the trend at our hospital is to treat the most complex endophytic tumours with a robotic approach. Three very complex Robotic Partial Nephrectomy(RPN) have been performed; in two of them, the lesion was studied preoperatively with three-dimensional models(11).

==fine discussions==

==inizio conclusion==

LPN represents a feasible and safe procedure for renal tumours of a high surgical complexity if performed in highly experienced laparoscopic centres. The procedure offers good intraoperative outcomes and a low rate of post-operative complications.

==fine conclusion==

==inizio reference==

1- B. Ljungberg (Chair), L. Albiges, K. Bensalah, A. Bex (Vice-chair), R.H. Giles (Patient Advocate), M. Hora, M.A. Kuczyk, T. Lam, L. Marconi, A.S. Merseburger, T. Powles, M. Staehler, A. Volpe; EAU Guidelines 2019
2-Lee H, Oh JJ, Byun SS, et al. Can partial nephrectomy provide equal oncological efficiency and safety compared with radical nephrectomy in patients with renal cell carcinoma (≥4 cm)? A propensity score-matched study. Urol Oncol 2017;35:379–85.
3- Gill IS, Kavoussi LR, Lane BR, Blute ML, Babineau D, Colombo JR Jr, Frank I, Permpongkosol S, Weight CJ, Kaouk JH, Kattan MW, Novick AC. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors.J Urol. 2007 Jul;178(1):41-6. Epub 2007 May 11.
4- Ficarra V, Novara G, Secco S, et al. Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery. Eur Urol 2009;56:786–9.
5- Mir MC et al.; Decline in renal function after partial nephrectomy: etiology and prevention.; J Urol. 2015 Jun;193(6):1889-98.
6-Chang KD et al.; Functional and oncological outcomes of open, laparoscopic and robot-assisted partial nephrectomy: a multicentre comparative matched-pair analyses with a median of 5 years’ follow-up; BJU Int. 2018 Oct;122(4):618-626.
7-Mohamed Abdelhafez , Amend Bastian, Steffen Rausch, et al. Laparoscopic Versus Open Partial Nephrectomy: Comparison of Overall and Subgroup Outcomes. Anticancer Res, 37 (1), 261-265. Jan 2017
8- Michael W Patton, Daniel A Salevitz, Mark D Tyson 2nd et al. Robot-assisted Partial Nephrectomy for Complex Renal Masses. J Robot Surg, 10 (1), 27-31 Mar 2016
9-Patard JJ et al. Morbidity and clinical outcome of nephron-sparing surgery in relation to tumour size and indication. Eur Urol. 2007;52(1):148–154
10- Marszalek M et al.;Laparoscopic and open partial nephrectomy: a matched-pair comparison of 200 patients; Eur Urol. 2009;55(5):1171–1178
11- Francesco Porpiglia, Riccardo Bertolo, Enrico Checcucci et al. Development and Validation of 3D Printed Virtual Models for Robot-Assisted Radical Prostatectomy and Partial Nephrectomy: Urologists’ and Patients’ Perception. World J Urol, 36 (2), 201-207. Feb 2018

==fine reference==

Renal Cell Carcinoma associated with pancreatic metastasis: a case raport

==inizio objective==

We describe a case of right nephroureterectomy and contextual pancreatic nodulectomy in a patient with Renal Cell Carcinoma (RCC) associated with pancreatic metastasis.

==fine objective==

==inizio methodsresults==

81-year-old female patient. Medical history of compensated DM, hypertension, colonic diverticulosis, right mastectomy and adjuvant chemotherapy ( previous breast cancer). He went to our hospital institution for right abdominal pain not associated with other significant symptoms. Blood tests showed modest leukocytosis and a marked increase in PCR. Amylase and Lipase were regular. An abdominal ultrasound was performed that showed a lesion on the lower pole of the right kidney (9 x 6 cm) associated with hypo-anecogenic lesion of the pancreatic body (2,7 cm). Given the clinical and ultrasound picture, it was decided to perform a CT Abdomen with mdc which showed a heteroplasia of the lower pole of the right kidney (6,5 x 9 cm) inhomogeneously hypervascularized and with a central necrotic hemorrhagic area. In the perilesional area there were arterio-venous vascular ectasias with shunt effect. In the proximal portion of the pancreatic body there was a hypervascular nodular lesion (2 x 3 cm) compatible with pancreatic localization of RCC. This lesion caused dilation of the Wirsung. Given the good performance status of the patient, after multidisciplinary consultation it was decided to perform right nephro-adreno-ureterectomy and contextual removal of the pancreatic nodule (laparotomic technique). The wirsung duct upstream of the lesion was inoculated with Nelaton’s catheter. This allowed the drainage of pancreatic juices outside the patient in post-surgery. The tract of Wirsung afferent to the duodenum was dissected with Ligasure to prevent the reflux of duodeno-gastic or bile juices. Two 24 ch tubular drainages were left (one in the renal loggia the other in the pancreatic loggia)

==fine methodsresults==

==inizio results==

The post-operative course was regular. Renal drainage was removed on 3th day and pancreatic drainage on 6th. The Nelaton catheter was removed on the 12th day. The patient was discharged in the 14th day with blood tests in the standard except for a modest anemia (Hb 9.9 g / dl) and leukocytosis (11000). The outcome of the histological examination was: clear cell RCC, 4° grade (sec. WHO / ISUP), TNM stage pT3a, Nx, M1. Pancreatic lesion was confirmed by clear cell RCC metastasis. Following oncologist counseling, the patient started targhet terapy with sunitinib. At the first postoperative control CT (3 months after surgery) there are no signs of local and distant recurrence. Pancreas preservation did not induce diabetic decompensation. Renal function was at Creatinine values ​​of 1.6 mg/dl.

==fine results==

==inizio discussions==

Metastasis in the pancreatic gland is infrequent, representing between 2-5% of the tumors that affect this organ. However, secondary lesions of clear cell renal carcinoma (CCRC) can occur mainly in this location and it is frequently the only site of dissemination (1). Many authors support the effectiveness of treatment in patients with good performance status even considering the fact that pancreatic resection for RCC showed better survival compared to other non-renal cell cancer (2). The European Metastatic RCC Guidelines state that cytoreductive nephrectomy in patients with complete contextual resection of a single metastasis or few metastases could increase survival and delay therapy systemic. This is supported by a low degree of evidence (level 3) (3). Zerbi et al. have shown that pancreatic metastatectomy can be beneficial in terms of OS compared to non-treatment (4). However, it remains to be clarified which category of patient with Metastatic RCC can really benefit from a surgical treatment of metastasis and primary tumor. What is certain is that the use of the IMDC (Metastatic Renal Cancer Database Consortium) can actually direct us to the most appropriate therapeutic choice. In this regard, the EAU suggests to offering cytoreductive nephrectomy to patients with metastatic RCC to low and intermediate risk (4). The decision to subject the patient to surgery was dictated by the fact that she had a good performance status and that she was in the low-risk category according to IMDC.

==fine discussions==

==inizio conclusion==

Our opinion is that in selected patients with good performance status radical surgery (of the primary and possibly secondary lesion) should be taken into consideration as it can improve oncological and functional outcomes.

==fine conclusion==

==inizio reference==

(1) The pancreas as a target of metastasis from renal cell carcinoma: Results of surgical treatment in a single institution.
Ann Hepatobiliary Pancreat Surg. 2019 Aug;23(3):240-244. doi: 10.14701/ahbps.2019.23.3.240. Epub 2019 Aug 30.
Glinka J, Sanchez Claria R, Ardiles V, de Santibañes E, Pekolj J, de Santibañes M, Mazza O.
(2) Metastatic tumors to the pancreas: a systematic review and meta-analysis.
Minerva Chir. 2016 Oct;71(5):337-44. Epub 2016 Jul 14.
Sperti C, Pozza G, Brazzale AR, Buratin A, Moletta L, Beltrame V, Valmasoni M.
(3) EAU Metastatic RCC Guidelines 2018
(4) Pancreatic metastasis from renal cell carcinoma: which patients benefit from surgical resection? Ann Surg Oncol, 2008. 15: 1161.
Zerbi A, et al.

==fine reference==