POCKET GUIDE TO UROLOGY Sipaaem Oebtacesey JEFF A, WIEDER, M.D. ] ; q 4 j , J 3 ; : ) 3 J ] J j j ‘ ] ] ,IMPORTANT NOTICE, + This book is intended for use by hel ae professionals, * During our igoroussttpts o make Pocket Gude wo Urology acetate, We Inve depended on ferences tat re presume to Be ra and eee. ‘Typographical eos, panting ers, emission, and inaccuracies may be present despite ourmsticloas effet o maketh contents ofthis book roe, The infeemaion inthis bok may be inaccurate, Incomplete, end ‘ut of date. Healthcare profesional shoud ves) the iaformaton ‘ontsined within hs ext bare aplving it any cveamstance. «This book provides methods of working up, diagnoting, and weating various ‘medial conditions There maybe alfernves hata not Iisted. This Book {snot meant to sere ara srt eine, but ralber to provide suggestions to consider hen aking your decision paring the workup and treatment fof pasent. Approwiate work up and eatment must be determined by the health care pofesconl bared on each patients unique ccumstance. + This book ino substi fr appropriate medial raining and education, * Some medications a media! devices listed inthis book are nt approved by ‘the Food and Dri Administration (FDA) fr the indicton give herein. urthennore, tht Bok does no provide complete ar current presebing information Uefor prescribing any medication or modal device ‘Gc te ones sted within his Book, te helt ere provider should ‘completely read pout abel, package inser, nsraction, ad ‘presebing information and shou be are of a pre’ propia se, Including (bt no nied to) fe FDA satus, ts FDA approved indications, Contraindieations, dose, route of administration, adverse reactions us fetersctons and duration of therapy. «The information in hs book is subject change tay ine "This hook comes witout waranto and gusrantes expressed or impli The author, publish tors, and sponsors disclaim any and al ably, injury, Toss, damage, expense, and any oer consequences caused by the we, ‘mise, oe apliason ofthe information in Pocket Guide to role. + it you do not wan tbe bound by the conditions, stipulations, and warnings Tsted above, ther eference book are ava or your ss Copyright © 2021, 201, 2010, 2007, 2005 1999, Jeff A. Wider. MD. All rights reserved No part ofthis publistion may be reproduce, stored ina retrieval system, or transmit by say form or by any mean ieloing but no limited to digi, slecronic, magnetic, mechanical, photographic, photocopying, printing, ‘eurding, and scanning) without prior weitex pemision fom the author, Ist A. Wieder M.D, BN # 978-.0-9672845-76 Prine inthe United Sates of America Produce by J. Wieder Medical wor pockeipuidetourogy comPOCKET GUIDE TO UROLOGY Sixth Edition “If I have been able to see farther than others, it was because I stood on the shoulders of giants.” —Sir Isaac Newton i fore comics stacey ulin, det pater ‘oc re in od print. encourage you to read these publications on your ‘vn. With yoursuppo, hope to soatinu improvig ed updating the Pocket Gute to Urotegy Tanks al the pressor residents and co-workers Who ‘ontbuted ony eden and helped make this book reli, Jeff A. Wieder, M.D. ‘To ader additional copies of this book and for more information, please visit my website www.pocketguidetourology.comCONTENTS Volume 1: Oncology onal Te en Wilms’ Tumor & Other Pediatric Renal Tumors... 41 Bladder Tumors. Upper Urinary Tract Urothelial Cancer. Tumor Markers for Urotheial Cancer. Penile Tumors Androgen Deprivation... Prostate Specific Antigen (PSA) .. Volume 2: Non-oncology Void ‘ Voiding & Urodynamies. 303 Benign Prostatic Hyperplasia .. me 312 Urinary Incontinence: General Concepts... Urge Incontinence & Overactive Bladder Stress Urinary Incontinence in the Female. Stress Urinary Incontinence in the Mal Hematuria Urolithiasis Strictures of the Lower Urinary Tract Stritures of the Upper Urinary Tract Imaging & Radiology. Pregnancy, Development, & Pediatric Embryology. Pregnancy: Urologie Considerations. Vesicoureteral Reflax ey |CONTENTS Sexual Dysfunction & Infertility Erectile Dysfunction..... Male Hypogonadism Ejacalatory Disorders.. Male Infertility nn ‘Trauma rok Emergent Urologic Conditions .. Priapism, Genitourinary Trauma Genitourinary Infections: General Concepts.. Lower Urinary Tract Infections snmns Upper Urinary Tract Infections. Genital Infections. Prostatitis & Prostate Infection Sexually Transmitted Disease Gas Forming Infections weurenmeeenn Fungal Infections vinnenenenninnnnsns Malacoplakia & Tuberculosis... Urologic Surgery ‘Surgical Principles... Ureteral Stents snninnnnninnsnnanns Use of Intestine in the Urinary Tract... Reference Doses of Commonly Used Medications... Formulas and Conversion nnRENAL TUMORS Presentation Many tunors ar found incidentally daring the evaluation of unrelated medial sues; therefor, renal tuners ae often asymptomatic. 2. Symptoms include flan psi, hematin, weightloss, ve, nd Sweats. 5: Sign inchde flank mass, hypertension, nw varicoele (especially rapid ‘nse, an paranoplatic syndromes (0 page 12). 4 The clase rad (Tank mass, hematria, nd ak pin) now rare because amor are oe detected incdcatally at alow stage. The presence ofthe classic wid siguiiesedvanced disse, Wert Up Spal ay cla ora Tin] (oy spi Gos ts) Ting done ul ie mas is adequily characte" Options ince Renal ssovnd 2. Abdominal CT scan with & without intravenoascontst ‘3. MRI wih Gaolinim) al son Urea Tumor Suspected? —] ‘Urine anor mv, pyelogam, -twreteroscony ee page92) Cs ——] Nay) [ Ps ae |[ Sed | as ect NK aca Cr nid ag rye AISA) [Noma DSA = rama santnnicae | acs No change — | [Sinton cbmes] || "owctnana” | | ‘anced [Frat forsapeciod maligne (eopage2)] [Taewotamor Notice ae C= computer tenogrghy, ME ~ magne raceme ing * Complex es and sold renal asc shoul be evaatod with Calor MRL ‘spect tunersize and action (iit amenable to nephron paring sare?) el ‘vei and ven cava (tmar ob present), contr dae (ait ora), nal nds, Ih nods, ind othe organs (re metastars pesca?) ‘+See Imagiago Renal Cysts on page 49 and Deana Clifton on pg 46. ‘$Cnallyfocsted tuners, espacial the that pperto fil he olleting ye, te suspicious for rth carcinoma,2 POCKET GuIDETO UROLOGY ett Wieder, MD valuation of Suspected Renal Malignancy 7 Physical exam ‘nating blood pressure skin exam, and lymph node ‘exam Hypertens may be cused by a parancoplastc syndrome from RCC (ec page 12) or by 8 jostaglomerdar tumor. Skin lesions that ae sssclted with nti renal mor syndromes are shown below. Sis Caen Description [Syndrome ‘Adznons [Paced colored papules, aly oven tehaceun | "the chek tne orth msl is Iria pou THFOPSMENT Se on unk or BIE] Tubes gr pat | Ones pl exer plague on thTower ck] Sclerosis a a wo Test cofre papal TS S| — yp Fibula a amour —| Saal pps papel ne ae TOSON | og Loman | shaiefoticies The papas oe pa fe sooth Neh colored papel, aly —— the fa, ip, oul as and et en “WaT colored papas piel oF ‘icitemmonas | Peco dooum ofthehands and fo | Haars ‘Siickeaing one palms ofthe banis andar] 2845) —— one oles of the at __— Tans Maca — Ms pigeon of th gl pen BTID = Ha Hoge Das Syndrome HL RCC Hereditary Leomyoratoss Renal Cal Carcinoma. 2, Obtain maging wil the mai adequately characterized (seepage 1). If ‘eu cava vaso is pected, obtain an abdominal and chest MEL 3. Oban ab test-BUN, creatine, allaine phosphatase liver funtion tests, LDH, sera eaziom, complete blood count and wali. IF trinlis shows poten, obtain quantitative measure of wine protein (Goch spot wie protcn/reatnine rat, spo urine albuminreatinine fat, of 21 hour se for pot) 4, Asigna chronikidney disease (CKD) stge using proteinuria lve and “alee glomera ieation rte (GFR). ‘5. Por patients withrenal dysfunction, consider pe-eatment refer to a neprlogi, especialy npn with pre-treatment GFR = 45 m/min, cinara, medal diseases ht could worsen rena function such as {isetes malts hypertension, te) or when their post-treatment GFR i fexpectd tbe ss than 30 lini. 6, Measurement of diferent el fueton by renal sean may hep guide therapy, essay when the conratrl kidney Is small or appears to Ihave decreased finction bso on the CT of MEI 17. Obisina chest xa or chest CT-obtin acest CT ithe pint bas an lool chest xray, plmonary symptoms, or higher isk for metastasis 4 Ifthe patient hasbone pai, byprcalcemia, clvatedalalne phosphatase, ‘bone fact, orsupiious bone esons on other imaging, then cain a ‘bone san, Hyperalcemi and leared alaline phosphatase may be ‘ntsc by bone casas ory a paraneoplastic synurome (se page 12). 9, Ineroogic exam is abnormal or neurologic symptoms are preset, ‘obtain a bain MI to Too for metastasis and for esions associated wth ‘on Hippel Linda and iberos sles. Spine imaging shouldbe pesnnedisyaptms or exam sugges the pial cord affected 10, In women ts for rest cancer, emsier performing breast exam and a mammogram (beast cancer may metastasize othe kidne). 11, lope ofthe real lesion maybe indicated i some cases1 Tumors 3 Blopsy of Res Masses ‘Min genera, biopsy ofa sold or comple eet renal mas i not necessary before excision because mast ofthe lesions ae malignant The AUA 2021 guicelne states that biopsy of «suspicious real mast i “not required” for young healthy palin who are uniling o acco the ‘cet aasoited with biopsy ofr alder ofa paints who will bbe managsl conservatively regardless of the biopy ress. Although biopyis ot part of the standard evaluation it shouldbe considered when: 1. Thee isuspcion thatthe rena lesion may be ines faery, ‘sngionyolipoms, lymphoma, oa tuor metas t the Key. >, Acanddate for nephrectomy tat choose founder survellance, tblation, or embolization «Toconfim the diagnosis of RCC before sytemie therapy inpatient with measases who isnot candidate fr eytoreductve or palative Dephrcomy. In this eas, hoon lesion oa meta lesion may be biopsi 2. Renal mas biopsy technique—biopay is prformed pereumneusly under (CTor aluasound guidance using 6 or 18 gauge ole, The biopsy reed is advanced coataly ugh sheath to mince the risk of ‘tumor seeing along the biopsy act dt oat 203 cores should be akon tom each mast. Core biopsy is prefered over ne needle aspiration (PNA) because cove biopsy has higher diagnostic yield 3. Dingost yield 1 Renal mas biopsy is nondgoostic in approximately 14% of ees; howeve, a repeat biopsy willbe usualy be diagnos. When the initial biopy s oodiagnstc, cancer is usally discovered on subeqvent biopsies, The negative predictive value of benign biopsy i approximately 68-80% {which means hat 20'37% of patente with benign biopy will stl avea cancer). For example, nthe rare situation when ROC ‘exis with oneoeytoma, a alse negative biopsy ean aise when the eee sampls only the benign oncoeytoma. «The postive predictive value of mallennt biopsy is 9.8% (which ments that only 0.2% of patient witha malignant op wil ually hve benign lesion. «4. The coreordancsof biopsy pathology and surgical pathology is approximately 30-75% for tumor grade and > 5% for RCC type. Grade ‘an vary within tumor and biopsies ay miss the ae of wax ‘ge. Fone sty, the risk of underestimating tumor grade was 16% Gn Diets wth low grad caper on preoperative biopsy, 169% had high ‘gd tor inte nephuecomy specimen). 4.Sideefees 1 Seiousside effxs occur in 1% of nes, and include leeding ring {nansfiion, severe pain, pneumothorax, and svere infetion. ‘Tumor seding along the iopy tract tumor seeding i are estimated torbe=<2.01% of cases, with ex than 30 eases report since 1977, but ‘several aes reported afer 2010). Tumor scong fe moe key whe ‘he biopsy is doe with needle 20 pwage and without» exes. sheath Thus, biopsy ofa renal mas shoul seo needle 20 gute and ‘coaxial sheath to minimize the isk nor seeding along the biopsy ‘ract.Bapsy ofa ystic mass may havea higher rik of tamor spillage 5. Metastatic meimoma and ema angiomyolipoma (AML) sin postive for -HMB-45.1f biopsy ofa rena tuner stains positive fr HMB, then itis ‘lly iter AML or melanoma,4 Pocker GUIDE To UroLocy Jett Wieder, MD General Information About Renal Masses Primary Renal Masses 1 Benign examples ‘Simpl ren )st—the most common benign renal ass. '.Pupliary adenine the most common benign sold eal mas. © Other examples inch peudotumor, sngiomsyelipoma (AML), ‘oncocytenajxtglomerulartamor, mallocular este nophroma, and tmesoblastie esoma, 2. Malignant examples 2. Renal eel uscnomna(RCC)—the most common primary real cance in us Wil” suo most common primary renal cance in chile, © Other examples include clea el srcoma al thabdoid tumor. Secondary Renal Masses (Metastases o Kidney) Metastases to kidney (sted most common to east common) 3 Brest 4 Othe les common sites nce stomach, colon, cervix and melanoma Prendotumors "Thee appest oh solid nal masses on some imaging studies, but re ctually normal nal parenchyma. Examples inclde elumn of Beri, eal lobation, dreary hump, hilar lip or uncus nd nodular compensatory hypertopy ‘The following aging stadies can help difiatae pseudotumor om tru fumors: CT epimized o examine the Kidneys, MRI optimized to examine the kis, and DMSA renal san. On DMSA renal an, ssudctunors have normal isotope upake, whereas tue tuners have feereased isotope up. ‘3. Dromedary hump focal lye at mid Lateral kidney thought tobe fom Fale | Female > Wale | Wate Fenale [average Aer | ja. co sides a= Right [Rigi bat ——_[ a= Ri [Gras Color | Golde yellow [Yew ory | Magny ort Common Conral acer Sota, soir, J ‘macrescope seta, Sol, features [Uae Ute Common a . [Smoothamca, |News of sinopilic fetes [C*eMeMI Tact ex,” | polyol alo M45 postive ypervascuar [Mont ot Few [Capote | Peudreapate [Now Fibs apa ees [fen are Rare Mics [Cnn Rare Rare Disewse | VL}. 103, BAP, ssacaion’* | Concen, CHEK? ” |Tuterou sees [aut riers sleet Paraneoplastic [Up 103% Re hse iran | iypeecoic | Hyparcoie iypmrecoie ler sean Eahanes, ances ee oe [Arieiogram | Venous olin, F Av fst, ‘of tumor eerily, Neowasainy, — |Hypervasaiar |, tumor rerio, [Acceraton of ed pear esl oon [oem [Obie ec, Fscon er excision Diagnose 7 ro Pataog ae Meter ea Ea ‘ga kota cern a, fsteconnmeonicam + es ia ae oe Fear pea mqni ‘encosyonm md hve bem sexn mRCC. a a ogee a se nr seared iis na ae nck12 POCKET GuIDE TO UROLOGY Jett Wieder, MD Prancoplasti Syndromes Associated with RCC “Anproniatly 10-209 of patente wth ROC havea parancoplasic ‘Strom, These sadromes are reversible wih tumor resection. When ‘Paraneoplastic syndromes persist alr tumorresetion, metastatic disease is ‘Probably resent an thee patients have a poor prognosis Paraneoplastic yrome include levatod erytucyte sedimentation rat (ESR) Weight Iss, caexia Fever ‘Anemia ypercasion (om rein produce by the tm) ‘Hypercalcemia fom a PTH-Ake substance produced bythe tumor) ‘Stairs syntome (hepatic dysfunction) reverse hepatitis sssocited wit RCC at has nor metastasized othe liver. 8. Elevated alkaline phosphatase 9 Polyeythemia (tom erythropoietin produced by the tumor) Metastatic ROC 120% of patents present with metastatic “Primary Ro ana] Giscase Large primary tumors ven | CC Sze [a Presentatin® Figher risk of maacasi at protentaion. [Cem “| 2, When meatatie diseases dscoverd, | STio tem [7% solitary mets is present in only Sate Tem] 10% TMeoreases. The, metastases usally [57% Wen] 3% involve muliplestesraber hana ingle [FToiTSen] 4155 site =1sen[ 31% 3. Metastases occurby ymphatic spread! acladae Nail MT and hemalogenows pea with ual Fem J Url, 11:10, 20 ffequeney. 4. Distant metastases ae present n> 0% of patients with regional mph node metatscs ‘5. Metastases (not least common: lng, bone, regional ymph nodes, liver, arena land, contaatral Kidney, brain. The most common site of| ‘bone metas the spine. 6, Most metastases ore symptom at the ime of dignesis 7 Bleyated alkaline pophatas, calcium, over fonction tests (LFTS) may indicate a paraneplastc syndrome or metastatic disease. Persistence of & ‘paraneoplastic syodrome afer nephrectomy indicts unrecognized or Imicrometsatie disease 4. If metatses develop fer nephvectomy fran MO renal ance, they ‘usally occur within one year of sugey. Integrated Staging fr Renal Cancer "The UCLA Integrated Staging Sytem (UISS) uses the TNM stage, Fuhrman grad, andthe Faster Coopeaive Oncology Group performance tats (ECOG PS) say patients into categories that predict survival afer treatment. Fr survval based on UISS, ee page 31 Higher grade implies a worse prognosis 2. Chromaphabe, ellen duc renal medullary, and urclasifid RCC are ‘esgnaod ae high or low grade, Parma prado not appropiate. 4. Papilry RCC-Fulrman may be used, but histologe subtype (ype Tor ‘ype should aso be reported. 4, Clear ell RCC Fubra erading shouldbe uilized.Renal Tumor: B 5. ulrman maclear grading i wed for clear cll ad papillary RCC andi ‘based on melear characterise (, contr, nd mle). Mitte activity ior considered. The tumor ie assigned the highest wentified ‘rae. If inde shaped (arcomatoid) cals are present, nicear grade TV isasignel [Far rar Te] are) cee | [Se ‘Gas Pr | sar | — Rosa ns — |" 1 tein oo — ee —} 9 ft) | — ha ‘e fee ca | ie law power magnifeston 100, Nk may be een with high power mapiition (400). ‘Stage (ASCE 3017, “The fllowieg TNM clasifiaton rf to bth incl and pathological stoping. Higher stage implies a wore prognosis. Ths staping sysem apics ‘nly to veaal eel esreinom ond oto oer renal unr), 1 "Te rmay tumor cannot be aes TO Nocridence of pimary tumor ‘TI Tamor 7 em in greatest dmeaion, limited tothe Kidney ‘Tha Tamor <4 em in grate dimension, limited tothe Kidney ‘Hb Tamor> 4.0m but <7 em in greatest dimension, itd othe idee 7 Tamor™ 7 om in greatest dmeasion, limite to the kidney ‘Ta Tamoe> em but = 10 cin greatest dimension ited 0 the Kidey “Tab Tor 10cm, limited to the Kidney ‘TS Timor extend nt major veins orpeinplvic tissues, bunt nta ‘heater adrenal land and not beyond Geol’ facia "T3a_ amor extends into the renal vino ie segmental branches, ot ‘invades the pelvialyeal system riavadespeitenal anor ‘ena sins ft But ot beyond Gert’ fascia "Tab Tamor extends ito the vn cava blow the daphagaa ‘Tie: Tamorextendsnto vena cava above the diaphragm or nvade the wall ofthe vena cava ‘TA Timor invades beyond Gero’ fsa including contiguous xteation ito te iter adrenal hand) ix" Regional lymph Hodes cant beater NO Noregiona Imp nodemeastsis NI Netasasis in regional Impl nets) Distant Metis cM) MO" No dst metastasis MI Disa metastasis ‘Regional mph nodes include renal il, srt, interortocavl and caval, ‘Used wih eprint Amc Coleg of Sagi. Ain MR, as, $1, ‘Gees FL a Ee) AICC Caner Spin Man B.S New Ye14 POCKET GUIDE To UROLOGY ett Wieder, MD ‘Treatment of Localized (Non-metastatic) RCC ‘General Information Surgical eacsoa tho most fictive thrapy fr tating RCC. Thus, {excision is usual the recommended primary treatment fr localized RCC in surgical candicats. 2, Excision of renal ss may not be necessary i the flowing situations. a. Smal renal mises hat will undergo active surveillance (ee page 14). +, Some angomlipomas see Angomyolpoma, page 8) €. oanak eatgery Ir of TIF rena sts (ce page 469), 4k Mesut tothe Kidney (eg. Iymphoma)~teated wih systemic therapy forthe specie tumor type, Nephrectomy i eld indated Te ptt camot oleate sural extirpation £ Unrenectble emer 3. Radial nore is the gold standard for eating RCC. However, & nephron spring procedure i recommended in the following scenarios. ena masses “7 em tht sre amenable to nepon sparing therapy. [Ther isan imgerative indcatinn fo eal sparing (se page 16) 4.4 minimally invenive laparoscope or robo) telnigue is prefered for ‘action ofa rnal mast when it dos not compromise oncologcal contro ‘Survlance fr Enhancing Renal Masses in the Absence of Metastases "The 2021 AUA guideline aes that “When the oncologic risks are parila low and hepatology ofthe Iesion is uncertain (tumors em), AS active surveillance] with potealial delayed intervention is an acceptable option for the inital management fal patents, nat jst those ‘wth iit life expectancy or poor perfomance satu.” but “For patina whom the antipated oncologic benefits of intervention ‘outweigh the vss of eatment and competing risks of oath, clinins ‘Should commend interven.” The EAU 2021 guideline tates “fier ‘ive surveillance. ofl andor comorbid pacts with small renal masses” The NCCN 2021 guideline states “Active surveillance ian ‘option forthe nal management of patcts with clinical stage renal ‘masses = 2 en arin patents wah "incl stage TI masses and sleniiant computing sks of death or morbidity fom intervention.” 2. Tumors that arise from Hereditary Letomvomatols RCC or fom Succinate Dehydrogenase Deficiency RCC behave agzresively even when they are ‘all therfore, tors associated with hese synomes should nt be ‘managed by surveillance. 3 The nik of suvellance i lowest when the renal ass is <3 em. Primary] —Rikot | Rink Itc ie] Metastases igh Grade 20%arebenig, 13% are high |" em) at Preeatation| Tumor irae, 6 extend locally Se oe fuse the koey (P13) and Spee] Ta 4% have nodal or distant [yp] Tox [3 retasases. Te risk of ST To] 3 7 ‘malignancy hgh rae umor |= G15] A 3 oa spread bond the kidney, S35] — 3 30% and metastasis rises as hese BS ef the primary tumor increases. gay 1H: 102,209 & bin untoated patients with an “ut is: 29,26 ‘enhancing ren mass 3 em in [react dimerslon the isk developing metastases within 23 year of Atagnoss 1% Large tomors have ahigher Fisk of developingTumors s 4. Among ptets undergoing surveillance fo small eal mases, the mean ‘tumor growth ates approximately 0:3 em pe year. Tumor grovth rate docs nat isbly distinguish between benign and maligna lesions. However metastases appear toe more likely inpatients whose primary tumor denonatrate interval grow 5. Surwilace fora renal mass 4 em ha alow ak of metatais and local ‘tumor growth the short term. However, inthe long erm, survelance of these masses may compromise survival In aretospetive study of patents with a enkaneing ema mass <4 em, Zin et al 2008) compare 9,858 tints who underwent partial or rica nephrectomy o 435 patients who underwent non-sugieal agement (0 excision, no ablation). Becton improved caner specific survival by as much a 9.4% a 5 years. 6 Recommaided baseline testing —belore surveillance is bog, the following test are recommended to cbain an accurate basting assessment ‘ofthe primary tupor and to chek for mots 4 Abdominal cots etinal impng (CT or MR) with and without intravenous conta (i theres no contraindication to conta). Chest imaging (ray of CT) © Labs BUN, eatning, existed GFR, iver fnetion tts, LDH, alate phosphatase, serum calcium, complete blood cout, urinalysis. 4. Addin meat evaluation shoud be done when symtoms, laboratory test, or other asap suggest metastatic dase. 7 Optional baseline testingrenal mass biopsy i optional. I the patient ‘medial cndton would prelude treatment of tbe mass, then renal bopsy isnot indeaod the pact can tolerate weatment and would consider {teamentbased o biopsy ress, then biopry of the mas reasonable ‘The intensity of follow up canbe modified tase onthe tuna hisology 8. Assessing for growth ofthe renal mass 1. Theszeaf te mass on uleasound appear to comsate well withthe size ‘ofthe ass on CT oe MRL Therefore arte mass has bon well, ‘tracted witha baseline CT or MRI, ultrasound may be used to ‘monitor changes in tunor sie I the llrasound findings ar of ccc then CT or MI an be ebained and eampared to the sine lnmaging to contin tuna growth Data suggests that interobserver and in-obsever varsity ‘<3.1 men wen measuring tumor size. Therefore, variation of = 3 mm In tumor size shouldnt be interpreted as mor growth unless ther i 2 ‘persist increase sz oer at least 2 imaging studies. 9. Example followup protocol ifa paint let to undergo srvilance, theft flow up imaging should be conducted within 3 months aner ‘he ial diagnos (even ia biopsy is beniga) and should consist of | stdin ross sectional imaging (CT or MRI with nvenous contrast. This 5-6 month imaging compered tothe baseline maging fo determine _gromh re. Threat, allow up esting skoud inlade Renal imaging (wth lrasound, CT, ce MRD atleast annually — aging shouldbe done ven if bipsyshows a benign tamer because ‘emign umers can grow over tne an tate he Rey's amas Chest imaging analy and as clinically indeated chest xa i ‘commended in patents who had no rena mars bop or whee biopsy ‘snoodagnosi, oncoeytoms, tumor with oneocytic fetes, or aa callcarnoma. Although oncoeytoma considered benien, ‘cocyrma can coexist With RCC and ea be fet a distinguish | ‘ncocjrma from an oncoeytieeancr, this, patents with oncoeytomm ste followed a if thy have RCC. «Laboratory tests annually ands linc indicated16 POCKET GUIDE TO UROLOGY Jett Wieder, MD 10. Treatment ofthe renal mas should be considered when any ofthe following eteriaare present 4 The mast grow larger han 3 em in greatest dimension. 1, The mast demunstates ongoing interval growth (especially more thn 05 emper yea. ¢. The timor develops an infiltrative appearance on imaging 4 The clini stage increases The patient develops sympioms attributable to the renal mas. £Bioy shows ROC with aggressive fens, 11. Baring surveil, symptoms may develop, a metastasis may develop, the tumor may grow (possibly elimiating the option of nephen sparing therapy) and te cure rate of subsequent reaiment may decline. There is conflicting dala aout whee surveillance compromises canes specific urvival compare! to eaiment however, close surveillance fallowed by ‘syed intervention pear fo have acoepbleoncologi outcomes for stage TI renal tumors Radical Nephrectomy (RN) 1. RNs removal of Gert’ fascia and is contents (kidney and peienal {it Insome cacy the adrenal gland (Ge page 22) and tegonal ymph ‘nodes (80 page 23) are removed. Tumor thrombus should be removed 2. Open an laparoscopic RN acicve equivalent cancer contol, survival, ‘std quality of, but laparoscopic RN ress nes intanperative blood Toss, less postoperative pun, and shorter bospitl sty. {Radical neprerimy may bean option for renal ence f any clinical ‘sage However, maical nephrectomy best uid in patents who meet lof the following teria 4 Partial nephreomy would place the patent at high sk for postive ‘gical margin or would no reserve suicient viable normal kidney to take the risk f partial nephrectomy wortwle No imperative ination for feal sparing. No preoperative ronal snaulicency (eg GER > 6 mlmin) 44 No preoperative proteinuria Normal eontaateral dns Expected postapeatve GER > 45 mlimin, 4. Partial nephrectomy is usual prefered for eiical stage 1 tumors (tumor'= 7 om is greatest dimension confine tthe Kd) 5. Radical nephrectomy is usually tized for sage > T2 mors Renal Sparing Treatment (Nephron Sparing Treatment) 1. Radical nephrectomy removes the ate kidney Gnclaing all normal and normal real sus), whereas eal sparing Weatment temps to spare ‘mich ofthe nara pista Kidney as possible. Nepron sparing {stent resulta lse duction ofthe lomerlar fration rate (GFR) ‘compared to radial npc Ingeaive indications fr renal sparing reanent—reoal sparing ‘retment may be indicated regards of tumor characteristics when [reservation of eal fuetion orci Impertveindintons clade "Tumori soar kiey 1, Poor cntaatea ena fection © Bilateral real tumors {Poor overall eal nction ‘© Contatr! Kn i threatened by a dscase shat may worsen real funtion (diabetes, yperonsion, et) Contralateral dey sheatned by a disease that can cause ena tumors (tuberous seers, VHL, et)Renal Terors ” 3. The feasiilty fra paring depends onthe tumor size anit location within te koe Pepa tuners = Ven im se ee more amenable ‘ena sparing ettment, Whe renal spring would compromise complete {stain the malgnaney or wouldnt preserve slice normal kidney to make the risk worth, then radielneprectmy is pefered 4. Renal sparing canbe performed in ita x extracorporeal (phretomy with bench surgery and autotnsplataton). Inst surgery i preferred. Renal sparing surgery ean be achieved by partial nephrestomy or by. thermal alton. Paral neshrectomy (PN) PN i excision ofthe tumor wih margin of| ‘normal isu, Paral nephrectomy ithe prefered method of nephron ‘sparing therapy becouse an abundance of longterm data cons is ‘fica. ls, most population based analyses show tht concer specific ‘mortality ower ater PN than after ablation ‘Thermal sblation thermal ablation wes cold or heat to destroy the tumor insta. without excision) Thermal ablation appears to result in ess decline in GER than partial nephvciomy, but ablation has a higher local ‘recurenc rae than partial or radical nephrectomy. Furthermore, ‘erapective data sugget that elation ress ato fold higher rok of bring romney cancer compared io portal nephrectomy. {8 Removal arena sue may dorase the glomerular iltation rate (GFR). ‘Lower GFR afer real surgery comespods oa higher risk of cardiovascular evens, s higher rik of dying from crdine events, and Tower overall survival especialy whan GFR less han 60 mint). Given te above Radings,peterving a mach eal function ae posible may hep reduce the risk of death, ‘Thermal Ablaion 1 Thermal bation i tumor destruction without excision, which is usually sccomplied by eezing(eyeablaio) or heating (radiofeqiency tion). Although no randomized trl hs compo eryoubation ad ‘adiffequency ablation, reuospectve data shows that they have similar ‘oncolopiceficaey and simile complication rates. 2 Cryeabation—the tumor is cooled 1 -20°C to 40°C (these tempersres induc cell necrosis). Two freeze-thaw eyeles improve! [GIA common regimen is 10 minaes of ezing, hen & mines of thawing, then another 10 minutes offering (the “10-810 proto) Freezing s monitored by ultrasound. The necrosis 2ne is smaller thas the faz repion revealed by ultrasound In edero account fr his the Inypetebot ee ofthe ee bl on elasound mst extend beyond dee ‘ofthe tum (by at east Sn). Por deal oncryoblation, nlading ts Imechansm of action and monitoring during fezing, se page 217. bs. Radifiaguency ablation he tamor i hented to between 50°C and 10S°C tse temperate induce cll necrosis). probe delves high fequeey atemating caveat into the tumor (160-500 Kitz). This ‘eentreate elecromapnctic eld that mints the molec nest t0 the pote. This agitation erates tion batveen molecules that eat th Susu toe (he sour ft ea not the probes the best arises lm he agitated molecules sround the probe). Heating the tise to tempertures higher than 10S°C ca ets gus formation, which, hinder the devery of current The oa is to ensure tumor necrosis by maintain a temperature of 50°C to 105°C throughout the tor, while ‘ot exreding 154C: Ablation ean be monitored using ultrasound CT, or MR18 POCKET GuIpE TO URoLocY Jett Wieder, MD 2. Ablation canbe accomplished through an open, laparoscopic, or pereutancous aproach In most cases, «percutaneous approach s roered because minimizes morbi. 4. Bp of the renal maces recommended before proceeding with mor ‘blaion. The intensity of follow up canbe moxie depending on he tumor histology tenn mors nay rogue minimal fllow up, whereas high grade or agressive tumors may require moe intense Pllaw up) 4. Dermal ablation s generally reserved for non-zytic clinical stage TI tumors that ar = Sem isize Bocuse 1"Thc isk of complication (ich a tumor frctre and bleeding) are igher when tor size > 3 om, »b. Mhesate of eeurence is higher when tumor siz is» 3 cm. ©: Disease fe survival lower when tumor size > 3 cm. {4 Thermal abiatin as not be wel studio in este masses. ‘5. Tumors tha are nares, clos the eral hilu,o close toa renal sinus are more dficlto treat with thermal sbation, Peripheral exophytc tumors are eaiero abate 6. When structure acento th key sr 100 close wo allow fo safe blton ofthe tunon the clinician can move these nearby srctres ay from the expected ablation zone to permit safe tumor ablation (sing ‘methods soc as perostanous hyro-disesion o spacer talon). 7. Complications ine hemaoms, pain, and infection, Preumothorex can ‘oui when abating vpper pole eal masses. Rare serious complications include bleedingroquring rnsfison, persistent winary extravasation, ‘complete ln of psa eal function, injury to nearby organs uch as Theureter or bowel) and tumor song along the probe tact ‘Thermal ablation appears to result xs decline ix GER than patil nephrectomy: Local recurrences more common ater a single ablation (6%) an afer partial nephrectomy (396) or radical nephrectomy (16). However persistent oor and local recurrence can he eated with repeat ablation. When repeat ablation ae included, the risk of loca recwrence is simlar between ablation and PN. Salvage excision ofthe tumor may be more Ail afer ston 10, Reaspective dai suggests tat ablation resus na two fold higher risk of ding fom Bane cancer compared fo part nephrectom. 11, The EAU 2021 guideline tates that ablation shouldbe offered o "Tail, nd comorbidpatints with small real masses." and “info patients shout the higher isk of loalrecurence and/or tur progression "The ‘AUA.2021 guide states that physicians should cosidr thal blstion as “an aterate approach forthe managemeat of eT soli eal ‘masses <3 cm size.” and tha patent counseling sould ince “an [ncresod elibend of tor persistence o lea cutene. relative to surial excision.” 12 Residual tumor sir slain and local rcurence—thi is defined as any ofthe following 2 Imaging shots tumor be he same area of prior teatment that enhances ‘ith contrat nore han 3-6 months afer ablation, enlarges overtime, ‘ral regress overtime. Imaging shows now stl tumors (tumors immediately surrounding the tet are) «Biopsy shows tumor in the same are of prior reaimen ‘¢ Tumor detected along the tact where the probe was placed.Renal Temore » 13. Renal bigs for residual tumor ool reurence ir there suspiion of eda cancer or nel recarence on imaging then areal mas biopy shouldbe performed b. The by should sample he enhancing rea of the tumor. Biopsies of ‘non-enhancing ae at ely to show fibrosis especialy the center of the mas, where ablation is typically initiated). 14 Fr real masses tat have undergone successful ablation, immediate pos btn aging shows slight enlargement ofthe tumor, and may show fim enharcement. Ove the next few mont, the tnt viks std 0 longer eahances (though with raditequency ablation, timorshrinkxge say be minima). 15, Patents with no biopsy or patents whose biopsy i ondiagnostic, ‘ncacytona or tumor with oacoeyle feature should probably be {ellowed ith aremtion that the tamor is eal cel eareinoma ‘Although oncoeyoms is considered benign, oncacyloma can cosit with RCC, itca be dificult wo ditinguish oncocytoma fom an oncocyic aner, ad itcan grow enough overtime to theatea te kidney’ unsion, 16, Examplellow up protocol patent elects to undergo thermal bain, he fat follow ap imaging shoud be condcted a ¥ months and ‘month fer ablation and should coi of abdominal cross sectional ‘imaging (CT or MR) wih and without intravenous contrast (less ‘contrast i: contraindicated). These 3.and 6 month scans determine ‘reaimentscces. Thereafter, flow up testing should ince 1 For patizts whose pre-ablatio renal mass biopsy shows a benign tumor ‘tumor tai not encocyoma ithe 3 and 6 month cans show 8 tweament succes and there are no ongoing treatment related compiations, hn further abominal imaging and chest imaging sno ecesy. For patients who did not have a renal mass biopsy or whos biopey shots ECC, oncocytoms, tor with oncoeyte features oe ‘ondiagnostic findings, use he follow up protocol dseibe below, 1 Renal imaging (with ltasound, CT, o MR) analy fr 5 years ands clinically indicated, Renal imaging maybe pefoned mare ‘often and sing more dete sans (CT oe MRI rae than ‘leound} wea there x concem about recuence. Renal imaging lates yeas can be considered basod onthe ptt sk, ‘i, Chest imaging annually fr 5 yeas and as clinically indicated. Chest imaging afer 3 years canbe considered based on the patent’ rik. i Labomtory tests annually and as clnclly inetd. Partial Nephrctomy (PX) 1. PN removes the tumor with margin of normal rena tissue. The method of removingthetimor cin be clasfed nt wo calegorie, 2 Tncisen—the normal Kidney around the tum i nied othe tumor canbe emoved witha modest maezscopic margin of oral kidney. 'b.Hnucleston the tum i em by blunt disection between the tumor fecudocapele and thermal Kidney therefore, thee i ‘nnn fen nkzowopi) agin of mri elise round be ‘umer Some cancers donot have a pseudocapsule. Ia puocapa is ‘hen, it may be more difficult to develop th croc anus plane (rie could cause diseton int the tumor). Alo, tumor invades the rondorpeae in up to one thi of eases, Nonetheless, reropective at suggests tat incisional removal and enucleation have silat ‘ncoloi oteomes. For example, Minevini ct al 2011) showed that ‘ucleton and incisional pata bepheczomy achieved equivalent20 POCKET GutpE To URoLocY Jett Wieder, MD 10-year cancerspecfc survival, and ha enucleation had a lower postive mari rate (39448 19a) Phe AUA 2021 guldeline aes "Uni prspecive evaluation avallable for sporadic tumors, enucleation i best wilzed on a selective ass ‘Sonsidered i patient ith foil RCC, mica disease oF severe CKD fehrone dey disease. 2. PN for stage TI tamors—when complete mor excision canbe achieve, partial nephrectomy she tretment of choice for most clinical stage TT ‘mors (tumors <7 cm in greatest dimension) becouse {PN resale in lower ik of ehvoni eal isuiciency than RN. 1, PN and RN have equivalent oncolapie efficacy in stage TI tumor. ©. Canoe spectc matali is lower with PN han with ablative therapies 53. PN forsiage T2—partal nephrectomy i an option for stage T2 tumors ‘when PN will completely ease the cancer and will preserve asuicint {mount of noma Kidney to make the risk worthwhile In these ase, PN ress higher blood los and higher rik of complications than RN, ‘Alen, large tumor havea higher iketihood of aggresive pathologic feats (sue asinfilzaton beyond the amor capsule) therefore, ii uci onlywtiize PN when ican be done with minimal isk of eavng ‘ancer behind, Radial nephrectomy i so an option for sige T2 cance 4, Suge T3 or Tada nephrectomy is generally peeformed for these "tages of primary cancer unless thee i a imperative indication for eal hot impact props. A clase margin achieves the same cure rte asa ample margin: terefre clase margin should Be considered as uly negative 2 Poive suri margins occur in approximately 3% of patents mnderpoing PN 'b, With short cm follow up (<3. yea), postive margin des not appear to alter ance specific or overall survival «Patents with apotive margin havea higher risk of lca recurrence Iowever most aot ill romain dseare fv. nf, when pearl radial aereeomy is performed fora postive margin afer patil, ephectomy, sida tamor is found = 16% ofthe tine 4. hen a positive margin found, but here i no ras residual nor reine trully appropriate Because mst of these patient ill remain disease foe However, radial nephrectomy repeat partial ‘ephretomy may be considered ia paints wit particularly ‘ggressive tor sucomstoid, high wade, or collecting duct fancer) boca these pains may e at higher isk fra eal «When theres ross residual tumor emining ar PN, consider performing other adcal nephrectomy or repeat partial nephrectomy to Fomove the Yesdul tuner. Ablation may be wed select eases, 6, Renal smi ene —thi dfn asthe dartion of ine that par or ‘ofthe kidey without tera blood flow Because of vascular clamping ‘Clamping of rel blood low i done to minimize bleeding while excising ‘hotumor Ischemia time is designated as ether warm (oo cooling ofthe icy ring ischemia) o cold (coaling of he kidney during ischemia) Ineversible renal damage is thought ooocur afer 20:30 mines of warm ‘choi tne ant after bout 9O minutes of cold ischemia time,Renal Tumort a 1. Minimiingischomic eal damage during partial nophrectomy ‘2: Avoid hypotension and hypovolemia {6 Taditonaly patients rouved mannitol 12.5 grams 1V administered at mines and 10 mines pie to clamping the real rey. Manno! ‘reduces ache inary by scavenging foe radial and y reducing ‘oxidative collar damage Rewospectve at aggets no benoit ‘sing mannitol In addon, arent randomize tril by Spliviro {QO in patents wth preoperative GFR 45 nln showed that ‘sing asingle 12.5 gram dase of mannitol ding PN dl ot rove -ostperaive GFR compare to placebo (however, his rial did ot ‘rami wheter mannitol is beneficial when using the ual regimen of ‘oo 125 gram doses or when iis used fo patents With preoperative (GER <43 mln). «Clamp he eal artery only once (avid unclnping and r-lamping), 44 Leaving the renal vein unclamped may penniteograde real fusion; however, itmay result in more bleeding, «Rather han clamping the ain rena artery, clamp only segmental teres tat ed the region of the amor £ Minimize eal schema ime-—when the kidney i ot cole then ‘warm chemia time should deal be ese than 20 mines. Iwate fachemi imei expeted tobe longer than 20 minutes, the the ‘tional approach has beea to cool the kiey (afer clamping the tery, round the kidney with a ic ath fer 15 mine nd cool the Kidny 0 15°C. Re-cool the kidney at leat every 30 mine) Hever ‘recen’randomized study (Bre tal, 2021) shows tht renal lnpothomia offers no benef forthe preservation of real fnction then champ tims 60 minds. Although fo pasts he sty had Gri <45ythe sud was abl to show that hypothermia dd not benefit these patient. When renal hypothermia i lized, cold schema tine ‘shoul daly Be les than 80 minutes, but the Kidney can completly ‘recover fer 60:90 mine of cold ischemia. £8. Lapuoacapic vere open PN ‘Open and lnparescopic PN achieve equally effective cance onto and b, Warm ischemia time is usualy Longer wit laparoscopic PN. © Compare e open PN, laparoscopic PN has lowe nanperatve blood los, bt higher rik of postoperative hemorkage. Open nd laparosope PN haye asia wanton rt 4. Patients undergoing laparoscopic PN have a higher rik of being ‘conver to radical nephrectomy than paints undergoing pen PN (2.1% vere 0.059), © Laparotcopic PN ha higher ate of e-operaton for complications ‘han opin PN (249% ver 1.6) Raileal Nephrectomy (RN) Versus Pardal Nephrectomy (PN) 1. EORTC 32004 was prospective randomize ral comparing open PN and ‘pen RN inpatients witha normal contralateral kidney and RCC that was tolitry a= 5 em in dante. or PN. a macrmscopic marin normal onal Gs wa removed (.e.enscestion was not performed). 2. Complicwions EORTC 30004 showed tha partial nephrectomy has @ higher ra of complications compared toric! nephrectomy. The following complications were more key with PN. ' Hemortage with >| tro blood los 1% vecus 1.2%) 1, Urine eit (4% versus 0%) © Re-openton fr complications (4.49% vers 24%)22 POCKET GuIpE'T0 UROLOGY Jett Wieder, MD 3. Renal function Partial nephrecomy ress lower rik chronic renal nsficiency ‘han radical nephrectomy: Retrospective abd randomized (EORTC 53004) data shows tat patente undergoing radial nephrectomy have 8 higher isk of developing postoperative glomerslr fila rate (GFR) Jess than 60 mnin. However, appears thatthe risk of severe renal Aystncton (GER = 30 is sila afer patil and radial nepcctoms. Retrospective dt suggests that parti nephretomy is ess key to ‘ase proeiria compared to radial nepivestoay. 4. Oncologi fine and suvival 1 The rate of pastve surgical margin is higher with PN thon with RN 2-36 versus B) Randomized (BORTC 30904) and retrospective studies show that PV (and RN achive eqlvtent cancer spec survival inpatients with Stage 71 cancer ut local recurence ie higher with PN (336 versus 1%) hough the dita are conflicting, some retronpective studies suggest ‘ha patents ndergoing PN for clinical stage TT RCC hae a longer ‘ver srl than patients wnderging radical neprecton: Inmproved ovenllsrvvaln patents undergoing PN occurs mainly by ‘edcing non-RCC related deaths Sine lower GFR correlates with Tower overall vival, paral nepveciomy may achieve its overall, survival beef by preventing decline GFR 4 EORTC 30904-afer + median followup of year this study was tnable to demstate equivalent cancer contol for RN and PN. twas tlko unable to confirm he etospective fading that PN achieves higher ‘overall uv The inabity to show an advantage for PN probably ‘ove besause poor acu forced te sty to closed prmaturely (Cs0rG of the ogee patonts were enroled) therefore, the stay was tmnderpowerodto adequately assess survival endpoints. The autor ate “Oneoloiceqivalence of NSS [Nephron Sparing Surgery] and RN ‘couldnt be detly shown in this randomized study but s nowadays [pencraly accepted” and EORTC 30901". support the recommendation {ose NSS in sal tumors asa first-line procedare whenever technically feasible.” 5. Erectile djtuncton (ED) retrospective data suggests that RN ead to 2 higher rat of postoperative ED than PN. One posible explanation fo this {stat the renal icioney fom RN produces endothelial xl stanton, whish increases the rat of ED. 6. Summary ‘FN hav higher rat of perioperative complication compared to RN. ‘PN wuts na lower rik of eon eal insuiciency than RN ©. PNachiovereaivalent or posibly bate) overall survival compared 0 RN. The potenti over survival beset fr PN arises frm a reduction Jnnon-RCC rtd deaths perhaps by preventing renal insuiieney) 44. The rate of postive surgical margns i higher with PN than wih RN (223% ver 6) PN has sigh higher local recurrence rate than RN (3% versus 190, PN achieves oquvaleat cancer spect survival compre 1 KN. Adrenalectomy Daring Nephrectomy Tc pslateral adrenalectomy i recommended when there i suspicion of dhe invasion or metastasis tothe adrenal gland based on preoperative Imaging or based on intraoperative indngs. Adenaestomy may aio be ‘considered when here sa lange upper pole tumor: Otherwise, he Ipslteral aden gland can be spared. Routine removal the isiltra ‘renal gland during nephrectomy doesnot improve survivalRenal Tumors a 2. Direct invasion or mints to the adrenal gland is uncommon 5. unietnlsrealectomy is peformod, adrenal italien ie rare ‘when the patent has enortnal coats areal plan 4. Fo patents undergoing eyloructive nephrectomy for metastatic RCC, ‘the indications for adrenal spring are he sme fr patients with ‘owmetaaate RCC, ‘Regional Lymph Node Dissetion (LND) Clinica stge NO patens—when preoperative imaging and intraoperative “Sindngs stow no lymphadenopathy, then performing repianal LND i a «EORTC 30881 was a prospective randomized tral comparing RN alone {to RN with LND in patonts wit incl tage TI-T3, NOMO RCC. i Wit a median fllow up of 12.6 year, thee wasn difference in ‘oven survival, disease-specific ural o eal progression. Thus, regional Imp nde dscetion doesnot improve survival patents ‘tho undergo RNfor clinical tage T1-73, HOMO RCC: fi, END didnot incase th ak of sil complications. {i ReginalIymph node metasass were ound in 1% of palpably ‘normal nodes and in 7% of palpably eolarged nodes (hi why [END is recommended when palpable nodes are discovered intsperatvely se below). by Some woogist advocate LND for pation with high rik f node metastases. The sk of node metasuaes ca be prediied preoperatively ‘ing acomogram (nt J Caner, 121: 2536, 207) o inaaperalvely sng fozen section high sk has > 2 isk actors stage T3 34, uno size> 10cm, tumor neoss, or sarcomatoid elemens). 2 Clinical stage NI patents (i. preoperative imaging ar intaoperaive Findings stow Iymphadenopaty)LND does not improve survival in utenti lineal stage N1, However, regional LND finding removal 9f abnormal node) i recommended in 1 patents because it help fo ‘accurately tage te tumor Some enlarged iymph nodes donot harbor ‘malgnany 53. The most ommon location of node metastasis is intesortocaval for ight sided tumos, and prs-aoce fr let sided tor. nerortoceal node ‘metastasis canbe preset inthe abscnceof hilar nade metastasis. 4. Crispen etal 2011 recommend the flowing LND templates 1 For lftsided tumor, remove the prt sotc and intrortcaval nodes ‘fom ens ofthe dapat the common line ay. . Forrightsided tumors, remove Bilateral RCC 1 Whan posible, renal paring surgery is prefired fr bilateral RCC. In cases whee bilateral RN is necestar, the patio it placed on dns. ‘Real tansplant may bean option if the patent remains ance. 2. When plaeng RN on onesie and nephron sparing sugry on the ober side, consder performing the nephron sparing surgery first nd devine ‘he RN ual ater dat. Thisbepe avo ily (Ging eeovey rs the nephren sparing surgery, te need fr dslsis canbe avoided if comtalatal kidney is sil preset to help sustain eal faction. [RCC with Tumor Thrombus 1-RCC can gow into the lamen of veins that dain the kidney. Tumor within the venous lumen i alle mor tombs 2. Tumor trmbus typically remains attached to and coatiauous withthe primary eal mass24 POCKET GuIDE To UROLOGY Jett Wieder, MD 3. Tumor thrombus roth tend o follow the dietion of venous flow: therfore, thrombus tat extends into the inferior vena cava (IVC) wl sally grow caplalad toward the hear. Once it each the hear i wl ‘apically grove no the ight strum rater than into the superior nea, 4, Visous systems Gaclding TM stage on pge 13) have boon proposed 0 lesignate the leva to which the thrombus extends. Commonly se lve ‘ue renal vein ony, IVC below the hepa eis, TVC above the hepatic ‘ns, IVC abovethe diaphragm, or into the right eat more extensive tumor thrombus asoeated wih a lower disease specifi ural ‘5. The thrombus i wunly fe lating in the venous amen, butt an ‘nde nto the vin val. When the tumor thrombus nades into the vein ‘val then the iysived vein walls exis (eythetic graft may be use to ‘eooastuct the ven). Tumor thrombus imading the caval wall ha. worse ‘prognosis than fe loan thrombus 6. Insurgial candies tumor thrombus should be removed during ‘nphrelomy becuse long term survival hasbeen achieved even when the ‘thrombus extends nto the ight Beat 7. Cardiopulmonary or veno-venous bypass maybe necessary to remove an ‘extensive tumor tombus, expecially it extends above the diaphragm, Care report show that systomie hecapy can shrink tumor thrombus. When A thraie incision or eariopalmonary bypass poses an unacceptable risk, "temic therapy may reduce the hrmbus level enough to allow complet ‘escetion without traci inision and wiht cardiopulmonary bypass Adjevant Therapy ater Nephrectomy TeMany randomize! ties of adjuvant therapy have been conducted, using gens suchas rato, itrern, ntereuin, sunt, sorte, ‘itn ed papa, So fr, only one sty bs shown benefit with ‘juvant therapy the S-TRAC tral. 2, STRAC talents with non-metastaic clear cell RCC who were at high rik for ecurence after nephrectomy were randomized to either unit rplacco, High ris for ecrtence was defined asthe presence ‘of any ofthe falling stage 4, regional lymph node masa, or ‘combination of zage T3NO * Funan grade 22 + ECOG performance ‘status> I. Suni 50 me po q day was adnnistred on a -week-on 2eeekof eyelofor 1 year as tolerated, but was stopped sooner if rocarencecocured win I year Median disease fee survival was {ignfcanty longer (by 1.2 yoo inthe sunt group. Daa for overall Survival were not are atthe time of the report, Grade 3 and 4 sdverse ‘vents were mor commen inthe suit group. Based on these resus, the FDA approved sunt for adja iretment of patents wih high Fisk of rcarrence following nephrectomy for RC. ‘Therandomiand ASSURE tril also stud adjuvant sunita inpatients witha high ik of rcurence after nephrectomy for RCC, bud ASSURE “Showed no diferace i deat fre survival berween adjuvant susiinib and placebo, 4 Given the contig dato scape fiw suvivel and the lack f proven ‘vera survival benef any clinicians ee not convinced that suniinb should be ilizod for adjuvant therapy. fn fat, the BAU 2021 guideline Siaes "Do not ofr advan suntin following srgcally resected big "ik clear ena el carcnoma” Also, there was major disagreement inthe CCN guideline panel about whether adjuvant suntin i appropri ‘adjvantsuniin iulize, shoul probably be estreted to paints ‘ith clear call REC Secsse -TRAC only studied een ell RCC),Tumors 25 yperfitration Renal Injery When final renal isu removed, glomerular hyp in the etining tssue to restore lotion capacity 2, Prolonged glomerular hyperftraton ny ese renal injury. Thisnjry lead ofa segmental plomeraloscleroris and progresive real fae "Hyperfiltaton injury may take moe than 10 yeast develop. 3. Proteinuria is the harbinger of hyperfilration rena injury, eer, prcedes pathologie and elinical evidence of eal damage 4.Itmore than 75% ofthe facto! renal ive i removed, hyperfitation renal injy is mor key to ocr When 50% of nina el tssue is removed hyperilintio injury uncommon. Fr example, fer ‘nphreteny i dney donors, glomerular fron rate (GFR) des not ‘een sigaticanly with 20 years of follow up 5 actors tht increas the isk of hyperftation injury include removal of 75% of fictional renal mast, high roe diet, obesity, steroid se, Inpertension,hypetpidemia, and poorly controled diabetes mel. 6. Wigs of odcinek of iypartiraon real ny ‘4 Anglotasin converting enzyme inhibitors (ACEI) may help prevent Iyperfltraton jury by lowering ntraglemerale presse. Some ‘siggsstbeponing an ACEI 24 hor rine protein i> 150 me. bs, Weight losin bese patients ©: Low prin, fw sodium det 4 Stit canto of dishes, hypestension, and hypetpidemi, Avoid werd te Avoid ephrotoxins (eg. NSAIDS) Follow Up after PN o RN Fer Localized RCC |The msjonty of ecurencrs occ within 3 year afer nephrectomy. 2. Laboratory tes BUN, ecatnine, estimated glomerular fietion rt, ‘pd urinals ar obtained routinely Oe aerator test are bined a ‘he diereion ofthe physi, and may inl iver incon et, allan phosphate, lactate dehydrogenase, and serum cleium. In tients it es than oa whole Kidney, pertorm periodic 24 hour wine for ereaticie, pron, and volume to asses for ypertiltatin inary. 3. Bone car is eeommended when allalie phosphate is leated, wen the pat: has sla symptom sch x pin, or when otber imaging suggests he presence of tone lesions. 4- Imaging the central nervous system is recommended when therein sea onset of neurological sins or symtoms. 5. Follow up daring the ist years afer PN or RN ifa microscopic postve mara presun, increase the isk clegory a eat I level higher, 2 Low ride (pT grade -2 & NOMO)— history, physical exam, lab ets, sibdominal CT or MRI (without and without IV contr) and chest. Xen a1 2, 4, and 5 years afer sargery, and when cially indicted, After 2 yar, the cliniian may consider alternating between abdominal ‘kasd and abdominal eos sectional imaging. ' Intermediate isk (pT grade 3-4 or 2 any gree; & NOMO)—bisory, phys exam, lab est abdominal CT or MRI (witout and witout TV oni), and chest xy at 6 months and at 2,3, 4, and 5 years ae Surgery. and when lincally indicted. Aer yeas, the cincian may ‘onder alerating beween abdominal ltascund and erst ston inagig «High ie (pT3 any grade & NOMO)—history, physical exam, ab ‘Selmi CT oe MEI thot and without IV contrast), ad chest Cr 516,12, 18,24, 30, 36,48, snd GO mons er surgery, nd when lineal indiested,25 POCKET Gutpe To UROLOGY Jeff Wieder, MD. 4. Nery high rik ph, NIMO, sarcomatoid, or macroscopic positive ‘margn) istry, physial exam, lab tet, abdominal CT or MRE (without and wibout TV coawast and chest CT at 3, 6,9, 12, 18,24, 30, 34, 48, and 60 months aftr sugey, and whe clinically indicated. 6 Follow up beyond S yours afer PN or RN 1 After 3 years, sdominal and chest imaging re optional, bu history, physical exam, ad labs shoul be obtaine at 67 years anda 8-10 Sora fer surpey. aging beyond S yeas may be most appropiate or Patents with ger risk eancer. chest imaging is continued yond S years in high risk or very high rik patent, fen chest xray may be considered rahe than chest CT. «, Additonal stag sould be obtained when clinically nda. 7 Patents wit salary Kuney shouldbe advised that participation in ontctolsion sports place the kidncy a ik for traumatic injury. Need to avoid contaclision sports is determined onan individal ass ‘Treatment of Metastatic RCC RCC with Oligometastas 1. Oligometastasis the presence of few metastases (68 <3). 2 Inpatients with ligometsass, long tm survival has ben chieved when the primary and metastatic lesions were ete. 53. When oligometasass presat atthe same time asthe primary ROC, the prefered treatment x excision of th primary tumor a the metastases (Cora brain and bone metastasis, radiation therapy is also an option). 4, When oligometaass develop ater nephrectomy lea recurrence in renal foss of ote metastasis), the prefered eaten is tumor resection (ie brain and bone metaste, radition therapy i lso an option). 5. When resection the metastases sat Tease, then te metastasis may ‘be ete with ablation or adation depending onthe metastasis. location). Another option systemic therapy. 6, When oligametataes are resected, the progosis is beter when {4 The metastases ova inthe Tung rather than in another ation ', The metastases sis afer nephrectomy (itl sage M0) compared to ven the metas present wih the rary tor (aia stage M1). RCC with Non-Oligametatases 1. Paints with mest renal oll eareinoma canbe casio int rik ‘atgoros using ihr the Memorial Sloan Ketring Cancer Center Prognotic Model (MSKCC) or the Inematonal Metastatic Renal Cell (Caeiaoma Datatese Consortium Criteria (MDC). 2, Cytorouctiveneprectomy —dfined as RN in MI patents before ‘administering sytemic therapy (RN is performed to fede tum burden). la Mi patients, randomized as that showed RN followed by interferon (INT) improved ine o progression and oveal survival compared to INT lone. Curent, INT is rey used to teat mets disease, and there ‘nae bee no aniomized was specifically adresing eyoredctive ‘ephreromy wih novor agent, lower, del ues ha pation wih Intermediate riskor high isk metastatic RCC donot Bene from ‘yloreducive nephrectomy Before frosine nase inhibitor therapy ‘compared to yrorine Kinase nko therapy alone Cored opectomy ian option for some patients with low risk metastatic RCC. Tt appears that patents mos ily benefit fram eytreductive nephrectomy have good performance stat (6 ECOG performance aus Oo) no bain metastasis, and metastases ony in the lng.3. Palliavetreameat of the primary tumor—when the primary tuner causes Significant symptoms (ey pin, gross hematuria, nephreetoay tumor ‘embolization may be performed in order to conto cancer elated symptoms Radiation snot effective or primary tumor conta. 4. Fn line temic treatment fr metastatic clea ell ROC Favorable rise i Prefaed regimens: pazopanib ust, eabocantin + nivlumab, leva + pembrlizamab, a sxtin + pembroliztna, 1. Other recommended regimes: piimumad + nivolumal, or ‘abezantnb or asin + aveluab, Ii. Used in select cases: high dose IL-2 or ain. Intermediate or poor ik {F Prorred epimens: eabozanin,cabozaninid +nivolana, ‘plimunal * ivolomsb, aii pembrlizunab, or lenvaini + pembrlizamab {i Oth recommended regimens: pazopaniby, usta, or situ + avelumab, i Usdin selec cases high dase 1-2 ati or temsrlimes, 5. Fist line systemic treatment fr metastatic non-cler cll RCC ‘Prefer rerinen: clinical tor suitinb. '. Other recommended regimens: cabozantnib, everlimus, ot Jenvaii+everolimus Used ia select cases many options are availble, incading oti, ternciamab,teniolin, es 6. For interned rik patents who respond wel oft ine systemic ‘herapy (ea lng term sustained response andr minimal residual ‘metastases, then nephreciomy may be considered This option is based ob at from the SURTIME tia, which randomized pints with east ‘lear ell RCC to immediate cytredactiveneplzeiomy fllowed by Sunt eto deferred nephrectomy (unitinbadministred fit, hen ‘nephrectomy if there was no progression on suniti)- Over survival ‘va lng fr patients inthe dered nephrectomy group. 7. Chemothapy is inellxive lor mou types of ROC however, thas shown ‘modest scvity in medullary RCC and collecting dact RCC. Oral targeted therapies ie yosine Kine inhibitors) are not effective for real ‘medullary RCC. Thus, eter clinical rl or systemic chemotherapy is the teatiment of choice for metastatic medullary RCC. 8. Systemic rapes are poorly efetiv aginst bran metastases. Brain ‘metastaser may be troted with radiation or surgical resection especially ‘they are symptomati or growing. 9 Radiaon ay bo used fer palliation of bone and bain metas, ‘Tyrosine Kinae Inhibitors (TKIs) 1. Tyrosine kinase inhibiors reduce angiogenesis and cel proiferatin. They init vious tyrosine Kinases, sucha vase endothelial growth factor receptor (VEGF) platlt derived growth factor receptor (PDGFR), and Stem cell ctr recepor (KIT). 2. Thar ated forthe treatnent of vanced or meinsaic RCC. 5. TKisapperto improve median progremion re survival by 2-6 months ‘nd improve median ovr ural by fe months. 4, Examples of Tks include sunt, sraenb,pecopni extn, abozannb, lenatn, and ei, 5. Compare osunitini,pezopani causes ls ig, les hand sn foot syndrome less led tse, ls hrmboeytapeni, and beter quality of life, bat higher sk of elevated LFTs. Both paaopani and suit are option eft ine teatment flow risk metatatecear eel ROC.28 POCKET GuIpE'T0 UROLOGY Jett Wieder, MD 6 Side ffectsskin reactions ("hand and foot syedrome”), gastoinestna (Vomiting dire, clevated amylase, elevated ve uncon est, allered ‘ue, Eypophosphatemia, hypothyroidism, bypertensen, prosinra, bleeding, hemat ogi (thrombocytopen, cuopena), elopeia, bsadach, fatigue and embolic events (eg, soke and myocardial Infact) Low eeton feton, ards ischemia and prolonged QT ave been report 7. During therapy, cvck blood pressure, complet blood count, urinalysis for olen, thyroid finetion et an serum chemistries (Sodium, possum, ‘Phosphate, creatine, liver funtion tests, amyae,Fipase) Monitoring of ‘jection ston ean be considered &, Since these mediation impair angiogenesis, they can interfere with ‘wound healing: Tp avoid poot wound beaing, sop the TKI before elective $urgery. Do not resume the TRI wail wound healing is adequate The ime fame in whic he TKI stopped before and afer surgery depends onthe Te being used Immane Check Poin Inhibitors Immune checkpoint inhibitors ae medications that blk an important regulatory tp ofthe immune system. These medications typically reduce the fumer’s ay to evade the immune sytem, which allows the immune sytem to more efectivelyatack the cancer 2, PD-V/PD.LI patvay inhibitors examples nce pembwolizuma, rivolamab, and welumab, For details on these medicines, ee pape $2 (pembolizumab) page 3 (aivolumsb), and page 83 (avelumab). 2 The programme doth rseptor- (PD: i Woested On Imphocytes. ‘Whe catia otcine bind o PD, the imme sysem has a roed ‘apaiy to ck nomal sos (creasing lo immune reactions) fst reduced apacity to tack malignant asus (hindering the body's ‘Shiliy tll ance), PD-LI (programmed deat gand 1) sa eon that bind othe PD-1 receptor Many cancers evade the body's defenses ty expressing sigh level of PDL, which binds fo PD-1 and inhibits ‘he immune yt’ bility to kill cancer »b. Modicins can block the binding of PD-LI to PD-1 by attaching to PD-LI (PDALT insite) oe by attaching tothe PD-T receptor PD inhibitors), However both PD- abies and P-L inhibi achieve theirantcnce effets by inhibiting the PD-LPD-L patho. The increased immune atv frm Blocking the PD-1/PD.L1 pathway ‘an alsoresutin an aac on normal tinue (which eas fo soe of the ‘Sie efet) Snow all PD-t indore and PD-L inhibitors black the ‘ame pay tho all tend to have sims fects. 3. CTLA- pathway itor examples ineloe pimamab ‘8 CTLAS (esloorc T lymphocyte antigen 4) isa protein receptor on tctivatd Teel Under noma ercumstances, ligand binds to the CTLA= receptor and dowarzegulate the eytotoxi atv of Peal. ' Iplimomab ts menoclonal antibody that bs to the CTL A receptor ‘and blocks the down-regulation of eytotoxic activity, which ineeass {he manne tne iy te hl vane “Mammalian Target of Rapamycin (mTOR) Inhibitor THiTOR is proten that elites hypoxia inducible factor (HIF) and ‘ascular endothla growth factor (VEGF). When miTOR i inhibited, ‘VEGF decreases which reduces angiogenesis) and HIF decreases (which reduces cll rl feraton). Thus, mTOR Inhibitors reduce angiogenesis and el profijeraion.Renal Terre 2» 2. Temsiroims and everolnns inkibit TOR, 5-Temsiatis i FDA approved forte tetinent of advanced RCC in patents wth predictors of shat survival 4.Eyerolimsis FDA approved forthe weament of advanced ROC ater failure ofsorafeni or untini. Bverolimus is also FDA approved ‘shrink ngiomyolipeme (AML) inpatients with tuberous seers whose ‘AML doesnot require surgery. 5. Side effeds— include rash, stomatitis (eg. mouth les), infeetons, ‘asthenia (reales), peripheral edema, gasvontestal aus, vomiting, ‘iates, anorexia), hematologic (hrombocytopeia, neutropenia, ‘anemia, hyperglycemia, hyperlipidemia, elevated creatinine, vated liver Ration ts, and iypophosphatemin. Rae side effet inci ‘bowel pesraton and itr pneumonitis cough, dyspnes hypoxia). Interleukin {Interleukin 2 (L-2)—aeytokine dat stimulate el mised immu 1 ‘was onc af the fit FDA approved ieatments for advanced RCC, bt ts rarely we now because of is toxicity andi initad effcivees in most patients. 1 TL-2 nase to eat cea cell RCC (the types of RCC usually do aot respond IL-2), ‘Tobe acandidat for IL-2, the patient mast have no rain metastasis and Ive adsjat cara, renal, od pulmonary funtion. Good perfomance sts (ECOG BS <2), predominantly lear ell carcinoma, {nd abssce of sarcomatoid festurs ae prefered, The mat effective pimen thigh dove bos IL-2. Each cyslo ‘consis of intravenous IL-2 (60,000 o¢ 720,000 Ug) q hous x 14 doses. Zeycles ae given wih 59 day of eatin between eles. In ‘responding patients his 2eyce courte i repeated every 6-12 weeks. 4. Side efecto inclde over cil, weight gai, id tention, reverie eal and hepatic insuficiney, and hypotension «Response ~ 16% (5% complet response; 11% part response). {Criteria predict a better response IL-2: ECOG PS of, absence of| ‘metas in maltiple rps, no bone micas, lng oaly meats, ‘ior nghrctomy, and no sarcomatoid feature inthe prisary tor 2. Interferon interferon is ese effstive than IL-2 ‘Bevacizumab with Interferon Ali-28 T-Bevacizumab, a ecombinant monoclonal antibody inhibits angiogenesis and tumer growth by binding to and noutalizing vascular endothelin row fiir A (VEGF-A), 2 Revacinab with inerforon af metastatic RCC. 3 Inpatients with lear ell RCC, bevacizumab wih intron af 28 improves progression fee survival by 35 months compare o intron sone, butt dit not improve overall survival. Thus, Bevatzumab with interferons mare effective than nerferon lone Most patients that Were ‘tudld hala previous nephrectomy. Side effets elude dry mouth, headache, bypetnsion, stomatitis (¢ ‘mouth ule), gastoiatestinal yspepsn, anorexia constipation), Aygpne, vice changes, miner bleeding and poor wound healing” Rare side effets include bowel peefration and hemorhage. 5. To avid poor wound healing, top bevacizuma a eset 28 days bere lective suey Itmay be resumed at least 28 days afer sure. i FDA approved for teaiment of30 POCKET GutpE.T0 UROLOGY Jett Wieder, MD “Treatment for RCC (Adapted from the NCCN, AUA, & KAU Guldenes) | Dssinsr wean waif werinet, orb is xpecaney je —) Nel Ye] Savalas eat] Crees) Radler io apy ae Triana Geka Trem | [nmertomaze te dems RCC ‘Seine dance | |" plist shea soy med ge ett = Tr er ng Nopoaliaince | Umalcanic) | mom ean bona) “Paetenmpe |prmccd [Se * sin [Pace (patie emi pas ie sai ffaersinaceMpa te) | a Fight eles ec toning | | [> ‘Siage T4, or uf — Ropialignph some. | | Come eta) Suse T3Ni€Ftrn pat || [°"Repetom™ ign ay Gee ‘ai For iettate RCC inde the Ebtatymaeo ‘actions (ONS ~ cra erous sytem: RCC ~ real eal carcinoma; ‘EDC Exstm Coopertve Onsioey Group * Paral epirecomy ithe peered eaten for most inl wage 1 tumor, ‘Abinton ay be wiz oslo 1 tumors (nail tuners <3) ‘+ Paint hat roe il to eft fom etoredutve oprecomy have good performance tats eg BCOG performance tat Oo 1 nara metas a meas oly in hen. ‘Reina ph ade dissetion (LND) does ot improve survival LND i ces in pets wth cncl ND dacs, usu be cnsieed i Potent a high ik eins ede mctsases LND recomended in ptots vid ctneal NI dese (eld Iymph node ound on maging oF Tropes) eer tei osu stage te tame ome clr Iymph der do ot bor malig) {1 Paton atelaony when thea noma ister arena land oo ropes aging or when there ran senopertve sespcion of adel Involvement 4 When potve mais pres repeat etn may be considered in tin’ wth an aggresive mor 14 Beision of te metas sual prefered (ora ran ad bone metastas, ‘alin therapy dbo a option). + Adjovant stn one for yeaa ler. Tal ecrence ins tro sth renal ss ar ada nephrectomy ad tumor in th intel Key afer renal sping hep {Rik is argnl barton the Memoval Slna Kateri Cancer Center Prognostic ‘Model (SKC) rte tration Metastatic Renal Cell Carcinoma Database (Concetum Crea (IMDC)Renal Tumort a Recurrence and Survival ‘Rocarrence After Curative Treatment fr Primary RCC 1. paar radical nephrcetomy eal eeuence interes oss is ‘are (£24). Resection af loalrcarence (in the nbence of melasttic Aiseae) cn achive lng erm survival. 2. Inthe absmnceof gente and fails! ROC syndromes, ecurrence in he conralataal Kidney i re (2-49), 3. Lung ite most common seo distant recurrence 44 Mos reeamenoes oorar within years of talent. Poor Proguoste Factors of RCC 1. Higher ECOG performance status 2 Symons tenor FeOGT ney | Wea ay 1 [pea bray | Beier < 5 o Been oe + comp teas papilla, and unclassified RCC. 1. Higher lvl of tumor hrmbue 12. Tumor duombus invading the vena cava wall 13. Residual mor—inompltereseeton or positive margin 14 Presence of metasese Sarvival Basel on Nomograms ‘Nomogramscan predict metastasis ie survival and cancer spec sarvival, ‘or patients who undergo patil o radical nephrectomy for RC. 1 Peopentive J Url, 1796): 2146, 2008; Eur Urol, 352) 287, 209, 1 Postopeative—J Clin Oneal, 25: 1316, 2007. Survival Base. onthe UCLA Integrated Stalag Systm (UISS) AT TN Fuhrman | S-Year Disease| When Tata Stage _| FCOG?S | "Grade | specie Survival |" With T Tz 31% nino [34 ENON, oy ‘oy’ 80%, Radical | ~Any ‘Neprcctomy* ssxowo [31 T me “Fao —| Ay —| Any ae TART] — any | ame sedeuncweaiy| A ma 7 Tz Zetia ust e 1 nose |}? —} Nepean oo a 2m | Immnoterpy os si a % “Tames drone was peed when uno rons war prea [CK PS BOOK peonmcs ses pgs) "32 POCKET GuIDE To UroLocy Jett Wieder, MD Survival Basod on TNM State ae a wae con Te nan oo as mr oe 7 sea) race Traine Sonia hs Seat eerste | 8 ea serieste | a the renal vein or vera cava” & thrombectomy an as os oa | = mae i a a eae} Ter oe Sr eee Neo "an sage out a Re | — Fay [RN radical pir, PN= paral pepe ER imore cnet mer ms oat wih lower cae pei viral Tumor treba invading te caval wall basa Wore prognisthan ee ‘oun tomas + Suivi fom tine of tsi escetin Pulmonary mcttarprobably ave ‘sy rognss hs oe mtu oeatons A Tonger ner Serwera inde Slope of meas especialy 2 yer rasa wih itneer vel fo he ine of meta rexehon ‘+ Nest itn yas of ign Te patients hve a worse survival han at devel aia mctast ae 1 Chiione singe rsetion cyathray or aan Resection is fen preter, 4} Mate whi ne yen of pose. 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