OBJECTIVE:To investigate the treatment outcome of laparoscopic partial nephrectomy in the patients with renal tumors of moderate to high complexity (R.E.N.A.L. score 7-10).METHODS:In the study, 186 patients with a renal score of 7-10 renal tumors who underwent laparoscopic partial nephrectomy in Peking University Third Hospital from February 2016 to April 2021 were selected. Laparoscopic partial nephrectomy was performed after examination. The patients were followed-up, and their postoperative hemoglobin, creatinine, complications, and length of hospital stay recorded. The data were represented by mean±standard deviation or median (range).RESULTS:There were 128 males and 58 females in this group, aged (54.6±12.8) years, with body mass index of (25.4 ± 3.4) kg/m2; The tumors were located in 95 cases on the left and 91 cases on the right, with maximum diameter of (3.1±1.2) cm. The patient's preoperative hemoglobin was (142.9±15.8) g/L, and blood creatinine was 78 μmol/L (47-149 μmol/L). According to preoperative CT images, the R.E.N.A.L. score was 7 points for 43 cases, 8 points for 67 cases, 9 points for 53 cases, and 10 points for 23 cases. All the ope-rations were successfully completed, with 12 cases converted to open surgery. The operation time was 150 minutes (69-403 minutes), the warm ischemic time was 25 minutes (3-60 minutes), and the blood loss was 30 mL (5-1 500 mL). There were 9 cases of blood transfusions, with a transfusion volume of 800 mL (200-1 200 mL). Postoperative hemoglobin was (126.2±17.0) g/L. The preoperative crea-tinine was 78 μmol/L (47-149 μmol/L), the postoperative creatinine was 83.5 μmol/L (35-236 μmol/L), the hospital stay was 6 days (3-26 days), and surgical results achieved "the trifecta" in 87 cases (46.8%). In the study, 167 cases were followed up for 12 months (1-62 months), including 1 case with recurrence and metastasis, 4 cases with metastasis, and 2 cases with other tumors (1 case died).CONCLUSION:Laparoscopic partial nephrectomy is safe and effective in the treatment of renal tumors with R.E.N.A.L. score of 7-10. Based on the complexity of the tumor, with the increase of difficulty, the warm ischemia time and operation time tend to increase gradually, while "the trifecta" rate gradually decreases. The complications of this operation are less, and the purpose of preserving renal function to the greatest extent is achieved.

BACKGROUND: The incidence of small renal mass (SRM) increases, and the prognosis of SRM is poor once metastasized. Therefore, we conducted this study to assess the clinical and pathological characteristics of SRM to determine the risk factors that influence the metastasis and prognosis of SRM. METHODS: A small renal mass is defined as a solid tumor mass with the largest diameter of 4 cm or less on the pathological diagnosis. The metastasis is confirmed by imaging or pathological examination. We retrospectively included 40 patients with metastatic SRM (mSRM) treated in the department of urology of Peking University Third Hospital from October 2002 to October 2020. Meanwhile, 358 patients with nonmetastatic SRM treated in our hospital from January 2015 to December 2017 were selected as controls. Clinicopathologic features were compiled. RESULTS: Multivariate logistic regression analysis showed that age (P = .027, odds ratio [OR] = 1.037, 95% confidence interval [CI] 1.004-1.070), clinical symptoms (P < .001, OR = 4.311, 95% CI 1.922-9.672), World Health Organization/International Society of Urological Pathology (WHO/ISUP) nuclear grade 3/4 (P = .004, OR = 7.637, 95% CI 1.943-30.012; P = .004, OR = 20.523, 95% CI 2.628-160.287), and lymphatic invasion (P = .030, OR = 15.844, 95% CI 1.314-191.033) were risk factors for distant metastasis of SRM. Once metastasis occurs, the prognosis of SRM is poor. Multivariate Cox regression analysis of the prognosis of mSRM showed that age (P = .016, hazard ratio [HR] = 1.125, 95% CI 1.022-1.239), preoperative serum creatinine (P = .041, HR = 1.003, 95% CI 1.000-1.005), vascular invasion (P = .041, HR = 1.003, 95% CI 1.000-1.005), and metastasis (P < .001, HR = 24.069, 95% CI 4.549-127.356) were risk factors for overall survival (OS), and only metastasis (P < .001, HR = 9.52, 95% CI 5.43-16.7) was a risk factor for progression-free survival (PFS) of SRM. CONCLUSIONS: SRM with advanced age, clinical symptoms, high pathological nuclear grade, and lymphatic invasion are more likely to have distant metastasis. And SRM with older age, poor preoperative basic renal function, pathological vascular invasion, and metastasis have worse OS.

Objective:To investigate the efficacy and safety of laparoscopic partial nephrectomy in the treatment of renal tumors with renal score of 10.Methods:From February 2016 to March 2021, 23 patients who underwent laparoscopic partial nephrectomy in Peking University Third Hospital with renal tumors of R. E.N.A.L. score of 10 was studied retrospectively, including 16 cases of male and 7 cases of female, with 11 cases on the right side and 12 cases on the left side. The patients’ age was (55.0±16.4) years, and BMI was (25.4±3.6) kg/m 2. The maximum diameter of the tumor was (3.5±1.4)cm. Laparoscopic partial nephrectomy was performed after complete examination. The observation indexes included operation time, blocking time, complications, postoperative hospital stay and the trifecta (negative surgical margin, blocking time ≤25 minutes, and no perioperative complications). Results:All operations were successfully completed, only 4 cases were converted to open surgery. The median operation time was 153 min(99-346 min). The median blocking time was 27 min(14-60min). The median postoperative hospital stay was 6 d(4-11 d). Postoperative complications occurred in 7 cases(fever in 5 cases, intestinal obstruction in 1 case, postoperative blood transfusion and leg intermuscular venous thrombosis in 1 case). 9 cases (39.1%) achieved the trifecta. 19 cases who completed by laparoscopy, their operation time was 151 min(99-303 min), blocking time was 28 min(18-60 min), postoperative hospital stay was 6 d(4-11 d), fever occurred in 4 cases, and 6 cases achieved the trifecta (31.6%). The follow-up time was 3-62 months, with a median of 32 months, and there was no recurrence or metastasis.Conclusions:Laparoscopic partial nephrectomy is safe and effective in the treatment of renal tumors with renal score of 10.Although the tumor is highly complex, it also achieves the purpose of preserving nephron to the greatest extent. If technical conditions permit, laparoscopic partial nephrectomy could be considered for the treatment of highly complex renal tumors.

Purpose: This study aims to develop and validate a nomogram based on a novel platelet index score (PIS) to predict prognosis in patients with renal cell carcinoma (RCC). Patients and methods: We retrospectively analyzed the data of 759 consecutive patients with RCC. The Kaplan-Meier curves were performed to analyze the platelet parameters and PIS was established. The patients were randomly divided into training (N=456, 60%) and validation cohorts (N=303, 40%). The nomogram was created based on the factors determined by multivariable Cox proportional hazard regression of the training cohort. We assessed the discrimination and calibration of our nomogram in both training and validation cohorts. And then the nomogram was compared with other reported models. Results: High platelet count (PLT>285×109/L) and low platelet distribution width (PDW≤10.95fL) were associated with shorter progression-free survival (PFS). Thus, PLT and PDW were incorporated in a novel score system called PIS. On multivariable analysis of training cohort, PIS, American Joint Committee on Cancer (AJCC) stage, and sarcomatoid differentiation were independent prognostic factors, which were all selected into the nomogram. The nomogram exhibited good discrimination in both training (C-index: 0.835) and validation cohorts (C-index: 0.883). The calibration curves also showed good agreement between prediction and observation in both cohorts. The C-index of the nomogram (C-index: 0.810~0.902) for predicting 2-year, 3-year, and 4-year PFS were significantly higher than Leibovich (C-index: 0.772~0.813), SSIGN (C-index: 0.775~0.876), Cindolo (C-index: 0.642~0.798), Yaycioglu (C-index: 0.648~0.804), MSKCC (C-index: 0.761~0.862), Karakiewicz (C-index: 0.747~0.851), and AJCC stage models (C-index: 0.759~0.864). Conclusion: The nomogram based on a novel PIS could offer better risk stratification in patients with RCC.

目的 分析肉瘤样肾癌(sRCC)的临床病理特征及预后情况,为临床诊治提供依据.方法 回顾性分析2015年1月至2020年7月于北京大学第三医院行根治性肾切除术的34例sRCC患者的临床资料,分析其影像学、病理学特点和预后情况.结果 影像学显示肿瘤位于左侧13例(38.2％)、右侧21例(61.8％),平均直径为(9.71±3.5)cm.其中29例(85.3％)患者合并肾静脉或下腔静脉瘤栓,3例(8.8％)患者合并远处转移.病理学上,sRCC以透明细胞癌为主(31例,91.2％),核分级为4级者居多(24例,70.6％).镜下可见坏死者25例(73.5％)、肾窦侵犯者30例(88.2％)、肾周脂肪囊侵犯者9例(26.5％)、肾上腺侵犯者5例(14.7％)、淋巴结转移者12例(35.3％).28例患者随访1～50个月,16例(47.1％)患者死亡,中位总体生存时间为14个月;20例(58.8％)患者出现肿瘤进展,中位无进展生存时间为14个月.结论 sRCC在临床病理上表现为高度侵袭性,预后极差,中位生存时间及无进展生存时间仅1年左右.

Introductions: The objective of this study was to determine the prognostic value of positive lymph nodes (LNs) in patients with renal cell carcinoma (RCC) and tumor thrombus (TT) and to explore risk factors predicting LNs metastasis. Methods: We retrospectively analyzed 216 patients with RCC and TT treated at a single institution from January 2015 to December 2019. Overall survival (OS) and progression-free survival (PFS) was estimated using the Kaplan-Meier curves divided by pathological LN status. Associations between clinicopathological features and survival outcomes were evaluated using Cox regression models. Logistic regression model was performed to determine risk factors associated with LN metastasis. Results: We identified 216 patients with RCC and TT including 85 (39.4%) who did and 131 (60.6%) who did not undergo lymph node dissection. Pathologically positive LNs were found in 18 (8.3%) cases. pN1 had significant worse OS (median: 21 vs. 41 and 56 months, p < 0.001) and PFS (median:14 vs. 29 and 33 months, p < 0.001) than pN0 and pNx respectively. However, survival outcomes of OS and PFS were similar between pNx-0/M1 and pN1/M0 group and between 1- and ≥2-node-positive group. Non-CCRCC (p = 0.001), sarcomatoid differentiation (p < 0.001), and pathologically positive LNs (p = 0.025) were independent prognostic predictors predicting worse OS while distance metastasis (p = 0.009), non-CCRCC (p = 0.023), necrosis (p = 0.014), sarcomatoid differentiation (p = 0.003), and pathologically positive LNs (p = 0.007) were independent prognostic indicators predicting worse PFS. Clinically positive LNs (p = 0.014) and sarcomatoid differentiation (p = 0.009) were predictors of positive LNs. Conclusions: LNs metastasis independently associated with worse survival outcomes in RCC and TT populations, with similar survival outcomes compared to distance metastasis. Therefore, more accurate risk stratification is warranted for guiding postoperative surveillance and adjuvant therapy.

Renal primitive neuroectodermal tumors with inferior vena cava (IVC) tumor thrombus is an extremely rare entity that poses a massive challenge to diagnosis and treatments. Histopathology remains the gold standard for definite diagnosis. Radical nephrectomy with NC tumor thrombectomy is a challenging procedure requiring vascular management techniques and experience. Adjuvant chemotherapy contributes to improved progression-free, but not overall, survival. Objective: To investigate the clinicopathological characteristics, treatments, and prognosis of patients with renal primitive neuroectodermal ectodermal tumors (rPNETs) with inferior vena cava (IVC) tumor thrombus. Patients and Methods: We retrospectively reviewed 6 patients with rPNETs and IVC tumor thrombus between January 2005 and December 2019, and identified 39 published cases through a literature review. The clinicopathological characteristics, treatments, and survival data were analyzed. Results: The median patient age patients was 26 years, and the male to female ratio was approximately 1:1. The average tumor diameter was 12.5 cm. Seventeen patients (37.8%) showed metastasis at diagnosis. Forty-three cases (95.6%) were managed with surgical resection, and 35 (77.8%) received adjuvant chemotherapy after surgery. Follow-up data were available for 41 patients (median follow-up, 10 months; range, 4.5-13.0). The median overall survival (OS) and median progression-free survival (PFS) were both 30.0 months. Patients who received adjuvant chemotherapy had better PFS than those who underwent surgery only (30.0 months [95% confidence interval [CI], 4.3-55.7] vs 5.0 months [95% CI, 1.0-9.0]; P = .036). In terms of OS, however, the difference between the 2 groups was not significant (30.0 months [95% CI, 8.4-52.6] vs 7.0 months [95% CI, 4.5-9.5]; P = .244). Conclusions: rPNET with IVCTT is an extremely rare entity that mostly occurs in young adults. Although multidisciplinary treatment is used, the prognosis of this disease remains unclear. RN with IVC tumor thrombectomy is a challenging procedure requiring vascular management techniques and experience. Adjuvant chemotherapy contributes to improved PFS, but not OS. Thus, early diagnosis and treatment play a key role in improving prognosis. (C) 2021 Elsevier Inc. All rights reserved.

目的 探讨双侧散发性肾癌(bilateral sporadic renal cell carcinoma,BSRCC)的手术治疗策略.方法 回顾分析我院2000年6月～2020年6月37例BSRCC的临床资料.全麻下建立腹膜后操作空间,行后腹腔镜保留肾单位手术(nephron-sparing surgery,NSS)或根治性肾切除术(radical nephrectomy,RN).对肿瘤体积大、与周围组织粘连严重、复杂囊性肿瘤,行后腹腔镜探查、中转开放手术或直接行开放手术切除.结果 37例均成功行双侧手术治疗,其中22例行双侧NSS,15例行一侧NSS、对侧RN.1例行同期NSS+RN后出现ClaveinⅣa级肾功能不全,行血液透析治疗,其余36例术后恢复良好,未发生并发症.14枚囊性肿瘤中,除2枚行腹腔镜探查、中转开放NSS外,其余12枚成功行完全后腹腔镜下NSS.82枚肿瘤中,肾透明细胞癌66枚,肾嗜酸/嫌色细胞混合性肿瘤7枚,低度恶性潜能多房囊性肾肿瘤3枚,乳头状肾细胞癌(renal cell carcinoma,RCC)Ⅰ型2枚,RCC未分类型2枚,肾嫌色细胞癌1枚,管状囊性RCC 1枚.术后病理核分级:G17例,G218例,G310例,G42例.35例随访4～194个月,中位时间30个月.30例存活,5例死亡,10例术后发生远处转移.2年总生存率91.3％,2年无进展生存率82.6％.结论 BSRCC积极行双侧手术治疗效果良好,双侧腹腔镜NSS是较为理想的选择.对囊性RCC行腹腔镜NSS难度较大,常需手术经验丰富的医师进行操作.BSRCC具有多灶性、易复发的特点,术后应严密随访.

目的 探讨不同病理类型双侧肾癌(BRCC)的临床病理特点、手术治疗策略和预后.方法 回顾性分析2004年6月至2019年6月北京大学第三医院收治的5例不同病理类型BRCC患者的临床资料.5例均为男性,平均年龄53(33～61)岁.同时性BRCC 3例,异时性BRCC 2例.5例均为双侧单发肿瘤.10枚肿瘤中实性肿瘤3枚,囊性肿瘤7枚.肿瘤平均直径2.4(1.4～6.7)cm.平均R.E.N.A.L.评分5(4～8)分.5例患者术前平均血清肌酐79(74～108)μmoI/L.结果 5例均成功行双侧手术治疗:其中3例行双侧后腹腔镜下保留肾单位手术(NSS);1例行一侧后腹腔镜下根治性肾切除术(RN),对侧后腹腔镜下NSS;1例因一侧囊性肿瘤体积较大,粘连严重行后腹腔镜探查,中转开放NSS,对侧后腹腔镜下NSS.3例同时性BRCC患者均采用分期手术策略,双侧手术平均间隔时间3(1.5～4)个月.5例平均手术时间126(110～221)min,行NSS者平均热缺血时间24(11～40)min.平均手术失血量20(10～50)mL.5例患者术后平均血清肌酐95(77～121)μmol/L,术后平均住院时间6(3～16)d.术后病理示5例均为一侧肾透明细胞癌,其中对侧低度恶性潜能多房囊性肾肿瘤者3例、肾嫌色细胞癌者1例、管状囊性肾细胞癌者1例.5例平均随访时间26.7(18.6～194.3)个月,均无局部复发或远处转移,肾功能良好.结论 不同病理类型BRCC临床较为罕见,治疗以分期双侧NSS为首选.腹腔镜下NSS治疗复杂性肾囊性肿瘤难度较大,需临床经验丰富的医师进行操作.BRCC多灶发病的概率显著高于单侧肾癌,术后应严密随访,不同病理类型BRCC的预后取决于恶性度较高、分期较晚的一侧.同一机体发生不同病理类型的BRCC,为该病的肿瘤起源研究提供新的线索和思路,但BRCC的发生机制尚需基因测序的大样本研究进一步阐明.

To the Editor: Renal cell carcinoma (RCC) accounts for approximately 3% of all malignancies in adults.[1] Locally advanced RCC has a relatively distinct and adverse prognosis with a 5-year cancer specific survival (CSS) rate ranging from 28% to 67% after curative surgery.[2] It is important to accurately stratify the risk of disease recurrence for locally advanced RCC. Several prognostic models like Stage, Size, Grade, and Necrosis (SSIGN), Leibovich, Cindolo, Yaycioglu, Memorial Sloan Kettering Cancer Center (MSKCC), Kattan, and Karakiewicz have been developed to predict the prognosis of localized RCC and the concordance index (C-index) has been found to range from 0.65 to 0.84.[3,4] To our knowledge, these models have mainly been developed based on the data from low-risk patients with RCC. In an external prospective cohort comprising patients with intermediate or high-risk RCC, the performances of these models were found to be sharply decreased (C-index range from 0.587 to 0.69).[4] Thus, in this study, we aimed to develop a more accurate prognostic model for better risk stratification in locally advanced RCC. Patients were identified from a retrospective, single-center database consisting of 759 patients who had undergone nephrectomy for RCC from January 2015 to December 2017 at Peking University Third Hospital. The study was approved by the Peking University Third Hospital Medical Science Research Ethics Committee. According to the 8th Tumor-Node-Metastasis (TNM) classification, patients with T3-4N0M0 or T1-4N1M0 RCC were defined as having locally advanced RCC. Thus, patients who were diagnosed with locally advanced RCC and underwent curative-intent surgery were included in our study cohort. Patients with bilateral or recurrent tumors, severe comorbidities, and incomplete data, and those who had undergone cytoreductive surgery were excluded. Based on the inclusion and exclusion criteria, a total of 215 patients were enrolled in our study and formed the analytical cohort. Patient demographic and clinicopathological data were collected, including sex, age, symptoms at presentation, body mass index, medical comorbidities, surgical approach, surgical time, inter-operative blood loss, tumor side, and tumor size, and pathologic data including histologic subtype, nuclear grade, necrosis, sarcomatoid and rheumatoid differentiation, lymphovascular invasion, renal sinus invasion, perirenal fat invasion, urinary collecting system invasion, venous tumor thrombus, lymph node invasion, and adrenal invasion. The total points of the SSIGN, Leibovich, Cindolo, Yaycioglu, MSKCC, Kattan, and Karakiewicz models were calculated for each patient. Disease progression was defined as any evidence of recurrence or metastasis, or tumor progression in the pre-existing metastatic site. Progression-free survival (PFS) was defined as the time from the date of surgery to disease progression. Patients were advised to not receive any post-operative adjuvant therapy until disease progression. Categorical variables are reported as numbers and proportions, and continuous variables are reported as mean ± standard deviations or median and interquartile range (IQR). The associations of relevant clinicopathological data with PFS were assessed using Cox proportional hazards regression models. The backward stepwise selection was used to identify the independent factors for multivariable Cox proportional hazards regression models. Selected independent factors and important clinical factors were incorporated in the nomograms to predict the probability of 2-, 3-, and 4-year PFS. The performance of the nomogram was measured using the C-index, which ranges from 0.5 (no predictive power) to 1 (perfect prediction). Calibration was evaluated using a calibration curve, which assessed the outcomes between the observed outcome probabilities and the nomogram-predicted probabilities with a bootstrapped resampling of 1000 times. Nomogram establishment and calibration were conducted using R software (Version 4.0.3) using the “rms” package, and other statistical analyses were performed using SPSS (Version 26, IBM, Armonk, NY, USA). All tests were two sided, and P < 0.05 was considered statistically significant. Patients’ characteristics are shown in [Supplementary Table 1, https://links.lww.com/CM9/A807]. The mean age of the 215 patients in this study was 59.33 ± 11.42 years and most patients were male (N = 151, 70.2%). The median time of follow-up was 36 months (IQR: 27–40 months). Sixty-four patients (29.8%) were found to have disease progression during follow-up. The median PFS of the study cohort was 46 months (IQR: 38–57 months). Univariable and multivariable Cox regression analysis is shown in Supplementary Table 2, https://links.lww.com/CM9/A807. In the multivariable analysis, nuclear grade (HR: 1.892 for III–IV, P = 0.019), lymph node invasion (HR: 3.817, P = 0.004), and venous tumor thrombus (HR: 1.809, P = 0.036) were independent factors. Symptoms at presentation (HR: 1.622, P = 0.080) remained in the multivariable model, although it was not statistically significant. Considering the clinical importance of the symptoms at presentation, we established a nomogram based on nuclear grade, lymph node invasion, venous tumor thrombus, and symptoms at presentation [Figure 1].Figure 1: The nomogram to predict PFS was created based on symptoms at present, nuclear grade, venous tumor thrombus, and lymph node invasion. PFS: Progression-free survival.The discrimination of the nomogram was relatively high and had a C-index of 0.751 to 0.783 for our cohort. Calibration curves were developed using a 1000 bootstrap resampling method and good agreement was found between the predicted and actual probabilities [Supplementary Figure 1, https://links.lww.com/CM9/A806]. The 2-, 3-, and 4-year predicted accuracy of our nomogram, SSIGN, Leibovich, Cindolo, Yaycioglu, MSKCC, Kattan, and Karakiewicz models is shown in Supplementary Table 3, https://links.lww.com/CM9/A807. The Karakiewicz model was found to perform the best (C-index: 0.673–0.781) and the Kattan model was determined to perform the worst (C-index: 0.566–0.624). Our nomogram exhibited better accuracy than the SSIGN, Leibovich, Cindolo, Yaycioglu, MSKCC, Kattan, and Karakiewicz models. In this study, we analyzed 215 consecutive patients diagnosed with locally advanced RCC and reported several noteworthy findings. First, we found that nuclear grade, venous tumor thrombus, and lymph node invasion were independent prognostic factors among these patients. Second, we established a nomogram that exhibited good discrimination and calibration when used in our study cohort. Third, compared with other conventional models, our nomogram was found to be slightly but significantly superior for risk stratification of locally advanced RCC. To the best of our knowledge, locally advanced RCC is pathologically heterogeneous, which groups perirenal fat invasion, renal sinus invasion, urinary collecting system invasion, and segmental renal vein invasion as T3 stage; tumor invasion beyond Gerota fascia as T4 stage; and lymph node invasion as N1 stage. Previous studies report that the prognosis varies depending on the pathologic features even if it is the same stage.[5] We found that among these, venous tumor thrombus and lymph node invasion were independent prognostic factors that correlated with PFS in locally advanced RCC. Besides, the nuclear grade was also an independent prognostic factor in our study cohort, which suggested that the current TNM staging system may not be sufficient to provide satisfactory risk stratification in patients with locally advanced RCC. Owing to the shortcomings of the current TNM staging system, several models have been reported to predict prognosis in patients with RCC. However, the performances of current models were found to sharply decrease in the prospective clinical trial cohort comprising patients with intermediate or high-risk localized RCC.[4] We speculated that in the development cohort, the patients were mainly grouped as low-risk RCC. Thus, in the intermediate or high-risk RCC cohorts, the predicted accuracy of these models was limited. Considering this speculation, we developed a nomogram based on a group of patients with locally advanced RCC. Notably, our nomogram was found to be superior compared with other conventional models. Besides, our nomogram only incorporated four simple variables including the symptoms at presentation, nuclear grade, venous tumor thrombus, and lymph node invasion, all of which were easy to obtain post-operatively. Our study has several limitations. First, the C-index of our nomogram was 0.751 to 0.783 and slightly higher than that of the other models, which suggested moderate, but not optimal, predicted accuracy of the model. Thus, the potential prognostic factors of locally advanced RCC were extremely complex and could not be thoroughly revealed based on these four simple factors. A multi-parameter model coupled with clinical and gene information should be investigated in future studies to improve the predicted accuracy of prognosis in these patients. Second, our nomogram was developed, and internal validation was performed based on data from a single-center cohort. Further studies are needed to externally validate the proposed nomograms. To summarize, we developed a nomogram with good discrimination and calibration to predict the prognosis of locally advanced RCC. Our nomogram was superior to other conventional models in predicting the 2-, 3-, and 4-year PFS, indicating its ability of better risk stratification in these patients. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Conflicts of interest None.

Background Sarcomatoid differentiation in renal cell carcinoma (RCC) with vena caval tumour thrombus has been shown to be associated with aggressive behaviours and poor prognosis; however, evidence of the impact of rhabdoid differentiation on prognosis is lacking. This study evaluated the impact of sarcomatoid differentiation and rhabdoid differentiation on oncological outcomes for RCC with vena caval tumour thrombus treated surgically. Methods We retrospectively analysed patients treated surgically for RCC with vena caval tumour thrombus at our institute from Jan 2015 to Nov 2018. Prognostic variables were evaluated for associations with progression-free survival (PFS) and cancer-specific survival (CSS) by Kaplan–Meier survival analysis and log-rank test. Univariate and multivariate analyses were performed to determine independent prognostic variables. Results We identified 125 patients with RCC and vena caval tumour thrombus, including 17 (13.6%) with sarcomatoid differentiation alone, 8 (6.4%) with rhabdoid differentiation alone and 3 (2.4%) with both sarcomatoid and rhabdoid differentiation. Compared to pure RCC, patients with sarcomatoid differentiation but not rhabdoid differentiation have worse PFS ( p = 0.018 and p = 0.095, respectively). The univariate and multivariate analyses both showed sarcomatoid differentiation as a significant predictor of PFS. Compared to pure RCC, patients with sarcomatoid differentiation ( p = 0.002) and rhabdoid differentiation ( p = 0.001) both had significantly worse CSS. The univariate analysis showed sarcomatoid differentiation, rhabdoid differentiation, metastasis and blood transfusion as significant predictors of CSS (All, p < 0.05). In the multivariate analysis, sarcomatoid differentiation (HR 3.90, p = 0.008), rhabdoid differentiation (HR 3.01, p = 0.042), metastasis (HR 3.87, p = 0.004) and blood transfusion (HR 1.34, p = 0.041) all remained independent predictors of CSS. Conclusions Sarcomatoid differentiation and rhabdoid differentiation are both independent predictors of poor prognosis in RCC with vena caval tumour thrombus treated surgically.

OBJECTIVE:To investigate the effect of NBI assisted white light transurethral resection of bladder tumor (TURBT) in the treatment of bladder urothelial carcinoma and to summarize the experience of narrow band imaging (NBI) operation.METHODS:Patients with bladder urothelial carcinoma were selected, and TURBT was performed after anesthesia. First of all, the bladder tumor was found and resected under white light. Then we replaced with NBI, looked for suspicious lesions and resected them, The specimens excised under white light and NBI were collected separately. The number, location and pathological results of the lesions under white light were recorded, and the residual lesions under NBI were also recorded. To evaluate the effect of NBI, the ratio of residual bladder tumor was calculated. The cases were divided into three groups according to the time sequence. The clinical data of each group were collected and the learning curve of TURBT under NBI assisted white light was observed.RESULTS:A prospective study of 45 patients with bladder tumor from April 2018 to January 2020, including 32 males and 13 females, aged from 23 to 89 years, with an average age of 65.2 years. All the operations were successfully completed, without obvious complications after operation. Nine cases were single and 36 cases were multiple. The maximum diameter of the tumors was 0.5 to 4.0 cm, with an average of 2.2 cm. The histopathology of the resected tissue under white light was urothelial carcinoma, and 19 cases (42.2%) were pathologically positive by NBI resection. The 45 cases were divided into three groups according to the time sequence, 15 cases in each group. The true positive rate of NBI was 33.3%, 46.7% and 46.7%, respectively, and the false positive rate was 60.0%, 46.7% and 26.7%, respectively in the three groups.CONCLUSION:TURBT is an effective way to treat bladder urothelial cancer, NBI is an effective supplement of white light, which can increase the detection rate of bladder cancer and reduce post-operative recurrence. The NBI light source has a certain learning curve. With the increase of cases, the false-positive rate of NBI is gradually reduced. After the NBI operator has rich experience, the recognition degree of flat tumor is gradually improved under white light, and the residual rate of NBI is reduced after the removal under white light.

马蹄肾(horseshoe kidney,HSK)合并肾肿瘤临床少见,国内外文献鲜有报道.HSK位置偏低,常合并肾旋转不良,且异位血管较多,后腹腔镜下肾部分切除难度较大.现将北京大学第三医院泌尿外科收治的2例HSK后腹腔镜肾部分切除术的病例报告如下.

Objection: The aim of the study was to determine the prognostic value of preoperative blood parameters in patients with renal cell carcinoma (RCC) and tumor thrombus (TT) treated surgically.Method: we retrospectively analyzed 152 patients diagnosis with RCC and TT and treated surgically. Clinicopathologic data and blood parameter were obtained. Univariable and multivariable analysis using the Cox regression model were performed to determine risk factors that were associated with progression-free survival (PFS) and overall survival (OS). Kaplan-Meier curve and logistic regression were performed to analyze the risk factors.Results: Preoperative Hgb＜120g/L (HR=2.48, P=0.024) and lymph node metastasis (HR=3.98, P=0.032) were an independent prognostic factors associated with OS. Preoperative PLT≥300×109/L (HR=2.10, P=0.014) and lymph node metastasis (HR=3.42, P=0.021) were an independent prognostic factors associated with PFS. In Kaplan–Meier survival analysis, preoperative anemia had worse OS than without anemia (P=0.003) and thrombocytosis had worse PFS than without thrombocytosis (P=0.001). Preoperative anemia were associated with more symptomatic (P=0.009), surgical time≥6h (P=0.016), Blood loss≥1000ml (P=0.014), transfusion(P=0.012), higher thrombus level (III-IV) (P=0.004) and higher nuclear grade (III-IV) (P=0.002) while thrombocytosis were associated with more symptomatic (P=0.008) and higher nuclear grade (III-IV) (P=0.042)Conclusions: Preoperative anemia and thrombocytosis was associated with adverse prognosis in patients with non-metastatic RCC with TT. Both preoperative hemoglobin level and platelet count may be clinical useful for risk stratifying patients receiving operation for non-metastatic RCC with TT.

Adrenal pseudocysts are rare entities in clinical practice and many are picked up incidentally.1 The incidence of congenital anomaly of inferior vena cava is estimated to range from 0.2% to 3.0% in the general population.2 We report an exceptional case of a giant right-sided adrenal pseudocyst with inferior vena cava duplication to illustrate the clinical and histopathological features of this entity.

Background To assess therapeutic value of lymph node dissection (LND) in non-metastatic renal cell carcinoma (RCC) with tumor thrombosis (TT) and identify the prognostic factor in these population. Methods We retrospectively reviewed 128 patients with RCC and TT in our institution from February 2015 to January 2019. The baseline characteristics of LND and no LND group were compared. Kaplan–Meier analysis, univariable and multivariable Cox regression models were used to analyze these population. Results Of 128 patients, 58(45%) underwent LND and 70(55%) without LND. Patients who received LND had significantly higher cN1 rate (64% vs 37%; P = 0.004), longer operation time (357 min vs 307 min; p = 0.002) and longer hospital stay (12.6d vs 9.5d; p = 0.094) than that in no LND group. There were 102 patients (79.7%) received followed up with the median 12 months (IQR:8 ~ 19). Estimated three-year overall survival was worse in LND group (75% vs 90%; p = 0.048) but were not significantly different in subgroup of cN0 and cN1. The overall survival were not significantly different between two groups after adjustment for age, tumor size, surgical approach, tumor thrombosis level and histologic type. Non-CCRCC (HR:4.97; 95%CL:1.56 ~ 15.78; P = 0.006) and occurrence of major complication (HR:3.33; 95%CL:1.05 ~ 10.58; P = 0.041) were the predictors of worse OS while positive lymph node is the only independent predictor of worse OS (HR:5.26; 95%CL:1.28 ~ 21.66; P = 0.021) in these populations after receiving LND. Conclusion In this study, we confirm that LND in non-metastatic RCC with TT was not associated with a survival benefit, even we adjusted for clinic node status. Category like age, tumor size, surgical approach, tumor thrombosis level and histologic type were not a indication for LND. Lymph node positive was identified as an independent poor prognostic factor. Therefore, LND in RCC with TT should be considered as a staging procedure rather than therapeutic one.

传统观点认为,肾癌对放射治疗不敏感.近年来,越来越多的研究证据表明以立体定向体部放疗为代表的高剂量适形放疗可显著提升肾癌放疗疗效.随着分子生物学研究的不断深入,已发现缺氧诱导因子-1α、酸性鞘磷脂酶、信号转导及转录激活蛋白1等生物大分子在改善肾癌放疗敏感性方面起到重要作用;立体定向体部放疗的远位效应对远离放射野的肿瘤转移灶的控制具有重要意义.运用立体定向体部放疗治疗无法手术的肾癌患者,可从一定程度控制肿瘤进展,延长患者寿命,有效保护肾功能,有较好的应用前景.但立体定向放疗治疗肾癌仍处于探索阶段,其远期疗效仍需进一步研究验证.本文拟对肾癌立体定向体部放疗的研究进展作一综述.

患者,男,64岁.主因"全膀胱根治性切除术后9年,下腹痛2周"入院.既往史:高血压病史25年,糖尿病病史9年,阑尾切除术后10年.9年前患者因膀胱肿瘤于我院行腹腔镜全膀胱根治性膀胱切除-回肠膀胱术.术后病理诊断为膀胱腺癌(非脐尿管型),出院后患者未定期随访复查.现患者因下腹痛2周再次入院.术前血常规:中性粒细胞百分数为78.4 ％.尿常规:尿潜血2+,尿蛋白2+,尿白细胞3+.肾功能、凝血功能正常.泌尿系CT示(图1):膀胱切除、回肠代膀胱术后,腔内附壁肿物,大小约5.7 cm×2.4 cm×4.8 cm,性质待定;左输尿管结石,双肾小结石,左肾小囊肿;双侧肾盂肾盏、输尿管扩张积水.膀胱镜、输尿管镜:新膀胱右侧内壁偏输入袢侧可见一肿物,呈隆起性生长,无蒂,长径约5 cm.输尿管镜取病理活检5块.活检病理:黏膜组织的形态和免疫标记符合肠源性上皮,呈高级别上皮内瘤变,局灶形成黏膜内癌.患者在全麻下行开腹探查、肠粘连松解、新膀胱部分切除术.