INTRODUCTION:Patients with obesity have a reduced access to kidney transplantation due to the higher risk of surgical and medical complications. Our aim was to provide clinical guidelines in this population focused on: (i) the main anthropometric parameter that contraindicates open kidney transplantation; (ii) other clinical factors to consider before transplantation; (iii) contraindications to robot-assisted transplantation; (iv) efficient and safe weight loss methods for kidney transplantation candidates with obesity. METHODS:After a systematic review of studies published between January 2010 and June 2025 performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria, these guidelines were developed by a multidisciplinary task force and reviewed by independent experts. RESULTS:In total, 153/962 publications met the inclusion criteria. The decision to allow kidney transplantation should not be based solely on Body Mass Index (BMI), but also on skin-to-vessel distance and pelvis angle. Robot-assisted kidney transplantation may be considered in highly selected patients with obesity and limited vascular disease, even those with grade 3 obesity. Patients with frailty should receive appropriate care before weight loss therapies. After appropriate nutritional preparation, bariatric surgery should be considered fairly quickly in patients with kidney failure and grade ≥ 2 obesity (grade B), or grade 1 obesity and poorly controlled type 2 diabetes. While Roux-en-Y gastric bypass achieves superior long-term weight loss than sleeve gastrectomy, it is associated with an increased mortality and morbidity. Pharmacological treatment (mainly GLP-1 agonists) is currently evaluated for weight loss in this population. CONCLUSIONS:These guidelines allow personalizing the management in kidney transplantation candidates with obesity.

BACKGROUND:Allograft nephrectomy (AN) is a rare but morbid procedure required after graft failure or neoplasia. We systematically reviewed current knowledge on AN surgical techniques, complications, and alternatives. PATIENTS AND METHODS:Undertaken to inform the French Association of Urology guidelines on allograft nephrectomy, this review was reported following PRISMA guidelines. PubMed/MEDLINE was searched (January 2000-March 2024) for studies of patients with non-functional first kidney transplants requiring AN or alternative strategies. Case reports, editorials, and non-systematic reviews were excluded. RESULTS:AN is predominantly performed via an open extraperitoneal approach. For non-functional grafts, consensus is lacking regarding subcapsular versus extracapsular techniques. However, the subcapsular approach reduces operative time, bleeding, and intraoperative complications, though overall morbidity data remain conflicting. The surgical approach does not impact alloimmunization. Regarding arterial embolization, protocols are not standardized. Yet, it achieves >80% success with lower mortality and morbidity than AN. Its main complication is post-embolization syndrome, potentially leading to secondary AN. Embolization prior to AN effectively reduces intraoperative bleeding and operative time. CONCLUSION:The extraperitoneal subcapsular approach appears to be the safest surgical option. Arterial embolization is a valuable alternative or adjuvant strategy to AN in managing graft intolerance syndrome after graft failure.

BACKGROUND Vascular complications remain a significant concern after kidney transplantation. While external iliac (EI) implantation is standard, common iliac (CI) implantation is occasionally performed in selected cases, particularly in the presence of vascular disease or anatomical constraints. We compared vascular outcomes according to the arterial anastomosis site. MATERIAL AND METHODS We conducted a bicentric retrospective study including kidney transplant recipients between 2015 and 2019. Implantation strategy differed between centers, with a preferential use of CI implantation in one center and EI implantation in the other. Patients underwent arterial anastomosis to the CI (n=157) or EI vessels (n=359). The primary endpoint was vascular complications graded according to the Clavien-Dindo classification. Secondary endpoints included ≥60% vascular stenosis, lymphocele rate, and graft failure at 2 years. RESULTS Baseline characteristics differed between groups, reflecting center-specific practices and case-mix variations. Overall vascular complication rates were similar (22.9% in CI vs 20.1% in EI; P=0.46). However, Clavien-Dindo ≥III complications were more frequent in the CI group (14.6% vs 7.5%; P=0.01). Severe vascular stenosis requiring intervention (Clavien-Dindo III) occurred more often in CI recipients (7.0% vs 0.8%; P<0.01). Lymphocele was also significantly more frequent in the CI group (27.4% vs 9.2%; P<0.01; OR 4.55, 95% CI 2.56-8.09; P<0.001). At 2 years, graft failure rates did not differ significantly (4.1% vs 5.3%; P=0.29). CONCLUSIONS In this bicentric retrospective analysis, CI implantation was associated with a higher rate of severe vascular complications, particularly stenosis, and lymphocele, without a significant impact on graft failure at 2 years. These findings should be interpreted with caution, as they likely reflect, at least in part, differences in patient selection and center-specific surgical practices.

This study aimed to assess ureteroscopy’s impact on renal function in patients with a solitary kidney (SK), where nephron preservation is paramount. With the rising prevalence of SKs due to congenital anomalies or acquired conditions, understanding the safety profile of ureteroscopy, particularly its effects on renal function, seems essential. A literature search following PRISMA guidelines was conducted to identify reports published until May 2024. Eligible studies were included if they focused on ureteroscopy in SK patients and reported renal function outcomes. Data extraction and bias assessment were performed using standardized protocols as Joanna Briggs Institute’s checklist for non-randomized studies. Renal function changes (eGFR or serum creatinine), complications, and follow-up data were analyzed. Outcomes included acute kidney injury (AKI) and persistent renal function deterioration, as defined by the Collège-Français-des-Enseignants-d’Urologie (CFEU) criteria. 15 studies were included, involving 615 patients. The renal function remained stable in ten (67

Les fistules recto-urétrales (FRU) sont responsables d’une altération de la qualité de vie liée à des symptômes fonctionnels urinaires (pneumaturie, fécalurie, écoulement d’urine par le rectum) ou des infections urinaires (basses ou hautes, souvent récidivantes). Leur origine est surtout iatrogène, après des interventions chirurgicales comme la prostatectomie radicale, où leur prévalence varie de 0,03 % à 10 % selon les séries. Ces FRU peuvent également faire suite à une radiothérapie pour cancer de prostate. La prise en charge de ces FRU est complexe et varie selon l’existence d’une irradiation préalable ou non. Différentes techniques chirurgicales ont été évaluées, mais il n’existe actuellement pas de consensus sur la meilleure approche. La technique de York-Mason est privilégiée pour les FRU simples et sans antécédent d’irradiation, alors que pour des cas plus complexes sur tissus irradiés, des approches comme la voie transpérinéale avec interposition de lambeau musculaire sont souvent recommandées. L’évaluation de la qualité de vie des patients est cruciale, car la prise en charge des FRU peut avoir un impact significatif sur la continence urinaire et fécale et sur les fonctions sexuelles. Malgré les succès des réparations, les patients peuvent continuer de souffrir de séquelles fonctionnelles affectant leur qualité de vie. Bien que des avancées aient été faites dans le traitement des FRU, un algorithme de prise en charge cohérent et efficace est nécessaire pour standardiser les pratiques et améliorer les résultats. Cette mise au point expose les différentes stratégies de prise en charge des FRU et souligne l’importance d’une approche personnalisée.

Flexible Ureteroscopy (FURS) in patients with a solitary kidney (SK) has been sparsely studied, especially its safety. Available literature suggests that the renal function remains stable after FURS with low evidence. We aimed to assess and predict the postoperative renal function after FURS in patients with SK, using Machine Learning (ML) models. A dualcenter retrospective study was conducted between 2013 and 2023, including patients undergoing FURS in solitary kidneys. Demographic, peri-operative data, pre- and postoperative serum creatinine and estimated Glomerular Filtration Rate(eGFR) were collected. Multivariate analysis intended to identify risk factors for renal function decline. After data splitting, 12 ML models were trained and tested to predict the 3 months postoperative serum creatinine. A total of 87 patients were included. 84

Rectourethral fistula (RUF) is associated with poor quality of life related to urinary functional symptoms (pneumaturia, fecaluria, urine passing through the rectum) or urinary tract infections (upper or lower, often recurrent). Most are iatrogenic, occurring after surgery such as radical prostatectomy, where their prevalence ranges from 0.03 in various series. RUF can also occur after radiation therapy administered for prostate cancer. Management of RUF is complex and depends on whether the patient has had previous radiation therapy or not. Different surgical techniques have been evaluated, but currently there is no consensus as to the best approach. The York-Mason technique is preferred for simple RUF in patients without prior irradiation, while for more complex cases, with antecedent irradiation, transperineal approaches with muscular flap interposition are often recommended. Evaluation of quality of life is crucial, because management of RUF can have severe consequences on urinary continence and sexual function. Despite successful anatomical repair, patients often continue to suffer from functional sequalae that affect their quality of life. Although progress has been achieved in the treatment of RUF, a coherent and efficient management algorithm is necessary to standardize the practical aspects and improve the outcomes. This update summarizes the different strategies that are available for management of RUF and underscores the importance of an individualized approach.

INTRODUCTION:Potential donors for transplantation are screened for malignancies that can be transmitted on to the recipient. The discovery of cancer or a history of cancer often leads to contraindications for organ donation, while in some cases the cancer transmission risk is very low. The current context of organ shortage leads us to reconsider the use of organs from donors with cancer or a history of cancer when the risk of transmission is minimal or less than the risk of death on the waiting list. The Transplantation Committee (CTAFU) in partnership with the Cancer Committee (CCAFU) of the Association Française d'Urology (AFU) were asked to publish guidelines for clinical practice concerning the use of donors with cancer or a history of urological cancer (prostate cancer, kidney cancer, urothelial tumors, testicular cancer). MATERIAL AND METHODS:A review of the literature with a systematic approach (PubMed/Medline) was conducted by a steering group of CTAFU members concerning the assessment of the urologic cancer transmission risk from the donor to the recipient. The conclusions of the supporting evidence were discussed by a working group composed by members of the CTAFU and the CCAFU, who then developed clinical guidelines. RESULTS:The risk of transmitting prostate cancer is very low. The working group has identified several situations for which organ donation can be done without risk, in particular for low-risk prostate tumors, other situations that require consultation and expertise, and higher-risk cases where transplantation is not recommended. In donors with history of treated kidney cancer, organ removal is not contraindicated for low-grade pT1 tumors. Several conditions are necessary for other stages and grades depending on the time to remission. In case of incidental finding of a kidney tumor during the donor screening, the use of the organs depends on the stage of the tumor, the possibility of ex vivo partial nephrectomy and the possibility to have a quick and reliable histologic examination. Urothelial carcinomas are much more at risk of transmission, and it is not recommended to transplant an organ from a donor with a bladder tumor or upper urinary tract tumor. Recommendations were made for donors with a history of urothelial carcinoma based on the group risk of recurrence. Similarly, the discovery of a testicular tumor in the donor contraindicates the use of organs. Donors with a history of treated stage I testicular cancer may be accepted under certain conditions, as well as stage II and III donors who have been in remission for more than 10years. CONCLUSION:The use of donors with a tumor or a history of urological tumor may be considered and should allow the pool of potential donors to be expanded. Guidelines have been established not to lose healthy organs, without compromising the safety of the recipient.

La recherche de néoplasie fait partie intégrante du bilan prétransplantation. Le cancer de la prostate étant le cancer le plus fréquent chez l’homme, son surdiagnostic chez les candidats à la transplantation pourrait réduire l’accès à la transplantation sans bénéfices oncologiques. Une gestion optimale du cancer de la prostate chez les candidats est donc essentielle afin de limiter l’impact de son diagnostic chez les patients sur liste d’attente pour transplantation rénale. Les données actuelles indiquent que le choix de traitement du cancer de la prostate pour des formes localisées avait peu d’impact sur l’accès et les résultats de la transplantation rénale. De plus, la surveillance active chez les patients de faible risque était en augmentation, du fait de la possibilité de maintenir un accès à la transplantation rénale sans résultats négatifs sur le plan oncologique.

objective: In France, kidney transplantations (KT) are mainly performed by urologist. Young urologists and residents are involved in this activity mostly performed in emergency.How do they feel about KT training? is KT an attractive part of the urologist activity?Methods: This survey has been designed in the form of a questionnaire by the French Committee of kidney Transplantation (CTAFU) and the French Association of Urologists in training (AFUF). It has been sent by e-mail to all the AFUF members. Interest in KT and performance of the training were evaluated.Results: 126 members filed the form. 51,5 % of the residents feel secure to perform KT at the end of their residency. KT is considered as an interesting surgery for 92,1 % of the participants: 76,5 % are willing to get involved in KT during their residency/fellowship. 44% are willing to continue a long-term involvement. 65,9% of the residents consider their practical training insufficient: 56,8% have been supervised for a KT performance during their residency and 86% declare a lack of practical training and had a patient-based learning. 92,1 % declare an insufficient theorical training. 33.3% say the schedules of transplantation limit their interest in KT. 34.4% of the participants receive a transplant bonus in addition to the usual on-call salary.Conclusion: Young urologists wish to continue their involvement in KT activity, but improved theoretical and practical training are essential. In addition, the conditions under which this activity is performed and remunerated are a matter of concern.

IntroductionLes patients traités par immunothérapie sont parfois opérés conjointement au traitement systémique. Les indications sont : la néphrectomie de cytoréduction, la cystectomie dans le cadre d’essais cliniques et l’exérèse des métastases de cancer du rein chez certains patients oligométastatiques. L’objectif de cette étude était d’évaluer la faisabilité de la chirurgie sous immunothérapie et les modifications histologiques à l’analyse anatomopathologique.Matériel et méthodesNous avons réalisé une étude de cohorte exposée/non exposée monocentrique rétrospective et avons inclus les patients opérés d’un cancer urologique précédemment traités par immunothérapie de février 2018 à juin 2022. Nous les avons comparés avec un groupe contrôle similaire selon le type de cancer, l’âge et le sexe, traité chirurgicalement et sans immunothérapie. Nous avons étudié les complications périopératoires et cherché la présence d’un infiltrat inflammatoire.RésultatsNous avons inclus 50 patients dans l’étude. Les deux groupes étaient comparables sur l’âge (63,7 versus 63,3 ans, p=0,95) et le sexe (quatre et six femmes dans chaque groupe). Le nombre de complications peropératoires décrites était comparable (20 % versus 16 %, p=1). La quantité de saignement moyenne était comparable (664 versus 629mL ; p=0,89). Le taux de complications postopératoires (48 % versus 56 % ; p=0,78) et leur gravité (Clavien III–IV 8 % versus 24 % ; p=0,24) étaient comparables. L’analyse anatomopathologique décrivait la même intensité d’infiltrat inflammatoire péri-tumoral (96 % versus 96 % ; p=1).ConclusionL’immunothérapie préopératoire ne semble pas être associée à une augmentation de la difficulté chirurgicale et des complications périopératoires. L’analyse histologique en aveugle des pièces opératoires n’a pas révélé de caractéristiques spécifiques liées à l’immunothérapie préopératoire.Niveau de preuveGrade 3 HAS.

L’utilisation de clips en polymère avec verrouillage (Weck® Hem-o-loks®, Teleflex Medical) est largement plébiscitée pour le contrôle des vaisseaux lors des interventions de néphrectomies cœlioscopiques. Or ces clips sont contre-indiqués pour l’occlusion de l’artère lors des néphrectomies pour don de rein depuis 2005. Nous avons passé en revue les aspects réglementaires, les différentes méta-analyses et les recommandations publiées sur les différents systèmes pour ligaturer l’artère rénale au cours d’une néphrectomie cœlioscopique pour don de rein. Nous avons également interrogé 31 centres français de transplantation rénale sur leur technique d’occlusion de l’artère rénale. Cette enquête a été comparée à celles précédemment publiées en Amérique du Nord et en Europe.

Introduction > Patients treated with immunotherapy might need surgical procedures in addition to the medical treatment. The main indications are cytoreductive nephrectomy, cystectomy (as part of clinical trials) and metastasis removal in some oligometastatic patients. This study aims to assess the feasibility of surgery for patients treated by immunotherapy and describes the histological modifications found in the pathological analysis. Material and methods > We conducted a retrospective, monocentric study. We included all patients operated for a urologic cancer and previously treated with systemic immunotherapy between February 2018 and June 2022. We compared this population with a control group of patients treated with surgery without having previous immunotherapy. Patients were compared according to the cancer type, age and sex. We compared perioperative complications. We performed an analysis for evaluation of the peri-tumoral inflammatory infiltration. Results > We included 50 patients in this study. The two groups were comparable in age (63.7 vs. 63.3 years old, P = 0.95) and sex (4 and 6 women in the first and second group). The peroperatory complication rate was comparable (20% vs. 16%, P = 1). The mean bleeding volume was comparable (664 vs. 629 mL; P = 0.89). The postoperative complication rate (48% vs. 56%; P = 0.78) and their grade (Clavien III-IV 8% vs. 24%; P = 0.24) were comparable. The anatomopathological analysis described the same rate and intensity of peri-tumoral inflammatory infiltrate (96% vs. 96%; P = 1). Conclusions > Preoperative immunotherapy does not appear to be associated with increased surgical difficulty and perioperative complications. Blind histological analysis of the surgical specimens did not reveal any specific features related to pre operative immunotherapy.

Intravesical Bacillus Calmettes-Guerin (BCG) instillations is the gold standard adjuvant treatment for high and very high-risk non-muscle-invasive bladder cancer (NMIBC). Antibiotics may be required to treat asymptomatic bacteriuria before instillations or to prevent side effects. By modifying the bladder microbiota and through its bactericidal action, it could modify the efficacy of BCG. This study evaluates the impact of antibiotics received during BCG-induction treatment on the oncological outcomes for high and very high risk NMIBC. We retrospectively included all patients who received a full induction regimen of BCG therapy between January 2017 and June 2022. Clinical and tumor characteristics as well as tolerability were collected. Recurrence-free survival (RFS) and progression-free survival (PFS) were compared according to the prescription of antibiotics, its type and duration. A total of 126 patients were included, 86.5% of the tumors were high risk and 13.5% very high risk. The median follow-up was 31 months (7-60). 36% of the patients received antibiotics during BCG-induction treatment (among which 44% received fluoroquinolones). 21.4% of patients had tumor recurrence. There was no difference in RFS (p=0.902) or PFS (p=0.88) according to the duration or the type of antibiotics received. The use of a prolonged antibiotic treatment (> 7 days) significantly increased the duration of the BCG-induction treatment from 35 to 41,5 days (p=0,049) and the median number of delayed treatments by 1,5 [0-4]. Neither the use of antibiotics nor their duration modified the risk of recurrence or the intensity of side effects in multivariate analysis. Antibiotics received during BCG-induction immunotherapy did not influence oncological short-term outcomes or intensity of side effects.

Laparoscopic partial nephrectomy (LPN) after hyperselective embolization of tumor vessels (HETV) in a hybrid operating room (HOR) that combines traditional surgical equipment with advanced imaging technology, is a non-clamping surgical approach to treat localized kidney tumors that has shown promising short-term results. The aim of this study was to evaluate the long-term oncological and functional outcomes of this procedure. All consecutive patients treated for a localized kidney tumor by LPN after HETV between May 2015 and October 2022 in a single academic institution were included in the study. Clinical, pathological and biological data were collected prospectively in the uroCCR database. We evaluated intraoperative data, postoperative complications, surgical margin and modification of renal function after surgery. We included 245 patients. The median tumor size was 3.2 (2.5–4.4) cm. The R.E.N.A.L. complexity was low, medium and high for 104 (43.5%), 109 (45.6%) and 26 (10.9%) patients, respectively. Median LPN time was 75 (65–100) min and median blood loss was 100 (50–300) mL. Surgical postoperative complications occurred in 56 (22.9%) patients with 17 (5.7%) major complications. The median Glomerular Function Rate variation at 6 months was −7.5 (−15–−2) mL/min. Malignant tumors were present in 211 (86.1%) patients, and 12 (4.9%) patients had positive surgical margins. After a median follow-up of 27 (8–49) months, 20 (8.2%) patients had a tumor recurrence and 4 (1.6%) died from cancer. At 5 years, disease free survival, cancer specific survival and overall survival rates were 84%, 96.8% and 88.3%, respectively. Performing LPN after HETV in a HOR is a safe and efficient non-clamping approach to treat localized kidney tumors.

La néphrectomie partielle laparoscopique (NPL) après embolisation hyper-sélective des vaisseaux tumoraux (EHVT) dans une salle d'opération hybride, combinant équipement chirurgical traditionnel et technologies d'imagerie avancées, est une approche chirurgicale sans clampage qui a montré des résultats prometteurs à court terme pour le traitement des tumeurs rénales localisées. Le but de cette étude était d'évaluer les résultats oncologiques et fonctionnels à long terme de cette procédure. Tous les patients traités pour une tumeur rénale localisée par NPL après EHVT entre mai 2015 et octobre 2022 dans notre institution ont été inclus dans l'étude. Les données cliniques, anatomopathologiques et biologiques ont été collecté prospectivement dans la base de données UroCCR (NCT03293563, numéro d'autorisation CNIL : DR-2013-206). Nous avons évalué les données périopératoires, les complications postopératoires, les résultats oncologiques, les marges chirurgicales et l'évolution de la fonction rénale après la chirurgie. Nous avons analysé les facteurs de risque de récidive et les facteurs de risque de complication en utilisant une analyse univariée et une régression de Cox. Nous avons inclus 245 patients opérés par 15 chirurgiens. La taille médiane des tumeurs était de 3,2 (2,5–4,4) cm. Le temps opératoire médian sans embolisation était de 75 (65–100) min et les pertes sanguines médiane étaient de 100 (50–300) mL. Des complications postopératoires chirurgicales sont survenues chez 56 (22,9 %) patients avec 17 (5,7 %) complications majeures. La variation médiane du DFG à 6 mois était de −7,5 (−15 ; −2) mL/min. Une tumeur maligne et des marges chirurgicales positives ont été identifiées à l'analyse histologique chez respectivement 211 (86,1 %) et 12 (4,9 %) patients. Après un suivi médian de 27 (8–49) mois, 20 (8,2 %) patients ont présenté une récidive tumorale. En analyse multivariée, le stade pT (OR : 4,4, p = 0,027) et les marges chirurgicales positives (OR : 4,29, p = 0,029) étaient des facteurs de risque de récidive (Tableau 1). L'utilisation d'une salle d'opération hybride pour réaliser une NPL après EHVT est une approche sans clampage sûre et efficace pour traiter les tumeurs rénales localisées. Elle semble être une alternative chirurgicale à la néphrectomie partielle robotisée.

Background. Sarcopenia is defined as a loss of muscle mass and strength. Its effects on post-operative outcomes in oncology and geriatrics have already been shown. Approximately 40% of patients in end-stage renal failure are affected with sarcopenia. A recent study suggests that sar-copenia could predict surgical complications after renal transplantation in obese patients. The aim of this study was to evaluate the effect of sarcopenia on parietal complications (eg, wound healing, lymphocele, hematoma).Methods. Two indices of muscle fat infiltration (intra-muscular adipose content [IMAC], Hounsfield unit average calculation [HUAC]) and 3 of muscle mass index (total psoas index [TPI], visceral fat area/total abdominal muscle area [VFA/TAMA], and skeletal muscle mass index [SMMI]) were retrospectively measured on pretransplant computed tomography scans for patients undergoing kidney transplantation between 2007 and 2017. Patients were considered sarcopenic when the index was above the third quartile for muscle fat infiltration (IMAC, HUAC) and VFA/TAMA, and under the first quartile for muscle mass (TPI, SMMI). The occur-rence of wound healing, collection (hematoma and lymphocele), and acute rejection were com-pared between sarcopenic and nonsarcopenic patients.Results. Of 484 transplanted patients, 117 patients had a computed tomography scan before trans-plantation. Patients with a high HUAC had significantly more collections (P = .02) and total parietal complications (P = .09). Patients with a high IMAC had significantly more acute rejection (P = .001).Conclusions. Muscle fat infiltration appears to influence the outcome of renal transplantation. The management of sarcopenia in pretransplantation should be a subject of further research.

Systematic screening for prostate cancer is widely recommended in candidates for renal transplant at the time of listing. There are concerns that overdiagnosis of low-risk prostate cancer may result in reducing access to transplant without demonstrated oncological benefits. The objective of the study was to assess the outcome of newly diagnosed prostate cancer in candidates for transplant at the time of listing, and its impact on transplant access and transplant outcomes according to treatment options. This retrospective study was conducted over 10 years in 12 French transplant centers. Patients included were candidates for renal transplant at the time of prostate cancer diagnosis. Demographical and clinical data regarding renal disease, prostate cancer, and transplant surgery were collected. The primary outcome of the study was the interval between prostate cancer diagnosis and active listing according to treatment options. Overall median time from prostate cancer diagnosis to active listing was 25.0 months [16.4-40.2], with statistically significant differences in median time between the radiotherapy and the active surveillance groups (p = .03). Prostate cancer treatment modalities had limited impact on access and outcome of renal transplantation. Active surveillance in low-risk patients does not seem to compromise access to renal transplantation, nor does it impact oncological outcomes.