Purpose: To systematically review the published literature on surgical margins as a risk factor for local recurrence (LR) in patients undergoing partial nephrectomy (PN) for pT1 renal cell carcinomas (RCC). Evidence acquisition: A systematic literature search of relevant databases (MEDLINE, Embase and the Cochrane Library) was performed according to the PRISMA criteria up to February 2022. The hypothesis was developed using the PPO method (Patients = patients with pT1 RCC undergoing PN, Prognostic factor = positive surgical margins (PSM) detected on final pathology versus negative surgical margins (NSM) and Outcome = LR diagnosed on follow-up imaging). The primary outcome was the rate of PSM and LR. The risk of bias was assessed by the QUIPS tool. Evidence synthesis: After assessing 1525 abstracts and 409 full-text articles, eight studies met the inclusion criteria. The percentage of PSM ranged between 0 and 34.3%. In these patients with PSM, LR varied between 0 and 9.1%, whereas only 0–1.5% of LR were found in the NSM-group. The calculated odds ratio (95% confident intervals) varied between 0.04 [0.00–0.79] and 0.27 [0.01–4.76] and was statistically significant in two studies (0.14 [0.02–0.80] and 0.04 [0.00–0.79]). The quality analysis of the included studies resulted in an overall intermediate to high risk of bias and the level of evidence was overall very low. A meta-analysis was considered unsuitable due to the high heterogeneity between the included studies. Conclusion: PSM after PN in patients with pT1 RCC is associated with a higher risk of LR. However, the evidence has significant limitations and caution should be taken with the interpretation of this data.

Purpose: To assess the difference between renal mass biopsy (RMB) performed either before or during the ablation procedure. Methods: A retrospective multicenter study was performed in patients with a cT1 renal mass treated with ablation between January 2007 and July 2019, including a search in the national pathology database for patients with a RMB planned for ablation. Patient and tumor characteristics and information on malignant, benign, and non-diagnostic biopsy results were collected to establish rates of overtreatment and number of ablations avoided in case of benign or non-diagnostic histology. Results: RMB was performed in 714 patients, of which 231 patients received biopsy before planned ablation, and 483 patients at the time of ablation. Pathology results before ablation were malignant in 63% (145/231), benign in 20% (46/231) and non-diagnostic in 17% (40/231). Pathology results at the time of ablation were malignant in 67.5% (326/483), benign in 16.8% (81/483) and non-diagnostic in 15.7% (76/483), leading to a total of 32.5% of ablation of benign or non-diagnostic lesions. Of the patients with a benign biopsy obtained before ablation, 80.4% (37/46) chose not to undergo ablation. Patients with inconclusive biopsy before planned ablation chose an informed individualized approach including ablation, repeated biopsy, or no intervention in 56%, 34% and 10%. Conclusion: This study emphasizes the importance of obtaining a biopsy prior to the ablation procedure in a separate session to lower the rate of potentially unnecessary ablations.

Objective: To assess complication rates and intermediate oncological outcomes of laparoscopic‐assisted cryoablation ( LCA ) in patients with small renal masses ( SRM s). Patients and Methods: A retrospective review of 808 patients treated with LCA for T1a SRM s from 2005 to 2015 at eight European institutions. Complications were analysed according to the Clavien–Dindo classification. Kaplan–Meier analyses were used to estimate 5‐ and 10‐year disease‐free survival ( DFS ) and overall survival ( OS ). Results: The median [interquartile ( IQR )] age was 67 (58–74) years. The median ( IQR ) tumour size was 25 (19–30) mm. The transperitoneal approach was used in 77.7% of the patients. The median postoperative hospital stay was 2 days. In all, 514 patients with a biopsy‐confirmed renal cell carcinoma ( RCC ) were available for survival analyses. The median ( IQR ) follow‐up for the RCC ‐cohort was 36 (14–56) months. A total of 32 patients (6.2%) were diagnosed with treatment failure. The 5‐/10‐year DFS was 90.4%/80.0% and 5‐/10‐year OS was 83.2%/64.4%, respectively. A total of 134 postoperative complications (16.6%) were reported, with severe complications (grade ≥ III ) in 26 patients (3.2%). An American Society of Anesthesiologists score of 3 was associated with an increased risk of overall complications (odds ratio 2.85, 95% confidence interval 1.32–6.20; P = 0.005). Conclusions: This large series of LCA demonstrates satisfactory long‐term oncological outcomes for SRM s. However, although LCA is considered a minimally invasive procedure, risk of complications should be considered when counselling patients.

To describe the impact of a multidisciplinary tumor board (MTB) for renal cell carcinoma (RCC) patients in a locoregional renal cancer network by evaluating shared decision making (SDM) and adherence to MTB recommendations. This prospective cohort study included all cases from a Dutch renal cancer network with suspicion of or histologically confirmed RCC discussed in MTBs between 2017-2022. Main endpoints were distribution of cases presented, proportion of recommendations with multiple treatment options enabling shared decision making (SDM), definite treatment after SDM and adherence to MTB recommendations. Further endpoints were definite treatment per tumor stage stratified by age and inclusion in clinical trials. Outcomes were displayed as means and proportions (%). Pearson's Chi-Squared test was used to analyze the effect of age on definite treatment advice. Overall, 2651 cases were discussed, of which 1900 (72%) were new referrals and 751 (28%) rediscussions. Majority of cases were cT1a-b tumors (46%) and 22% were local recurrences or metachronous metastatic. Adherence to MTB recommendation was 96% and in 30% multiple treatment options were recommended, allowing for SDM. In 45% of cases with cT1a tumors multiple treatment options were recommended by the MTB, resulting in (cryo)ablation (32%) and AS (30%) as most frequent definite treatments after SDM. Among patients with cT3-4 tumors the inclusion rate in clinical trials was 47%. A network MTB creates opportunity to discuss multiple treatment options and clinical trials in SDM with patients at a high rate of adherence to MTB recommendation.

Objectives: To determine the rate of benign pathology in cT1 tumors following partial nephrectomy in the Netherlands, thereby evaluating the rate of overtreatment. Methods: Data were collected from a nationwide database containing histopathology of resected renal tissue from 2014 to 2022. Patients who underwent partial nephrectomy for suspected RCC staged T1a-b were extracted for analysis. Data are shown in percentages, and multivariable logistic regression was performed to determine predictive factors for benign pathology. Results: 3409 cases were analyzed, of which 403 (12%) were benign and 3006 (88%) malignant. Subtype analysis showed 2126 (62%) cases of clear-cell RCC, followed by 604 (18%) of papillary RCC and 344 (10%) oncocytomas. Mean age was 63 years among patients with malignant pathology versus 65 years for patients with benign lesions (p < 0.001). Mean tumor size was 3.2 cm for malignant pathology and 2.9 cm for benign (p < 0.001). The rates of benign and malignant pathology did not change between 2014 and 2022 (p = 0.377). Multivariable regression showed age ≥ 65 years (65–79 years [OR 1.881, p = 0.002], ≥ 80 years [OR 3.642, p < 0.001]) and tumor size (OR 0.793, p < 0.001) as predictors for benign pathology. The main limitation of this study is that we do not know the biopsy rate of our cohort. Conclusion: This study reports a low rate of 12% benign pathology after partial nephrectomy in the Netherlands. It remains debatable whether these rates are acceptable, or if renal tumor biopsies should be utilized more frequently to reduce overtreatment.