BACKGROUND: Xanthogranulomatous pyelonephritis (XGPN) is a rare form of chronic renal inflammation, caused by long-term obstruction of the urinary tract. Pyonephrosis is a severe suppurative complication of acute obstructive pyelonephritis. Although minimally invasive approaches have many advantages, the safe dissection of the kidney may not be always achievable.
METHODS: We reviewed 27 cases diagnosed with either XGPN or pyonephrosis, who underwent laparoscopic total nephrectomy between October 2016 and March 2022 in our department. All interventions were performed using the Karl Storz 3D laparoscopic system. The surgical approach was standard transperitoneal nephrectomy for the majority of XGPN, while pyonephrosis cases were carried out in a retroperitoneally. All procedures were performed or supervised by the same surgeon.
RESULTS: The mean operative time was 269.85 minutes (range 145-360). The mean hemoglobin drop after surgery was 1.41 g/dl (range 0.3-2.3 g/dl). Difficult dissection was encountered in 13 cases (48.14%). Nine out of 13 interventions were carried out in a complete intracorporeal fashion, while conversion to open surgery was needed in 4 cases. Vascular complications involving the major blood vessels comprised of one case of inferior vena cava (IVC) tear. Digestive tract-related complications comprised two fistulas of the descending colon and one peritoneal breach. Multiorgan resection was performed in 6 cases.
CONCLUSIONS: Total nephrectomy in cases of XGPN and pyonephrosis is a challenging procedure. The laparoscopic approach is feasible, as most complications are resolved intracorporeally. However, it may remain reserved for large-volume centers with experienced surgeons.

The utility of partial nephrectomy (PN) in locally advanced, stage T3 renal cell carcinoma (RCC) is controversial. This retrospective study aimed to review the oncological and functional outcomes of patients with T3a RCC who underwent PN. We included all patients with pT3a stage RCC undergoing either open, laparoscopic, or robotic PN at our center between January 2015 and 2023. A Wilcoxon rank sum test was utilized to compare nephrectomy types (radical nephrectomy [RN] vs PN). Survival analysis was conducted using Kaplan-Meier plots and a log-rank test. P-value < 0.05 indicated statistical significance. There were no significant differences in demographic characteristics between the RN and PN groups, except age (53.0 vs 6.5, respectively; P = 0.012) and body mass index (28.7 vs 34.3, respectively; P = 0.020). Furthermore, there were also no significant differences in the rates of local recurrence (P = 0.597), metastatic progression (P = 0.129), and chemotherapy use (P = 0.367) between nephrectomy types. Patient survival did not differ significantly based on the type of nephrectomy (log-rank P-value = 0.852). Together, our findings indicated that PN and RN yield near-equivalent oncological outcomes in terms of local recurrence, metastasis, and overall survival rates among pT3a RCC patients during a nearly 3-year follow-up period.

BACKGROUND: Surgical techniques of radical and partial nephrectomy have changed over the last 20years. Indications for partial nephrectomy have widened and mini-invasive surgery (laparoscopy and robotic assistance) has become widely used. However, both still have a significant morbidity. The objective of this article is to review complications of renal surgery and their predictive factors and to offer algorithms of management.
METHODS: Recent literature regarding complications of radical and partial nephrectomy was queried using Pubmed engine search. The most relevant articles were analyzed and served as a basis for this work.
RESULTS: The literature on complications of radical and partial nephrectomy has a low level of evidence. There are only retrospective series. The most frequent complications of radical nephrectomy occur during surgery in 5-10% of the cases: wound of the pedicle or of an adjacent organ. The management can often be conservative. Laparoscopy has a similar morbidity compare to the open approach but has greatly increased postoperative outcomes and comfort. Partial nephrectomy has a 20% complication rate. Many factors have an impact on the risk of complications (tumor size, inflammation of perirenal fat, access, surgeon experience, centre volume, comorbidities and age of the patient) and must be taken into consideration before advising partial nephrectomy. The two most feared complications of partial nephrectomy are bleeding (per- or postoperative, 10% of the cases) and urinary fistula (<5% of the cases). Robotic assistance is associated with a lower morbidity in many publications.
CONCLUSIONS: Complications after partial and radical nephrectomy are quite frequent but have decreased with the improvement of surgical techniques. French urologists should maintain their interest in novel technologies and simplification of perioperative pathway to further improve patients\' outcomes.

Selection of patients for upfront cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) has to be improved.
To evaluate a new scoring system for the prediction of overall mortality (OM) in mRCC patients undergoing CN.
We identified a total of 519 patients with synchronous mRCC undergoing CN between 2005 and 2019 from a multi-institutional registry (Registry for Metastatic RCC [REMARCC]).
Cox proportional hazard regression was used to test the main predictors of OM. Restricted mean survival time was estimated as a measure of the average overall survival time up to 36 mo of follow-up. The concordance index (C-index) was used to determine the model\'s discrimination. Decision curve analyses were used to compare the net benefit from the REMARCC model with International mRCC Database Consortium (IMDC) or Memorial Sloan Kettering Cancer Center (MSKCC) risk scores.
The median follow-up period was 18 mo (interquartile range: 5.9-39.7). Our models showed lower mortality rates in obese patients (p = 0.007). Higher OM rates were recorded in those with bone (p = 0.010), liver (p = 0.002), and lung metastases (p < 0.001). Those with poor performance status (<80%) and those with more than three metastases had also higher OM rates (p = 0.026 and 0.040, respectively). The C-index of the REMARCC model was higher than that of the MSKCC and IMDC models (66.4% vs 60.4% vs 60.3%). After stratification, 113 (22.0%) patients were classified to have a favorable (no risk factors), 202 (39.5%) an intermediate (one or two risk factors), and 197 (38.5%) a poor (more than two risk factors) prognosis. Moreover, 72 (17.2%) and 51 (13.9%) patients classified as having an intermediate and a poor prognosis according to MSKCC and IMDC categories, respectively, would be reclassified as having a good prognosis according to the REMARCC score.
Our findings confirm the relevance of tumor and patient features for the risk stratification of mRCC patients and clinical decision-making regarding CN. Further prospective external validations are required for the scoring system proposed herein.
Current stratification systems for selecting patients for kidney removal when metastatic disease is shown are controversial. We suggest a system that includes tumor and patient features besides the systems already in use, which are based on blood tests.

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