Robert G. Uzzo

PURPOSE: Treatment decisions for renal malignancies depend largely on qualitative data, including a description of tumor anatomy and the experience of the treating surgeon. Currently characterization of renal tumor anatomical elements is descriptive and lacks standardization. Surgical decision making and data set comparisons would be significantly enhanced by a consistent, reproducible system that quantitates the pertinent characteristics of localized renal lesions. We have developed and propose a standardized nephrometry scoring system (R.E.N.A.L. Nephrometry Score) to quantify the anatomical characteristics of renal masses on computerized tomography/magnetic resonance imaging. MATERIALS AND METHODS: The nephrometry score is based on 5 critical and reproducible anatomical features of solid renal masses. Of the 5 components 4 are scored on a 1, 2 or 3-point scale with the 5th indicating the anterior or posterior location of the mass relative to the coronal plane of the kidney. We applied the R.E.N.A.L. Nephrometry Score to 50 consecutive masses resected at Fox Chase Cancer Center. RESULTS: The R.E.N.A.L. Nephrometry Score consists of (R)adius (tumor size as maximal diameter), (E)xophytic/endophytic properties of the tumor, (N)earness of tumor deepest portion to the collecting system or sinus, (A)nterior (a)/posterior (p) descriptor and the (L)ocation relative to the polar line. The suffix h (hilar) is assigned to tumors that abut the main renal artery or vein. The nephrometry scoring system accurately classified the complexity of 50 consecutive tumors undergoing excision at our institution. CONCLUSIONS: Standardized reporting of renal tumor size, location and depth is essential for decision making and effective comparisons. The R.E.N.A.L. Nephrometry Score is a reproducible standardized classification system that quantitates the salient anatomy of renal masses. This novel approach for the systematic characterization of renal tumors provides a tool for meaningful comparisons of renal masses in clinical practice and in the urological literature.

No AccessJournal of UrologyAdult Urology1 Oct 2009Guideline for Management of the Clinical T1 Renal Massis accompanied byIncreased Tissue Factor Expression and Poor Nephroblastoma PrognosisPercutaneous Microwave Ablation or Nephrectomy for VX-2 Carcinoma in Rabbit KidneyTemporary Segmental Renal Artery Occlusion Using Reverse Phase Polymer for Bloodless Robotic Partial Nephrectomy Steven C. Campbell, Andrew C. Novick, Arie Belldegrun, Michael L. Blute, George K. Chow, Ithaar H. Derweesh, Martha M. Faraday, Jihad H. Kaouk, Raymond J. Leveillee, Surena F. Matin, Paul Russo, and Robert G. Uzzo Steven C. CampbellSteven C. Campbell Financial interest and/or other relationship with Pfizer, Sanofi Aventis, Novartis, Aventis Pharmaceuticals. More articles by this author , Andrew C. NovickAndrew C. Novick The Panel dedicates this work to Dr. Andrew Novick, who served as Chair of the Panel until his untimely death in 2008. Dr. Novick was well recognized for his contributions to renal surgery, and kidney cancer in particular. More articles by this author , Arie BelldegrunArie Belldegrun Financial interest and/or other relationship with Galil Medical, Wilex, Bayer, Pfizer, ROEI Medical, Amgen, Agensys, Hana Biosciences, Cougar Biotechnology. More articles by this author , Michael L. BluteMichael L. Blute More articles by this author , George K. ChowGeorge K. Chow More articles by this author , Ithaar H. DerweeshIthaar H. Derweesh More articles by this author , Martha M. FaradayMartha M. Faraday More articles by this author , Jihad H. KaoukJihad H. Kaouk Financial interest and/or other relationship with Endocare, Intuitive Surgical. More articles by this author , Raymond J. LeveilleeRaymond J. Leveillee Financial interest and/or other relationship with Pluromed, LMA Urology-Suisee, Boston Scientific, ACMI, Applied Medial, ValleyLab, Ethicon, Intuitive Surgical. More articles by this author , Surena F. MatinSurena F. Matin Financial interest and/or other relationship with Johnson & Johnson Wound Management. More articles by this author , Paul RussoPaul Russo Financial interest and/or other relationship with Wilex AG. More articles by this author , and Robert G. UzzoRobert G. Uzzo Financial interest and/or other relationship with Pfizer, Bayer. More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2009.07.004AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail References 1 : Kidney. In: AJCC Cancer Staging Manual. Edited by . New York: Springer Verlag2002: 323. Google Scholar 2 : Cancer statistics, 2008. CA Cancer J Clin2008; 58: 71. Google Scholar 3 : Global increases in kidney cancer incidence, 1973–1992. Eur J Cancer Prev2002; 11: 171. Google Scholar 4 : Increased incidence of serendipitously discovered renal cell carcinoma. Urology1998; 51: 203. Crossref, Medline, Google Scholar 5 : Incidence of benign pathologic findings at partial nephrectomy for solitary renal mass presumed to be renal cell carcinoma on preoperative imaging. BJU Int2008; 68: 737. Google Scholar 6 : Incidence of benign lesions for clinically localized renal masses smaller than 7 cm in radiological diameter: influence of sex. J Urol2006; 176: 2391. Link, Google Scholar 7 : Small renal tumors: correlation of clinical and pathological features with tumor size. J Urol2007; 178: 414. Link, Google Scholar 8 : Are small renal tumors harmless?: Analysis of histopathological features according to tumors 4 cm or less in diameter. J Urol2006; 176: 896. Link, Google Scholar 9 : National utilization trends of partial nephrectomy for renal cell carcinoma: a case of under utilization?. Urology2006; 67: 254. Google Scholar 10 : Laparoscopic nephrectomy: Initial case report. J Urol1991; 146: 278. Link, Google Scholar 11 : Open radical nephrectomy for localized renal cell carcinoma. In: Comprehensive Textbook of Genitourinary Oncology. Edited by . Philadelphia: Lippincott, Williams & Wilkins2002: 725. Google Scholar 12 : Laparoscopic versus open radical nephrectomy: 9-year experience. J Urol2000; 164: 1153. Link, Google Scholar 13 : A prospective study of laparoscopic radical nephrectomy for T1 tumors–is transperitoneal, retroperitoneal or hand assisted the best approach?. J Urol2006; 175: 1230. Link, Google Scholar 14 : Natural history of chronic renal insufficiency after partial and radical nephrectomy. Urology2002; 59: 816. Google Scholar 15 : Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared to partial nephrectomy. J Urol2008; 179: 468. Link, Google Scholar 16 : Surgical management of renal tumors 4 cm. or less in a contemporary cohort. J Urol2000; 163: 730. Link, Google Scholar 17 : Matched comparison of radical nephrectomy vs. nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc2000; 75: 1236. Google Scholar 18 : Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy. J Urol2004; 171: 1066. Link, Google Scholar 19 : Comparison of outcomes in elective partial vs. radial nephrectomy for clear cell renal cell carcinoma of 4 to 7 cm. BJU Int2006; 97: 939. Google Scholar 20 : Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol2007; 178: 41. Link, Google Scholar 21 : Cryoablation versus radio frequency ablation of the small renal mass: a meta-analysis of published literature. J Urol2008; 179: 328. Link, Google Scholar 22 : Renal cryoablation: outcome at 3 years. J Urol2005; 173: 1903. Link, Google Scholar 23 : Long-term results of cryoablation for renal cancer and complex renal masses. Urology2006; 68: 2. Google Scholar 24 : Residual and recurrent disease following renal energy ablative therapy: a multi-institutional study. J Urol2006; 176: 1973. Link, Google Scholar 25 : Growth rates of primary and metastatic lesions of renal cell carcinoma. Int J Urol2001; 8: 473. Google Scholar 26 : The natural history of observed enhancing renal masses: meta-analysis and review of the world. J Urol2006; 175: 425. Link, Google Scholar 27 : Small renal parenchymal neoplasms: further observations on growth. Radiology1995; 197: 589. Google Scholar 28 : Enhancing renal masses with zero net growth during active surveillance. J Urol2007; 177: 849. Link, Google Scholar 29 : Management of renal masses in patients medically unsuitable for nephrectomy–natural history, complications, and outcome. Urology2004; 64: 909. Google Scholar 30 : Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol2006; 7: 735. Google Scholar 31 : A prospective randomized EORTC intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol2007; 51: 1606. Google Scholar 32 : Image-guided tumor ablation: standardization of terminology and reporting criteria. Radiology2005; 235: 728. Google Scholar 33 : Excise, ablate or observe: the small renal mass dilemma—a meta-analysis and review. J Urol2008; 179: 1227. Link, Google Scholar 34 : Surgical salvage of renal cell carcinoma recurrence after thermal ablative therapy. J Urol2008; 180: 104. Link, Google Scholar 35 : Outcomes of partial nephrectomy after previous radiofrequency ablation: the NCI experience. J Urol, suppl2008; 179: 214. abstract 609. Link, Google Scholar 36 : Correlation of radiographic imaging and histopathology following cryoablation and radio frequency ablation for renal tumors. J Urol2008; 179: 1277. Link, Google Scholar 37 : Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med2004; 351: 1296. Google Scholar 38 : Delayed intervention of sporadic renal masses undergoing active surveillance. Cancer2008; 112: 1051. Google Scholar 39 : Growth characteristics of renal cortical tumors in patients managed by watchful waiting. Can J Urol2004; 11: 2407. Google Scholar 40 : Solid renal tumors: an analysis of pathological features related to tumor size. J Urol2003; 170: 2217. Link, Google Scholar American Urological Association Education and Research, Inc., Linthicum, Maryland© 2009 by American Urological AssociationFiguresReferencesRelatedDetailsCited byMillan B, Breau R, Bhindi B, Mallick R, Tanguay S, Finelli A, Lavallée L, Pouliot F, Rendon R, So A, Dean L, Lattouf J, Basappa N and Kapoor A (2022) A Comparison of Percutaneous Ablation Therapy to Partial Nephrectomy for cT1a Renal Cancers: Results from the Canadian Kidney Cancer Information SystemJournal of Urology, VOL. 208, NO. 4, (804-812), Online publication date: 1-Oct-2022.Campbell S, Uzzo R, Karam J, Chang S, Clark P and Souter L (2021) Renal Mass and Localized Renal Cancer: Evaluation, Management, and Follow-up: AUA Guideline: Part IIJournal of Urology, VOL. 206, NO. 2, (209-218), Online publication date: 1-Aug-2021.Campbell S, Clark P, Chang S, Karam J, Souter L and Uzzo R (2021) Renal Mass and Localized Renal Cancer: Evaluation, Management, and Follow-Up: AUA Guideline: Part IJournal of Urology, VOL. 206, NO. 2, (199-208), Online publication date: 1-Aug-2021.Laguna M (2019) Re: Nephrometry Score Correlated with Tumor Proliferative Activity in T1 Clear Cell Renal Cell CarcinomaJournal of Urology, VOL. 202, NO. 6, (1094-1094), Online publication date: 1-Dec-2019.Antonelli A, Cindolo L, Sandri M, Annino F, Carini M, Celia A, D'Orta C, De Concilio B, Furlan M, Giommoni V, Ingrosso M, Mari A, Muto G, Nucciotti R, Porreca A, Primiceri G, Schips L, Sessa F, Simeone C, Veccia A and Minervini A (2019) Predictors of the Transition from Off to On Clamp Approach during Ongoing Robotic Partial Nephrectomy: Data from the CLOCK Randomized Clinical TrialJournal of Urology, VOL. 202, NO. 1, (62-68), Online publication date: 1-Jul-2019.Laguna M (2019) Re: Diagnostic Needle Biopsies in Renal Masses: Patient and Physician PerspectivesJournal of Urology, VOL. 202, NO. 1, (28-29), Online publication date: 1-Jul-2019.Harris A, Hensley P, Goodwin J, Dugan A, Peard L, Bell J, Bhalodi A and Bylund J (2018) Examining and Understanding Value: The Cost of Preoperative Characteristics, Intraoperative Variables and Postoperative Complications of Minimally Invasive Partial NephrectomyUrology Practice, VOL. 6, NO. 4, (215-221), Online publication date: 1-Jul-2019.Kassiri B, Cheaib J and Pierorazio P (2019) Patients with Small Renal Masses Undergoing Active Surveillance—Is Yearly Chest Imaging Necessary?Journal of Urology, VOL. 201, NO. 6, (1061-1063), Online publication date: 1-Jun-2019.Sotimehin A, Patel H, Alam R, Gorin M, Johnson M, Chang P, Wagner A, McKiernan J, Allaf M and Pierorazio P (2019) Selecting Patients with Small Renal Masses for Active Surveillance: A Domain Based Score from a Prospective Cohort StudyJournal of Urology, VOL. 201, NO. 5, (886-892), Online publication date: 1-May-2019.Laguna M (2018) Re: Assessing Time of Full Renal Recovery following Minimally Invasive Partial NephrectomyJournal of Urology, VOL. 200, NO. 2, (241-242), Online publication date: 1-Aug-2018.Antonelli A, Mari A, Longo N, Novara G, Porpiglia F, Schiavina R, Ficarra V, Carini M and Minervini A (2017) Role of Clinical and Surgical Factors for the Prediction of Immediate, Early and Late Functional Results, and its Relationship with Cardiovascular Outcome after Partial Nephrectomy: Results from the Prospective Multicenter RECORd 1 ProjectJournal of Urology, VOL. 199, NO. 4, (927-932), Online publication date: 1-Apr-2018.Laguna M (2017) Re: Renal Functional Outcomes in Patients Undergoing Percutaneous Cryoablation or Partial Nephrectomy for a Solitary Renal MassJournal of Urology, VOL. 199, NO. 3, (606-606), Online publication date: 1-Mar-2018.Laguna M (2017) Re: When to Perform Preoperative Chest Computed Tomography for Renal Cancer StagingJournal of Urology, VOL. 199, NO. 2, (339-339), Online publication date: 1-Feb-2018.Zabell J, Demirjian S, Lane B, Derweesh I, Isharwal S, Suk-Ouichai C, Wu J, Palacios D and Campbell S (2017) Predictors of Long-Term Survival after Renal Cancer SurgeryJournal of Urology, VOL. 199, NO. 2, (384-392), Online publication date: 1-Feb-2018.Laguna M (2017) Re: Partial Nephrectomy versus Radical Nephrectomy for Clinical T1b and T2 Renal Tumors: A Systematic Review and Meta-Analysis of Comparative StudiesJournal of Urology, VOL. 198, NO. 6, (1204-1206), Online publication date: 1-Dec-2017.Sood A, Abdollah F, Sammon J, Menon M and Rogers C (2017) Classification of Partial Nephrectomy as an Outpatient Surgery under CMS Part B Reimbursement Program—Does the Evidence Justify the Recommendation?Urology Practice, VOL. 4, NO. 6, (444-447), Online publication date: 1-Nov-2017.Yang D, Thompson R, Zaid H, Lohse C, Rule A, Boorjian S, Leibovich B, Cheville J and Tollefson M (2017) Severity of Preoperative Proteinuria is a Risk Factor for Overall Mortality in Patients Undergoing NephrectomyJournal of Urology, VOL. 198, NO. 4, (795-802), Online publication date: 1-Oct-2017.Laguna M (2017) Re: Management of Small Renal Masses: American Society of Clinical Oncology Clinical Practice GuidelineJournal of Urology, VOL. 198, NO. 3, (480-482), Online publication date: 1-Sep-2017.Campbell S, Uzzo R, Allaf M, Bass E, Cadeddu J, Chang A, Clark P, Davis B, Derweesh I, Giambarresi L, Gervais D, Hu S, Lane B, Leibovich B and Pierorazio P (2017) Renal Mass and Localized Renal Cancer: AUA GuidelineJournal of Urology, VOL. 198, NO. 3, (520-529), Online publication date: 1-Sep-2017.Laguna M (2017) Re: Findings and Impact of Early Imaging after Partial NephrectomyJournal of Urology, VOL. 198, NO. 2, (253-254), Online publication date: 1-Aug-2017.Shah P, Moreira D, Patel V, Gaunay G, George A, Alom M, Kozel Z, Yaskiv O, Hall S, Schwartz M, Vira M, Richstone L and Kavoussi L (2017) Partial Nephrectomy is Associated with Higher Risk of Relapse Compared with Radical Nephrectomy for Clinical Stage T1 Renal Cell Carcinoma Pathologically Up Staged to T3aJournal of Urology, VOL. 198, NO. 2, (289-296), Online publication date: 1-Aug-2017.Cate F, Kapp M, Arnold S, Gellert L, Hameed O, Clark P, Wile G, Coogan A and Giannico G (2017) Core Needle Biopsy and Fine Needle Aspiration Alone or in Combination: Diagnostic Accuracy and Impact on Management of Renal MassesJournal of Urology, VOL. 197, NO. 6, (1396-1402), Online publication date: 1-Jun-2017.Lenis A, Tan H, Halpern J, Laviana A, Shuch B and Hu J (2016) Ablative Therapies for Early Stage Kidney Cancer and the Evolving Role of the UrologistUrology Practice, VOL. 4, NO. 2, (162-168), Online publication date: 1-Mar-2017.Ito T, Derweesh I, Ginzburg S, Abbosh P, Raheem O, Mirheydar H, Hamilton Z, Chen D, Smaldone M, Greenberg R, Viterbo R, Kutikov A and Uzzo R (2016) Perioperative Outcomes Following Partial Nephrectomy Performed on Patients Remaining on Antiplatelet TherapyJournal of Urology, VOL. 197, NO. 1, (31-36), Online publication date: 1-Jan-2017.Lallas C, Scotland K, Zhang M, Schaeffer D, Calvaresi A, Gomella L, Brown D, Shaw C and Trabulsi E (2016) Clinical Influences 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date: 1-Nov-2016.Larcher A, Capitanio U, Terrone C, Volpe A, De Angelis P, Dehó F, Fossati N, Dell’Oglio P, Antonelli A, Furlan M, Simeone C, Serni S, Carini M, Minervini A, Fiori C, Porpiglia F, Briganti A, Montorsi F and Bertini R (2016) Elective Nephron Sparing Surgery Decreases Other Cause Mortality Relative to Radical Nephrectomy Only in Specific Subgroups of Patients with Renal Cell CarcinomaJournal of Urology, VOL. 196, NO. 4, (1008-1013), Online publication date: 1-Oct-2016.Pierorazio P, Johnson M, Patel H, Sozio S, Sharma R, Iyoha E, Bass E and Allaf M (2016) Management of Renal Masses and Localized Renal Cancer: Systematic Review and Meta-AnalysisJournal of Urology, VOL. 196, NO. 4, (989-999), Online publication date: 1-Oct-2016.Moskowitz D, Chang J, Ziogas A, Anton-Culver H and Clayman R (2016) Treatment for T1a Renal Cancer Substratified by Size: “Less is More”Journal of Urology, VOL. 196, NO. 4, (1000-1007), Online publication date: 1-Oct-2016.Borgmann H, Reiss A, Kurosch M, Filmann N, Frees S, Mager R, Tsaur I and Haferkamp A (2016) R.E.N.A.L. Score Outperforms PADUA Score, C-Index and DAP Score for Outcome Prediction of Nephron Sparing Surgery in a Selected CohortJournal of Urology, VOL. 196, NO. 3, (664-671), Online publication date: 1-Sep-2016.Shah P, Moreira D, Okhunov Z, Patel V, Chopra S, Razmaria A, Alom M, George A, Yaskiv O, Schwartz M, Desai M, Vira M, Richstone L, Landman J, Shalhav A, Gill I and Kavoussi L (2016) Positive Surgical Margins Increase Risk of Recurrence after Partial Nephrectomy for High Risk Renal TumorsJournal of Urology, VOL. 196, NO. 2, (327-334), Online publication date: 1-Aug-2016.Sabir S, Ahrar K and Matin S (2016) Predicting and Determining the Success of Percutaneous AblationJournal of Urology, VOL. 196, NO. 1, (7-8), Online publication date: 1-Jul-2016.Lay A, Stewart J, Canvasser N, Cadeddu J and Gahan J (2016) Likelihood of Incomplete Kidney Tumor Ablation with Radio Frequency Energy: Degree of Enhancement MattersJournal of Urology, VOL. 196, NO. 1, (41-45), Online publication date: 1-Jul-2016.Huang J, Zhang J, Wang Y, Kong W, Xue W, Liu D, Chen Y and Huang Y (2016) Comparing Zero Ischemia Laparoscopic Radio Frequency Ablation Assisted Tumor Enucleation and Laparoscopic Partial Nephrectomy for Clinical T1a Renal Tumor: A Randomized Clinical TrialJournal of Urology, VOL. 195, NO. 6, (1677-1683), Online publication date: 1-Jun-2016.Mir M, Pavan N and Parekh D (2016) Current Paradigm for Ischemia in Kidney SurgeryJournal of Urology, VOL. 195, NO. 6, (1655-1663), Online publication date: 1-Jun-2016.Laviana A, Kundavaram C, Tan H, Burke M, Niedzwiecki D, Lee R and Hu J (2016) Determining the True Costs of Treating Small Renal Masses Using Time Driven, Activity Based CostingUrology Practice, VOL. 3, NO. 3, (180-186), Online publication date: 1-May-2016.Laguna M (2016) Re: Partial vs Radical Nephrectomy for T1 Renal Tumours: An Analysis from the British Association of Urological Surgeons Nephrectomy AuditJournal of Urology, VOL. 195, NO. 5, (1377-1379), Online publication date: 1-May-2016.Patel H, Johnson M, Pierorazio P, Sozio S, Sharma R, Iyoha E, Bass E and Allaf M (2016) Diagnostic Accuracy and Risks of Biopsy in the Diagnosis of a Renal Mass Suspicious for Localized Renal Cell Carcinoma: Systematic Review of the LiteratureJournal of Urology, VOL. 195, NO. 5, (1340-1347), Online publication date: 1-May-2016.Gershman B, Psutka S, Matsumoto J, King B, Kawashima A, Morris J and Leibovich B (2015) Use of Personalized Printed 3-Dimensional Kidney Models for Simulation before Nephron Sparing Surgery: Methodology and Examples from a Case SeriesUrology Practice, VOL. 3, NO. 2, (124-133), Online publication date: 1-Mar-2016.Derweesh I (2015) Percutaneous Biopsy of Renal Masses—When is it Necessary?Journal of Urology, VOL. 195, NO. 3, (542-543), Online publication date: 1-Mar-2016.Jiménez J, Zhang Z, Zhao J, Abouassaly R, Fergany A, Gong M, Kaouk J, Krishnamurthi V, Stein R, Stephenson A and Campbell S (2015) Surgical Salvage of Thermal Ablation Failures for Renal Cell CarcinomaJournal of Urology, VOL. 195, NO. 3, (594-600), Online publication date: 1-Mar-2016.Laguna M (2015) Re: Trifecta and Optimal Perioperative Outcomes of Robotic and Laparoscopic Partial Nephrectomy in Surgical Treatment of Small Renal Masses: A Multi-Institutional StudyJournal of Urology, VOL. 195, NO. 2, (298-298), Online publication date: 1-Feb-2016.Laguna M (2015) Re: Five-Year Analysis of a Multi-Institutional Prospective Clinical Trial of Delayed Intervention and Surveillance for Small Renal Masses: The DISSRM RegistryJournal of Urology, VOL. 195, NO. 2, (297-298), Online publication date: 1-Feb-2016.Tabayoyong W, Abouassaly R, Kiechle J, Cherullo E, Meropol N, Shah N, Dong S, Thompson R, Smaldone M, Zhu H, Ialacci S and Kim S (2015) Variation in Surgical Margin Status by Surgical Approach among Patients Undergoing Partial Nephrectomy for Small Renal MassesJournal of Urology, VOL. 194, NO. 6, (1548-1553), Online publication date: 1-Dec-2015.Chang X, Liu T, Zhang F, Qian C, Ji C, Zhao X, Liu G and Guo H (2015) The Comparison of R.E.N.A.L., PADUA and Centrality Index Score in Predicting Perioperative Outcomes and Complications after Laparoscopic Radio Frequency Ablation of Renal TumorsJournal of Urology, VOL. 194, NO. 4, (897-902), Online publication date: 1-Oct-2015.Danzig M, Ghandour R, Chang P, Wagner A, Pierorazio P, Allaf M and McKiernan J (2015) Active Surveillance is Superior to Radical Nephrectomy and Equivalent to Partial Nephrectomy for Preserving Renal in Patients with Small Renal Masses: Results from the DISSRM RegistryJournal of Urology, VOL. 194, NO. 4, Online publication date: A, S, E, M, G, C, Leveillee R, Cadeddu J and Gahan J (2015) Oncologic of Radio Frequency Ablation for Small Renal Masses: Clear Cell vs of Urology, VOL. 194, NO. 3, Online publication date: A, Woldu S, A, G, Pierorazio P, J, M, G and McKiernan J (2015) Predicting Renal after Nephron Sparing SurgeryJournal of Urology, VOL. 194, NO. 3, Online publication date: M (2015) Re: Comparison of Partial Nephrectomy and Percutaneous Ablation for Renal MassesJournal of Urology, VOL. 194, NO. 2, Online publication date: B, E, T, P, L, R, T, J, Zhang Z, Kaouk J, Krishnamurthi V, Stephenson A, Fergany A, E, Uzzo R, Chen D and Campbell S (2015) A Phase Study of in Patients with Localized Renal Cell Carcinoma to of Renal of Urology, VOL. 194, NO. 2, Online publication date: M, C, T, Zhang Z, L, E, Demirjian S and Campbell S (2015) in Renal after Partial Nephrectomy: and of Urology, VOL. NO. 6, Online publication date: M (2015) Re: of the Renal A of Renal after Partial NephrectomyJournal of Urology, VOL. NO. 4, Online publication date: X, Zhang F, Liu T, Ji C, Zhao X, R, X, Wang and Guo H Radio Frequency Ablation versus Partial Nephrectomy for Clinical T1b Renal Cell Carcinoma: Long-Term Clinical and Oncologic of Urology, VOL. NO. 2, Online publication date: D, J, A, A, S, T, Tan H, M, M, E, R and M Renal Masses: A Systematic Review of Surgical and Population of Urology, VOL. NO. 1, Online publication date: T, M, Sharma N, E, J, Demirjian S, Kaouk J and Campbell S after Partial and Radical Nephrectomy in of Urology, VOL. NO. 6, Online publication date: S Renal Surgery and its Impact on Chronic Kidney A in of Urology, VOL. NO. 4, Online publication date: S, Lane B, Derweesh I, T, Fergany A and Campbell S Chronic Kidney to Surgical of Relative of and of Urology, VOL. NO. 4, Online publication date: R, Smaldone M, Kutikov A, T, J, D, Viterbo R, Greenberg R, Chen D and Uzzo R Growth and Outcomes of and Renal Masses under Active

PURPOSE: This AUA Guideline focuses on evaluation/counseling and management of adult patients with clinically localized renal masses suspicious for cancer, including solid-enhancing tumors and Bosniak 3/4 complex-cystic lesions. MATERIALS AND METHODS: Systematic review utilized research from the Agency for Healthcare Research and Quality and additional supplementation by the authors and consultant methodologists. Evidence-based statements were based on body of evidence strength Grade A/B/C (Strong/Moderate/Conditional Recommendations, respectively) with additional statements presented as Clinical Principles or Expert Opinions. RESULTS: Great progress has been made since the previous guidelines on management of localized renal masses were released (2009). The current guidelines provide updated, evidence-based recommendations regarding evaluation/counseling of patients with clinically localized renal masses, including the evolving role of renal mass biopsy. Given great variability of clinical, oncologic and functional characteristics, index patients are not utilized and the panel advocates individualized counseling/management. Management options (partial nephrectomy/radical nephrectomy/thermal ablation/active surveillance) are reviewed including recent data about comparative effectiveness and potential morbidities. Oncologic issues are prioritized while recognizing that functional outcomes are of great importance for survivorship for most patients with localized kidney cancer. A more restricted role for radical nephrectomy is recommended following well-defined selection criteria. Priority for partial nephrectomy is recommended for clinical T1a lesions, along with selective use of thermal ablation, particularly for tumors ≤3.0 cm. Important considerations for shared decision-making about active surveillance are explicitly defined. CONCLUSIONS: Several factors should be considered during counseling/management of patients with clinically localized renal masses, including general health/comorbidities, oncologic potential of the mass, pertinent functional issues and relative efficacy/potential morbidities of various management strategies.

PURPOSE: A contemporary review of the indications, techniques and outcomes is presented for nephron sparing approaches to solid renal masses, emphasizing their role for the treatment of renal cell carcinoma. We also reviewed the evolving role of minimally invasive forms of parenchymal sparing renal surgery. MATERIALS AND METHODS: MEDLINE and CANCERLIT computerized literature searches, and manual bibliographic reviews were performed to identify published peer reviewed articles pertaining to nephron sparing surgery or partial nephrectomy from 1980 to 2000. Pertinent articles were collated and reviewed. RESULTS: Nephron sparing surgery is increasingly being used to treat patients with solid renal lesions. The technical success rate of nephron sparing surgery is excellent, and operative morbidity and mortality are low. For renal cell carcinoma long-term cancer-free survival is comparable to that after radical nephrectomy, particularly for low stage disease. The overall incidence of local recurrence is low at 0% to 10%. For tumors 4 cm. or less local recurrence rates are even less at 0% to 3%. The risk of local recurrence depends primarily on the initial local pathological tumor stage. The reported incidence of multifocal renal cell carcinoma is approximately 15% and it also depends on tumor size, histology and stage. The risk of multifocal disease is low at less than 5% when the maximal diameter of the primary tumor is 4 cm. or less. Recent advances in renal imaging limit the radiographic evaluation necessary when planning complex nephron sparing approaches. Three-dimensional, volume rendered computerized tomography integrates all of the necessary information previously obtained by conventional computerized tomography, angiography, venography and pyelography into a single preoperative test, allowing better operative planning with maximal preservation of unaffected parenchyma in the remnant kidney. Minimally invasive modalities of tumor resection or destruction should be reserved for highly select patients and await improvements in technology, standardization of technique and long-term outcomes data before they may be completely integrated options. CONCLUSIONS: Nephron sparing surgery provides effective therapy for patients in whom preservation of renal function is a relevant clinical consideration. The importance of meticulous operative technique for achieving acceptable oncological and functional outcomes is emphasized. Accumulating data in appropriately select patients suggest a long-term functional advantage gained by the maximal preservation of unaffected renal parenchyma without sacrificing cancer control.

PURPOSE: Standard therapy for an enhancing renal mass is surgical. However, operative treatment may not be plausible in all clinical circumstances. Data on the natural history of untreated enhancing renal lesions is limited but could serve as a decision making resource for patients and physicians. We examined available data on the natural history of observed solid renal masses. MATERIALS AND METHODS: A Medline review of the literature was performed from 1966 to the present regarding untreated, observed, localized solid renal masses. To these data we added our institutional experience with a total of 61 lesions observed in 49 patients for a minimum of 1 year. Variables examined were initial lesion size at presentation, growth rate, duration of followup, pathological findings and progression to metastatic disease. Overall weighted mean estimates were calculated for lesion size at presentation, growth rate and followup based upon combining single institutional series with complete information. RESULTS: We identified 10 reports from 9 single institutional series in the world literature regarding the natural history of untreated solid localized renal lesions. The series included 6 to 40 patients (mean 25) with a mean followup of 30 months (range 25 to 39). When combined with our institutional data, a total of 286 lesions were analyzed, of which 234 could be included in the meta-analysis. Mean lesion size at presentation was 2.60 cm (median 2.48, range 1.73 to 4.08). Meta-analysis revealed a mean growth rate of 0.28 cm yearly (median 0.28, range 0.09 to 0.86) at a mean followup of 34 months (median 32, range 26 to 39) in all series combined. Pathological confirmation was available in 46% of the cases (131 of 286) and it confirmed 92% (120 of 131) as RCC variants. Evaluable data in this subset of confirmed RCC demonstrated a mean growth rate of 0.40 cm yearly (median 0.35, range 0.42 to 1.6). Lesion size at presentation did not predict the overall growth rate (p = 0.46). Progression to metastatic disease was identified in only 1% of lesions (3 of 286) during followup. CONCLUSIONS: The majority of small enhancing renal masses grow at a slow rate when observed. Although metastatic and cancer specific death are low, serial radiographic data alone are insufficient to predict the true natural history of these lesions. Therefore, physicians and patients assume a calculated risk when following these tumors. Basic biological data are needed to assess the natural history of untreated renal masses.