Angelo Mottaran

March is Kidney Cancer Awareness Month, and this Research Topic was launched to mark it by gathering recent work on the prevention, diagnosis and treatment of kidney cancer. The burden is considerable: GLOBOCAN estimated about 434,000 new cases and 156,000 deaths worldwide in 2022 (1). Renal cell carcinoma (RCC) accounts for most of these tumors, and, as outlined in the call for this collection, more than 30% of patients with RCC are diagnosed with metastatic disease, which underscores the need for earlier detection and more effective therapy.Progress over the past decade has been substantial. Combinations of immune checkpoint inhibitors, alone or with vascular endothelial growth factor receptor tyrosine kinase inhibitors, have reshaped the care of advanced disease, and the 2022 World Health Organization classification introduced molecularly defined categories of RCC (2). Progress in prevention and early detection has been slower, and the evidence guiding the care of rare tumors and unusual presentations remains thin.The Research Topic closed with 23 published articles: nine Original Research articles, one Systematic Review, two Reviews and 11 Case Reports, contributed by teams from many countries. We group them into four themes: biology, risk and biomarkers; diagnosis; rare and aggressive histologies; and treatment (Figure 1).Understanding why kidney tumors arise and how they behave is a precondition for prevention and for precision therapy. Huang et al. showed, in RCC cell lines and mouse xenografts, that overexpression of BNIP3, a hypoxia-regulated pro-apoptotic protein, reduced proliferation and invasion and increased apoptosis through hypoxia-inducible factor 1α-dependent autophagy, identifying autophagy as a potentially targetable vulnerability.Obesity is an established risk modifier for clear cell RCC (ccRCC), yet how metabolic dysfunction shapes tumor biology is poorly defined. He et al. combined transcriptomic data from five ccRCC cohorts with obesity-related adipose profiles and machine learning, and identified FCGR2A, localized to M2-polarized macrophages in single-cell data, as a hub gene at the interface of the two conditions. Gong et al. similarly derived an ammonia metabolismbased risk score from public data, validated it in external and immunotherapy cohorts, and showed that silencing one of its genes, CSAD, reduced migration and invasion in four ccRCC cell lines. Both studies are hypothesis-generating, and both rest largely on retrospective transcriptomic datasets.Blood-based and clinical markers are inexpensive and easy to transfer to practice. Zhang Y. proposed a Renal Immune Prognostic Index that combines prealbumin, lymphocyte count and immunoglobulin M in patients undergoing surgery, with validation in an independent cohort of 350 patients. Erdoğan et al. evaluated the Gustave Roussy Immune score (albumin, lactate dehydrogenase and neutrophil-to-lymphocyte ratio) in 81 patients treated with nivolumab in second or later lines, and found that low scores were associated with higher response rates and longer survival. The only prospective study in the collection, by Quintás et al. for the Spanish Oncology Genitourinary Group, measured serum proteins and metabolites in 38 patients receiving first-line sunitinib: higher interleukin-6, arginase-1 and S100A9 predicted shorter survival, and tryptophan-kynurenine metabolism differed between patients with extreme outcomes. These signatures now need prospective and external confirmation, ideally in patients treated with current first-line combinations.Diagnosis begins with imaging. Zhang Y. et al. reviewed deep learning across the renal ultrasound workflow, including segmentation, volumetry, functional prediction and disease diagnosis, and report performance approaching that of specialists for structure recognition and lesion detection; they identify data quality, interpretability, cross-device generalization and clinical integration as the main barriers. The review addresses kidney disease broadly rather than cancer alone, but it illustrates how widely available imaging could support earlier and more consistent detection.Imaging can also mislead. Li et al. described a man with hematuria whose 1.6-cm enhancing renal-pole nodule was treated as RCC by partial nephrectomy and proved to be ectopic adrenal tissue, and Cui et al. reported an epithelial-type Wilms tumor, a malignancy typical of childhood, in a 23-year-old woman with a large renal mass. Both cases show that renal masses in adults can mimic RCC and that histopathology remains decisive.Pathology and genomics increasingly define renal tumors. Gonzalez et al. and Nithagon et al. describe papillary renal neoplasm with reverse polarity, a recently characterized, KRASassociated tumor with indolent behavior whose classification is still evolving. Nithagon and colleagues report what they describe as the first synchronous occurrence, in one kidney, of this tumor and a multilocular cystic renal neoplasm of low malignant potential, with genetically distinct profiles and no recurrence at nine months. Gonzalez and colleagues add PD-L1 expression in their case and note that only about 100 cases had been published. Cheng et al. reported a novel TCEB1 variant (p.V73E) in an ELOC(TCEB1)-mutant RCC, confirmed by next-generation and Sanger sequencing, and Wang Y. et al. presented two patients with VHLdeficient RCC managed with radiofrequency ablation, partial nephrectomy and/or pazopanib, discussing genetic testing and screening of relatives. Taken together, these reports show that accurate classification often requires immunohistochemistry and sequencing, and that it matters: indolent entities may be suited to nephron-sparing surgery, whereas hereditary syndromes call for family-level action.Several contributions concern tumors for which no standard exists. Zhu et al. reported collecting duct carcinoma, a rare, aggressive subtype in which most patients present with...

March is Kidney Cancer Awareness Month and at Frontiers in Oncology, we are dedicated to spotlighting the groundbreaking discoveries transforming the landsca... March is Kidney Cancer Awareness Month and at Frontiers in Oncology, we are dedicated to spotlighting the groundbreaking discoveries transforming the landsca...

Robot-assisted nephroureterectomy (RANU) has demonstrated equal oncological outcomes and better perioperative outcomes compared to open and laparoscopic procedures for treating upper tract urothelial carcinoma (UTUC). However, RANU is still limited by technical difficulties like patient positioning, port placement, transitioning between anatomical regions and cost-effectiveness issues. The new surgical robot HUGO RAS increasing competition may spread the robotic approach also for this procedure. We aimed to demonstrate the feasibility of single docking RANU using HUGO RAS platform along with the description of our setting. We reported the first RANU performed in Europe at IRCCS Sant'Orsola Hospital (Bologna, Italy) using the HUGO^™ Robot-Assisted Surgery (RAS) System. Our main goal was to demonstrate the technical feasibility of RANU with HUGO^™ RAS along with its safety in terms of perioperative outcomes and complications. We also aimed to describe our surgical setup. We collected patient's characteristics, intraoperative and perioperative complications, docking time, operative time, clashing of the instruments, or technical errors of the system. The procedure was performed in a 78-year-old male with a clinically organ-confined high risk UTUC. No need for conversion to open/laparoscopic surgery was required. No intraoperative complications, instrument clashes or failure of the system that compromised the completion of the surgery were recorded. Docking, total operative, and console times were 7, 185 and 130 minutes, respectively. RANU with the HUGO^™ RAS System is a feasible and safe procedure in terms of perioperative outcomes and complications. Our setup allowed a rapid docking procedure and a smoothly completion of the surgery.

The Central European Journal of Urology is an open access quarterly-issued journal, which provides a forum for the presentation of original clinical, experimental and other research studies...

Introduction and objectives Robot-Assisted Simple Prostatectomy (RASP) and Holmium Laser Enucleation of the prostate (HoLEP) are both well-established, minimally-invasive surgical treatment options for lower urinary tract symptoms caused by benign prostatic enlargement. We have reported the first comparative analysis of both techniques in patients with prostates of 200ml. Materials & methods Between 2009 and 2020 a total of 53 patients with a prostate volume of 200ml were surgically treated at OLV Hospital Aalst (Belgium): 31 underwent RASP and 22 underwent HoLEP. Preoperative and postoperative assessments included uroflowmetry with maximum urinary flow rate (Qmax) and post-void residual volume (PVR), as well as the International Prostate Symptom Score (IPSS) and quality of life (IPSS-QoL). The complication rates were evaluated according to the Clavien-Dindo Classification. Results Patients treated with RASP had significantly larger prostate volumes compared to HoLEP (median 226 vs. 204.5 ml, p=0.004). After a median follow-up of 14 months, both groups showed a significant improvement in the maximum flow rate (+10.60 vs. +10.70 ml/s, p=0.724) and a reduction of the IPSS score (-12.50 vs. -9, p=0.246) as well as improvement of the QoL (-3 vs. -3, p=0.880). Median operative time was similar in both groups (150 vs. 132.5 min, p=0.665). The amount of resected tissue was lower in the RASP group (134.5 vs. 180 g, p=0.029) and there was no significant difference in postoperative PSA (1.2 vs. 0.8 ng/ml, p=0,112). Despite a similar median catheterization time (3 vs. 2 days, p=0.748), the median hospitalization time was shorter in the HoLEP group (4 vs. 3 days, p=0.052). Complication rates were similar in both groups (32% vs. 36%, p=0.987). Conclusion Our results suggest similar outcomes for RASP and HoLEP in patients with very large prostates 200ml. These findings will require external validation at other high-volume centers.

Article: Robot-assisted simple prostatectomy with the novel HUGO™ RAS System: feasibility, setting, and perioperative outcomes - Minerva Urology and Nephrology 2022 Sep 12 - Minerva Medica - Journals

Background and Objectives: The aim of this article is to present a single-surgeon, open retroperitoneal lymph node dissection (RPLND) series for testicular cancer in a high-volume center. Materials and Methods: We reviewed data from patients who underwent RPLND performed by an experienced surgeon at our institution between 2000 and 2019. We evaluated surgical and perioperative outcomes, complications, Recurrence-Free Survival (RFS), Overall Survival (OS), and Cancer-Specific Survival (CSS). Results: RPLND was performed in primary and secondary settings in 21 (32%) and 44 (68%) patients, respectively. Median operative time was 180 min. Median hospital stay was 6 days. Complications occurred in 23 (35%) patients, with 9 (14%) events reported as Clavien grade ≥ 3. Patients in the primary RPLND group were significantly younger, more likely to have NSGCT, had higher clinical N0 and M0, and had higher nerve-sparing RPLND (all p ≤ 0.04) compared to those in the secondary RPLND group. In the median follow-up of 120 (56–180) months, 10 (15%) patients experienced recurrence. Finally, 20-year OS, CSS, and RFS were 89%, 92%, and 85%, respectively, with no significant difference in survival rates between primary vs. secondary RPLND subgroups (p = 0.64, p = 0.7, and p = 0.31, respectively). Conclusions: Open RPLND performed by an experienced high-volume surgeon achieves excellent oncological and functional outcomes supporting the centralization of these complex procedures.

Introduction and Hypothesis: Robotic sacropexy (RSC) emerged in the last years as a valid alternative to the laparoscopic technique. However, the robotic approach is still limited by platform availability and concerns about cost-effectiveness. Recently, new robotic platforms joined the market, lowering the costs and offering the possibility to expand the robotic approach. The aim of our study was to demonstrate the technical feasibility and safety of the procedure with this new platform along with the description of our surgical setting. Materials and Methods: We reported data on the first five consecutive patients who underwent RSC at Onze Lieve Vrouw Hospital (Aalst, Belgium), performed with the novel HUGO™ Robot-Assisted Surgery (RAS) System. The platform consists of four fully independent carts, an open console, and a system tower equipped for both laparoscopic and robotic surgery. We collected patients' characteristics, intraoperative data, intraoperative complications, and clashes of instruments. Results: All procedures were completed according to the same surgical setting and technique. No need for conversion to open/laparoscopic surgery and/or for additional port placement was required. No intraoperative complications, instrument clashes, or system failure that compromised the surgery's completion were recorded. Median interquartile range docking, operative, and console time were 8 (6–9), 130 (115–165), and 80 (80–115) minutes, respectively. Conclusion: This series represents the first worldwide report of a robot-assisted sacropexy executed with the novel HUGO RAS System. Awaiting future investigation, this preliminary experience provides relevant data in terms of operative room settings and perioperative outcomes that might be helpful for future adopters of this platform.

Background: In robot-assisted partial nephrectomy (RAPN) renorrhaphy is used to achieve hemostatic control of the tumoral resection bed, with detrimental impact on renal function. Hemostatic agents are used to achieve rapid and optimal hemostasis. GATT-Patch is a new hemostatic sealant that has already demonstrated promising results. Objective: Compare GATT-Patch and standard renorrhaphy in terms of hemostatic capacity, ischemia time, and prevention of urinary leakage after RAPN in a porcine model. Design, Setting, and Participants: In this preclinical randomized controlled trial, four pigs underwent 32 RAPNs. After resection, GATT-Patch application and performance of classic renorrhaphy were randomized. After the procedure, the resection bed was reinspected. A necropsy study evaluated the adhesiveness of the patch, and retrograde pyelography was performed to determine the leakage burst pressure. Intervention: Application of GATT-Patch and performance of classic renorrhaphy were randomized and surgeons blinded to the hemostatic technique to be performed. Outcome Measurements and Statistical Analysis: Warm ischemia, hemostatic control, active bleeding during hemostatic control, total procedure time, bleeding at reinspection, and presence of urinary leakage on retrograde pyelography were recorded. Continuous variables were compared using the Student t -test. Categorical variables were compared using the Chi-square or Fisher's exact test. Results and Limitations: GATT-Patch reduced warm ischemia time (WIT), time to achieve hemostatic control, active bleeding time, and total procedure time, achieving hemostasis in 100% of the cases. Rebleeding at reinspection occurred in 0% of the GATT-Patch group. Renal parenchyma damage was observed in 100% of renorrhaphy cases and in 0% of GATT-Patch cases. Conclusions: GATT-Patch guaranteed optimal hemostasis and urine sealant effect after RAPN in porcine models. Compared to renorrhaphy, we observed a reduction in WIT, total procedure time, and potential reduction in healthy parenchyma loss. Patient Summary: GATT-Patch stops bleeding and provides hemostasis faster than suturing after resection of portions of the kidney in pigs. It might be tested in patients undergoing partial nephrectomy for kidney cancer.