High-quality evidence comparing supine to prone percutaneous nephrolithotomy (PCNL) for the treatment of complex stones is lacking. This study aimed to compare the outcomes of supine (SUP) and prone (PRO) PCNL. Materials and Methods:A non-inferior randomized controlled trial was performed according to the CONSORT criteria. The inclusion criteria were patients over 18 years of age with complex stones. SUP was performed in the Barts flank-free modified position. Except for positioning, all the surgical parameters were identical. The primary outcome was the difference in the success rate on the first postoperative day (POD1) between groups. The secondary outcome was the difference in the stone-free rate on the 90 th postoperative day (final SFR). A noninferiority margin of 15% was used. Demographic, operative, and safety variables were compared between the groups.Statistical significance was set at p<0.05.Results: Overall, 112 patients were randomized, and their demographic characteristics were comparable. The success rate on POD1 was similar (SUP:62.5% vs. PRO:57.1%, p=0.563). The difference observed (-5.4%) was lower than the predefined limit. The final SFR was also similar (SUP:55.4% vs. PRO:50.0%, p=0.571). SUP had a shorter operative time (117.9±39.1 vs. 147.6±38.8; p<0.001, minutes) and PRO had a higher rate of Clavien ≥ 3 complications (14.3% vs. 3.6%; p=0.045).

Objective: To determine the prognostic value of the American Society of Anesthesiologists (ASA) classification and of the main clinical pathologic variables in renal cell carcinoma (RCC) patients who underwent surgical treatment. Methods: In this international collaborative study, 376 RCC patients who underwent partial nephrectomy (PN) or radical nephrectomy (RN) during the period 1989-2009 were assessed. The pathological data were reviewed by a single pathologist, and all of the surgically treated patients had been previously evaluated by a team of anesthesiologists and classified as ASA 1, ASA 2, or ASA 3. Results: In total, 318 patients were included in the study, with a mean followup of 48 months. Incidental tumors represented 47% of the cases, while 11.6% presented with metastases at diagnosis. Among the patients assessed, 38 (11.9%) were classified as ASA 1, 213 (67%) as ASA 2, and 67 (21.1%) as ASA 3. An association between the ASA classification and the main clinicopathological variables of RCC was observed. The univariate analysis for overall survival (OS) revealed significant differences in the survival curves according to the ASA classification (p < 0.001). High-grade neoplasms, the presence of metastasis at diagnosis, clinical stage III/IV, and incidental tumors remained as independent predictors of survival. Moreover, the multivariate analysis revealed a negative impact of the ASA classification on OS (p = 0.001). Conclusions: The present study demonstrated a correlation between the ASA classification and the main prognostic factors of RCC and its impact on survival rates. ASA 3 patients had more aggressive tumors, increased risk of perioperative complications, and worse outcomes compared with ASA1 or ASA 2. Thus, the ASA classification may be considered an additional tool for assessing and planning the treatment of RCC patients.

Objective:To evaluate immunohistochemical erythropoietin (EPO) expression in clear cell renal cell carcinoma (ccRCC), its association with major clinicopathological variables and its prognostic impact.Methods:A total of 220 patients with renal cell carcinoma (RCC) surgically treated between 1989 and 2009 were evaluated in this multi-institutional study. All the cases were reviewed by a single pathologist and the immunohistochemical reactivity to EPO was analysed using tissue microarray.Results:A total of 176 patients with ccRCC were considered, with an average of 48 months of follow-up. Of the tumours evaluated, 47 (26.7%) were negative for EPO expression, and 129 (73.3%) were positive. EPO expression was associated with incidental tumour (p = 0.016), tumour size (p = 0.015), Karnofsky Performance Score (KPS) (p = 0.016), blood transfusion (p = 0.009) and adrenal involvement (p = 0.038). The median ages of the patients with positive and negative EPO expression were 56.2 years and 66.6 years. Immunohistochemical EPO expression affected overall survival (OS) and disease-specific survival (DSS) rates. The DSS rates of the patients whose tissue was positive and negative for EPO expression were 85.3% and 76.1%, respectively (p = 0.044). In a multivariate analysis, the absence of EPO expression proved to be a bad prognostic factor and negatively affected the OS (p < 0.001) and DSS (p < 0.001) rates.Conclusion:The absence of tumour EPO expression is an independent predictive factor with a negative effect on survival rates. The use of EPO as possible marker in the management of ccRCC patients requires further studies and a better understanding of the role of EPO in tumour biology.

avoidance of pleura and visceral structures with needle puncture. As upper pole access may be limited due to rib shadowing, interpolar or lower pole calyceal punctures tend to be selected. This may be a foreseeable prerequisite for reliance on flexible nephroscopy for complex stone, but incorporation of thulium mitigates the inefficiency of flexible stone treatment. 1 A more lateral and downward trajectory of the renal sheath associated with supine access encourages drainage of stone fragments and, as the authors postulate, decreases intrarenal pressure which may explain better stone clearance and lowered rate of urinary sepsis. An upright seated posture for supine PCNL confers better ergonomics enjoyed by both surgeon and trainees. Lastly, familiarity with both supine and prone PCNL allows for flexibility of access when treating the toughest of cases.Ultimately, the selection of positioning will be based on the surgeon's training and comfort level, but I firmly predict a rising trend of supine PCNL with emergence of strong data as presented by the authors.

Several parameters may affect the stone-free rate such as the stone size, density and complexity, the anatomical variations, and the patient profile (e.g., body mass index [BMI] and comorbidities). Recent reports suggest that greater sensitivity and specificity make computed tomography (CT) the best tool to evaluate success [8][9][10][11] .To address this knowledge, we conducted a study to define predictors of stone-free rate after PCNL in the supine position in a large series of patients, evaluated by CT scan. METHODSA retrospective analysis of prospectively collected data was performed including all consecutive adult patients who underwent supine PCNL between June 2011 and October 2019 in a single center. Informed consent was obtained from patients preoperatively, and the study protocol was approved by the local ethics committee (institutional review board number: 8258117.8.0000.0091).