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What ' s known on the subject? and What does the study add?Stone density on non-contrast computed tomography (NCCT) is reported to be a prognosis factor for extracorporeal shockwave lithotripsy (ESWL). In this prospective study, we determined that a 970 HU threshold of stone density is a very specifi c and sensitive threshold beyond which the likelihood to be rendered stone free is poor. Thus, NCCT evaluation of stone density before ESWL may useful to identify which patients should be offered alternative treatment to optimise their outcome. OBJECTIVE• To evaluate the usefulness of measuring urinary calculi attenuation values by non-contrast computed tomography (NCCT) for predicting the outcome of treatment by extracorporeal shockwave lithotripsy (ESWL). PATIENTS AND METHODS• We prospectively evaluated 50 patients with urinary calculi of 5 -22 mm undergoing ESWL.• All patients had NCCT at 120 kV and 100 mA on a spiral CT scanner. Patient age, sex, body mass index, stone laterality, stone size, stone attenuation values (Hounsfi eld units [ HU ] ), stone location, and presence of JJ stent were studied as potential predictors.• The outcome was evaluated 4 weeks after the ESWL session by NCCT.• ESWL success was defi ned as patients being stone-free (SF) or with remaining stone fragments of < 4 mm, which were considered as clinically insignifi cant residual fragments (CIRF). RESULTS• Our survey concluded that 26 patients (52%) were SF, 12 (24%) had CIRF and 12 (24%) had residual fragment on NCCT after a one ESWL treatment.• Stones of patients who became SF or had CIRF had a lower density compared with stones in patients with residual fragments [ mean ( SD ) 715 (260) vs 1196 (171) HU, P < 0.001 ] .• The Youden Index showed that a stone density of 970 HU represented the most sensitive (100%) and specifi c (81%) point on the receiver-operating characteristic curve.• The stone-free rate for stones of < 970 HU was 96% vs 38% for stones of ≥ 970 HU ( P < 0.001). A linear relationship between the calculus density and the success rate of ESWL was identifi ed. CONCLUSION• The use of NCCT to determine the attenuation values of urinary calculi before ESWL helps to predict treatment outcome, and, consequently, could be helpful in planning alternative treatment for patients with a likelihood of a poor outcome from ESWL. KEYWORDSshockwave lithotripsy , non-contrast computed tomography , urolithiasis Study Type -Therapy (prospective cohort) Level of Evidence 2b

ObjectiveTo present the outcomes of active surveillance (AS) for renal angiomyolipomas (AMLs) and to assess the clinical features predicting delayed intervention of this treatment option. Patients and MethodsWe retrospectively reviewed the outcomes of patients diagnosed with AMLs on computed tomography (CT) who were managed with AS at our institution. The AS protocol consisted of 6-and 12-month, then annual follow-up visits, each one including a physical examination and CT imaging. Discontinuation of AS was defined as the need or decision for an active procedure during the follow-up period. Causes of delayed intervention, as well as the type of active treatment (AT), were recorded. Clinical features at presentation of patients failing AS were compared with those who remained under AS at the time of the last follow-up. Predictive factors of delayed intervention were analysed using univariate and multivariate Cox regression models. ResultsOverall, 130 patients were included in the analysis, of whom 102 (78.5%) were incidentally diagnosed, while 15 (11.5%) and 13 patients (10%) presented with flank pain and haematuria, respectively. After a mean (SD) follow-up of 49 (40) months, 17 patients (13%) discontinued AS and underwent AT. Patients who underwent delayed intervention were more likely to present with a higher body mass index, larger tumours and symptomatic disease. Angioembolization represented the first-line AT after AS (64.7%), whereas partial nephrectomy was adopted in 29.4% of patients. On the univariate analysis, risk factors for delayed intervention included tumour size ≥4 cm, symptoms at diagnosis, and history of concomitant or contralateral kidney disease. On the multivariate analysis, only tumour size and symptoms remained independently associated with discontinuation of AS. ConclusionsTumour size and symptoms at initial presentation were highly predictive of discontinuation of AS in the management of AMLs. Selective angioembolization was the first-line option used for AT after AS was discontinued.

Given these considerations, CN in mRCC should not be disregarded, at least not in selected cases of low metastatic burden or in symptomatic cases. Conflicts of InterestNone declared. References 1 Mejean A, Ravaud A, Thezenas S et al. Sunitinib alone or after nephrectomy in metastatic renal-cell carcinoma. N Engl J Med 2018; 379: 417-27 2 Hanna N, Sun M, Meyer CP et al. Survival analyses of patients with metastatic renal cancer treated with targeted therapy with or without cytoreductive nephrectomy: a national cancer data base study. J Clin Oncol 2016; 34: 3267-75 3 Arora S, Sood A, Dalela D et al. Cytoreductive nephrectomy: assessing the generalizability of the CARMENA trial to real-world national cancer data base cases. Eur Urol 2019; 75: 352-3 4 Choueiri TK, Motzer RJ. Systemic therapy for metastatic renal-cell carcinoma. N Engl J Med 2017; 376: 354-66 5 Capitanio U, Montorsi F. Renal cancer. Lancet 2016; 387: 894-906 6 Cella D, Escudier B, Tannir NM et al. Quality of life outcomes for cabozantinib versus everolimus in patients with metastatic renal cell carcinoma: METEOR phase III randomized trial. J Clin Oncol 2018; 36: 757-64 7 Turajlic S, Xu H, Litchfield K et al. Tracking cancer evolution reveals constrained routes to metastases: TRACERx renal. Cell 2018; 173: 581-94.e12 8 Ouzaid I, Capitanio U, Staehler M et al. Surgical metastasectomy in renal cell carcinoma: a systematic review. Eur Urol 2018 [Epub ahead of print].