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<b><i>Introduction:</i></b> The objective of this study was to present our clinical experience of using the thulium fiber laser in retrograde intrarenal surgery (RIRS). <b><i>Methods:</i></b> A prospective clinical study performed after the IRB approval (Sechenov University, Russia). Patients with stones &#x3c;30 mm were treated with SuperPulsed thulium fiber laser (SP TFL) (NTO IRE-Polus, Russia) through a 200-μm-diameter fiber. Stone size, density, the duration of the operation, and laser on time (LOT) were measured. Based on the surgeon’s feedback, retropulsion and intraoperative visibility were also assessed (Likert scale). Stone-free rates (SFRs) were assessed with a low-dose CT scan 90 days after the operation. <b><i>Results:</i></b> Between January 2018 and December 2019, 153 patients (mean age 54 ± 2.8 years) underwent RIRS with SP TFL (mean stone density 1,020 ± 382 HU). Median stone volume was 279.6 (139.4–615.8) mm³. Median LOT was 2.8 (IQR 1.6–6.6) min with median total energy for stone ablation 4.0 (IQR 2.1–7.17) kJ, median ablation speed was 1.7 (1.0–2.8) mm³/s, median ablation efficacy was 13.3 (7.3–20.9) J/mm³, and energy consumption was 170.3 (59.7–743.3) J/s. Overall, the SFR (at 3 months) was 89%. The overall complication rate was 8.4%. Retropulsion was present in 23 (15.1%) patients. Visibility was estimated as optimal in most patients, with poor visibility reported in only 13 (8.5%) patients. <b><i>Conclusion:</i></b> The SP TFL is a safe and efficient tool in lithotripsy, irrespective of the stone type and density. Retropulsion is minimal and visibility is maintained with SP TFL. Nonetheless, further clinical studies are needed to ensure optimal comparison with conventional holmium:YAG lithotripsy.

INTRODUCTION AND OBJECTIVES: We investigated the prognostic significance of the various manifestations of extrarenal extension which comprise pathologic stage T3a renal cell carcinoma (RCC) among patients treated with extirpative therapy for nonmetastatic disease.METHODS: A retrospective review of 595 patients who underwent nephrectomy for pathologically-confirmed T3aN0/NxM0 clear cell RCC between 1970 and 2011 was performed. All pathologic slides were re-reviewed by a single urologic pathologist. Associations of the type of extrarenal extension (perinephric fat, renal sinus fat, and renal vein in isolation or in any combination) with disease progression, death from RCC, and death from any cause were evaluated using Cox models adjusting for demographic and pathologic features.RESULTS: Overall, perinephric fat invasion, renal sinus fat invasion, renal vein tumor thrombus, and multiple sources of extrarenal extension were present in 160 (27%), 59 (10%), 167 (28%), and 209 (35%) patients, respectively. Median follow-up after surgery was 9.1 years (IQR 6.7, 13.2), during which time 343 patients developed disease progression at a median of 1.5 years (IQR 0.5-4.3), 271 patients died from RCC at a median of 3.5 years (IQR 1.6-7.3), and 463 patients died from any cause at a median of 4.9 years (IQR 2.0-10.0) following surgery. No significant differences in the rates of disease progression, death from RCC, or death from any cause were observed in the presence of isolated perinephric fat invasion, renal sinus fat invasion, or renal vein tumor thrombus. However, on multivariable analyses, patients with multiple sources of extrarenal extension were at a significantly increased risk of disease progression (HR 1.31, 95%CI¼1.05-1.64, P¼0.017), death from RCC (HR 1.64, 95%CI¼1.28-2.11, P<0.001), and death from any cause (HR 1.31, 95%CI¼1.08-1.60, P¼0.007) compared to patients with an isolated source of extrarenal extension.CONCLUSIONS: Isolated involvement of the perinephric fat, renal sinus fat, or renal vein carry similar prognostic weight, justifying grouped classification as T3a in the contemporary AJCC primary tumor classification. However, presence of multiple sources of extrarenal extension is associated with higher risk for disease progression, cancerrelated death, and death from any cause after nephrectomy. If validated, these findings may help refine risk-stratification of non-metastatic T3a RCC.

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