Renal Mass and Localized Renal Cancer (2021): Difference between revisions

 
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*** Pooled positive predictive value: 98.8%
*** Pooled positive predictive value: 98.8%
*** Pooled specificity: 94.4%
*** Pooled specificity: 94.4%
** Potential limitations of RMB include:
** '''Potential limitations of RMB include (4):'''
*** A benign biopsy must be distinguished from a non-diagnostic biopsy (renal parenchyma or connective tissues) result.
**# '''A benign biopsy must be distinguished from a non-diagnostic biopsy (renal parenchyma or connective tissues) result.'''
**** Non-diagnostic rate of renal mass biopsy is approximately 14%, which can be substantially reduced with repeat biopsy
**#* Non-diagnostic rate of renal mass biopsy is approximately 14%, which can be substantially reduced with repeat biopsy
*** A benign biopsy may not always correlate with benign histology.
**# '''A benign biopsy may not always correlate with benign histology.'''
**** Pooled negative predictive value: 80.8%
**#* Pooled negative predictive value: 80.8%
*** Grade concordance from biopsy to surgically resected tissue is imperfect.
**#*Due to the imperfect nature of renal mass biopsy, patients with benign renal mass biopsy may warrant follow-up.
*** Oncocytic neoplasms may represent a diagnostic dilemma.
**# '''Grade concordance from biopsy to surgically resected tissue is imperfect.'''
*** Biopsy or aspiration of cystic renal masses is generally not advised due to concerns regarding tumor spillage and a high likelihood of obtaining a non-informative result due to sampling error.
**# '''Oncocytic neoplasms may represent a diagnostic dilemma.'''
** '''<span style="color:#ff0000">Consider biopsy when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious.</span>'''
** '''<span style="color:#ff0000">Indications</span>'''
** '''<span style="color:#ff0000">Should be obtained if it will influence management</span>'''
***'''<span style="color:#ff0000">Consider biopsy when a mass is suspected to be hematologic, metastatic, inflammatory, or infectious.</span>'''
*** '''<span style="color:#ff0000">NOT required for (2):</span>'''
*** '''<span style="color:#ff0000">Should be obtained if it will influence management</span>'''
***# '''<span style="color:#ff0000">Young or healthy patients who are unwilling to accept the uncertainties associated with RMB</span>'''
**** '''<span style="color:#ff0000">NOT required for (2):</span>'''
***# '''<span style="color:#ff0000">Older or frail patients who will be managed conservatively independent of RMB findings</span>'''
****# '''<span style="color:#ff0000">Young or healthy patients who are unwilling to accept the uncertainties associated with RMB</span>'''
** For biopsy of solid renal mass, multiple core biopsies should be obtained and are preferred over fine needle aspiration.
****# '''<span style="color:#ff0000">Older or frail patients who will be managed conservatively independent of RMB findings</span>'''
***'''<span style="color:#ff0000">Biopsy or aspiration of cystic renal masses is generally not recommended, due to (2):</span>'''
***#'''<span style="color:#ff0000">Concerns regarding tumor spillage</span>'''
***#'''<span style="color:#ff0000">High likelihood of obtaining a non-informative result due to sampling error</span>'''
**For biopsy of solid renal mass, multiple core biopsies should be obtained and are preferred over fine needle aspiration.


== Management ==
== Management ==
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* Discuss potential effect of intervention on risk of chronic kidney disease (CKD), dialysis, and survival.
* Discuss potential effect of intervention on risk of chronic kidney disease (CKD), dialysis, and survival.


=== '''Options''' ===
=== Options ===
# '''Nephrectomy''' (partial vs. radical)
# '''Nephrectomy''' (partial vs. radical)
# '''Thermal ablation''' (radiofrequency vs. cryoablation)
# '''Thermal ablation''' (radiofrequency vs. cryoablation)
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***## '''<span style="color:#ff0000">Recurrent urolithiasis</span>'''
***## '''<span style="color:#ff0000">Recurrent urolithiasis</span>'''
***## '''<span style="color:#ff0000">Morbid obesity</span>'''
***## '''<span style="color:#ff0000">Morbid obesity</span>'''
*** In patients undergoing partial nephrectomy,
** Surgical considerations
**** Renal function can be optimized by (2):
*** Renal function can be optimized by (2):
****# Optimizing nephron mass preservation
***# Optimizing nephron mass preservation
****# Avoiding prolonged ischemia
***# Avoiding prolonged ischemia
**** Negative surgical margins should be prioritized
*** Negative surgical margins should be prioritized
***** Extent of normal parenchyma removed should consider the clinical situation and tumor characteristics, including growth pattern, and interface with normal tissue.
**** Extent of normal parenchyma removed should consider the clinical situation and tumor characteristics, including growth pattern, and interface with normal tissue.
****** '''To optimize parenchymal mass preservation, tumor enucleation should be considered in patients with:'''
***** '''To optimize parenchymal mass preservation, tumor enucleation should be considered in patients with:'''
******# '''Familial RCC syndromes'''
*****# '''Familial RCC syndromes'''
******#* '''Aggressive RCC syndromes, such as HLRCC, should be best managed with wide margin PN or RN.'''
*****#* '''Aggressive RCC syndromes, such as HLRCC, should be best managed with wide margin PN or RN.'''
******# '''Multifocal disease'''
*****# '''Multifocal disease'''
******# '''Severe CKD'''
*****# '''Severe CKD'''
*'''<span style="color:#ff0000">Radical nephrectomy</span>'''
*'''<span style="color:#ff0000">Radical nephrectomy</span>'''
** '''<span style="color:#ff0000">Indication (1)</span>''' (when intervention is necessary for solid or Bosniak 3/4 complex cystic renal mass):
** '''<span style="color:#ff0000">Indication (1)</span>''' (when intervention is necessary for solid or Bosniak 3/4 complex cystic renal mass):
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**#* '''<span style="color:#ff0000">If ALL are not met, PN should be considered</span>''' unless there are overriding concerns about the safety or oncologic efficacy of PN.
**#* '''<span style="color:#ff0000">If ALL are not met, PN should be considered</span>''' unless there are overriding concerns about the safety or oncologic efficacy of PN.
*'''<span style="color:#ff0000">Lymphadenectomy'''
*'''<span style="color:#ff0000">Lymphadenectomy'''
** '''<span style="color:#ff0000">Indicated for clinically concerning regional lymphadenopathy (for staging purposes)</span>'''
** '''<span style="color:#ff0000">Indications (1):</span>'''
**#'''<span style="color:#ff0000">Clinically concerning regional lymphadenopathy (for staging purposes)</span>'''
*'''<span style="color:#ff0000">Adrenalectomy</span>'''
*'''<span style="color:#ff0000">Adrenalectomy</span>'''
** '''<span style="color:#ff0000">Absolute (1):</span>'''
** '''<span style="color:#ff0000">Indications</span>'''
**# '''<span style="color:#ff0000">If preoperative imaging or intraoperative inspection suggests metastasis or adrenal enlargement</span>'''
***'''<span style="color:#ff0000">Absolute (1):</span>'''
**#* One exception is when patient has a well-characterized adenoma, which may not mandate surgical excision
***# '''<span style="color:#ff0000">If preoperative imaging or intraoperative inspection suggests metastasis or adrenal enlargement</span>'''
** '''<span style="color:#ff0000">Relative (1):</span>'''
***#* One exception is when patient has a well-characterized adenoma, which may not mandate surgical excision
**# '''<span style="color:#ff0000">Locally advanced features are identified preoperatively or during exploration and the gland is in close proximity to the tumour</span>'''
*** '''<span style="color:#ff0000">Relative (1):</span>'''
**#* Adrenal may be spared in this setting if the contralateral adrenal gland is absent and the ipsilateral gland demonstrates normal morphology and no malignant involvement.
***# '''<span style="color:#ff0000">Locally advanced features are identified preoperatively or during exploration and the gland is in close proximity to the tumour</span>'''
***#* Adrenal may be spared in this setting if the contralateral adrenal gland is absent and the ipsilateral gland demonstrates normal morphology and no malignant involvement.
*Approach
*Approach
** A minimally invasive approach should be considered when it would not compromise oncologic, functional, and perioperative outcomes.
** A minimally invasive approach should be considered when it would not compromise oncologic, functional, and perioperative outcomes.
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* '''<span style="color:#ff0000">Indications</span>'''
* '''<span style="color:#ff0000">Indications</span>'''
** '''<span style="color:#ff0000">Alternative approach for management of cT1a solid renal masses <3cm</span>'''
** '''<span style="color:#ff0000">Alternative approach for management of cT1a solid renal masses <3cm</span>'''
** Patients should be informed about the increased risk of tumor persistence or local recurrence after primary TA, compared to surgical incision, which may be treated with repeat ablation.
** Patients should be informed about the increased risk of tumor persistence or local recurrence after primary TA, compared to surgical excision, which may be treated with repeat ablation.
** In patients undergoing TA
* Approach
*** Percutaneous is preferred over surgical approach, whenever feasible, to minimize morbidity.
**Percutaneous is preferred over surgical approach, whenever feasible, to minimize morbidity.
*** Both radiofrequency ablation and cryoablation may be offered as options
* Modality
*** '''Biopsy should be performed prior to (preferred) or at the time of ablation''' to provide pathologic diagnosis and guide subsequent surveillance.
** Both radiofrequency ablation and cryoablation may be offered as options
* '''Other considerations'''
**'''Biopsy should be performed prior to (preferred) or at the time of ablation''' to provide pathologic diagnosis and guide subsequent surveillance.


==== Active surveillance (AS) ====
==== Active surveillance (AS) ====
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*** '''<span style="color:#ff0000">Tumour factors (2)'''
*** '''<span style="color:#ff0000">Tumour factors (2)'''
***# '''<span style="color:#ff0000">Solid renal mass < 2cm'''
***# '''<span style="color:#ff0000">Solid renal mass < 2cm'''
***#*'''<span style="color:#ff0000">In patients with familial RCC syndromes, tumours can be observed if <3 cm as the risk of metastases remains low in this setting</span>'''
***#** '''<span style="color:#ff0000">HLRCC and succinate dehydrogenase deficiency RCC are the exception as tumors in these syndromes are often very aggressive.</span>'''
***# '''<span style="color:#ff0000">Complex but predominantly cystic renal masses'''
***# '''<span style="color:#ff0000">Complex but predominantly cystic renal masses'''
*** '''<span style="color:#ff0000">Patient factors (7)'''
*** '''<span style="color:#ff0000">Patient factors (7)'''
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***# '''<span style="color:#ff0000">Marginal renal function (≥CKD3b)'''
***# '''<span style="color:#ff0000">Marginal renal function (≥CKD3b)'''
***# '''<span style="color:#ff0000">Patient preference'''
***# '''<span style="color:#ff0000">Patient preference'''
*** For patients who prefer AS in whom the risk/benefit analysis for treatment is equivocal, consider renal mass biopsy (if the mass is solid or has solid components) for further oncologic risk stratification.
***#* For patients who prefer AS in whom the  
*** For patients who prefer AS in whom the the anticipated benefits of intervention outweigh the risks of treatment, AS with potential for delayed intervention may be only pursued if the patient understands and is willing to accept the associated risks.
***#**Risk/benefit analysis for treatment is equivocal, consider renal mass biopsy (if the mass is solid or has solid components) for further oncologic risk stratification.
**** In this setting, renal mass biopsy (if the mass is predominantly solid) is encouraged for additional risk stratification.
***#** Anticipated benefits of intervention outweigh the risks of treatment, AS with potential for delayed intervention may be only pursued if the patient understands and is willing to accept the associated risks.
**** If the patient continues to prefer AS, close clinical and cross-sectional imaging surveillance with periodic reassessment and counseling should be recommended.
***#*** In this setting, renal mass biopsy (if the mass is predominantly solid) is encouraged for additional risk stratification.
***'''<span style="color:#ff0000">In patients with familial RCC syndromes, tumors can be observed if <3 cm as the risk of metastases remains low in this setting</span>'''
***#*** If the patient continues to prefer AS, close clinical and cross-sectional imaging surveillance with periodic reassessment and counseling should be recommended.
**** '''<span style="color:#ff0000">HLRCC and succinate dehydrogenase deficiency RCC are the exception as tumors in these syndromes are often very aggressive.</span>'''
* '''<span style="color:#ff0000">In patients undergoing AS, periodic clinical surveillance and/or imaging is recommended in asymptomatic patients</span>'''
* In patients undergoing AS
** Periodic clinical surveillance and/or imaging is recommended in asymptomatic patients
** '''Patients with no prior imaging should have surveillance imaging initially every 3 to 6 months'''
** Preferred modality is not well established, but initial imaging should preferably consist of contrast-enhanced cross-sectional imaging.
** '''Frequency and intensity are tailored to patient-risk,''' based on tumour size, tumor complexity, infiltrative appearance and median growth
** '''Frequency and intensity are tailored to patient-risk,''' based on tumour size, tumor complexity, infiltrative appearance and median growth
** '''Chest x-ray is warranted annually or if intervention triggers are encountered or symptoms arise.'''
***'''Patients with no prior imaging should have surveillance imaging initially every 3 to 6 months'''
** Due to the imperfect nature of renal mass biopsy, patients with benign renal mass biopsy may warrant follow-up.
*** Preferred modality is not well established, but initial imaging should preferably consist of contrast-enhanced cross-sectional imaging.
** '''<span style="color:#ff0000">Indications for intervention (treatment or AS intensity) (5):</span>[https://www.auanet.org/documents/Guidelines/PDF/RCC-Active-Surveillance-Algorithm.pdf §]:'''
*** '''Chest x-ray is warranted annually or if intervention triggers are encountered or symptoms arise.'''
*** '''<span style="color:#ff0000">2021 AUA (5)'''
* '''<span style="color:#ff0000">Indications for "intervention" (treatment or increased AS intensity) (5):</span>[https://www.auanet.org/documents/Guidelines/PDF/RCC-Active-Surveillance-Algorithm.pdf §]:'''
***# '''<span style="color:#ff0000">Tumour size >3cm</span>'''
*# '''<span style="color:#ff0000">Tumour size >3cm</span>'''
***# '''<span style="color:#ff0000">Growth kinetics (>5mm/year)</span>'''
*# '''<span style="color:#ff0000">Growth kinetics (>5mm/year)</span>'''
***#* Caution if different imaging modalities are used due to normal variations in maximal tumor diameter and volume calculations; interreader variability may also be significant.
*#* Caution if different imaging modalities are used due to normal variations in maximal tumor diameter and volume calculations; interreader variability may also be significant.
***# '''<span style="color:#ff0000">Stage progression</span>'''
*# '''<span style="color:#ff0000">Stage progression</span>'''
***# '''<span style="color:#ff0000">Clinical changes in patient/tumour factors</span>''' (e.g. infiltrative on imaging, suspicion of advanced T stage)
*# '''<span style="color:#ff0000">Clinical changes in patient/tumour factors</span>''' (e.g. infiltrative on imaging, suspicion of advanced T stage)
***# '''<span style="color:#ff0000">Additional biopsy results</span>''' (e.g. unfavourable histology)
*# '''<span style="color:#ff0000">Additional biopsy results</span>''' (e.g. unfavourable histology)


== Follow-up ==
== Follow-up ==


* Counseling
=== Counseling ===
** Discuss the implications of stage, grade, and histology including the risks of recurrence and possible sequelae of treatment.
* Discuss the implications of stage, grade, and histology including the risks of recurrence and possible sequelae of treatment.
* '''Treated malignant renal masses'''
 
** '''History and physical exam'''
=== Treated malignant renal masses ===
** '''Laboratory (2):'''
 
**# '''Serum creatinine, eGFR'''
==== Investigations ====
**# '''Urinalysis'''
 
*** Other laboratory evaluations (e.g., complete blood count, lactate dehydrogenase, liver function tests, alkaline phosphatase and calcium level) may be obtained at the discretion of the clinician or if advanced disease is suspected.
*'''History and physical exam'''
*** With significant nephron mass loss, hyperfiltration can occur resulting in glomerular damage, exacerbation of proteinuria and progressive sclerosis with further decline in GFR., Therefore, repeat assessment of blood pressure, eGFR, and proteinuria should be performed soon after nephrectomy then again in 3-6 months to assess for development or progression of CKD
* '''Laboratory (2):'''
*** Patients found to have progressive renal insufficiency or proteinuria should be referred to nephrology
*# '''Serum creatinine, eGFR'''
** '''Imaging'''
*# '''Urinalysis'''
*** '''Regional'''
** Other laboratory evaluations (e.g., complete blood count, lactate dehydrogenase, liver function tests, alkaline phosphatase and calcium level) may be obtained at the discretion of the clinician or if advanced disease is suspected.
**** '''Abdominal imaging'''
** With significant nephron mass loss, hyperfiltration can occur resulting in glomerular damage, exacerbation of proteinuria and progressive sclerosis with further decline in GFR., Therefore, repeat assessment of blood pressure, eGFR, and proteinuria should be performed soon after nephrectomy then again in 3-6 months to assess for development or progression of CKD
***** '''CT or MRI pre- and post-intravenous contrast preferred'''
** Patients found to have progressive renal insufficiency or proteinuria should be referred to nephrology
***** See schedule below
* '''Imaging'''
*** '''Distant'''
** '''Regional'''
**** '''Chest'''
*** '''Abdominal imaging'''
***** See schedule below
**** '''CT or MRI pre- and post-intravenous contrast preferred'''
**** Bone scan
**** See schedule below
***** Not indicated in routine follow-up of treated malignant renal mass
** '''Distant'''
***** Indications (3):
*** '''Chest'''
*****# Bone pain
**** See schedule below
*****# Elevated alkaline phosphatase
*** Bone scan
*****# Radiographic findings suggestive of a bony neoplasm
**** Not indicated in routine follow-up of treated malignant renal mass
**** CT/MRI brain and/or spine
**** Indications (3):
***** Not indicated in routine follow-up of treated malignant renal mass
****# Bone pain
***** Indication (1):
****# Elevated alkaline phosphatase
*****# Acute neurological signs or symptoms
****# Radiographic findings suggestive of a bony neoplasm
*** Other
*** CT/MRI brain and/or spine
**** Additional site-specific imaging can be ordered as warranted by clinical symptoms suggestive of recurrence or metastatic spread
**** Not indicated in routine follow-up of treated malignant renal mass
**** Positron emission tomography (PET) scan should not be obtained routinely but may be considered selectively.
**** Indication (1):
*** Patients with findings suggesting a new renal primary or local recurrence of renal malignancy should undergo metastatic evaluation including chest and abdominal imaging.
****# Acute neurological signs or symptoms
** '''Follow-up schedule'''
** Other
*** '''Nephrectomy'''
*** Additional site-specific imaging can be ordered as warranted by clinical symptoms suggestive of recurrence or metastatic spread
**** '''Risk-stratified into (4):'''
*** Positron emission tomography (PET) scan should not be obtained routinely but may be considered selectively.
****# '''Low-risk: pT1 and Grade 1/2'''
** '''Patients with findings suggesting a new renal primary or local recurrence of renal malignancy should undergo metastatic evaluation including chest and abdominal imaging.'''
****# '''Intermediate-risk: pT1 and Grade 3/4, or pT2 any Grade'''
 
****# '''High-risk: pT3 any Grade'''
==== Follow-up schedule ====
****# '''Very high-risk: pT4 or pN1, or sarcomatoid/rhabdoid dedifferentiation, or macroscopic positive margin'''
 
***** '''If final microscopic surgical margins are positive for cancer, the risk category should be considered at least one level higher''', and increased clinical vigilance should be exercised.
===== Nephrectomy =====
**** '''Follow-up based on risk stratification'''
* '''<span style="color:#ff0000">Risk-stratified into (4):'''
***** '''See [https://www.auanet.org/documents/Guidelines/PDF/RCC-Follow-Up-Algorithm.pdf Table 1] from original guidelines'''
*# '''<span style="color:#ff0000">Low-risk: pT1 and Grade 1/2'''
**** '''Imaging:'''
*# '''<span style="color:#ff0000">Intermediate-risk: pT1 and Grade 3/4, or pT2 any Grade'''
***** '''Abdominal'''
*# '''<span style="color:#ff0000">High-risk: pT3 any Grade'''
****** '''After 2 years, abdominal ultrasound (US) alternating with cross-sectional imaging may be considered in the low- and intermediate-risk groups at physician discretion.'''
*# '''<span style="color:#ff0000">Very high-risk: pT4 or pN1, or sarcomatoid/rhabdoid dedifferentiation, or macroscopic positive margin'''
****** '''After 5 years, informed/shared decision-making should dictate further abdominal imaging.'''
** '''If final microscopic surgical margins are positive for cancer, the risk category should be considered at least one level higher''', and increased clinical vigilance should be exercised.
***** '''Chest'''
* '''<span style="color:#ff0000">Follow-up based on risk stratification'''
****** '''Modality'''
** '''<span style="color:#ff0000">See [https://www.auanet.org/documents/Guidelines/PDF/RCC-Follow-Up-Algorithm.pdf Table 1] from original guidelines'''
******* '''Chest x-ray low- and intermediate-risk groups'''
***'''<span style="color:#ff0000">If low-risk, abdominal and chest imaging at 12, 24, 48 and 60 months'''
******* '''CT chest for high and very high-risk groups.'''
***'''<span style="color:#ff0000">If intermediate-risk, abdominal and chest imaging at 6, 12, 24, 36, 48 and 60 months'''
****** After 5 years, informed/shared decision-making discussion should dictate further chest imaging and chest x-ray may be utilized instead of chest CT for high and very high-risk groups.
* '''Imaging:'''
*** '''Thermal ablation'''
** '''Abdominal'''
**** '''If biopsy confirmed malignancy or was non-diagnostic, pre- and post-contrast cross-sectional abdominal imaging should be done within 6 months after TA.'''
*** '''After 2 years, abdominal ultrasound (US) alternating with cross-sectional imaging may be considered in the low- and intermediate-risk groups at physician discretion.'''
**** '''Subsequent follow-up should be according to the intermediate-risk recommendations (see [https://www.auanet.org/documents/Guidelines/PDF/RCC-Follow-Up-Algorithm.pdf Table 1] from original guidelines)'''
*** '''After 5 years, informed/shared decision-making should dictate further abdominal imaging.'''
** Management of recurrence
** '''Chest'''
*** Patients with findings suggestive of metastatic renal malignancy should be evaluated to define the extent of disease and referred to medical oncology.
*** '''Modality'''
*** Surgical resection or ablative therapies may be considered in select patients with isolated (ipsilateral kidney and/or retroperitoneum) or oligo-metastatic disease.
**** '''Chest x-ray low- and intermediate-risk groups'''
* Pathologically-proven benign renal masses
**** '''CT chest for high and very high-risk groups.'''
** Occasional clinical and laboratory evaluation for sequelae of treament; most do not require routine periodic imaging.
*** '''After 5 years, informed/shared decision-making discussion should dictate further chest imaging and chest x-ray may be utilized instead of chest CT for high and very high-risk groups.'''
 
===== Thermal ablation =====
* '''If biopsy confirmed malignancy or was non-diagnostic, pre- and post-contrast cross-sectional abdominal imaging should be done within 6 months after TA.'''
* '''Subsequent follow-up should be according to the intermediate-risk recommendations (see [https://www.auanet.org/documents/Guidelines/PDF/RCC-Follow-Up-Algorithm.pdf Table 1] from original guidelines)'''
 
==== Management of recurrence ====
* Patients with findings suggestive of metastatic renal malignancy should be evaluated to define the extent of disease and referred to medical oncology.
* Surgical resection or ablative therapies may be considered in select patients with isolated (ipsilateral kidney and/or retroperitoneum) or oligo-metastatic disease.
 
=== Pathologically-proven benign renal masses ===
* Occasional clinical and laboratory evaluation for sequelae of treatment; most do not require routine periodic imaging.


== References ==
== References ==


* Campbell, Steven C., et al. "Renal Mass and Localized Renal Cancer: Evaluation, Management, and Follow-Up: AUA Guideline Part I." ''The Journal of urology'' (2021): 10-1097.
* Campbell, Steven C., et al. "Renal Mass and Localized Renal Cancer: Evaluation, Management, and Follow-Up: AUA Guideline Part I." ''The Journal of urology'' (2021): 10-1097.