University of Florence

Robot-assisted partial nephrectomy (RAPN) represents the preferred minimally-invasive approach for localized renal tumors. Increasing attention has focused on optimizing parenchymal preservation, with enucleation proposed as a potentially advantageous strategy. This study aimed to compare perioperative and functional outcomes of enucleation versus enucleoresection in a large, contemporary multicenter RAPN cohort. Data were extracted from the multicentric and multicontinental European Association of Urology Young Academic Urologists (EAU-YAU) Renal Cancer Working Party database. Patients undergoing RAPN between 2015 and 2024 with clearly documented resection technique (enucleation vs enucleoresection) were included. The resection technique was chosen based on the surgeon's preference. Perioperative, pathological, and renal functional outcomes were evaluated. Acute kidney injury (AKI - defined according to the AKIN classification) and chronic kidney disease (CKD) worsening served as primary endpoints. Logistic regression and Cox proportional hazards models were used to assess the association between surgical technique and the risk of AKI and CKD progression; Kaplan-Meier curves were used to depict time-to-event and functional outcomes, while longitudinal eGFR analyses were performed to evaluate renal function trends over time. Among 1260 patients, 527 (42%) underwent enucleation and 733 (58%) enucleoresection. Adoption of both techniques remained stable over time. Baseline characteristics were comparable. Enucleoresection was associated with longer ischemia time, higher intraoperative complication rates, and a lower positive surgical margin rate (5.2% vs 8.3%, p=0.003). Postoperative AKI occurred more frequently after enucleoresection (18% vs 3%, p<0.001), although eGFR recovery was similar at a median follow-up of 12 vs 25 months. In the overall cohort and among patients with baseline CKD stages 1-2, enucleation was associated with a lower risk of CKD progression (p<0.001). Enucleation during RAPN offers a parenchyma-sparing approach with potential functional advantages, particularly in patients with preserved baseline renal function. This benefit must be balanced against a slightly higher risk of positive margins, reinforcing the necessity of thoughtful case selection and standardized surgical technique.

Hemoptysis is a potentially life-threatening symptom that often prompts emergency department (ED) evaluation and hospitalization. Reliable prognostic tools to guide clinical decision-making and optimize resource use are currently lacking. To prospectively validate the Florence Hemoptysis Assessment Score (FLHASc) in patients presenting with hemoptysis to the ED, and to eventually derive and validate an improved version of the score (FLHASc2). We analyzed data from the POPEIHE study (NCT06067997), a multicenter prospective cohort of 546 consecutive adult patients presenting with hemoptysis to 9 Italian EDs. The primary outcome was a composite of in-hospital death, need for ventilatory support, intensive care unit (ICU) admission, blood transfusion, or invasive hemostatic procedures. We evaluated the prognostic performance of the original FLHASc, then derived a new model (FLHASc2) using multivariate logistic regression in a randomly selected derivation cohort (n=321) and validated it in the remaining cohort (n=225). A simplified version of the score was also tested. The original FLHASc demonstrated moderate discriminatory ability (AUC 0.71; 95% CI: 0.65-0.76) and suboptimal calibration. The FLHASc2 showed improved performance (AUC 0.79, 95% CI: 0.73-0.87 in derivation and 0.81, 95% CI: 0.73-0.88, in validation cohorts; Brier score<0.10 in both). The simplified FLHASc2 (sFLHASc2), assigning one point per variable, maintained comparable accuracy (AUC 0.80, 95% CI: 0.72-0.87) and identified 47.8% of patients as low risk (2.7% event rate). When combined with a negative chest X-ray, the observed event rate in this subgroup dropped to 0.87%, with a negative predictive value of 99.1% (CI 95%, 96.5-100%). The FLHASc2 and its simplified version are accurate prognostic tools for identifying hemoptysis patients at low risk of short-term adverse outcomes. Use of the sFLHASc2 combined with chest X-ray may allow safe ED discharge in nearly half of cases. A prospective management trial is warranted to confirm its clinical impact. NCT06067997.