 I'd like to thank the KCA and the organizing committee for an opportunity to speak here today. So you know, I would submit to you that the prognostic value afforded by lymph node dissection and kidney cancer is undisputed. We all know that patients with proven node mets do poorly, so I will not spend time discussing this today. The real question is whether there is a therapeutic benefit associated with lymph node dissection. Whether this benefit can be seen in patients with clinically node negative kidney cancer and patients with node positive disease. And can we identify populations of these patients that are at high risk for nodal metastases and they can benefit from node dissection? So let's just start with this patient. This is a typical patient that we all see in our clinics. Had CAT scan for an unrelated reason, found to have essentially an asymptomatic right sided renal mass, no signs of local regional nodal disease. We all know that this patient should probably be treated with nephrectomy or nephron sparing surgery of some sort. The question is whether he should have a lymph node dissection. The Europeans actually pulled this trial off. They randomized about 700 patients to nephrectomy or nephrectomy and lymph node dissection. And you can see here, this study was powered to detect 10% difference in survival. And you can see here that progression-free survival, the Kaplan-Meier curves are essentially overlapping and same thing is for the cancer-specific and overall survival. So no difference whether lymph node dissection was performed at the time of nephrectomy. Remember, these are all patients with clinically node negative disease. A little bit closer look at the data. Again, you can see that no difference in rate of death from oncologic outcomes or overall survival. No difference in local disease progression. No difference in distant and or local disease progression as well. So no impact on any of the oncologic outcomes could be demonstrated by this study. Again, a closer look at this study's population, you can see that vast majority over 70% of these patients had organ-confined kidney cancer and you can make an argument that the probability of nodal positivity in this specific cohort is very, very low. And in fact, some of the numbers worth remembering, overall, only 3% rate of node positivity in this specific study in patients that were randomized to lymph node dissection arm. If the nodes were not palpable at the time of surgery, these patients had only 1% probability of subclinical metastatic disease. And more interesting in patients that did have palpable lymphenopathy at the time of surgery, only 16% of these patients had actually, these nodes were actually kidney cancer. So what I take away from that study is that I think in the population of patients with clinically localized kidney cancer, I think routine lymph node dissection is probably not necessary. Let's look at a little bit of a different extreme. Here's a patient that presents with locally advanced renal mass, most likely renal mass, low carcinoma, obviously, and a presence of regional nodal disease. I think we all, yes, let's just assume there's no evidence of systemic metastatic disease. And I think all of us would agree that this patient needs an effrectomy. The question is whether he'll benefit from aggressive local regional lymph node dissection. There are multiple studies on this issue, but the most modern and robust series comes from Anderson, about 70 patients treated with an effrectomy and aggressive lymph node dissection at the time of surgery for kidney cancer with local regional nodal disease but no evidence of systemic metastases. Again, perhaps not surprisingly, you can see that majority of these patients progress systemically within a year, but you can see that there's a very well-defined population, perhaps maybe 20% or so, that are actually cured by this approach long-term. If you look at overall and cancer-specific survival, again, at five years, close to 40% of these patients are alive. These authors also looked at predictors of outcome associated with this patient population. You can see that presence of circumventory features, advanced nodal disease, poor performance status, were all associated with inferior ocnologic outcomes, but presence of papillary histology was actually associated with improved survival. Similar data from the UCLA group here, they actually provide a control arm of patients that would look at regional nodal disease that did not undergo no dissection compared to patients that did, and you can see here that patients treated with an effrectomy and aggressive lymph node dissection actually enjoyed improvement in their oncologic outcomes. This was not seen again in patients with no clinical evidence of nodal disease, no impact on oncologic outcomes, whether they underwent lymph node dissection or not. Again, this is in accord with the European randomized study. So if we assume that, you know, all patients should fall somewhere in this continuum of those with early low-stage disease with low probability of nodal mets, these patients we know don't benefit from no dissection, and those with already clinical evidence of regional lymph ethnopathy for this group, I would submit that lymph node dissection is probably too little and too late, I think the most relevant group of patients, probably the patients that are which somewhere in between here, and these are the patients with high risk and high probability of harboring occult metastatic disease. Can we identify this patient group? And our colleagues in May have been doing this for almost a decade now. They've identified five risk features with the primary tumor that are associated with high probability of regional nodal disease. Again, you know, perhaps not surprisingly again, high nuclear grade, presence of sarcoma joint features, large tumor size, advanced tumor stage, and presence of histologic necrosis. And what they've shown nicely is that as number of these poor prognostic features increases, the probability of regional nodal disease is increased. And perhaps, you know, patients with two or three or more of these risk features would actually benefit from lymph node dissection at the time of nephrectomy. Very similar concept here. This is a European group that developed a nomogram to predict probability of nodal disease based on very simple and accessible preoperative clinical features. Very highly accurate in prediction of regional nodal disease. However, this nomogram has not been externally validated. If we decide to do a lymph node dissection, I think most of us would agree that simple node plucking is not sufficient. I think a thorough lymph node dissection should be performed. This study demonstrates nicely that the more lymph nodes you remove, the higher probability of a finding of a positive lymph node. And again, in this specific study, removing more than 13 lymph nodes essentially doubled the node positivity rate. So I'm not suggesting that we should be sitting there and counting lymph nodes. I think a structured approach based on mapping studies and template dissections probably makes the most sense as advocated by the Mayo Group here. And I would be remiss not to mention potential complications associated with the lymph node dissection. I think the most relevant and robust data comes from, again, the European randomized study. And just to summarize, really no significant rates of increased complications associated with lymph node dissection compared to patients that got an effect to me only. So in summary, I think obviously nodal status provides very important prognostic information, but I would submit to you that currently there's no approved adjuvant agent. So what you do with this information perhaps is limited. There's no proven benefit to adjuvant lymph node dissection in patients with clinically localized early stage kidney cancer. You can achieve durable rates of remission and prolonged survival and small but a significant fraction of patients with obvious local regional nodal disease. I think risk-adapted methodology as employed by the Mayo Clinic makes sense in patients with locally advanced disease. And if lymph node dissection is to be performed, I think template anatomic dissection rather than node plucking should be performed. Thank you.