Consumo producido por el escaneo

This study was carried out at the Department of Urology at Helsinki University Hospital from 2015-2020. Financial support from the Finnish Urology Association and Helsinki University Hospital research funds (EVO) is gratefully acknowledged.

I am grateful to Adjunct Professor Mika Matikainen, head of the Department of Urology, for the opportunity to carry out this thesis. I am grateful to him for providing the facilities and time off from clinical work as well as serving as a member of my thesis committee. It is a privilege to have such a flexible and supportive superior. I wish to express my gratitude to Adjunct Professor Jukka Sairanen and Adjunct Professor Arto Mikkola for allowing me to have time off from the Urology Department to immerse myself in my research. I thank you both for being such good role models in managing thousands of things brilliantly at the same time while never losing your commitment.

I thank Professor Antti Rannikko for his contagious love of science and research. Thank you, Antti, for always finding research facilities when they were urgently needed. I am sure that you will lead our clinic further into the world of science than we could ever dream of.

My heartfelt thanks go to my supervisors, the excellent Adjunct Professor Harry Nisén and Professor Kimmo Taari, for guiding me throughout the whole thesis project. Harry, you have always seen our goals as crystal clear despite the minor obstacles on our journey. Your enthusiasm, passion and determination have kept me going. I will be forever thankful to you for leading me to the world of RCC both scientifically and clinically. I hope this love never dies. Kimmo, you are so warm-hearted, you always found time to ask how I was doing and kept the spirits up during this process. Thank you for being there for me.

Petrus and Harri, ‘apuohjaajat’. It has been a pleasure working with you both. You were very hands-on, always promptly replied even to my most basic questions, and most of all, you were so supportive – without you, this thesis would probably have never been finished. Riikka, thank you for backing me up when needed. You are both a great co-researcher and a brilliant colleague. I offer my sincere thanks to Tuomas, for your quick and precise comments and

your magical STATA skills. I am amazed. I offer my sincere thanks to all co- writers, Kaisa Erkkilä, Ulf-Håkan Stenman, Petteri Hervonen, Tuomas Mirtti, Petri Bono, Ilkka Kantonen and Jarmo Simpanen for supportive collaboration. I acknowledge Tuomas Mirtti and Anni Virtanen for supplying example images of histological RCC subtypes. I thank Merja Rignell for help in obtaining death certificates and for coffee and empathy offered in the cellar of Meilahti Hospital outside of office hours.

My warmest thanks go to my reviewers, Adjunct Professors Markku Vaarala and Jukka Häkkinen, for kindly agreeing to examine my thesis. Your thorough work and precise comments improved my thesis text significantly. I am obliged to adjunct professor Martti Nurmi for accepting the role of the official opponent in this thesis dissertation. I am grateful to our language consultant for his expertise. I thank members of my thesis committee, Adjunct Professors Ville Sallinen and Mika Matikainen for being there for me and for constructive comments about study plans.

I thank all the colleagues in the HUH Urology Department. It has been a pleasure working with you. You have always been willing to help, and I have been privileged to be able to learn from you all. Working with you has been fun, no matter what the circumstances have been. As the famous slogan says: ‘Urology is for cool kids’. Special thanks go to Heli and Robin for making the time at work so enjoyable that it might be difficult to get things done.

I am deeply indebted to Vellu, Indrek and Sebastian, my dear colleagues in Lappeenranta, from their guidance to the exciting world of urology and for patiently teaching me the majority of my surgical skills. Thank you for believing in me despite seeing my first fumbling operations.

I warmly thank all my friends along the way for being there for me. You mean the world to me.

Anastasia, growing up together and sharing many ups and downs in life has meant a great deal to me. I wish you would live closer.

My dear friends from the university, Eeva, Eliisa, Helka, Kanerva, Marianna, Ninnu and Ulla, are still referred as ‘tytöt’ after so many cherished years together. Thank you for your loving and continuous peer support in every aspect of life and immediate whatsapp responses to all my questions about family life, hairstyles, Netflix series, science, and to specific questions about how to finish one’s thesis. I am especially thankful for Kanerva’s most recent

hands-on experience of this thesis struggle and for Eliisa’s holistic approach to science.

My friends from university times. Maiju, Nora, Jaakko, Kökö and Timppa, thank you for joyful moments at home and away. We have had great trips filled with laughter. Good friends are the best distraction during the dull moments of life.

To my friends met during the Lappeenranta years, Elisa, Emma-Lotta, Maire, Minna and Mikko, I know that taking first steps in surgery together has brought us close. Katja and Marianne, I could never imagine that true friends could be found in a schoolyard when picking up children.

I thank my in-laws Jussi, Pirkko, Hilkka and Iina and my godmother Hiksu, for their concrete contribution to my thesis work by babysitting my children.

My sister Iina, thank you for not only sharing experiences of coincidental thesis projects but for being my loyal and loving friend since the day you were born. Iina, Selene, Samuel and Sakke, it has been a true privilege to have relatives living just next door. I hope that our children will be as close as we are.

My deepest thanks go to my parents, Helena and Olavi, for always believing in me. Knowing that I can always count on you, no matter whether it means no-notice childcare or renovating a flat from floor to the ceiling, has given me a solid foundation to concentrate on less practical matters, such as this project. Thank you for being there for me.

Above all, I am ever grateful to my beloved husband, Juho-Antti for his understanding and patience during this project. Having an absent and absent- minded wife has not always been easy for you. However, I have always been able to depend on you and your love. It means everything to me. I love you. And your bad jokes.

My children, Isla, Okko and Pihla, I am very fortunate to have you. Your existence has slowed this project considerably but filled my life with happiness, joy and love beyond all expectations – what a great bargain! Thank you for being you.

Helsinki, April 2020