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Purpose: Robotic systems have the potential to overcome inherent limitations of humans and offer substantial advantages to patients including reduction in surgery time. Our group has undertaken the challenge of developing autonomous wound closure system. One of the initial steps is to allow accurate assessment of wound skin topology and wound edge location. We present a vision-laser scanner to generate 3D point cloud for 3D reconstruction of wound's edge and topology. Methods: When the laser range sensor measures Z coordinate, two encoders installed on the actuators of the gantry robot provide the precision values of X, Y coordinates simultaneously. The 3D point cloud of the wound skin is generated by recordings of X, Y and Z during scanning is performed over wound skin surface. To reduce the scanning time, we exploit a supplementary laser LED to project a regular laser spot on the wound skin surface, which can provide an additional measurement point by incorporating artificial neural network estimation approach. In the meantime, the point cloud of the wound edge can be extracted by detecting if the laser spot is located on the wound edge in the image from 2D camera. Results: The mean absolute error (MAE) and standard deviation (σ) of wound edge are measured in MeshLab environment. The MAE (σ) in X (tangent), Y (tangent), and Z (normal) are 0.32 (0.22) mm, 0.37 (0.34) mm, and 0.61 (0.29) mm, respectively. The experimental results demonstrate that the vision-laser scanner attains high accuracy in determining wound edge location along the tangent of the wound skin. Conclusion: A vision-laser scanner is developed for 3D reconstruction of wound's edge and topology. The experimental tests on the different wound models revealed the effectiveness of the vision-laser scanner. The proposed scanner can generate 3D point cloud of the wound skin and its edge simultaneously, and thus significantly improve the accuracy of wound closure in clinical applications. [ABSTRACT FROM AUTHOR]

Introduction: For patients with localized node-negative (Stage I and II) clear cell renal cell carcinomas (ccRCC), current clinicopathological staging has limited predictive capability because of their low risk. Analyzing molecular signatures at the time of nephrectomy can aid in understanding future metastatic potential. Objective: Develop a molecular signature that can stratify patients who have clinically low risk ccRCC, but have high risk genetic changes driving an aggressive metastatic phenotype. Patients, Materials, and Methods: Presented is the differential expression of mRNA and miRNA in 44 Stage I and Stage II patients, 21 who developed metastasis within 5 years of nephrectomy, compared to 23 patients who remained disease free for more than 5 years. Extracted RNA from nephrectomy specimens preserved in FFPE blocks was sequenced using RNAseq. MiRNA expression was performed using the TaqMan OpenArray qPCR protocol. Results: One hundred thirty one genes and 2 miRNA were differentially expressed between the two groups. Canonical correlation (CC) analysis was applied and four CCs (CC32, CC20, CC9, and CC7) have an AUC > 0.65 in our dataset with similar predictive power in the TCGA-KIRC dataset. Gene set enrichment showed CC9 as kidney development/adhesion, CC20 as oxidative phosphorylation pathway, CC32 as RNA binding/spindle and CC7 as immune response. In a multivariate Cox model, the four CCs were able to identify high/low risk groups for metastases in the TCGA-KIRC (p < 0.05) with odds ratios of CC32 = 5.7, CC20 = 4.4, CC9 = 3.6, and CC7 = 2.7. Conclusion: These results identify molecular signatures for more aggressive tumors in clinically low risk ccRCC patients who have a higher potential of metastasis than would be expected. [ABSTRACT FROM AUTHOR]

Renal cell carcinoma has historically been managed by radical nephrectomy, but as knowledge of the disease has advanced, nephron sparing surgery has become the norm in appropriately selected tumors. Laparoscopic partial nephrectomy (LPN) has been shown to have comparable oncologic outcomes and a shorter convalescence period compared to the traditional open partial nephrectomy. Dissemination of techniques has led to significantly increased use of minimally invasive nephron sparing surgery, and LPN remains a cost-effective and efficacious method for approaching small renal masses. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the impact of implementing magnetic resonance imaging (MRI) and ultrasonography fusion technology on biopsy and prostate cancer (PCa) detection rates in men presenting with clinical suspicion for PCa in the clinical practice setting. Patients and Methods: We performed a review of 1 808 consecutive men referred for elevated prostate‐specific antigen (PSA) level between 2011 and 2014. The study population was divided into two groups based on whether MRI was used as a risk stratification tool. Univariable and multivariable analyses of biopsy rates and overall and clinically significant PCa detection rates between groups were performed. Results: The MRI and PSA‐only groups consisted of 1 020 and 788 patients, respectively. A total of 465 patients (45.6%) in the MRI group and 442 (56.1%) in the PSA‐only group underwent biopsy, corresponding to an 18.7% decrease in the proportion of patients receiving biopsy in the MRI group (P < 0.001). Overall PCa (56.8% vs 40.7%; P < 0.001) and clinically significant PCa detection (47.3% vs 31.0%; P < 0.001) was significantly higher in the MRI vs the PSA‐only group. In logistic regression analyses, the odds of overall PCa detection (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.29–2.35; P < 0.001) and clinically significant PCa detection (OR 2.04, 95% CI 1.48–2.80; P < 0.001) were higher in the MRI than in the PSA‐only group after adjusting for clinically relevant PCa variables. Conclusion: Among men presenting with clinical suspicion for PCa, addition of MRI increases detection of clinically significant cancers while reducing prostate biopsy rates when implemented in a clinical practice setting. [ABSTRACT FROM AUTHOR]

Objectives: To study the feasibility and perioperative outcomes associated with a laparoscopic approach to completion nephrectomy in patients with locoregional disease recurrence after partial nephrectomy (PN) for renal cell carcinoma. Patients and Methods: We performed a retrospective review of patients who underwent PN between 2006 and 2016 and developed locoregional recurrence, defined by the presence of new disease within the original surgical bed. Those undergoing planned laparoscopic completion nephrectomy constituted the study cohort. Perioperative outcomes as well as clinical and pathologic parameters associated with ability to effectively perform laparoscopic completion nephrectomy were assessed. Results: Among 1259 patients who underwent PN during the study period, 45 cases (3.6%) of locoregional disease recurrence were observed. A laparoscopic approach to completion nephrectomy was attempted in 33 patients. Overall, 16 (48.5%) patients experienced a postoperative complication, 9 of whom (27.3%) had a major event (Clavien grade ≥3). Intraoperative open conversion was necessary in 12 (36%) patients. Higher R.E.N.A.L score of the original tumor (p < 0.001) and clinical evidence of synchronous metastatic relapse (p < 0.001) were associated with increased likelihood of open conversion. Blood loss (725 mL vs 175 mL, p < 0.001), operative time (280 minutes vs 160 minutes, p < 0.001), risk of major postoperative complication (58% vs 9.5%, p = 0.005), and hospital length of stay (4.5 days vs 2 days, p = 0.026) were significantly higher in individuals requiring open conversion. Conclusion: Laparoscopic completion nephrectomy for true locoregional recurrence is a technically demanding procedure associated with significant postoperative morbidity and a high rate of open conversion. Although feasible, careful patient selection may optimize surgical outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Kidney cancer ranks among the top 10 most prevalent cancers in Western society, ∼90% of which are renal cell carcinomas. There has been a paradigm shift in the management of small renal masses with strong emphasis now placed on nephron-sparing surgery and increased utilization of laparoscopic approaches to partial nephrectomy. In this review, the current state of laparoscopic partial nephrectomy (LPN) is discussed. Evidence Acquisition: The PubMed database was queried using the MeSH terms 'laparoscopy' and 'nephrectomy,' as well as the search term 'partial.' A search was performed filtering for 'clinical trial,' 'review,' 'humans', and 'English.' Evidence Synthesis: Articles that discussed intraoperative techniques, functional and oncologic outcomes, and a comparison between robot-assisted partial nephrectomy and LPN were synthesized. Conclusion: LPN reduces ischemia time, affords equivalent functional outcomes, oncologic outcomes, and equivalent complication rates compared with open partial nephrectomy. Future advances in laparoscopic technique and advancements in robotic technology offer potential to improve surgical and patient outcomes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the oncologic outcomes among a large cohort of octogenarian patients placed on active surveillance for a localized renal mass. Methods: We retrospectively reviewed patients ≥80 years of age presenting for asymptomatic, incidentally detected clinically localized stage T1 renal mass between 2006 and 2013 who were followed by active surveillance (AS). The primary endpoint was development of metastatic renal cell carcinoma. Secondary outcomes included intervention-free survival, cancer-specific survival, and overall survival. Results: Eighty-nine octogenarians (median age = 83.4 years) were placed on AS for a median 29.9 months. Median Charlson Comorbidity Index and Katz Index of Independence in Activities of Daily Living scores were 2 and 5, respectively. For all comers, median initial tumor size was 2.4 cm with median growth rate of 0.20 cm/year. Eight (9.0%) patients failed AS due to delayed intervention and three (1.1%) due to systemic progression after median follow-up of 27.8 and 39.9 months, respectively. Two (2.2%) patients in the delayed intervention cohort developed metastasis after treatment. Tumor growth rate was significantly higher among those undergoing intervention versus no intervention (0.60 vs. 0.15 cm/year, P = 0.05) and among patients with systemic progression versus no metastasis (1.28 vs. 0.18 cm/year, P = 0.001). Five-year intervention-free, metastasis-free, cancer-specific, and overall survivals were 90.6, 95.6, 95.6, and 85.7%, respectively. Conclusion: AS represents an effective management strategy in octogenarians given low overall risk of metastasis. Tumor growth kinetics may identify patients at risk of systemic progression in whom treatment should be considered. [ABSTRACT FROM AUTHOR]

Purpose: To determine the incidence and predictors of major complications in patients undergoing percutaneous cryoablation (PCA) for small renal masses. Methods: We performed a retrospective analysis of patients undergoing PCA from 2005 to 2012. We analyzed demographic, radiographic, and complication data. We defined complications as any deviation from the expected postoperative course. We determined predictors of complications. Results: A total of 190 patients were included in the study. The mean age was 69 years, and 132 (69%) were males. The mean tumor diameter was 2.2 cm (0.8-4.0 cm). The mean number of probes utilized per procedure was 2.3. We observed 16 (8.4%) complications including 14 Clavien grade I, which includes 6 (2%) large renal/retroperitoneal hematomas, 4 (2%) pneumothoraxes, 2 (1%) urinary tract infections, and 2 (1%) atrial fibrillations. There were two (1%) Clavien grade II complications (intestinal perforations). In univariable analysis, larger tumors and more probes were associated with higher risk of complications (all ps < 0.05). In multivariable analysis, larger tumor dimension (odds ratio [OR] = 2.85; 95% confidence interval [CI] = 1.34, 6.05; p = 0.006) was independently associated with major complications. After multivariable adjustments for patient's characteristics such as age, gender, American Society of Anesthesiologists, year of surgery, and histopathology, larger tumor dimension (OR = 2.85; 95%CI = 1.34, 6.05; p = 0.006) and more cryoablation probes (OR = 1.94; 95%CI = 1.36, 2.75; p < 0.001) were independently associated with higher risk of major complications. Conclusions: In a cohort of patients undergoing PCA for T1a small renal mass, larger tumor dimension and more cryoablation probes were independently associated with higher risk of complication. Although PCA is relatively safe and the major complications are infrequent, careful patient selection is crucial. [ABSTRACT FROM AUTHOR]

Although laparoscopic renal surgery dates to almost 30 years ago, in which the first laparoscopic nephrectomy was performed in 1990, the history of laparoscopy extends back over 100 years, when laparoscopy was first performed on dogs. Over the last 30 years, laparoscopic renal surgery has seen many advancements in technology and technique. With the introduction of robotics and new instruments, renal surgery is becoming increasingly less invasive, and patients are having improved operative outcomes. As new technology develops, the envelope will continue to be pushed by urologists with the hope of improvement of patient outcomes and satisfaction. [ABSTRACT FROM AUTHOR]

Background: The management of locally recurrent renal-cell carcinoma (RCC) following cryoablation remains a clinical dilemma. There is limited data regarding the management of locally recurrent disease in the setting of patients who have failed initial percutaneous cryoablation (PCA). We evaluate and report our experience with salvage PCA for local recurrence following renal cryoablation failure. Patients and Methods: We reviewed our experience with patients who underwent salvage PCA for local biopsy proven RCC recurrence following primary cryoablation procedures. Complications and oncologic outcomes were evaluated. Recurrence-free survival after primary and repeat cryoablation was plotted using the Kaplan-Meier curves. Results: A total 250 patients underwent primary cryoablation for RCC and 20 (8%) patients were identified who underwent repeat PCA for 21 locally recurrent tumors. The mean tumor size was 2.4 cm. Biopsy revealed clear cell in 14 patients, three papillary and four chromophobe RCC. All repeat cryoablation procedures were completed successfully, with no treatment failures on postprocedure imaging. There were no complications or deaths. With the median follow-up of 30 months (range 7-63), 3 (15%) patients experienced local recurrence. One patient had an enhancing lesion at 13 months following repeat PCA and underwent a third PCA. Two patients had recurrence at 6 and 35 months respectively and underwent successful laparoscopic partial nephrectomy. Local recurrence-free, metastasis-free and cancer-specific survival rates were 85%, 100%, and 100% respectively. Limitations include retrospective design and small number of patients. Conclusions: Repeat PCA after primary cryoablation failure is feasible, has a low complication rate, and acceptable short-term oncologic outcomes. Further studies with durable follow-up are required. [ABSTRACT FROM AUTHOR]

Purpose: Surgical complications have a significant impact on intended quality of care. The aim of our study was to identify factors that contribute to the propagation of additional postoperative complications. Materials and Methods: Over a 1-year period, we prospectively identified and retrospectively reviewed data on all patients who experienced a surgical complication within 30 days of their procedure. A complication was defined as any deviation from the expected postoperative course and was described using the Clavien-Dindo classification. Data reviewed included length of stay (LOS), Clavien grade, readmission status, and management of the complication. Surgeries were stratified into retroperitoneal, pelvic, and endoscopic procedures. The association between complications and Clavien grade was measured using Spearman rank-order correlation. The probability of subsequent complications and readmission was measured using exact logistic regression. Results: Of the 4414 patients who underwent a urologic procedure, 191 (4.3%) had at least one complication. One hundred thirty-four (70%) of these patients had more than one complication, 84 (44%) had more than three complications, and 12 (6.3%) had up to a seventh complication. LOS was affected by the severity of the initial complication. Patients with initial Clavien grades 1, 2, 3a, 3b, and 4 had an LOS of 3.75, 4.17, 4.21, 4.94, and 8.58 days, respectively. Variables associated with the risk of developing a second complication included diabetes mellitus, longer operative times (OR 1.83), and greater estimated blood loss (OR 1.32). Conclusions: Surgical patients with an initial complication are at higher risk for multiple subsequent postoperative complications. Complications are associated with an extended LOS and higher readmission rates. Diabetes, longer operative time, and greater blood loss were identified as risk factors for multiple complications. [ABSTRACT FROM AUTHOR]

Objective To evaluate whether elective off-clamp laparoscopic partial nephrectomy ( LPN) affords long-term renal functional benefit compared with the on-clamp approach. Patients and Methods This is a retrospective review of patients who underwent elective LPN between 2006 and 2011. Patients were followed longitudinally for up to 5 years. In all, 315 patients with radiographic evidence of a solitary renal mass and normal-appearing contralateral kidney underwent elective LPN; 209 were performed on-clamp vs 106 off-clamp. One patient who required conversion from LPN to open PN was excluded from the study. Additionally, four patients in the on-clamp cohort who underwent subsequent radical nephrectomy for local-regional recurrence were excluded from longitudinal functional evaluation after their procedure. The primary objective was to evaluate differences in postoperative estimated glomerular filtration rate ( eGFR) between hilar clamping groups. Subgroup analyses were performed for patients with clamp times >30 min and those with baseline renal insufficiency ( eGFR <60 mL/min/1.73m2). Risk of developing worsened or new-onset renal insufficiency was also compared. Results The mean preoperative eGFR was similar between the on-clamp and off-clamp cohorts (80.7 vs 84.1 mL/min/1.73m2, P > 0.05). Univariable and multivariable analyses did not show significant differences in postoperative eGFR between both groups among all-comers, those with clamp times >30 min, and patients with baseline renal insufficiency. Risk of chronic kidney disease was not diminished by the off-clamp approach with up to 5 years of follow-up. Conclusions Progressive recovery of renal function after hilar clamping in the elective setting eclipses short-term functional benefit achieved with off-clamp LPN by 6 months; there was no significant difference in eGFR or the percentage incidence of chronic kidney disease between the on-clamp and off-clamp cohorts with up to 5 years follow-up. As such, eliminating transient ischaemia during elective LPN does not confer clinical benefit. [ABSTRACT FROM AUTHOR]

Objective: To understand the effective radiation dose during percutaneous cryoablation (CA) and radiofrequency ablation (RFA) and characterize variables that may affect the individual dose. Materials and Methods: The effective radiation dose was determined by conversion of the dose-length product from CT scans performed during percutaneous CA or RFA for patients with solitary renal masses (<4 cm) at four academic centers. Radiation dose per case was compared between patients and institutions using multivariate and univariate analysis. Lifetime attributable risk of cancer was calculated for each institution and utilized to determine the number needed to harm for a range of ages at the time of exposure. Results: One hundred twenty-three patients met the inclusion criteria with a mean age of 71 years. Sixty-nine percent of patients were male, mean body-mass index (BMI) was 29.4, and mean tumor size was 2.2 cm. The mean effective radiation dose per ablation was 40 mSv (range 3.7-147). On multivariate analysis, only BMI and institution were associated with the radiation dose. No significant difference in radiation exposure was seen for RFA or CA procedures. Conclusions: Radiation exposure during percutaneous ablation is similar to a multiphase CT scan. However, there is wide variability in individual treatment exposure, varying from 3.7 to 147 mSv, depending primarily on institution and BMI. Standardization of protocols is required to achieve as low as reasonably achievable levels of radiation. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the effect of a novel valveless trocar system (VTS) on perioperative outcomes in patients undergoing robotic-assisted laparoscopic prostatectomy (RALP). Methods: A single-institution retrospective review was performed of 792 patients undergoing RALP. Preoperative patient variables, tumor characteristics, and perioperative variables were collected and analyzed. The first 150 patients were excluded from analysis to account for the learning curve of robotic surgery. Univariate and multivariate linear regression models were used to assess factors affecting operative time (ORT). Results: A total of 257 and 385 patients underwent RALP utilizing the VTS and conventional insufflation, respectively. There were no significant differences in American Society of Anesthesiologist score, body mass index (BMI), prostate volume, final Gleason score, estimated blood loss, and complications between the cohorts. The only difference noted was a significantly shorter mean ORT in the VTS cohort (149.5 vs. 170.1 min, p < 0.0001). In light of this finding, further analysis was performed to identify associations with ORT. Multivariable analysis demonstrated that VTS, BMI, final Gleason score, prostate volume, surgeon, and node dissection were significantly associated with ORT. The use of the VTS decreased mean ORT by 23.2 min when controlling for confounding factors ( p < 0.001). The performance of a nerve sparing operation was found to decrease ORT by 15.9 min ( p < 0.001), though more often performed for lower-risk disease. Conclusion: The use of a novel VTS demonstrated decreased ORT in patients undergoing RALP when controlling for confounding factors. Prospective randomized trials are needed to evaluate its ultimate benefit in various surgical cohorts. [ABSTRACT FROM AUTHOR]

Background and Purpose: Increased body mass index (BMI) has been shown to have inferior perioperative outcomes in patients undergoing laparoscopic partial nephrectomy (LPN). The aim of this study was to determine the differences in perioperative outcomes for patients undergoing LPN in normal, overweight, and obese persons using established BMI risk categories. Methods: A retrospective review of 488 patients undergoing LPN was performed stratifying patients according to BMI of <25 kg/m2, 25 to 30 kg/m2, and >30 kg/m2. The analysis of variance test, chi-square analysis, and bivariate regression models were used to compare comorbidities and perioperative outcomes among the groups. Results: One hundred and eighty nine of 369 patients were identified as being obese. Obese patients were found to have a significantly higher American Society of Anesthesiologists class (2.4 vs 2.1) than normal weight patients ( P=0.03). No significant differences were demonstrated in estimated blood loss, operative time, transfusion requirement, or rate of conversion between the groups. In addition, there was no significant difference in cardiovascular, pulmonary, thromboembolic, or infectious complications between the groups. Obesity was significantly associated with bleeding necessitating angioembolization ( P=0.033). Conclusion: LPN demonstrates equivalent perioperative outcomes in normal, overweight, and obese patients. The minimally invasive approach achieves equivalent outcomes in patients undergoing major abdominal surgery although further studies of alternate procedures are needed to validate our findings. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the performance of multiparametric magnetic resonance imaging ( mpMRI) in predicting prostate cancer on repeat biopsy; and to compare the cancer detection rates ( CDRs) of MRI/transrectal ultrasonography ( TRUS) fusion-guided biopsy with standard 12-core biopsy in men with at least one previous negative biopsy. Patients and Methods We prospectively enrolled men with elevated or rising PSA levels and/or abnormal digital rectal examination into our MRI/ TRUS fusion-guided prostate biopsy trial. Participants underwent a 3 T mpMRI with an endorectal coil. Three radiologists graded all suspicious lesions on a 5-point Likert scale. MRI/ TRUS fusion-guided biopsies of suspicious prostate lesions and standard TRUS-guided 12-core biopsies were performed. Analysis of 140 eligible men with at least one previous negative biopsy was performed. We calculated CDRs and estimated area under the receiver operating characteristic curves ( AUCs) of mpMRI in predicting any cancer and clinically significant prostate cancer. Results The overall CDR was 65.0% (91/140). Higher level of suspicion on mpMRI was significantly associated with prostate cancer detection ( P < 0.001) with an AUC of 0.744 compared with 0.653 and 0.680 for PSA level and PSA density, respectively. The CDRs of MRI/ TRUS fusion-guided and standard 12-core biopsy were 52.1% (73/140) and 48.6% (68/140), respectively ( P = 0.435). However, fusion biopsy was more likely to detect clinically significant prostate cancer when compared with the 12-core biopsy (47.9% vs 30.7%; P < 0.001). Of the cancers missed by 12-core biopsy, 20.9% (19/91) were clinically significant. Most cancers missed by 12-core biopsy (69.6%) were located in the anterior fibromuscular stroma and transition zone. Using a fusion-biopsy-only approach in men with an MRI suspicion score of ≥4 would have missed only 3.5% of clinically significant prostate cancers. Conclusions Using mpMRI and subsequent MRI/ TRUS fusion-guided biopsy platform may improve detection of clinically significant prostate cancer in men with previous negative biopsies. Addition of a 12-core biopsy may be needed to avoid missing some clinically significant prostate cancers. [ABSTRACT FROM AUTHOR]

Objectives To evaluate appendiceal onlay flap ureteroplasty for repairing complex right proximal and mid-ureteric strictures. Patients and Methods Between August 2006 and August 2012 four women and two men (mean age 34.2 years) underwent right laparoscopic appendiceal onlay flap ureteroplasty. The mean stricture length was 2.5 cm. Stricture formation was secondary to impacted ureteric stones in three patients and failed pyeloplasty for congenital pelvi-ureteric junction obstruction in the remaining three. Each patient had ipsilateral flank pain before surgery. Results The mean operating time, estimated blood loss and hospital stay were 244 min, 175 mL and 3.2 days, respectively. No intra- or peri-operative complications were noted. The objective success rate was 100% (all patients had radiographic and/or endoscopic resolution of their ureteric strictures). The subjective success rate was 66%, (two patients developed recurrent discomfort, which upon exploration was found to be attributable to fibrosis away from the appendiceal onlay graft, where the gonadal vessels crossed the ureter). Both patients with recurrent pain underwent laparoscopic ureterolysis and bladder advancement flap proximal to the appendiceal onlay, which markedly improved one patient's pain but the other patient continued to have discomfort, ultimately resulting in a laparoscopic nephroureterectomy. Conclusions Appendiceal onlay ureteroplasty is a viable treatment option for patients with complex right proximal and mid-ureteric strictures, while minimising the potential morbidity of appendiceal and ileal interposition. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic (LAP) and robot-assisted laparoscopic (RAL) approaches have been applied to ureteroneocystostomies (UNC) although such experience has been limited to a small number of patients and limited follow-up. Herein, we detail our experience with over 100 minimally invasive UNC, the largest such series to date. Methods: All minimally invasive UNC performed at our institution between 1997 and 2013 and all open UNC performed between 2008 and 2013 were identified. Perioperative parameters of relevance were identified and recorded. Chi-squared and ANOVA with post hoc Tukey analysis were performed for all categorical and continuous variables, respectively. Results: A total of 130 patients met our study criteria. One hundred five underwent the minimally invasive approach (20 RAL and 85 LAP). Mean follow-up duration was 504 days. Patients in the RAL, LAP, and open cohorts were of similar age, gender and laterality distribution, American Society of Anesthesiologists (ASA) score, body-mass index, history of previous abdominal surgery, history of prior treatment for the ureteral lesion, and surgical indication (). Operative time was similar across all cohorts (235-257 minutes, p=0.123). Estimated blood loss (EBL) was significantly lower in the RAL and LAP cohorts (100 and 150 mL) compared to their open counterparts (300 mL, p=0.001) although a decrease in hematocrit was similar across all groups. Only four intraoperative complications (4.7%) and two (2.4%) conversions to open were identified in the LAP group, without statistical significance. No intraoperative complications or conversions were identified in the RAL or open cohorts. Median length of stay (LOS) was significantly shorter in the minimally invasive cohorts compared to open ( p<0.002). Ninety-day readmission rates (18.8-20%), major complications (10-20%), and failure rates (5.9-16%) were highest in the open cohort although without statistical significance. Conclusion: RAL or LAP UNC is feasible, safe, and comparable to the open technique with some perioperative benefit in EBL, LOS, and stent duration. [ABSTRACT FROM AUTHOR]

Objectives: To present our experience demonstrating the feasibility of off-clamp laparoscopic partial nephrectomy (LPN) for hilar tumors and evaluate intermediate oncologic and renal functional outcomes. Patients and Methods: A retrospective review of LPN cases in nine patients was performed. Hilar lesions were defined as renal cortical tumors in direct physical contact with the renal artery, vein, or both as identified on preoperative imaging and confirmed intraoperatively. Although the renal hilum vasculature was isolated for possible clamping if needed, tumor extirpation was performed off-clamp, eliminating warm ischemia time (WIT). The clinicopathologic parameters, perioperative course, complications, and long-term oncologic and renal functional outcomes were analyzed. Results: Nine patients underwent off-clamp LPN for complex hilar tumors. The mean age was 60.5 years, mean American Society of Anesthesiologists physical classification (ASA) score was 2, and mean BMI was 27.7 kg/m2. The mean tumor size and volume were 3.2 cm and 35.8 cm3, respectively. A greater proportion of the tumors (55.6%) were endophytic and mostly of clear cell histology (78%). The mean operative time was 131 minutes, estimated blood loss 250 cc, need for transfusion 0%, and complication rates 22%. No positive margins were present intraoperatively or on final pathology. After a median follow-up of 42.8 months, there was no evidence of clinical or radiographic recurrence in any patient. There was no change in the mean estimated glomerular filtration rate preoperatively and at a median follow-up of 32 months (97.2 mL/minute vs 81.3 mL/minute; p=0.052). Conclusion: Complex renal hilar tumors can be successfully managed with laparoscopic nephron-sparing surgery with elimination of WIT with preservation of perioperative, renal functional, and oncologic outcomes. [ABSTRACT FROM AUTHOR]

Objective To present outcomes of a randomized, patient-blinded controlled trial on Pfannenstiel laparoendoscopic single-site ( LESS) vs conventional multiport laparoscopic live donor nephrectomy., Patients and Methods Patients presenting as left kidney donors between January 2009 and November 2011 were randomized to LESS donor nephrectomy ( LESS-DN: n = 15) or conventional laparoscopic donor nephrectomy ( LDN: n = 14)., Patients were blinded to the surgical approach preoperatively and attempts to continue patient blinding postoperatively were made by applying dressings consistent with multiple conventional laparoscopic incisions for all patients., De-identified data related to the operation, peri-operative course and postoperative follow-up were prospectively collected and compared between the two groups with an intention-to-treat analysis., Results There were no significant differences between the groups when comparing operating time, estimated blood loss ( EBL), i.v. fluid administration, renal allograft warm ischaemia time ( WIT), length of hospital stay ( LOS) and total inpatient analgesic requirements., Quantitative pain assessment was not significantly different on postoperative day ( POD) #0, however, it was significantly lower in the LESS-DN group, beginning on POD #1 ( P < 0.05)., The changes in haematocrit and serum creatinine in the two groups were not significantly different, and there were no blood transfusions in either group, nor was there a decline in estimated glomerular filtration rate to <60 mL/min per 1.73 m2 of body surface area in any patients., Two patients in the LESS-DN group were converted to conventional LDN, both because of failure to progress effectively., All allografts were functional at the time of transplantation and revascularization, with no cases of hyperacute rejection., Conclusions Peri-operative variables including EBL, WIT and LOS were equivalent when comparing Pfannenstiel LESS-DN with conventional LDN., Patient-reported visual analogue pain scale scores were significantly lower in the LESS-DN group beginning on the first postoperative day. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Off-clamp laparoscopic partial nephrectomy (LPN) is thought to preserve renal function by limiting warm ischaemia time (WIT) and consequently reperfusion injury. To date, studies using the off-clamp technique represent a heterogeneous group, with limited follow-up showing feasibility and safety in a restricted number of cases. We report the largest experience of off-clamp vs on-clamp LPN with perioperative outcomes and intermediate follow-up of renal functional outcomes with stratification by WIT. OBJECTIVE To evaluate perioperative and 6-month renal functional outcomes of patients undergoing off-clamp vs complete hilar control laparoscopic partial nephrectomy (LPN)., PATIENTS AND METHODS A retrospective review of 489 patients undergoing LPN was completed., Preoperative imaging assessed tumour characteristics., Patient demographics, perioperative parameters, and postoperative outcomes were documented., Multivariable regression analysis was used to assess factors contributing to changes in postoperative renal function between off-clamp and clamped LPN., RESULTS In all, 289 LPNs were performed on-clamp and 150 were performed off-clamp., Tumours in the on-clamp group were larger than those in the off-clamp group (mean [range] 3.3 [0.5-13.5] vs 2.7 [0.4-9] cm, P= 0.003)., Univariable analysis comparing off-clamp to on-clamp cohorts showed that estimated glomerular filtration rate (eGFR) was better preserved in the off-clamp cohort at 6 months (−5.8% vs -11.4%, P= 0.046). Multivariable analysis of the groups showed that estimate blood loss ( P= 0.015) and warm ischaemia time (WIT, P< 0.001) were the only significant predictors of decreased eGFR in the postoperative period., Difference in eGFR at 6 months was not significant when WIT was limited to 30 min. The complication rate was greater in the clamped cohort (10% vs 20%, P= 0.012)., There was no difference in transfusion rate or positive margin status., CONCLUSIONS LPN without hilar clamping is feasible, safe and associated with less renal injury as assessed by postoperative GFR in select patients., With experience, it can be applied to complex renal lesions. [ABSTRACT FROM AUTHOR]

Purpose: The objective of the study was to evaluate the initial experience with an elective in interventional uroradiology. Methods: Seven urology residents completed a minimum 2-month elective in interventional radiology (IR). A survey was administered before and immediately after the elective. The survey sought information on proficiency in uroradiology procedures and the role of IR in current training and future practice based on a 5-point ascending Likert response scale. Procedures performed during the elective were reviewed and recorded from the resident case logs. Results: Urology residents reported an increased proficiency in all interventional procedures after the IR rotation. Endovascular techniques, ablative therapies, and needle biopsy had significant increases in performance proficiency ( P=0.031). On completion, residents strongly agreed that interventional uroradiology should be a part of residency training, and image-guided therapies will play a significant role in the future of urology. Residents performed on average 14.9 arterial interventions, 28.5 venous interventions, 15.8 genitourinary interventions, and 3.1 tumor ablations per month. In addition, urology residents performed image-guided biopsies, drainages, as well as gastrointestinal and biliary interventions gaining experience with performing and interpreting ultrasonography, fluoroscopy, and CT. Conclusion: Interventional uroradiology provides urology residents invaluable experience with image-guided procedures, increasing comfort with performance and interpretation. Residents believed that interventional uroradiology should be incorporated into the residency curriculum. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Pathological stage, lymph node metastasis and tumour grade have been established as prognostic factors for upper-tract urothelial carcinoma, but there are few studies to date assessing location within the ureter as a prognostic factor. There are also few studies comparing surgical approaches to radical nephroureterectomy (NU), partial ureterectomy and endoscopic resection (ENDO) with regard to oncological outcomes. This study did not find any prognostic significance for tumour location or surgical approach with regard to outcomes in patients with ureteric tumours. Although NU is the standard treatment for invasive ureteric tumours, partial ureterectomy and ENDO can safely be performed in selected patients. Despite the risk of a shorter time to recurrence, ENDO can be recommended in low grade, non-invasive ureteric tumours but only with close, thorough surveillance practices. OBJECTIVE To assess the impact of tumour location within the ureter and the impact of surgical approach on recurrence-free survival (RFS) and cancer-specific survival (CSS) with regard to ureteric tumours., PATIENTS AND METHODS Data were retrospectively reviewed from 60 patients with isolated primary ureteric tumours, treated at a single tertiary referral centre., Patients were treated with radical nephroureterectomy (NU, n= 33), partial ureterectomy ( n= 17) or endoscopic resection (ENDO, n= 10)., Kaplan-Meier curves were used for the analysis of RFS and CSS after surgery, stratified by tumour location and surgical approach., RESULTS With a median follow-up of 29 months, tumour location was not associated with disease recurrence ( P= 0.423)., The ENDO group had shorter time to disease recurrence., There were no significant differences in the probability of CSS with regard to either tumour location or surgical approach ( P= 0.523 and P= 0.904, respectively)., CONCLUSIONS Tumour location or surgical approach were not significant predictors of oncological outcomes in patients with ureteric tumours., Although NU is standard treatment for invasive ureteric tumours, partial ureterectomy and ENDO can safely be performed in selected patients. Despite the risk of a shorter time to recurrence, ENDO can be recommended in low grade, non-invasive ureteric tumours., All urothelium-preserving approaches require thorough surveillance. [ABSTRACT FROM AUTHOR]

Background and Purpose: Surgical management of a renal neoplasm in a solitary kidney is a balance between oncologic control and preservation of renal function. We analyzed patients with a renal mass in a solitary kidney undergoing nephron-sparing procedures to determine perioperative, oncologic, and renal functional outcomes. Patients and Methods: A multicenter study was performed from 12 institutions. All patients with a functional or anatomic solitary kidney who underwent nephron-sparing surgery for one or more renal masses were included. Tumor size, complications, and recurrence rates were recorded. Renal function was assessed with serum creatinine level and estimated glomerular filtration rate. Results: Ninety-eight patients underwent 105 ablations, and 100 patients underwent partial nephrectomy (PN). Preoperative estimated glomerular filtration rate (eGFR) was similar between the groups. Tumors managed with PN were significantly larger than those managed with ablation ( P<0.001). Ablations were associated with a lower overall complication rate (9.5% vs 24%, P=0.01) and higher local recurrence rate (6.7% vs 3%, P=0.04). Eighty-four patients had a preoperative eGFR ≥60 mL/min/1.73 m2. Among these patients, 19 (23%) fell below this threshold after 3 months and 15 (18%) at 12 months. Postoperatively, there was no significant difference in eGFR between the groups. Conclusions: Extirpation and ablation are both reasonable options for treatment. Ablation is more minimally invasive, albeit with higher recurrence rates compared with PN. Postoperative renal function is similar in both groups and is not affected by surgical approach. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? With the advancement of minimally invasive surgery, the management of small renal masses (SRM) has dramatically changed. Ablative technology such as radiofrequency ablation (RFA) and cryoablation have emerged as viable alternative modalities to extirpative surgery. RFA is one of the most studied and applied energy-based, needle-ablative treatment modalities, with encouraging mid- and long-term oncological outcomes. Monopolar devices have several shortcomings. The electrodes are susceptible to the cooling effect of nearby blood vessels that act as a 'heat sink', limiting the extent of tissue ablation and forming lesions with asymmetric borders and 'skip lesions'. Therefore, it is difficult to monitor and accurately predict the size of ablated lesions. A novel bipolar radiofrequency ablation (BRFA) device has been recently developed to address concerns with monopolar systems (Trod Medical, Paris, France). The BRFA system addresses the limitations of monopolar RFA, in terms of lesion size, targeting, consistency and concerns about cell death in the ablated area. We evaluated the BRFA device in 10 patients undergoing laparoscopic partial or radical nephrectomy. The present study demonstrates the safety and efficacy of a novel BRFA device. A BRFA device can produce a defined reproducible lesion with a precise transition zone to normal tissue. The area of ablated tissue exhibited completely devitalized cells and precise transition zone. With these characteristics, the potential advantages of this new technology during RFA ablation of SRM include less collateral damage and more complete ablation without skip lesions. This has the potential to lower rates of local recurrence and reduce incidence of skin burns. Further follow-up studies are necessary to determine its oncological efficacy. OBJECTIVE To evaluate a novel bipolar radiofrequency ablation (BRFA) system for the destruction of kidney tumours in patients., MATERIALS AND METHODS Bipolar radiofrequency ablation (BRFA) was used to ablate renal masses in 10 patients undergoing laparoscopic radical or partial nephrectomy., The probe was placed percutaneously and laparoscopically guided into the tumour after routine laparoscopic exposure. The electrical current was continuously adjusted by the generator to overcome disruption from increasing impedance created from desiccated tissue., The specimens were then excised in routine fashion and analysed by a single pathologist., Lesion size and shape, and size of the transition zone to viable tissue were measured via nicotinamide adenine dinucleotide (NADH) staining., RESULTS Ablation was successful in all 10 tumours. Mean time to set up and place the probe was between 2 and 4 min. Duration of ablation was 200 s., None of the ablated tissue showed signs of viable cells by histological examination and NADH staining., The mean size of the ablation zone was 6.26 cm3, with regular borders and a tapered cylindrical shape similar to the shape of the outer coil., The width of the transition zone, or area spanning complete tissue ablation to the first viable cells, ranged from 10 to 60 µm., There were no complications noted due to the ablation., CONCLUSIONS A BRFA device can produce a defined reproducible lesion with a precise transition zone to normal tissue., The area of ablated tissue exhibited completely devitalized cells and precise transition zone. [ABSTRACT FROM AUTHOR]

Hypothesis: Regions of functional brain activation differ between novice and expert laparoscopists. Design: We compared novice and expert laparoscopists using positron emission tomography (PET) during the peg transfer task of the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) protocol. The first scan (rest) was performed with the subject's eyes closed. The second scan (video 1) was performed while watching a peg transfer video. The third scan (peg 1) was acquired during the peg transfer task. The forth scan (peg 2) was performed after practicing 15 minutes. The fifth scan (video 2) was performed after peg 2 as the subject watched a video clip of a laparoscopic partial nephrectomy. The sixth scan (peg 3) was conducted during the final peg transfer task after 15 more minutes of practice. Setting: Feinstein Institute for Medical Research. Participants: Five novice and 5 expert laparoscopists. Main Outcome Measures: Differences in brain activation as determined by changes in regional cerebral blood flow on PET scans with oxygen 15-labeled water. Results: The first analysis examined group differences between the 3 peg scans and the rest scan. The novice group had a significantly (P<.001) higher activation (with deactivation in the expert group) in the left precentral gyrus and insula and the right precuneus and inferior occipital gyrus. The second analysis compared the 2 video scans and the rest scan. In contrast to the expert group, the novices had significantly (P<.001) higher activation in the right precuneus and cuneus but deactivation in the bilateral posterior cerebellum. Conclusions: This study demonstrates differential regional brain activation patterns between novice and expert laparoscopists during surgery-related motor and visual association tasks. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Minimizing renal ischemia and reperfusion injury is an area of active investigation and is particularly significant in cases of laparoscopic renal surgery where the kidney experiences warm ischemia. Reports of partial clamping, early unclamping, and off-clamp laparoscopic partial nephrectomy have demonstrated potential technical modifications that can offer a protective role in preserving renal function. We investigated off-clamp laparoscopic partial nephrectomy for tumours with varying clinical stage to determine feasibility, perioperative outcomes, and renal functional changes when compared to a contemporary cohort of standard laparoscopic partial nephrectomy with complete hilar clamping performed by a single surgeon. OBJECTIVE To compare the operative outcomes and oncological efficacy of off-clamp (OC) laparoscopic partial nephrectomy (LPN) vs complete hilar control (HC) LPN for stage T1a-T2 renal cell carcinoma. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the feasibility of a novel transvesical port (TVEP) for natural orifice translumenal endoscopic surgery (NOTES) in the porcine model. Materials and Methods: The TVEP consisted of an internal guide core and external sheath design using computer-aided design software. Transvesical peritoneoscopy, renal biopsy, as well as combined transvesical/transgastric nephrectomy were performed through the TVEP in a porcine model. Operative parameters and port performance were measured. Results: Twelve procedures were successfully performed by four surgeons. No complications occurred with introduction of the TVEP. The mean time for placement was 5.6 minutes. Steady pressure controlled CO2 pneumoperitoneum up to 15 mm Hg with a flow of 2 L/min was achievable. The average scoring by physician of the TVEP was 4.75 for ease of placement, 5 for ability to maintain pneumoperitoneum, 4.25 for convenience of inserting instruments, and 4.5 for overall satisfaction. The average score regarding instruments exchangeability, however, was relatively low: 3.25. Conclusions: Real surgery using a novel TVEP is feasible in performing transvesical NOTES. [ABSTRACT FROM AUTHOR]

Background and Purpose: The R.E.N.A.L nephrometry score (NS) was developed to characterize renal tumor anatomy to facilitate standardized reporting and ultimately clinical decision making. Up to three points are assigned for each of the following criteria: Tumor size (R), exophytic vs endophytic nature (E), nearness to the collecting system (N), anterior vs posterior (A), and polar location (L), with more complex lesions receiving higher scores. There are no independent studies to date that validate the reproducibility of this scoring system. Our aim was to validate the R.E.N.A.L. NS system by assessing interobserver variability, and therefore reproducibility and fidelity of this proposed assessment tool. Patients and Methods: We reviewed our prospectively collected laparoscopic partial nephrectomy (LPN) database and identified 306 patients with available preoperative CT or MRI. Of these, 149 were independently read by two urology residents who assigned NS. The Pearson test was used to assess interobserver variability of total NS as well as each of the five components of the scoring system. Results: Interobserver correlation of total NS calculated by the Pearson test was found to be 0.92 ( P<0.001). Concordance rates for each of the individual nephrometry components R.E.N.A.L (hilar) were 96%, 92%, 86%, 96%, 89%, and 99% respectively. A t test showed no significant difference between final NS assigned by two different observers. Conclusion: The R.E.N.A.L. NS system is a comprehensive and reproducible tool that may aid surgeons in communicating tumor characteristics effectively. Interobserver correlation is high, rendering it a high fidelity assessment tool. [ABSTRACT FROM AUTHOR]

Background and Purpose: The centrality-index (C-Index), preoperative aspects and dimensions used for anatomic (P.A.D.U.A.) classification, and radius.exophyic/endophytic.nearness.anterior/posterior.location (R.E.N.A.L.) nephrometry schemes were developed as standardized scoring systems (SS) to quantify anatomic characteristics of kidney tumors. The objective of this study was to establish reliability and assess relationships between these three SS and perioperative and postoperative variables. Patients and Methods: A retrospective chart review was performed in 101 patients who underwent laparoscopic partial nephrectomy. The nephrometry schemes were correlated with intraoperative and postoperative parameters using Spearman correlations. In addition, interobserver reliability was assessed on 50 of the patients by interclass correlations comparing the scores assigned by two residents and one fellow who reviewed preoperative CT studies of these patients. Results: The interobserver correlation was 0.84 for the C-Index, 0.81 for the P.A.D.U.A., and 0.92 for the R.E.N.A.L. scoring systems, demonstrating excellent interobserver reliability. All three SS were significantly associated with warm ischemia time (WIT) (C-Index, P=−0.44; P.A.D.U.A., P=0.25; R.E.N.A.L., P=0.32) and percent change in creatinine level (C-Index, P=− 0.33; P.A.D.U.A., P=0.37; R.E.N.A.L., P=0.37). There were no significant associations between any of the three SS assessed and the occurrence of complications, operative time, or estimated blood loss. No significant correlation was found between the P.A.D.U.A. and R.E.N.A.L. SS and length of stay; however, C-Index did show a significant relationship for patients with lower scores having longer hospital stays ( P=−0.21). Conclusions: All three scoring systems demonstrated reliability among observers and represent novel methods of quantitatively describing renal tumors. They were all associated with WIT, percent change in creatinine level, and tumor size. They did not, however, correlate with any other perioperative parameters investigated. At this time, these SS provide a common language for describing renal tumors. [ABSTRACT FROM AUTHOR]

OBJECTIVE: • To present complications and rates of conversion from LESS to conventional laparoscopy (CL) at the time of upper tract LESS urologic procedures. PATIENTS AND METHODS: • Patients undergoing LESS upper tract procedures between September, 2007 and November, 2008 ( n = 125) were identified at six high-volume academic centers pioneering urologic LESS procedures. All LESS procedures were performed transperitoneally via a single umbilical incision using either adjacent conventional trocars or a dedicated single-site accessdevice. Reconstructive procedures incorporating a single planned 2 mm accessory needle port were included as LESS procedures and were not consideredconversions. • Patients, undergoing LESS procedures requiring conversion to CL with the placement of additional ports were identified. Conversion was defined as the placement of additional 5 or 10/12 mm ports beyond the primary incision. In each case the operative reports were reviewed, the reason for conversion was determined, and the number and types of additional ports and complications were noted. RESULTS: • Upper tract LESS procedures were performed in 125 patients comprising 13.3% of the total 937 laparoscopic procedures performed at the participating institutions during this time period. Conversion to CL was necessary in 7 patients (5.6%) undergoing LESS requiring the addition of 2– 5 ports. • Reasons for conversion included:facilitate dissection in 3 (43%), facilitate reconstruction in 3 (43%), and control of bleeding in 1 (14%). All attempted LESS cases were completed laparoscopically without need for open conversion. • Complications occurred in 15.2% of patients undergoing LESS surgery. Three of the 7 patients that required conversion to CL developed postoperative complications (Clavien grade II in two and IIIa in one). • Limitations of this study included the inability to standardize LESS patient selection criteria, instrumentation andsurgical technique as well as the lack of available complete data from a CL control group for comparison. CONCLUSION: • LESS surgery is technically feasible for a variety of upper urinary tract reconstructive and ablative procedures, although it appears to be associated with higher rates of complications than in mature CL series. Conversion to CL occurs infrequently and may be a reflection of stringent patient selection. [ABSTRACT FROM AUTHOR]

• Laparoscopic retroperitoneal lymph node dissection (L-RPLND) was first introduced in 1992, initially as a staging procedure. • With advances in instrumentation and laparoscopic techniques, as well as improved understanding of laparoscopic anatomy, L-RPLND has developed to duplicate open RPLND. • Unlike the relatively rapid adoption of laparoscopy for other applications including nephrectomy and prostatectomy, L-RPLND has been slow to be universally accepted. • The limited numbers of patients requiring RPLND and technical challenges in performing the dissection have undoubtedly contributed to its delayed reception. • This review will present available data on this technique and discuss issues potentially inhibiting acceptance by traditional surgeons. [ABSTRACT FROM AUTHOR]

The article provides information on the replication of surgical innovation process as portrayed in Tom Wolfe's novel, "The Electric Kool-Aid Acid Test". It discusses the surgical invention in the past including that from Max Nitze, Thomas Edison and George Kelling. The surgical procedures continue to develop as older modalities are applied in unconventional ways such as the approaches of natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS).