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Background and Purpose: Current surgical decision-making is overly subjective and often misjudges a patient's physiologic state. The concept of frailty has gained recent recognition and potentially represents a measureable phenotype, which can quantify a patient's physiologic reserve and risk of an adverse surgical outcome. We sought to investigate the relationship between preoperative markers of frailty and postoperative complications in patients undergoing minimally invasive surgery (MIS)., Methods: Frailty, using the methodology described by Fried and coworkers, was prospectively measured in patients who presented to urology, general surgery, and surgical oncology clinics where major MIS (endoscopic, laparoscopic, or robotic) was planned. The relationship between preoperative markers of frailty and 30-day postoperative complications was our primary outcome measure., Results: Our cohort includes 80 patients. Mean age and body mass index were 60.0 (range 19-87) years and 29.2 (range 18.4-53.1) kg/m(2), respectively. The majority of patients were male (57.5%) and Caucasian (65.0%). Thirteen patients were deemed "intermediately frail" or "frail," and the remaining 67 were classified as "not frail." Thirteen (16.25%) patients experienced any postoperative complication. Five (38.5%) of the intermediately frail and frail patients experienced a complication, compared with eight (11.9%) of the not frail patients (odds ratio=5.914; 95% confidence interval=1.25-27.96; P=0.025)., Conclusion: The advent of MIS has potentially lured surgeons into thinking older and patients with comorbidities may more easily tolerate this surgical approach compared with traditional open techniques. Our data suggest, however, that intermediately frail or frail patients are at increased risk of experiencing postoperative complications compared with not frail patients.

Background: The incidence of urolithiasis is twofold to threefold higher in men than in women. Several animal studies have suggested an association between testosterone levels and the formation of kidney stones. Specifically, castration has been shown to decrease stone formation in rat models. The association between testosterone and stone formation in humans, however, has not been well investigated., Patients and Methods: Early morning total and free testosterone levels were recorded for 55 male patients. Participants completed a demographics questionnaire, and clinical records of enrolled subjects were reviewed. When available, stone composition was determined in the stone formers. Mann-Whitney tests and logistic regression models were used to examine the data., Results: Of the 55 patients, 25 had no history of urolithiasis and 30 had a history of urolithiasis. Although the differences between the two groups were not statistically significant, the stone formers compared with stone-free controls tended to be older (median age 48.4 vs 36.5 years, P = 0.072) and have higher serum levels of testosterone (median serum concentration 384 vs 346 ng/dL, P = 0.112). In the multivariate analyses, after adjusting for age and body mass index, the testosterone-related odds ratio was 1.004 with a corresponding P value 0.051., Conclusions: Male stone formers were found to have higher serum total testosterone levels compared with a similar cohort without stones. This result is consistent with several animal models that have demonstrated that testosterone is a risk factor for stone formation. Our findings warrant confirmation in a larger, prospective study. There are potential therapeutic implications if testosterone is found to be a risk factor in urolithogenesis.

Introduction: Laparoscopic radical nephrectomy has quickly evolved as an oncologic standard of care. The "Simple" nephrectomy implies an easier procedure than perhaps its radical counterpart and one that budding laparoscopists may approach with more confidence. Though, strict indications for simple nephrectomy are few, these cases tend to have infectious or inflammatory pathology sometimes making the procedure more difficult than its radical counterpart., Methods: A retrospective review of our experience with laparoscopic simple nephrectomy (LSN) over a 7-year period was performed. A total of 42 patients (12 males/ 30 females) with a mean age 47.5 years underwent LSN: 25 retroperitoneal (RP), 17 transperitoneal (TP). Indications for nephrectomy included poorly functioning kidneys associated with pain+/-hydronephrosis, recurrent infections, renal arterial stenosis induced malignant hypertension, XGP with stones., Results: Forty-two of 45 attempted simple nephrectomies were completed laparoscopically. Three patients had open conversions: two for non-progression and one endovascular stapler malfunction. Three patients were converted from RP to TP due to severe scarring (two having prior nephrostomy tubes). Median operative time was 202.5 minutes (98-399). Eight patients were discharged within 23 hours with no complications, all having RP approaches and morcellated specimens. Mean post-operative oral intake was 17.8 hours and bowel function return was 1.3 days. Median estimated blood loss 100 ml (30-4500). Creatinine levels did not alter significantly. Median specimen weight was 88.9 grams (28-672). Fourteen complications occurred in nine patients (21.4%): five minor (flank ecchymosis and mild ileus) and nine major (re-intubation, flank hernia, wound opening requiring readmission, retroperitoneal infections, trocar fistula formation, bleed requiring transfusion). Four patients were transfused: one for post-op bleed from the ureteral stump, two for chronic anemia with minimal intraoperative blood loss, and one for intraoperative blood loss., Conclusions: Laparoscopic simple nephrectomy has few indications and includes a complicated patient population. The results show its efficacy and overall safety despite a moderate complication rate. Utilizing a retroperitoneal approach with specimen morcellation can reduce hospital stay. One should approach a laparoscopic nephrectomy for non-malignancy with caution for infectious or inflammatory indications.

A 52-year-old man with a significant history of nephrolithiasis was found to have a calcium oxalate dihydrate ureteral calculus that apparently formed on a hair. This nidus may have been introduced during previous instrumentation, perhaps on the tip of the ureteroscope, laser fiber, or even during the placement of a ureteral stent.

Background and Purpose: Hypothermia during vascular clamping protects the kidney from ischemia-induced nephron loss. Traditionally, cooling is achieved by packing the kidney in ice, which lowers the temperature of the rest of the surgical field as well, and the method cannot be used during laparoscopy. We evaluated the utility of a newly developed ureteral access system for circulating ice-cold saline., Materials and Methods: Domestic pigs underwent retrograde endoscopic cooling through an access sheath without (N = 2) or with (N = 3) renal artery occlusion, traditional ice-slush cooling with renal artery occlusion (N = 3), or occlusion without hypothermia (N = 3). Five days later, the pigs were sacrificed and the kidneys and ureters examined histologically., Results: Endoscopic cooling with renal artery occlusion and ice-slush cooling both produced renal hypothermia. The former produced medullary and cortical temperatures of 21.3 degrees C and 27.3 degrees C, respectively, and the latter medullary and cortical temperatures of 28.8 degrees C and 23.7 degrees C, respectively. Histologically, there were minimal changes in the first three groups, whereas venous congestion, multifocal chronic inflammation, and periarteriolar hemorrhage were seen after renal artery occlusion without hypothermia., Conclusion: Retrograde endoscopic renal hypothermia is effective and requires no novel equipment or special surgical skills. Clinical application has not yet been attempted.

Background and Purpose: One of the most challenging aspects of laparoscopic surgery is intracorporeal suturing and knot tying. A loss of depth perception and tactile sense and visual obstruction make placing accurate and well-tied knots a difficult and time-consuming task. Two devices conceived to ease the task of suturing and knotting while presumably speeding performance are the Suture Assist (SA; Ethicon Endo-Surgery) and EndoStitch (ES; US Surgical/Tyco). We set out to objectively assess suture placement accuracy and knot speed and strength of these two suturing devices and conventional laparoscopic suturing (CS)., Materials and Methods: To date, six surgeons with laparoscopic experience were trained on the three suturing techniques. A pelvic trainer was set up with a freshly marked and incised swine renal pelvis and ureter. Each surgeon placed four sutures of 2-0 polyester suture with each technique (repeated on three separate occasions) with five half-hitches for a total of 216 knots. Time, strength, and accuracy were measured for each suture/knot placement. The knot distance was then measured from the marked target using calipers and carefully dissected from the tissue. Each knot was individually tested on a Monsanto Model 10 tensiometer, whereby slippage, strength, and breakage points were determined., Results: The mean times (min:sec) and accuracy (millimeters) were as following: CS 5:08 and 0.457, ES 2:45 and 0.660, and SA 2:40 and 0.508. The difference in time was found to be statistically significant (P < 0.001), while the difference in accuracy was not. Only 182 of 216 knots were able to be included for analysis because of either a small knot lumen or device failure. Device failures necessitating intervention were encountered only with the SA, which had a misfire rate of 9.7% (7 of 72). The mean knot strength was measured at 41.1 N for CS, 57.3 N for SA, and 28.0 for ES. Knot break percentage (breakage) was calculated as 50.8% for CS, 20.7% for ES, and 95% for SA., Conclusion: Preliminary results show that each of the laparoscopic suturing devices has distinct advantages over conventional intracorporeal suturing and tying. Decreased times and comparable, if not greater, knot strengths may translate into improved laparoscopic suturing/tying performance for laparoscopic intracorporeal suturing devices.

Open pyeloplasty has long been considered the gold standard for the relief of ureteropelvic junction (UPJ) obstruction, but the incisional morbidity led urologists to explore less invasive alternatives such as endopyelotomy and the Acucise cutting balloon. Laparoscopic pyeloplasty was introduced in 1993 and has since been performed in patients as young as 2.5 years. The operation should be considered in patients with UPJ obstruction caused by a crossing vessel, high ureteral insertion, failed prior procedures, high-grade hydronephrosis, or marginal differential renal function. Hynes-Anderson, Foley Y-V, and Fenger procedures can all be performed laparoscopically, generally with excellent results. The procedure requires advanced laparoscopic skills and so is available in only a few medical centers at present.

Citrate therapy for recurrent calcium urolithiasis has become common over the last decade. The hypotheses that chronic stone formers must have biochemical defects that increase recurrence risks have instigated medical therapy directed at these defects. The utilization of stone clinics, detailed metabolic evaluations, and meticulous follow-up of recurrent stone formers has led to a greater understanding and knowledge of treatment options. Citrate therapy has been used like aspirin in the medical community perhaps without a clear understanding of its mechanism of action and indications. This article provides a synopsis of citrate use in the medical and surgical treatment of urolithiasis.