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INTRODUCTION AND OBJECTIVE:There are no well validated studies to define safe and ergonomically efficient pneumoperitoneal pressures (PP) for transperitoneal laparoscopic renal surgeries (LRS). Tho...

INTRODUCTION AND OBJECTIVE:A robotic approach to renal surgery has been shown to be safe and effective and is typically performed in a transperitoneal fashion. Retroperitoneal surgery avoids entry ...

INTRODUCTION AND OBJECTIVE:Retrograde intra renal surgery (RIRS) for renal stone and ureteroscopic laser lithotripsy(URS) for proximal ureteric stone are considered to be the most challenging stone...

INTRODUCTION AND OBJECTIVE:Minority serving hospitals (MSH) serve the highest percentage of black and Hispanic patients. Independent of patient and provider factors, treatment at MSH may result in ...

INTRODUCTION AND OBJECTIVE:Preoperative estimation of new baseline glomerular filtration rate (GFR) after renal surgery for RCC has important clinical implications. Here we develop and externally v...

INTRODUCTION AND OBJECTIVE:Percutaneous nephrolithotomy (PCNL) is the gold standard treatment option for management of large renal stones (>2 cm); however, tract dilatation method and larger sheath...

To determine the predictors of short and long-term renal function impairment after partial nephrectomy. MATERIALS AND METHODS: The clinical data of 769 consecutive patients submitted to partial nephrectomy were prospectively recorded in 19 urological Italian centers from 2009 to 2012 (RECORd1 Project). Of these, the clinical data of 708 patients alive, free from disease recurrence, and with a minimum 2-year functional follow-up were extracted. RESULTS: Patients underwent open (47.3%), laparoscopic (36,6%) or robot-assisted (16.1%) partial nephrectomy. Median baseline eGFR was 84.5 (interquartile range [IQR]: 69.9-99.1) ml/min/1.73m2. Immediate (3rd postoperative day), early (1th month) and late (24th month) renal function impairment >25% from baseline was identified in 25.3%, 21.6% and 14.8% of cases, respectively. Female gender and baseline eGFR were independent predictors of immediate, early and late RF impairment; age at diagnosis of immediate and late impairment; uncontrolled diabetes only to late impairment. Open and laparoscopic approaches and pedicle clamping were independent predictors of immediate and early renal function impairment. Overall 58/529 (11%) patients experienced postoperative cardiovascular events. Body mass index and late renal function impairment were independent predictors of postoperative cardiovascular events. CONCLUSIONS: Surgical modifiable factors were significantly associated with a worse immediate and early functional outcome after partial nephrectomy, while the clinical unmodifiable factors affected the renal function during the entire follow-up. Late renal function impairment is an independent predictor of development of postoperative cardiovascular events.

INTRODUCTION AND OBJECTIVES:Previous work has identified disconnect between opioid prescribing and utilization. This is particularly relevant for minimally-invasive surgery. However, factors that c...

Purpose of review Partial nephrectomy for larger kidney tumors (T1b) has gained widespread acceptance in most academic institutions, with similar oncologic outcomes to radical nephrectomy. This review focuses on the factors that affect renal function after partial nephrectomy, and presents current information about the relative importance of each factor as well as chronic kidney disease (CKD) after renal surgery. Recent findings CKD occurs over the long term in a significant percentage of patients following partial nephrectomy. The interaction of different factors including baseline kidney function (influenced by age and medical comorbidity), amount of preserved renal parenchyma (influenced by surgical technique), and ischemia time (warm or cold) determines the ultimate functional outcome. De-novo CKD resulting from surgery in previously healthy individuals may not place these patients at increased risk of progression or mortality. Summary Urologists continue to strive towards improved kidney function after partial nephrectomy, particularly for larger tumors. Careful identification of factors involved in functional outcome, and optimization of modifiable factors, will remain at the forefront of efforts to minimize renal functional loss after partial nephrectomy.

Jens Rassweiler*, Heilbronn, Germany; Kemal Sarica, Istanbul, Turkey; Petrisor Geavlete, Bucharest, Romania; Nida Zafer Tokatli, Ankara, Turkey; Jan Klein, Ulm, Germany; Olivier Traxer, Paris, France; AbdulQadir Al Zarooni, Yasser Farahat, Umm Al Quwain, United Arab Emirates; David M. Hoenig, Long Island, NY; Guido Giusti, Milan, Italy; Volkan Tugcu, Istanbul, Turkey; M. Abdurrahim Imamoglu, Ankara, Turkey; Ahmet Yaser Muslumanoglu, Istanbul, Turkey; Murat Savas, Antalya, Turkey; Remzi Saglam, Ankara, Turkey; Anup Patel, London, United Kingdom

Risk factors for conversion to hand assisted laparoscopic or open surgery during laparoscopic renal surgery are incompletely defined.We reviewed our institutional database of 759 standard laparoscopic and 833 hand assisted laparoscopic radical, simple, donor and partial nephrectomies, pyeloplasties and nephroureterectomies from June 1996 to February 2009, representing a total of 1,592 cases. We identified the incidence of and indications for conversion to hand assisted laparoscopic and open surgery, and determined risk factors for conversion.Of all 1,592 procedures 20 (1.3%) required conversion to open surgery. Of 759 standard laparoscopic procedures 21 (2.8%) were converted to hand assisted laparoscopic surgery and 1.7% were converted to open surgery for an overall standard laparoscopy conversion rate of 4.6%. Only 0.7% of hand assisted laparoscopic procedures were converted to open surgery. The rate of conversion to open surgery ranged from 0.3% for laparoscopic partial to 2.5% for laparoscopic simple nephrectomy. The rate of conversion to hand assisted laparoscopic surgery ranged from 0% for laparoscopic pyeloplasty to 6.5% for laparoscopic partial nephrectomy. Conversion to open surgery was most likely due to hemorrhage (50% of cases) or failure to progress (40%) while conversion to hand assisted laparoscopic surgery was most likely due to failure to progress (76%) and tumor anatomy (19%). Multivariate analysis revealed that the only significant risk factor for conversion to open surgery was greater American Society of Anesthesiologists score. Conversion to hand assisted laparoscopic surgery was associated with greater body mass index, American Society of Anesthesiologists score and partial nephrectomy.Conversion during laparoscopic renal surgery to open or hand assisted laparoscopic surgery is a rare but important event in laparoscopic surgery. The risk is influenced by the nature of the procedure and overall patient health.

As the worldwide population ages, an increasing number of elderly patients with renal malignancy are considered for laparoscopic radical renal surgery. We present a systematic review of physiological

Objective: Partial nephrectomy is a safe procedure in renal tumors less than 4 cm. The laparoscopic technique is one of the most complex surgeries in urology. We present our experie

Laparoscopic renal surgery in pediatric urology is moving forward at a slower pace than desired. To guide beginning surgeons in what to expect in their first years of surgical experience, we present our first 6 years of pediatric laparoscopic ablative renal surgery experience to highlight the changing laparoscopic surgical parameters during this interval.We retrospectively analyzed all children who underwent laparoscopic ablative renal surgery (nephrectomy and heminephroureterectomy) performed by 1 surgeon between January 2000 and December 2005. After searching the medical, operative and anesthesia records we compared patient characteristics and operative parameters such as blood loss and operative time through the years.A total of 39 children (25 girls, 14 boys) with a mean age of 6.9 years underwent laparoscopic renal surgery. Mean operative time was 204 minutes for nephrectomy (26 cases) and 291 minutes for heminephroureterectomy (14). A statistically significant decrease in operative time was noted in the fourth year for nephrectomy cases (20 cases, p = 0.003). Blood loss decrease was significant at the fourth year after 10 cases of heminephroureterectomy (p = 0.036). Thus, operative time was the only changing parameter with experience in nephrectomy, while blood loss changed in heminephroureterectomy.This report details the operative parameters changing during the first 6 years as our experience increased in an academic setting. This outcome serves as a realistic guide regarding expectations for beginning laparoscopists, and should encourage the continuation of pediatric laparoscopic renal surgery.

Robotic-assisted laparoscopic surgery has had considerable impact on the management of localized prostate cancer. The role of robot assistance in laparoscopic renal surgery is less well defined, however.There have been few recently published papers regarding the robotic approach to management of renal cancer.Few clear benefits have been demonstrated for robotic-assisted over the conventional laparoscopic approach for the management of renal cancer.

INTRODUCTION AND OBJECTIVES: To incorporate a computer-assisted volumetric assessement of potential spared paranchyma from preoperative CT scans to predict chronic kidney disease (CKD) at 6 months from extirpative renal surgery. METHODS: We performed a retrospecitve analysis of radical (RN) or partial nephrectomy (PN) patients with compatable CT scans from our institution. We used Vitrea v.6.3 computer software program (Vital Images, Minnetonka, MN) to create a 3D volume of the tumor, 1 cm margin, ipsilateral kidney (Figure), and contralateral kidney (cm3). Primary outcome analyzed was development of postoperative CKD (estimated glomerular filtration rate

Purpose: We challenge the requirement for routine placement of a nephrostomy tube following percutaneous renal surgery.Materials and Methods: A total of 50 patients underwent tubeless percutaneous renal procedures consisting of nephrolithotripsy, endopyelotomy, and stone extraction plus endopyelotomy performed during the same setting. In the initial 30 patients a Double-J* *Medical Engineering Corp., New York, New York.stent and a Councill nephrostomy tube were placed at the end of the procedure. The Councill catheter was removed 2 to 3 hours postoperatively. The subsequent 20 patients received only a Double-J stent with no Councill catheter. This study group was compared to a control group of 50 age, sex and procedure matched patients who had previously undergone standard percutaneous renal procedures with routine placement of postoperative nephrostomy tubes. The incidence of complications, analgesia requirements, length of hospitalization, interval to return to normal activities and cost of trea...

INTRODUCTION AND OBJECTIVES: With increasing incidental renal tumor detection, rates of renal surgery in the elderly and infirmed are rising. Our aim was to examine the association between high risk patient status (age 75 years and/or Charlson comorbidity [CCI] count 2) and post-operative complications in patients undergoing surgical management for clinically localized renal tumors. METHODS: We queried our prospectively maintained institutional database to identify all patients undergoing radical nephrectomy (RN) or partial nephrectomy (PN) for clinical stage I-II renal tumors from 2005-2012. Post-operative complications within 90 days were categorized by the Clavien-Dindo classification system. Univariate and multivariate logistic regression models were used to test the association between high risk status and post-operative complications adjusting for patient (risk group, gender, race), tumor (Nephrometry Score [NS], hilar designation, solitary kidney), and operative (year of surgery, nephron sparing and minimally invasive approaches, blood loss, operative time) characteristics. RESULTS: 1,092 patients (mean age 59.2 11.9 years, 64.2% male, mean CCI count 1.3 1.6) undergoing PN (71.9%) or RN (28.1%) for clinically localized renal tumors (mean tumor size 4.2 2.9cm, mean NS 7.8 2.0) met inclusion criteria. 255 (23.4%) patients were classified as high risk; of these, 175 (16%) incurred one or more complications (mean 1.6 1.0). High risk patients were more likely to experience a complication compared to those classified as low risk (22.4 versus 14.1%; p 0.002). Comparing high and low risk patients, significant differences in Clavien I-II (20.4 vs. 11.1%; p 0.001) and medical (16.1 vs. 8.1%, p 0.001) complications were observed, while no differences were seen in Clavien III-IV or surgical complications. Further, no differences in complications were observed comparing patients treated with RN and PN, albeit high risk patients were more likely to undergo RN (35.3 vs. 25.9%, p 0.04). Following adjustment, the odds of incurring any complication were 1.9 times higher in high compared to low risk patients (OR 1.9 [CI 1.3-2.8]). CONCLUSIONS: In our cohort, patients deemed high risk by age and comorbidity criteria were more likely to incur a complication following renal surgery regardless of surgical type. Improved understanding of surgical risks in the elderly and infirmed will better inform patients deciding between active surveillance and resection of localized renal tumors.

Present techniques for retroperitoneal endoscopic (RPE) access in children mimic those in adults but often result in peritoneal entry or gas leaks, both of which lead to a decrease in the retroperitoneal space. We describe a modification to the access technique that obviates these problems, thus, facilitating RPE in children.In the lateral decubitus position the initial port is placed immediately lateral to the paraspinal muscles, similar to open dorsal lumbotomy fascial incision. A 5 mm skin incision is made at the level of the costovertebral angle and an artery forceps used to tunnel bluntly past the lumbodorsal fascia. A 5 mm port is placed with a blunt trocar, and expansion of the retroperitoneal space performed with the telescope and gas insufflation. Ancillary ports are placed and the telescope then moved to an anterior subcostal port where popular RPE approaches place the initial port.Eighteen procedures were performed in children with a mean age of 10.8 years, including 12 nephrectomies, 3 dismembered pyeloplasties, 1 partial nephrectomy, 1 nephroureterectomy and 1 parapelvic cyst decortication. No gas leaks occurred, with 1 minor peritoneal entry early in the series not related to the access. Average surgical time for nephrectomy was 178 minutes (range 120 to 240). No intraoperative complications occurred.We present a safe and effective technique of initial port placement that follows the principles of open lumbotomy exposure. This approach to RPE minimizes peritoneal entry and gas leaks, thus, maximizing surgical exposure.