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Objective: To evaluate the safety and feasibility of laparoscopic adrenalectomy (LA) performed in several German centres with different laparoscopic experience, as LA has become the gold-standard approach for benign surgical adrenal disorders; however, for solitary metastasis or primary adrenal cancer its precise role is uncertain., Patients and Methods: The data of 363 patients who underwent a LA were prospectively collected in 23 centres. All centres were stratified into three groups according to their experience: group A (<10 LAs/year), group B (10-20 LAs/year) and group C (>20 LAs/year). In all, 15 centres used a transperitoneal approach, four a retroperitoneal approach and four both approaches. Demographic data, perioperative and postoperative variables, including operating time, surgical approach, tumour size, estimated blood loss, complications, hospital stay and histological tumour staging, were collected and analysed., Results: The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). In all, 263 of 363 lesions (72.5%) were benign and 100 (27.5%) were malignant. The mean (sd) operating time was 127.22 (55.56) min and 130.16 (49.88) min after transperitoneal and retroperitoneal LA, respectively. The mean complication rates for transperitoneal and retroperitoneal LA were 5% and 10.9%, respectively., Conclusion: LAs performed by urologists experienced in laparoscopy is safe for the removal of benign and malignant adrenal masses. LA for malignant adrenal tumours should be performed only in high-volume centres by a surgeon performing at least >10 LAs/year., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Context: Laparoscopic living-donor nephrectomy (LLDN) has achieved a permanent place in renal transplantation and in some centers has replaced open donor nephrectomy as the standard technique., Objective: To evaluate the published literature regarding the relative results and complications of open LLDN and the hybrid technique of hand-assisted LLDN., Evidence Acquisition: A systematic review of the literature was performed, searching PubMed and Web of Science. A "free text" protocol using the term living-donor nephrectomy was applied. Six hundred twenty-nine records were retrieved from the PubMed database and 686 records were retrieved from the Web of Science database., Evidence Synthesis: Fifty-seven comparative studies were identified in the literature search. The three techniques of open, laparoscopic, and hand-assisted laparoscopic donor nephrectomy were compared in terms of reported outcomes. With regard to the perioperative outcome parameters, laparoscopy was better than open surgery in terms of blood loss, analgesic requirements, and duration of hospital stay and convalescence. Postoperative graft function was not significantly different between the different forms of donor nephrectomy, although longer warm ischemia times are reported for laparoscopy., Conclusions: All three techniques of live-donor nephrectomy are standard of care. The laparoscopic techniques result in less postoperative pain and estimated blood loss with shorter hospital stay, while postoperative graft function is not inferior to that after open live-donor nephrectomy., (Copyright 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To evaluate the perioperative effectiveness of laparoscopic partial nephrectomy (LPN) for large (4-7 cm) renal masses, with a review of the experience of six European advanced laparoscopic centres., Patients and Methods: A survey was planned; data were extracted from each institutional data base to obtain information about patients who had undergone LPN for renal masses larger than 4 cm. Demographic, radiological growth patterns of the tumours and intraoperative data were collected. Post-operative complications and pathological data were also recorded. All data were processed through statistical software., Results: Data on 63 patients were collected. Radiological tumour size was 4.7 cm (4.1-7), growth pattern was cortical in 33 cases and cortico-medullar in 30 cases. Warm ischemia time (WIT) was 25.7 min in 7.3% cases bleeding occurred intra-operatively, post-operative surgical complications occurred in 14.6% cases. Pathological analyses revealed malignant lesion in 73% and positive margins in 6.5%. Complications and positive margins are more frequent for cortico-medullar lesions., Conclusions: This survey confirms that LPN for tumours 4-7 cm in size is feasible in experienced hands. WIT and overall complication rate remain questionable points.

Background: Low morbidity has been advocated for cryoablation of small renal masses., Objectives: To assess negative perioperative outcomes of laparoscopic renal cryoablation (LRC) with ultrathin cryoprobes and patient, tumour, and operative risk factors for their development., Design, Setting, and Participants: Prospective collection of data on LRC in five centres., Intervention: LRC., Measurements: Preoperative morbidity was assessed clinically and the American Society of Anaesthesiologists (ASA) score was assigned prospectively. Charlson Comorbidity Index (CCI) and Charlson-Age Comorbidity Index (CACI) scores were retrospectively assigned. Negative outcomes were prospectively recorded and defined as any undesired event during the perioperative period, including complications, with the latter classed according to the Clavien system. Patient, tumour, and operative variables were tested in univariate analysis as risk factors for occurrence of negative outcomes. Significant variables (p<0.05) were entered in a step-forward multivariate logistic regression model to identify independent risk factors for one or more perioperative negative outcomes. The confidence interval was settled at 95%., Results and Limitations: There were 148 procedures in 144 patients. Median age and tumour size were 70.5 yr (range: 32-87) and 2.6 cm (range: 1.0-5.6), respectively. A laparoscopic approach was used in 145 cases (98%). Median ASA, CCI, and CACI scores were 2 (range: 1-3), 2 (range: 0-7), and 4 (range: 0-11), respectively. Comorbidities were present in 79% of patients. Thirty negative outcomes and 28 complications occurred in 25 (17%) and 23 (15.5%) cases, respectively. Only 20% of all complications were Clavien grade > or = 3. Multivariate analysis showed that tumour size in centimetres, the presence of cardiac conditions, and female gender were independent predictors of negative perioperative outcomes occurrence. Receiver operator characteristic curve confirmed the tumour size cut-off of 3.4 cm as an adequate predictor of negative outcomes., Conclusions: Perioperative negative outcomes and complications occur in 17% and 15.5%, respectively, of cases treated by LRC with multiple ultrathin needles. Most of the complications are Clavien grade 1 or 2. The presence of cardiac conditions, female gender, and tumour size are independent prognostic factors for the occurrence of a perioperative negative outcome.

Objectives: To evaluate quality of life (QoL) after laparoscopic radical prostatectomy (LRP) and investigate whether the learning curve of laparoscopic novices has a negative influence on patients' QoL., Methods: Evaluation of QoL with the EORTC QLQ C-30 and the PR25 preoperatively (t0) as well as postoperatively after 1-3 mo (t1), 4-6 mo (t2), 7-12 mo (t3), 13-24 mo (t4), and yearly thereafter (t5-t7). Surgeons were grouped according to their prior experience in laparoscopy into experienced and novices., Results: LRP was performed in 343 patients; 268 (78%) participated in the study. The mean patient age was 63.3+/-6.3 yr; mean PSA, 10.0+/-9.2 ng/ml; mean follow-up, 26 mo. Global health was impaired for t1 (p<0.001) and then returned to baseline. Emotional functioning improved (p<0.001) for t2-t7 versus baseline. Physical functioning remained impaired for t1-t2, and role and social functioning for t1-t6. Only sexual functioning did not return to baseline for t1-t7. Urinary symptoms were worse at t1 and then improved gradually (p<0.001). No significant difference in any QoL domain could be identified for experienced surgeons versus novices except for financial difficulties at t2-t3, which related to social differences. Thirty-one (9%) patients with adjuvant therapy had significantly worse global health, bowel symptoms, urinary symptoms, fatigue, and sexual functioning., Conclusions: The learning curve of laparoscopic novices does not have a negative impact on patients' QoL. For intermediate- to long-term follow-up, patients reach their baseline or score even better in all domains except for sexual functioning but are significantly impaired if adjuvant treatment is performed.

Objectives: To evaluate outcome after retroperitoneoscopic cryotherapy for small renal tumours., Methods: Fourteen patients underwent cryoablation performed with six ultrathin 1.5-mm cryoprobes. Retroperitoneoscopic access was used for any tumour location. A double freeze-thaw cycle was performed under simultaneous retroperitoneoscopic visual control and real-time ultrasound monitoring., Results: Mean tumour size was 2.8 cm (range: 2.0-4.0), mean patient age was 68 yr (range: 49-83), and six left and eight right kidneys were treated. The mean operative time was 167 min (range: 120-200); mean blood loss was 93 ml (range: 0-300). Cryosurgery was successfully performed in all 14 patients, with 13 patients undergoing assisted retroperitoneoscopy and one patient, after previous open nephropexy, undergoing an open approach. Intraoperative biopsy specimens revealed renal cell cancer (RCC) in 10 (71%) patients. The only intraoperative complication was bleeding after removal of the cryoprobes in four (29%) patients, necessitating one intracorporeal stitch in each. Two (14%) of the first four patients presented postoperatively with superficial skin frostbite, which healed with conservative treatment. During mean follow-up of 21 mo (range: 2-42), 2 (14%) patients died from unrelated disease, and 12 patients remained without evidence of local recurrence. One patient with previous contralateral nephrectomy for RCC developed retroperitoneal lymph node metastasis on that side without recurrence in the cryoablated kidney., Conclusions: Retroperitoneoscopic cryotherapy using multiple ultrathin cryoprobes is safe and effective with encouraging oncologic results on intermediate-term follow-up. Prospective clinical trials and long-term oncologic data are needed to define its definitive role in treatment of renal tumours.

Introduction: Recently, some controversy has arisen as to whether pelvic lymphadenectomy is still necessary for patients with prostate cancer who are undergoing radical prostatectomy. We prospectively evaluated the results and morbidity of laparoscopic extended pelvic lymph node dissection in patients with high-risk prostate cancer defined as a serum prostate-specific antigen (PSA) level greater than 10 ng/mL or preoperative biopsy Gleason score of 7 or more., Technical Considerations: In 123 consecutive patients with clinically organ-confined high-risk prostate cancer, laparoscopic extended pelvic lymphadenectomy was performed before laparoscopic radical prostatectomy. The boundaries of the pelvic lymph node dissection were the bifurcation of the common iliac artery superiorly, the node of Cloquet inferiorly, the external iliac vein laterally, and the bladder wall medially. Preparation was done with bipolar forceps and scissors, with meticulous coagulation of all lymphatic tissue. The mean PSA level was 14.8 ng/mL (range 1.5 to 43.4). The mean number of lymph nodes removed was 21 (range 9 to 55). A total of 21 patients (17%) had lymph node metastases. The overall complication rate was 4%., Conclusions: Laparoscopic extended pelvic lymph node dissection is safe and effective. The results and morbidity are equivalent to those of open surgery, with the advantage of a minimally invasive operative technique.

Background: The aim of this study was to evaluate the early postoperative pain and pain management after standard open (ODN), hand-assisted laparoscopic (HLDN) and retroperitoneoscopic (RDN) donor nephrectomy., Methods: The visual analogue scale (VAS) was determined twice a day in 203 donors during the first five days after nephrectomy., Results: Mean VAS was significantly lower after RDN and HLDN than after ODN on day 2 (p=0.004) and days 3-5 (p<0.001). After RDN, "no pain" (VAS=0) was reported significantly earlier than after ODN. Irrespective of the technique used and the pain management, all donors reported significantly higher VAS in the morning. Opiates were administered for a significantly shorter average time period after RDN than after ODN (p=0.005). Cumulative morphine equivalent doses were higher after ODN than after RDN (p=0.001). Mean VAS reported after HLDN and RDN was similar., Conclusions: In summary, RDN and HLDN were clearly associated with much less early pain than ODN, independently of the used pain management.

Four surgical techniques for living donor nephrectomy were analyzed retrospectively in terms of perioperative outcome and early complication rate. A total of 182 donor nephrectomies including 69 open (OLDN), 14 fully laparoscopic (LDN), 34 hand-assisted laparoscopic (HLDN) and 65 retroperitoneoscopic (RLDN) nephrectomies were analyzed. There was a significant difference in mean operating time (OPT) between the OLDN (160 min) and RLDN (150 min) as compared to the LDN (212 min) and HLDN group (192 min) (P < 0.001). Mean warm ischemia time (WIT) was significantly shorter with OLDN (114 s), RLDN (121 s) and HLDN (128 s) when compared to LDN (238 s) (P < 0.001). Major complication rate was comparable among the groups. Independent of the preferred technique, donor nephrectomy is associated with complication rates. RLDN is comparable to OLDN in terms of OPT, WIT. Learning endoscopic donor nephrectomy could be associated with a higher complication rate.

Objectives: We retrospectively performed a comparative analysis of retroperitoneoscopic and open donor nephrectomy in terms of donor complications, as well as recipient complications and functional graft outcome., Methods: A total of 134 donor nephrectomies including 69 open (ODN) and 65 retroperitoneoscopic (RDN) nephrectomies was analyzed retrospectively. Both groups were comparable in terms of age, body mass index (BMI), operating time (OPT), warm ischemia time (WIT) and blood loss., Results: There were no statistically significant differences with respect to recipient outcome, mean values for age, BMI, OPT and cold ischemia time (CIT). The overall donor complication rate did not differ. Early functional graft follow-up showed significant differences in 24 h-urine output between the two groups (p<0.001), but serum creatinine was comparable after 7, 30, 180 and 365 days. The early rejection rate in the recipients was similar in the two groups., Conclusion: Retroperitoneoscopic donor nephrectomy (RDN) provides comparable perioperative features, such as operating time, warm ischemia time (WIT) and overall complication rate to the open donor nephrectomy (ODN). Additionally, it has no negative impact on recipients' operating time, graft ischemia and early graft function.

Objectives: Laparoscopic cryoablation has recently been proposed as a minimally invasive nephron-sparing treatment for selected patients. We report on our experience with a retroperitoneoscopic technique using multiple ultrathin cryoprobes., Methods: Seven patients underwent retroperitoneoscopic renal cryoablation for solid renal masses. Mean tumor size on the CT scan was 2.6 (1.5-3.5) cm. A double freeze-thaw cycle of renal cryoablation was performed under real-time ultrasound monitoring using a total of six 1.5-mm cryoprobes simultaneously., Results: Cryoablation was technically successful in all patients without any need for conversion. Mean duration of surgery was 161 (130-195) minutes and mean blood loss was 107 (50-250) ml. Perioperative biopsy of the tumor confirmed renal cell carcinoma in four patients and angiomyolipoma in two patients; it was inconclusive in one case. Mean follow-up for 13.6 (4-22) months showed no evidence of residual tumor or recurrence., Conclusions: Retroperitoneoscopy-assisted cryosurgical ablation using multiple ultrathin 1.5-mm cryoprobes is a minimally invasive treatment that is suitable to treat small renal tumors.

Introduction: The management of caliceal diverticular calculi has changed from an open surgical approach to endoscopic management., Technical Considerations: Different minimally invasive treatment modalities, such as extracorporeal shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, laparoscopy, and retroperitoneoscopy, can be offered to the patient. We report on a retroperitoneoscopic operative technique using endosonography for location and performing nephrotomy with complete excision of the caliceal diverticulum and ligation of the diverticular neck with an Endo-loop., Conclusions: The advantages of this minimally invasive technique include total excision of the diverticulum with no risk of recurrence and easy and complete closure of the diverticular neck.

The wish for a minimally invasive procedure is one of the utmost demands by all persons undergoing living-donor nephrectomies. The retroperitoneoscopic access for this procedure has proven to be a safe, minimally invasive, and efficient approach accompanied by early mobilization and a fast return to general daily activities. The incidence of complications during and after this technically demanding operation is comparable to that of other approaches. Because of the direct anatomic approach, retroperitoneoscopic living-donor nephrectomy has become the preferred access at our institution for both donors and surgeons.

Purpose: Open dismembered pyeloplasty according to Anderson-Hynes (AHP) is the gold standard treatment for ureteropelvic junction obstruction in children. However, during the last decade, the management has been revolutionized with introduction of laparoscopy and endourology yielding comparable results and less morbid outcomes. Methods: Between 1997 and 2010, dismembered and non-dismembered retroperitoneoscopic pyeloplasty was performed in 41 children with a median age of 130 month (range 5-192). 20 children underwent a dismembered pyeloplasty (Anderson-Hynes) and 21 children were operated by a non-dismembered pyeloplasty (Y-V-Plasty). Results: The mean operation time was 120 min (range 52-257). Intraoperative findings revealed in 29 cases a significant crossing vessel. Based on a furosemide nephrogram and subjective complaints, the success rate was 88 % with a median follow-up of 69 month (range 14-142). The 5 failures (2 Y-V-Plasty, 3 AHP) have been treated by open AHP ( n = 2), Laser endopyelotomy ( n = 2) and Lap-AHP ( n = 1) without further problems. Conclusion: With increasing improvement of the suture techniques, the laparoscopic pyeloplasty represents in experienced hands an alternative method with comparable success rates to the open technique. In our opinion, retroperitoneoscopic pyeloplasty is technically possible and feasible even in infants. We found in our series no statistically significant difference between dismembered and non-dismembered pyeloplasty. [ABSTRACT FROM AUTHOR]

Introduction: Nephrectomy for autosomal dominant polycystic kidney disease (ADPKD) has been reported to have significant morbidity and mortality. Because of the large kidney size, laparoscopic nephrectomy is technically demanding and there have been only few reports on this subject. We describe our retroperitoneoscopic technique and review the literature. Methods: Retroperitoneoscopic nephrectomy was performed in 2 patients. A four-port retroperitoneal access was used, after hilar control the kidney was freed and extracted. Results: The mean operative time was 155 min, the mean intraoperative blood loss was 125 ml. There were no intraoperative complications. A postoperative retroperitoneal hematoma in 1 of the patients was managed conservatively with transfusion. Conclusion: Retroperitoneoscopic nephrectomy for ADPKD is feasible. The main advantages of this technique compared to transperitoneal laparoscopy are the quick and easy access to the hilar vessels even in large polycystic kidneys and the strict extraperitoneal route. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Minimally invasive radical nephrectomy has gained widespread acceptance in the urological community. Both the laparoscopic and retroperitoneoscopic approach have been established and advocated for radical surgery. Our experience and the advantages and indications for each procedure are analyzed in this article. Methods: Data from two clinics that routinely perform either laparoscopic or retroperitoneoscopic nephrectomy for localized tumours are compared. At the Charité Urology Clinic, Campus Mitte, the transperitoneal laparoscopic approach is the preferred technique for T1 and selected T2 tumours. At the Basel University Hospital, the preferred technique for patients with clinical T1 renal tumours is retroperitoneoscopy. Results: During a period of 5 yr, 163 patients underwent minimally invasive nephrectomy using either the laparoscopic (n =125) or the retroperitoneoscopic (n =38) approach. There were no major intraoperative complications with either technique. Intra- and postoperative data were comparable and oncological outcome was similar for both techniques, at a mean follow-up of 25 mo. Conclusions: Both retro- and transperitoneal approaches of minimally invasive radical nephrectomy are safe procedures that achieve the same standard and duplicate oncological principles established for open surgery. [Copyright &y& Elsevier]