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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.

Objective: To create, distribute, and evaluate the efficacy of a portable, cost-effective 3D-printed laparoscopic trainer for surgical skills development., Methods: The UCI Trainer (UCiT) laparoscopic simulator was developed via computer-aided designs (CAD), which were used to 3D-print the UCiT. Once assembled, a tablet computer with a rear-facing camera was attached for video and optics. Four institutions were sent the UCiT CAD files with a 3D-printer and instructions for UCiT assembly. For a comparison of the UCiT to a standard trainer, peg transfer and intracorporeal knot tying skills were accessed. These tasks were scored, and participants were asked to rate their experience with the trainers. Lastly, a questionnaire was given to individuals who 3D-printed and assembled the UCiT., Results: We recruited 25 urologists; none had any 3D-printing experience. The cost of printing each trainer was $26.50 USD. Each institution used the Apple iPad for optics. Six of eight participants assembled the UCiT in < 45 minutes, and rated assembly as somewhat easy. On objective scoring, participants performed tasks equally well on the UCiT vs the conventional trainer. On subjective scoring, the conventional trainer provided a significantly better experience vs the UCiT; however, all reported that the UCiT was useful for surgical education., Conclusion: The UCiT is a low cost, portable training tool that is easy to assemble and use. UCiT provided a platform whereby participants performed laparoscopic tasks equal to performing the same tasks on the more expensive, nonportable standard trainer., (Copyright © 2018. Published by Elsevier Inc.)

Background: There is no clear consensus as to the optimal method of entry in laparoscopic renal surgery and no reports have compared them in Urology. To analyze contemporary practice patterns in entry technique and port placement for laparoscopic kidney surgery., Methods: We identified 60 high volume urological laparoscopic centers. A purpose-built questionnaire was sent to surgeons. The survey included 22 questions regarding access techniques and port configuration during laparoscopic kidney surgery. Data on were collected and retrospectively analyzed. Concordance among port configurations was assessed using Cohen's Kappa statistics., Results: The survey was sent to 60 surgeons and completed by 32 of them. Surgical procedures included were laparoscopic radical nephrectomy (1177 LRN/year) and laparoscopic partial nephrectomy (1047 LPN/year). The transperitoneal route was preferred (85%). Hasson technique was used for the access in 55% of the cases. Patient lateral recumbent position is the most frequently used during the port placement (41%). Although there is a high variability in the port positioning among the surgeons, in more than 90% of cases it was found a specific concordance in triangulation of optics and operating trocars. There were no significant differences between port configuration in LRN and LPN. Limitations include retrospective design and limited sample., Conclusions: A standard port configuration has not been previously reported in urological literature. Our study suggests that the transperitoneal approach, the Hasson technique and a specific triangulation of optics and operating trocars have a significant concordance in some high volume laparoscopic urologic centers.

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.

A tumor-bearing right kidney was completely excised from an 85-year-old woman using a laparoscopic approach. A newly devised method for intra-abdominal organ entrapment and a recently developed laparoscopic tissue morcellator made it possible to deliver the 190 gm. kidney through an 11 mm. incision., (Copyright © 1991 American Urological Association, Inc. Published by Elsevier Inc. All rights reserved.)

Laparoscopic partial nephrectomy (LPN) compares favorably to traditional open nephron-sparing surgery (NSS) in terms of oncologic and surgical principles for kidney tumors. Studies have shown the modality to be feasible with similar oncologic efficacy and superior renal functional outcomes compared with laparoscopic radical nephrectomy (LRN) for tumors. The main advantages of LPN include marked improvements in estimated blood loss, decreased surgical site pain, shorter postoperative convalescence, better cosmesis, and nephron preservation. This review article evaluates the literature regarding LPN and discusses the main steps of the operation, the perioperative workup and management, surgical complications, and its role in the surgical management of kidney masses., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Purpose: A clinical dilemma surrounds the use of aspirin therapy during laparoscopic partial nephrectomy. Despite reduced cardiac morbidity with perioperative aspirin use, fear of bleeding related complications often prompts discontinuation of therapy before surgery. We evaluate perioperative outcomes among patients continuing aspirin and those in whom treatment is stopped preoperatively., Materials and Methods: A total of 430 consecutive cases of laparoscopic partial nephrectomy performed between January 2012 and October 2014 were reviewed. Patients on chronic aspirin therapy were stratified into on aspirin and off aspirin groups based on perioperative status of aspirin use. Primary end points evaluated included estimated intraoperative blood loss and incidence of bleeding related complications, major postoperative complications, and thromboembolic events. Secondary outcomes included operative time, transfusion rate, length of hospital stay, rehospitalization rate and surgical margin status., Results: Among 101 (23.4%) patients on chronic aspirin therapy, antiplatelet treatment was continued in 17 (16.8%). Bleeding developed in 1 patient in the on aspirin group postoperatively and required angioembolization. Conversely 1 myocardial infarction was observed in the off aspirin cohort. There was no significant difference in the incidence of major postoperative complications, intraoperative blood loss, transfusion rate, length of hospital stay and rehospitalization rate. Operative time was increased with continued aspirin use (181 vs 136 minutes, p=0.01)., Conclusions: Laparoscopic partial nephrectomy is safe and effective in patients on chronic antiplatelet therapy who require perioperative aspirin for cardioprotection. Larger, prospective studies are necessary to discern the true cardiovascular benefit derived from continued aspirin therapy as well as better characterize associated bleeding risk., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

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/1.73m(2) ). 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/1.73m(2) , 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., (© 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.)

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.

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/m(2), 25 to 30 kg/m(2), and >30 kg/m(2). 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.

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/m(2). The mean tumor size and volume were 3.2 cm and 35.8 cm(3), 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.

Objective: To present our experience with laparoscopic partial nephrectomy (LPN) for hilar tumors and evaluate intermediate oncologic and renal functional outcomes., Materials and Methods: A retrospective review of LPN cases performed in 488 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. The clinicopathologic parameters, perioperative course, complications, and oncologic and 6-month renal functional outcomes were analyzed., Results: A total of 488 patients underwent LPN, of which 43 were hilar. The mean tumor size for hilar and nonhilar tumors was 3.6 cm and 3.1 cm, respectively. The mean operative time was shorter for hilar as compared with nonhilar tumors (129.1 minutes vs 141.8 minutes). Mean estimated blood loss was greater in LPN for hilar tumors (311.65 mL vs 298.4 mL). There were no statistically significant differences noted in any of the perioperative parameters investigated despite a higher nephrometry complexity score in the hilar group. Change in estimated glomerular filtration rate at 6 months showed a decrease of 10.9 mL/min and 8.8 mL/min for hilar and nonhilar tumors, respectively (P = NS). There was 1 recurrence detected in the hilar group, with a median follow-up of 41.6 months., Conclusion: In the hands of an experienced laparoscopist, LPN can safely be performed for hilar tumors, with preservation of perioperative outcomes and durable renal functional and oncologic outcomes., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objectives: There is lack of consensus in the Urology community regarding surveillance after laparoscopic partial nephrectomy (LPN), particularly for patients with stage I tumors. The purpose of this article is to characterize the rate of recurrence after partial nephrectomy in a low risk cohort., Methods: Data were collected on all laparoscopic partial nephrectomies performed at a single institution from January 2006 through May 2011. Patients without at least 1 year of follow-up information were excluded from examination. Patients were stratified based on the pathologic tumor stage at the time of partial nephrectomy. Patients with stage I (a and b) tumors were then examined for recurrence., Results: A total of 639 patients underwent LPN during the time period. Of this, 360 patients had stage T1 renal cell carcinoma (RCC) (302 with pT1a and 58 with pT1b) and met research criteria. There were 8 recurrences (2.2%) within this cohort ( Table 1 ). All of the tumors were of clear cell histology and none had Furhman grade 1 histology. Only one of these patients had a positive margin at the time of partial nephrectomy and all patients had negative biopsy of the tumor resection bed. A majority of the recurrences occurred locally in the ipsilateral kidney or retroperitoneum. Most of the recurrences occurred within 1-2 years postoperatively., Conclusions: Approximately 2% of patients who underwent LPN for RCC with resultant low risk, stage I tumor pathology developed metastasis. There were no recurrences in nonclear cell pathologies and no recurrences with Furhman grade 1 or tumors smaller than 3 cm.

Purpose of Review: An off-clamp, or zero-ischemia, approach to laparoscopic partial nephrectomy has been a proposed means of preserving global renal function by preventing ischemia to normal renal parenchyma. However, for clinical stage T1b tumors this provides a unique challenge as the large size of these tumors further complicates an already difficult procedure. This review provides an overview of outcomes for laparoscopic partial nephrectomies performed with or without hilar clamping for clinical stage T1b tumors., Recent Findings: There is a paucity of data for laparoscopic partial nephrectomies for this larger tumor size. The feasibility of performing laparoscopic partial nephrectomy for renal tumors 4-7 cm in size has clearly been demonstrated. Not unexpectedly, using an off-clamp technique during laparoscopic partial nephrectomy has variably shown increased intraoperative blood loss when compared to hilar controlled procedures. This does not, however, seem to translate into increased risk of transfusion or loss of visualization leading to compromise in oncologic outcomes. Lastly, some data suggest improved short-term and long-term preservation of renal function as estimated by estimated glomerular filtration rate., Summary: With accumulating data pointing to the long-term health benefits of nephron sparing surgery over radical nephrectomy and its oncologic equivalency confirmed, there is an increased push to perform partial nephrectomy for larger tumors. As demonstrated in the setting of a solitary kidney, every minute of warm ischemia counts and ischemia is an important modifiable variable that impacts renal function. As such, off-clamp dissection has potential advantages. The reviewed data show that foregoing hilar clamping for T1b tumors is not only feasible, but is likely beneficial with respect to renal function and does not appear to carry an increased risk of transfusion despite increased blood loss.

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., (© 2013 The Authors. BJU International © 2013 BJU International.)

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., (© 2012 THE AUTHORS. BJU INTERNATIONAL © 2012 BJU INTERNATIONAL.)

Purpose: Unlike traditional valved trocars, the valveless trocar maintains pneumoperitoneum during laparoscopy by forming a CO(2) curtain at the proximal end of the trocar. This gas barrier instantaneously maintains exact intraperitoneal pressure that yields to the transient physiological changes seen with breathing. Due to this different mechanism of action, pneumothorax development may be masked by the valveless trocar system., Materials and Methods: We retrospectively reviewed 850 transperitoneal laparoscopic kidney and adrenal surgeries in which a valveless trocar system was used to determine any record of pneumothorax detected intraoperatively or postoperatively. A patient with pneumothorax was considered a case and anesthetic parameters were reviewed. A matched control group was generated from patients treated with transperitoneal laparoscopic kidney and adrenal surgery using the valveless trocar with no complications., Results: Pneumothorax was diagnosed in 10 patients (1.2%). Two cases were the result of intentional excision of the diaphragm, which were repaired intraoperatively, while 8 were not recognized until the postoperative period. Five of the patients (63%) with unintentional pneumothorax required chest tube placement for a mean of 2.4 days. The remaining 3 patients (37%) were treated conservatively and followed with serial chest x-rays. The only anesthetic variable that was significantly different between the groups was Δ end tidal CO(2) with greater fluctuations in end tidal CO(2) in the pneumothorax group than in controls (p = 0.03)., Conclusions: Pneumothorax is a rare complication of laparoscopic urological surgery that is usually recognized intraoperatively through physiological changes. Valveless trocar systems mask these findings and can delay identification until the postoperative period., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To assess intraoperative cognitive and motor skills using audio- and video-based analysis., Materials and Methods: The study enrolled 11 surgeons who were categorized into novice (n = 4), intermediate (n = 4), and expert (n = 3) groups. Categorization of skill level was based on years of experience and as determined by the lead expert surgeon. A total of 32 cases were available for analysis, including 5 robotic and 27 laparoscopic renal cases. For each procedure, video and audio components were recorded and sent for grading to 4 blinded judges. The previously validated global rating scale (GRS) and operation-specific rating scale (ORS), as well as a novel cognitive rating scale (CRS), were used to assess performances. Statistical comparisons were performed by analysis of variance., Results: Comparison of the 3 skill levels using analysis of variance showed that each scale was able to differentiate among the levels (P <.05). The mean scores for the before and after audio GRS, ORS, and CRS showed significant difference between the novice, intermediate, and expert groups, demonstrating construct validity., Conclusion: The use of intraoperative audio is an innovative way to assess the cognitive ability of the surgeon. The CRS demonstrated construct validity. The addition of the CRS to the already validated GRS and ORS may serve as a reliable system to objectively evaluate laparoscopic and robotic surgical skill., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: The R.E.N.A.L. nephrometry is a standardized scoring system that quantifies the complexity of kidney tumors. We evaluated our experience with laparoscopic cryoablation and determined the ability of nephrometry to predict complications., Materials and Methods: We reviewed the records of all patients who underwent laparoscopic cryoablation from July 2005 to February 2010 at 3 institutions. The composite R.E.N.A.L. score was determined using preoperative imaging, and tumors were categorized as low (4-6), moderate (7-9) or high complexity (10-12). Perioperative data were analyzed to determine the presence of complications. The distribution of surgical complications and tumor categories was compared using the chi-square and Student's t test. Logistic regression was used to analyze the association between nephrometry score and postoperative complications., Results: A total of 210 patients underwent laparoscopic cryoablation, 77 of whom had available preoperative imaging. Mean patient age was 64.5 years and mean tumor size was 2.6 cm (range 1 to 4.5). Mean nephrometry score was 6.1 (range 4 to 12). Of the tumors 47 (61%) were categorized as low, 23 (30%) as moderate and 7 (9%) as high complexity lesions. Overall there were 15 (19.5%) complications, including 7 (9.5%) major and 8 (10%) minor complications. There was a significant difference in complication rates among the low (47 patients, 0%), moderate (23 patients, 35%) and high complexity (7 patients, 100%) groups, respectively (p <0.001). On multivariate analysis nephrometry score was independently associated with a higher risk of postoperative complications (OR 2.23, 95% CI 1.05-2.11, p = 0.008)., Conclusions: In a multi-institutional cohort of patients undergoing laparoscopic cryoablation, the R.E.N.A.L. nephrometry score is independently associated with the occurrence of complications. Therefore, nephrometry can be used to successfully stratify patients in terms of anticipated risk of complications which, in turn, may help with surgical decision making., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

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.

Unlabelled: 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., Methods: • Retrospective review of all LPNs between June 2006 and March 2010 was performed, stratifying 390 patients by clinical T stage (cT1a = 313, cT1b = 62, cT2 = 15). • Perioperative and postoperative parameters were analysed comparing patients who underwent OC LPN (n= 126) with those who had HC LPN (n= 264) collectively and within each clinical stage cohort., Results: • There was no significant difference in the proportion of OC LPN for cT1a tumours compared with cT1b and cT2, P= 0.21. • OC vs HC LPN patients had a greater estimated blood loss (EBL) but with no significant difference in perioperative blood transfusion rates. • When compared by clinical stage, EBL was greater only for clinical stage T1a disease (P= 0.02) but not cT1b (P= 0.91) or cT2 (P= 0.42) tumours. • There was no difference in the operative time or length of hospitalization between OC and HC LPN by stage: cT1a (P= 0.77 and P= 0.17), cT1b (P= 0.77 and P= 0.07) and cT2 (P= 0.42 and P= 0.66), respectively. • In our series, one case (0.3%) of HC LPN had a positive margin on final pathology, one case was converted to open partial nephrectomy (0.3%), and two cases of OC LPN (1.6%) were intraoperatively converted to HC LPN., Conclusions: • OC LPN is a feasible surgical option for patients with cT1-T2 renal cell carcinoma that completely avoids renal ischaemic injury with the benefits of minimally invasive surgery. • LPN can be performed OC in patients with larger, more complex renal tumours without compromising the operative time, blood loss requiring transfusions, length of hospitalization, complication rates, or positive surgical margin rates compared with HC LPN., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

LaparoEndoscopic Single-Site (LESS) nephroureterectomy is a recent iteration of laparoscopic renal surgery whereby the minimally-invasive approach of laparoscopy has been condensed to a single operative access site in efforts to minimize convalescence and improve cosmesis. To date, LESS nephroureterectomy has been reported successful for both adult and pediatric patient populations, most commonly for treatment of upper tract urothelial carcinoma in adults. For the treatment of upper tract urothelial carcinomas, comparative oncologic effectiveness of LESS compared to conventional laparoscopy or open surgery is pending further investigation. Overall, LESS nephroureterectomy has proven its role as a feasible and safe option of minimally-invasive surgery, minimizing the number and length of the surgical incisions used.

Purpose: Primary laparoscopic retroperitoneal lymph node dissection is done at our institution with therapeutic intent and it technically duplicates the open approach. Controversies associated with the procedure include the thoroughness of dissection, the high rate of chemotherapy exposure and the potential deleterious effects of pneumoperitoneum. We present our experience with laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors., Materials and Methods: We queried the Johns Hopkins minimally invasive surgery database from 1995 to 2010 for patients with a clinical stage I nonseminomatous germ cell tumor undergoing laparoscopic retroperitoneal lymph node dissection. Demographic, perioperative, pathological and followup information was collected and analyzed., Results: Of the 91 patients who underwent extended template laparoscopic retroperitoneal lymph node dissection during the study period 60 (66%) had lymphovascular invasion and 55 (60%) had greater than 40% embryonal carcinoma. Median estimated blood loss was 200 cc and mean length of stay was 2.1 days (range 1 to 4). Four patients (4.3%) experienced intraoperative complications and there were 4 open conversions (4.3%). Nine patients (9.8%) experienced postoperative complications. The mean lymph node count was 26.1 (range 7 to 72) and 28 patients (31%) had retroperitoneal metastasis. Followup was available for 55 patients at a median 38.0 months (range 12 to 168). No pN0 case recurred in the retroperitoneum but there were 5 systemic relapses in pN0 cases. Of the 21 patients with pN1 disease 14 elected chemotherapy and 7 elected surveillance. There was no relapse in either group., Conclusions: Laparoscopic retroperitoneal lymph node dissection appears to be safe, viable and effective for stage I nonseminomatous germ cell tumors. The lack of retroperitoneal recurrence in pN0-N1 cases supports the oncological efficacy of this approach. Its low morbidity and rapid convalescence compare favorably with those in open series., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Testicular cancer is the most common solid organ malignancy in young men between the ages of 15 and 35. Although much of this increase in survival can be attributed to improvements in systemic chemotherapy, surgery retains a critical role in the diagnostic and therapeutic management of testicular cancer. Laparoscopic retroperitoneal lymph node dissection is an effective staging and therapeutic procedure in patients with low-stage testicular cancer. It is an attractive alternative to the open approach, with faster recovery, improved cosmesis, and reduced post-operative morbidity driving its application. In experienced hands, it can be used in postchemotherapy patients., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives: To prospectively compare a novel type of valveless trocar that creates a curtain of pressurized carbon dioxide [CO(2)] gas (which maintains pneumoperitoneum at a lower gas flow rate) with standard trocars; to quantify the volume of CO(2) used; and to characterize CO(2) elimination during laparoscopic renal surgery., Methods: A total of 51 patients undergoing laparoscopic renal surgery by a single surgeon were prospectively evaluated using either the valveless trocar (n = 26) or standard trocars (n = 25). Patient demographics, operative time, volume of CO(2) gas consumed, CO(2) elimination, perioperative parameters, and postoperative complications were recorded and analyzed., Results: Both patient cohorts were comparable in their preoperative demographics, including body mass index, the number of patients with chronic obstructive pulmonary disease, and smoking history. Mean operative time was lower in the valveless trocar cohort (124.1 minutes) compared with the conventional trocar group (145.6 minutes), P = .047. Use of the valveless trocar was associated with a lower volume of intraoperative CO(2) consumed (120.0 ± 82.8 vs 300.6 ± 191.5; P < .001) and reduced CO(2) elimination compared with standard trocar use after the first 16 minutes of insufflation (P < .05). Minimal complications occurred, including 2 cases of subcutaneous emphysema in the valveless trocar group, and 1 case of respiratory acidosis in the conventional trocar group., Conclusions: Use of a valveless trocar significantly reduced CO(2) consumption during transperitoneal laparoscopy. The valveless trocar also demonstrated significantly reduced CO(2) elimination and absorption when compared with the standard trocar., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Unlabelled: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Several studies have shown the feasibility of performing both complex and reconstructive laparoendoscopic single site (LESS) surgical procedures in urology. To date, no studies have evaluated the rates of conversion to conventional laparoscopy and complications at the time of LESS procedures in urology. This study, a compilation of results from members of the NOTES working group, is the first study to address the rates of complications and conversions to conventional laparoscopy at the time of LESS surgery in urology., 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 access device. Reconstructive procedures incorporating a single planned 2 mm accessory needle port were included as LESS procedures and were not considered conversions. • 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 and surgical 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.

Purpose: Surgical site infections have been categorized by the Centers for Medicare and Medicaid Services as "never events". The incidence of surgical site infection following laparoscopic urological surgery and its risk factors are poorly defined. We evaluated surgical site infection following urological laparoscopic surgery and identified possible factors that may influence occurrence., Materials and Methods: Patients who underwent transperitoneal laparoscopic procedures during a 4-year period by a single laparoscopic surgeon were retrospectively reviewed. Surgical site infections were identified postoperatively and defined using the Centers for Disease Control criteria. Clinical parameters, comorbidities, smoking history, preoperative urinalysis and culture results as well as operative data were analyzed. Nonparametric testing using the Mann-Whitney U test, multivariable logistic regression and Spearman's rank correlation coefficient were used for data analysis., Results: In 556 patients undergoing urological laparoscopic procedures 14 surgical site infections (2.5%) were identified at mean postoperative day 21.5. Of the 14 surgical site infections 10 (71.4%) were located at a specimen extraction site. Operative time, procedure type and increasing body mass index were significantly associated with the occurrence of surgical site infections (p = 0.007, p = 0.019, p = 0.038, respectively), whereas history of diabetes mellitus (p = 0.071) and intraoperative transfusion (p = 0.053) were found to trend toward significance. Age, gender, positive urine culture, steroid use, procedure type and smoking history were not significantly associated with surgical site infection. Body mass index and operative time remained significant predictors of surgical site infection on multivariate logistic regression analysis., Conclusions: Surgical site infection is an infrequent complication following laparoscopic surgery with the majority occurring at the specimen extraction site. Infection is associated with prolonged operative time and increasing body mass index., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Laparoscopic live donor nephrectomy is a safe, minimally invasive alternative to the customary open approach. During the past two decades, laparoscopic renal surgery has increased the availability of renal allograft specimens for transplantation. Specifically, the laparoscopic approach has minimized postoperative pain and duration of recovery, making it a more attractive option for potential altruistic organ donors. Here we detail the techniques, challenges, and troubleshooting approaches necessary for this technically challenging, yet valuable operation.

Objectives: To identify risk factors associated with hemorrhage during laparoscopic partial nephrectomy (LPN), and to determine the impact of hemorrhage on hospital course., Methods: We retrospectively analyzed prospective data from 335 LPNs to identify clinicopathologic factors associated with hemorrhagic complications (blood loss requiring ≥ 1 U transfusion) and extended length of hospitalization (≥ 3 days). We excluded patients with a coagulopathy or perioperative vascular injuries., Results: We identified 23 patients (7%) undergoing LPN with hemorrhagic complications (group 1 and 312 patients (93%) without complications (group 2). Mean age was 64.1 ± 14.4 vs 57.6 ± 12.7(P = .006), American Society of Anesthesiologists (ASA) score ≥ 3 seen in 61% vs 37% (P = .02), mean tumor size (cm) was 2.90 ± 2.02 vs 2.59 ± 1.15 (P = .93), mean total operative time (min) was 250.1 ± 116.1 vs 191.8 ± 69.2 (P = 0.006), and mean hospital stay (days) was 4.7 ± 3.4 vs 3.1 ± 3.0 (P = .0002), for groups 1 and 2, respectively. Hypertension, diabetes mellitus, chronic renal insufficiency, obesity, smoking, and coronary artery disease-congestive heart failure were present in group 1 vs group 2: 39.1% vs 31.4% (P = .4), 17.4% vs 8% (P = .12), 8.7% vs 1.9% (P = .09), 4.3% vs 3.5% (P = .57), 17.4% vs 5.4% (P = .04), and 8.7% vs 2.2% (P = .11), respectively. On multivariate analysis, smoking (P < .0437) and ASA score ≥ 3 (P < .0233) were associated with hemorrhagic complications. Hemorrhagic complications were 3.5 times more likely in smokers than nonsmokers (95% confidence interval, 1.0-11.7), and 2.9 times more likely with an ASA class ≥ 3. Only age (P < .0002) and operative time (P < .0001) were associated with longer hospitalization., Conclusions: High ASA scores and smoking are risk factors for hemorrhagic complications during LPN. Hemorrhagic complications did not significantly affect hospitalization length., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Context: Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been developed to benefit patients by enabling surgeons to perform scarless surgery., Objective: To summarize and critically analyze the available evidence on the current status and future perspectives of LESS and NOTES in urology., Evidence Acquisition: A comprehensive electronic literature search was conducted in June 2010 using the Medline database to identify all publications relating to NOTES and LESS in urology., Evidence Synthesis: In urology, NOTES has been completed experimentally via transgastric, transvaginal, transcolonic, and transvesical routes. Initial clinical experience has shown that NOTES urologic surgery using currently available instruments is indeed possible. Nevertheless, because of the immaturity of the instrumentation, early cases have demanded high technical virtuosity. LESS can safely and effectively be performed in a variety of urologic settings. As clinical experience increases, expanding indications are expected to be documented and the efficacy of the procedure to improve. So far, the quality of evidence of all available studies remains low, mostly being small case series or case-control studies from selected centers. Thus, the only objective benefit of LESS remains the improved cosmetic outcome. Prospective, randomized studies are largely awaited to determine which LESS procedures will be established and which are unlikely to stand the test of time. Technology advances hold promise to minimize the challenging technical nature of scarless surgery. In this respect, robotics is likely to drive a major paradigm shift in the development of LESS and NOTES., Conclusions: NOTES is still an investigational approach in urology. LESS has proven to be immediately applicable in the clinical field, being safe and feasible in the hands of experienced laparoscopic surgeons. Development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery., (Copyright © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

• 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., (© 2010 BJU INTERNATIONAL. NO CLAIM TO ORIGINAL US GOVERNMENT WORKS.)

Purpose: Laparoscopic bowel injury is associated with significant morbidity and mortality when unrecognized. We assessed the incidence and outcomes of bowel injury in a contemporary cohort of patients, and reviewed the literature to examine the impact of experience with time on the incidence and consequences of bowel injury., Materials and Methods: Between 2006 and 2009 we performed 1,073 laparoscopic surgeries on the upper urinary tract, adrenal gland and retroperitoneal lymph nodes. Patients incurring bowel injury were identified retrospectively. We reviewed complications and management. In a separate literature survey we identified 21 studies on laparoscopic bowel injury from 1993 to 2009. We analyzed etiology, incidence and management., Results: Bowel injury occurred in 8 cases (0.75%), including 6 and 2 identified intraoperatively and postoperatively, respectively. Mechanisms included Veress needle and trocar placement, dissection and thermal injury. Intraoperative management included oversewing the injury, bowel resection and observation. No patient with intraoperatively recognized bowel injury sustained a postoperative adverse event. Patients with unrecognized injury presented in delayed fashion and required multiple procedures to manage the injury. No deaths occurred in this series. Urology series of bowel injury showed a combined 0.65% incidence in 14,447 laparoscopic procedures with 46.7% of injuries unrecognized at surgery. While the incidence of bowel injury has increased with time, the percent of unrecognized bowel injury has dramatically decreased from the early (70.4%) to the more recent (36.9%) laparoscopic era., Conclusions: The incidence of laparoscopic bowel injury has increased in the last 17 years. However, morbidity and mortality have decreased due to immediate recognition and repair., (Copyright (c) 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: To compare laparoendoscopic single-site (LESS) Pfannenstiel donor nephrectomy with a contemporary series of standard laparoscopic (SL) donor nephrectomies., Methods: The initial 6 LESS donor nephrectomies were compared with a case-matched 6 SL donor nephrectomies within the same time period (June 2008 till March 2009). Patient characteristics (sex, age, body mass index, graft volume, and vascular anatomy), perioperative data (operative time, warm ischemia time [WIT], and estimated blood loss), and postoperative information (complications, length of stay, visual analog scale [VAS], and total morphine requirements) were collected prospectively and analyzed retrospectively., Results: In the LESS group, there were no conversions to SL or open. There was no significant difference between the two groups in terms of baseline characteristics (age, body mass index, allograft volume). However, SL group included more right-sided patients (three compared with one) and more venous anomalies (retrorenal veins in two patients and multiple veins in another). There was no significant difference between SL and LESS in terms of operative time (117 vs. 142 minutes), WIT (5 minutes in both groups), estimated blood loss (150 vs. 100 mL), median length of stay (2 days in both), and total morphine equivalents (42 vs. 83 mg). None of the patients received transfusions perioperatively. A patient in the SL group developed a wound infection requiring packing and antibiotics. There were no perioperative complications in the LESS group. Although VAS scores were lower in the LESS versus SL group at each of post-operative day (POD) #2 (1.5 vs. 4) and discharge (0 vs. 2), this did not reach statistical significance., Conclusions: In this small retrospective series, SL was associated with more complex renal anatomy. However, there was no difference between the two groups in terms of WIT, narcotic requirements, and VAS scores. Therefore, the advantages of LESS may only be cosmesis. To verify these results, both procedures need to be compared prospectively in a randomized fashion.

Background and Purpose: Retroperitoneal lymph node dissection (RPLND) is recommended in children 10 years or older with paratesticular rhabdomyosarcoma (PTRMS). Primary tumors >5 cm are an additional risk factor for disease recurrence in the retroperitoneum. We report our experience with laparoscopic RPLND (LRPLND) in high-risk pediatric patients with PTRMS., Patients and Methods: Three patients, mean age 13.6 years (range 10-16 yrs), underwent modified template LRPLND after radical orchiectomy for preoperative rhabdomyosarcoma stage T(1a)N(0)M(0), T(1b)N(0)M(0), and T(2b)N(0)M(0), respectively. Primary paratesticular masses measured a mean 7.5 cm (range 4-10 cm). LRPLND was performed a mean of 8.6 days (range 7-12 d) after radical orchiectomy using four trocars that were placed equidistant in the midline., Results: Average operative time was 382 minutes (range 245-656 minutes). Mean estimated blood loss was 53 mL (range 10-75 mL), and mean postoperative hospital stay was 2.5 days (range 2-3 d). There were no postoperative complications. Retroperitoneal nodes had negative findings for microscopic disease in two patients and positive findings in one patient. All patients received adjuvant chemotherapy with vincristine, actinomycin, and cyclophosphamide., Conclusion: LRPLND for high-risk pediatric patients with PTRMS is a safe diagnostic and therapeutic procedure with the benefit of rapid convalescence, enabling early commencement of adjuvant chemotherapy.

With all its different presentations and etiologies, ureteropelvic junction obstruction has been a topic for much research and debate. For several decades, the 'gold standard' of treatment was unequivocally an Anderson-Hynes dismembered pyeloplasty. Various surgical modifications and minimally invasive alternatives have been studied. It was not until the last two decades that laparoscopic and robotic approaches have threatened to supplant the classic open approach as the preferred surgical treatment option. While the debate between the laparoscopic and robotic approaches has been a heavily contested one, it has rarely been founded on prospective, well-matched evidence. We review the existing literature and present our perspective on the clinical, academic and economic aspects of this contest between man and machine.

Objectives: To describe laparoendoscopic single site (LESS) donor nephrectomy procedure through a Pfannenstiel incision. Laparoscopic donor nephrectomy has become the standard approach in harvesting kidneys from live donors. This is usually performed through 3 ports placed in a triangular manner in addition to the Pfannenstiel incision where the kidney is removed., Methods: Through a 5 cm Pfannenstiel incision, three 5 mm ports were placed in a triangular manner. A 5 mm flexible-tip laparoscope was used to perform laparoscopic donor nephrectomy. Before ligating the renal hilum, the superior midline trocar was exchanged for a 12-mm trocar to allow for an Endo-GIA stapler. After the kidney was placed in the entrapment sac, the anterior rectus fascia between the 2 midline ports was incised and the kidney was removed. After closure of the fascial defects, the Pfannenstiel incision was closed in a subcuticular manner., Results: LESS Pfannenstiel donor nephrectomy was successfully performed in 6 patients without standard laparoscopic or open conversion. No additional needlescopic instruments were used. The median age was 46 years with median body mass index of 28.3 kg/m(2). The median operative time was 142 minutes with a median warm ischemia time of 5 minutes. Median hospital stay was 2 days and the median pain score at discharge was 0. None of the patients received transfusions perioperatively and none had peri-operative complications., Conclusions: LESS Pfannenstiel donor nephrectomy offers the benefits of improved cosmesis over the standard laparoscopic donor nephrectomy. Prospective randomized trials are needed to compare the postoperative pain levels in between these 2 techniques., (2010. Published by Elsevier Inc.)

Purpose: We present oncological outcomes at a followup of 10 years or greater after laparoscopic radical nephrectomy for cancer., Materials and Methods: Between February 1994 and March 1999 a total of 73 laparoscopic radical nephrectomies were performed by 2 surgeons for pathologically confirmed renal cell carcinoma. Data were obtained from patient charts, radiographic reports, telephone followup and a check of the Social Security Death Index., Results: Mean followup was 11.2 years (range 10 to 15). Each patient completed a minimum 10-year followup. Mean patient age at surgery was 60 years. Mean tumor size on computerized tomography was 5 cm (range 1.7 to 13). Pathological stage was pT1a in 41% of cases, pT1b in 30%, pT2 in 15%, pT3a in 10%, pT3b in 3% and pT4 in 1%. High grade tumors (Fuhrman 3 or greater) were present in 18 cases (28%). A positive surgical margin occurred in 1 case. Actual 10-year overall, cancer specific and recurrence-free survival rates were 65%, 92% and 86%, respectively. Overall, cancer specific and recurrence-free survival rates at 12 years were 35%, 78% and 77%, respectively. At a mean of 67 months 10 patients (14%) had metastatic disease, of whom 8 (11%) died., Conclusions: Long-term oncological outcomes after laparoscopic radical nephrectomy for renal cell carcinoma are excellent and appear comparable to those of open surgery.

Introduction: Laparoscopic trocars typically maintain pneumoperitoneum using trap door valves and silicone seals. However, valves and seals hinder passage of instruments, cause lens smudging, trap specimens and needles being removed from the abdominal cavity, and lose their seal with repeated instrument exchange., Aim: The aim of the present study was to evaluate the feasibility of a newly designed valve-less trocar., Methods: The valve-less trocar system creates a curtain of forced gas to maintain pneumoperitoneum. A separate unit filters smoke and recirculates captured escaping gas. The valve-less trocar was trialed in consecutive laparoscopic renal procedures of a single surgeon. Perioperative parameters and outcomes were collected and analyzed. The system's safety, advantages, and disadvantages were evaluated. Insufflation gas usage, elimination, and absorption were also measured., Results: Twenty-five patients underwent laparoscopic renal procedures using the valve-less trocar system. The procedures included laparoscopic partial, radical, and donor nephrectomy. The mean patient age was 58.26 years. The mean operative time was 125 minutes and the mean drop in Hb for the cohort was 2.34 g/dL (range 0.4-5.4). Two patients developed subcutaneous emphysema and of the two patients, one developed clinically insignificant pneumomediastinum postoperatively. There were no postoperative complications. The surgeon noted that the use of a valve-less trocar decreased smudging of laparoscopes, expeditiously evacuated smoke during cauterization leading to improved visualization, maintained pneumoperitoneum even while suctioning, and resulted in easy extraction of specimens and needles. It was noted that insufflation gas consumption was low and CO(2) elimination was not impaired., Conclusion: Use of a valve-less trocar is safe. Decreased laparoscope smudging may translate into decreased operative times and reduced gas consumption may equate to cost savings. Additionally, its use brings several advantages and convenience to the operating surgeon. However, the system should be compared with conventional trocars prospectively to demonstrate clinical and economic benefit.

Background and Purpose: As laparoscopy becomes more commonplace for urologists, ongoing attempts are under way to minimize the number and size of incisions used for access. Laparoendoscopic single-site surgery (LESS) was developed and has been increasingly attempted as an extension of classic laparoscopy. Investigators hypothesize that LESS may offer a superior cosmetic result, faster recovery, and equivalent efficacy to laparoscopic surgery. Our aim is to present our experience with renal LESS., Patients and Methods: A prospective data collection was performed on all patients who were undergoing renal LESS at our institution. A total of 11 renal LESS procedures were performed between July and November 2008: four LESS donor nephrectomies, two LESS radical nephrectomies, three LESS partial nephrectomies, and two LESS pyeloplasties. All LESS procedures replicated laparoscopic techniques but were performed through a single operative site using a 5-mm flexible-tip laparoscope and flexible working instruments., Results: Six of the patients were men. The mean operative time was 162.4 +/- 38.5 minutes. The mean estimated blood loss was 104.5 +/- 41.6 mL, with a mean length of hospitalization of 2.4 +/- 0.8 days. There were no intraoperative complications or blood transfusions. Postoperative pain requirements were tabulated and revealed a mean in-hospital analgesic requirement of 44.8 +/- 46.7 mg (range 7-158 mg) of morphine equivalents with three patients receiving intravenous ketorolac., Conclusion: Renal LESS is feasible as flexible laparoscopes and instruments continue to develop. In our initial experience, expert laparoscopic surgeons were able to perform these LESS procedures with equivalent efficacy without compromising perioperative measures, including operative time, blood loss, and hospital stay. Further prospective investigation through randomized studies is necessary to elucidate differences, if any, in postoperative analgesic requirements and patient satisfaction with postoperative cosmesis, and to confirm equivalent efficacy when compared with current standards.

Complex ureteral reconstruction has been performed with ileum, appendix, or other intestinal segments for the treatment of long ureteral strictures. In the past decade, challenging ureteral reconstruction has been approached using laparoscopic urology. We report the case of a 6-cm iatrogenic stricture after treatment of stone disease. The stricture was treated using a laparoscopic on-lay appendix graft. This laparoscopic technique used the on-lay concept, which, in addition to minimizing postoperative pain and the length of hospitalization, allowed a tension-free watertight anastomosis and preserved the ureteral vascular supply. This approach should be considered a viable minimally invasive alternative for ureteral reconstruction when endoscopic treatment has failed.

Purpose: We describe our experience with laparoscopic ureteral reimplantation in 45 adults, and report success rates and complications at intermediate term followup., Materials and Methods: We performed a retrospective chart review of 45 patients who underwent laparoscopic ureteral reimplantation between 1997 and 2007. Demographics, clinicopathological parameters, perioperative course, complications and followup studies were analyzed., Results: Elective laparoscopic ureteral reimplantation was performed in 35 female and 10 male patients with a mean followup of 24.1 months (range 1 to 76). All patients presented with distal ureteral stricture with a mean stricture length of 3 cm and a mean +/- SD preoperative serum creatinine of 0.91 +/- 0.04 mg/dl. Mean patient age was 47.8 +/- 2.2 years (range 17 to 87). Mean American Society of Anesthesiologists score was 2 (range 1 to 3). Median estimated blood loss was 150 ml. The overall success rate, defined as radiographic evidence of no residual obstruction, symptoms, renal deterioration or need for subsequent procedures, was 96%. Two patients had recurrent strictures and 1 underwent nephrectomy for flank pain and preexisting chronic pyelonephritis., Conclusions: According to intermediate followup data laparoscopic ureteral reimplantation can be performed with an excellent success rate and low morbidity. Our data substantiate this technique as an effective method for managing distal ureteral stricture.

Objectives: To assess the perioperative outcomes in patients >75 years old to better define the role of laparoscopic renal surgery in this expanding segment of the U.S. population. The outcomes of elderly patients undergoing laparoscopic renal procedures are less well defined than those of younger patients., Methods: We retrospectively reviewed the records of 115 patients >75 years old who had undergone laparoscopic renal surgery. The clinical and pathologic features and complication rates were analyzed. The patients were substratified according to the type of laparoscopic procedure performed and extreme age (>80 years)., Results: The mean age of our 115 patients was 79.9 years (range 75-91). The median estimated blood loss was 200 mL (interquartile range 100-387). The transfusion rate was 9.6%. The median length of stay was 4 days (interquartile range 3-5). The overall complication rate for the entire cohort was 22.6% and was 13.7% in those >80 years. The number of patients who experienced a complication was 22 (19.1%). Patients with a Charlson comorbidity index >2 were more likely to experience a perioperative complication than were patients with a Charlson comorbidity index <1 (35% vs 16%; P = .034)., Conclusions: Our data support the safety and feasibility of laparoscopic renal procedures in elderly patients. Furthermore, this safety extends to patients of advanced age (>80 years). The overall complication rates and other perioperative parameters appear to be comparable to those in published studies; however, patients with a Charlson comorbidity index >2 are at a greater risk of complications in the perioperative period.

Objectives: To report our long-term experience with salvage laparoscopic pyeloplasty after a failed open procedure. Laparoscopic repair of a primary ureteropelvic junction obstruction (UPJO) is associated with very high long-term success. However, there are limited data on patients who have failed previous open pyeloplasty. We have determined that salvage laparoscopic pyeloplasty is an excellent option for these patients., Methods: We queried our laparoscopic pyeloplasty database of 367 patients from July 1994 to May 2007 for patients who had undergone prior open pyeloplasty. We analyzed demographic data, perioperative course, complications, and follow-up studies on identified subjects. We assessed clinical status by verbal pain scale and diagnostic studies. Radiologic follow-up consisted of diuretic renal scan, intravenous pyelography, or both., Results: We identified 9 patients (2.5%) who underwent salvage laparoscopic pyeloplasty for persistent obstruction after open pyeloplasty. The mean age of our cohort was 30.5 years (range, 19-50 years). Mean operative time was 204 minutes (range, 80-264 minutes), estimated blood loss was 105 mL (range, 20-300 mL), and mean length of stay was 2.1 days (range, 2-3 days). No intraoperative or postoperative complications were reported. All patients reported relief of symptoms in the immediate postoperative period. At a median follow-up of 66 months (range, 12-119 months), 8 of 9 patients (89%) had clinical and radiologic resolution of UPJO with stable renal function, pain free status, and a patent ureteropelvic junction. The remaining patient failed laparoscopic repair within the first year with evidence of persistent obstruction, necessitating endopyelotomy., Conclusions: Our findings support the use of salvage laparoscopic pyeloplasty as an excellent option for patients who failed previous open pyeloplasty. This approach provides durable long-term outcomes.

Introduction: To evaluate the feasibility of percutaneous injection of saline in the renal subcapsular space to prevent bowel injury and histopathologic effects of bowel cryolesion during renal cryoablation in a porcine model., Material and Method: Six pigs underwent percutaneous renal cryoablation with two freeze cycles in the lower pole of both kidneys. Six kidneys were injected with 10 ml saline into the renal subcapular space before cryoablation. The bowel was brought into contact with the edge of the ice ball with laparoscopic assistance during renal cryoablation, on the side with saline injection as well as on the control side. One of these animals was kept for survival follow-up and laparotomy for 7 days post cryoablation. The bowel cryolesion sites were observed and compared based on the presence or absence of renal subcapsular saline injection., Results: The mean diameter of acute bowel injury with and without saline renal subcapsular injection was 7.25 +/- 1.26 and 14.5 +/- 0.58 mm, respectively. The influence of injecting a saline buffer was a significant decrease in the bowel cryolesion compared to controls (p = 0.0003). In addition, a pig kept for follow-up confirmed no bowel perforation after 7 days at a site that was cryolesioned on the side with renal subcapsular saline injection, but sustained bowel perforation in another segment lesioned by contact with a kidney without a saline injection. Gross and microscopic pathological examination was consistent with these interpretations., Conclusion: Preliminary results in a porcine model show that percutaneous renal subcapsular saline injection is a feasible and promising technique for preventing bowel complications of percutaneous image-guided renal cryoablation.