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[Excerpt] Urologists are increasingly aware of new surgical concepts including natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) [1–5]. In 2008, the Urology LESS and NOTES Working Group was formed under the auspices of the Endourological Society. In addition to having a stated goal of increasing awareness about LESS and NOTES, the working group also wanted to define nomenclature, guide scientific evaluation, and provide opportunities for safe clinical implementation [6]. In 2010, the European Society of Urotechnology similarly formed a working group dedicated to LESS and NOTES. In this paper, we report progress on the stated goals and make new recommendations for the future of LESS and NOTES in urology. To date, progress has been made with all stated goals. Nomenclature for LESS and NOTES has been clearly defined [7,8]. In addition, most urologists are now aware of the concepts of LESS and NOTES [1,3,4,8]. Society in general is also interested and largely supportive of the LESS and NOTES concepts [9,10]. Although savvy patients may be interested in LESS and NOTES procedures, we are always obligated to place the needs of the patient first when determining surgical approach. It may sound very appealing to the patient to have no visible surgical scars, but the same patient is less interested in the so-called scarless approach if the risk of complications or morbidity is significantly increased [9–11]. As such, the development of these nascent approaches should be methodical and the recommendations based on objective data. [...]

An exciting era of discovery in the field of scarless urological surgery has just begun. Hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy has been reported by a few groups in the last two years. Recently, our group at the Cleveland Clinic was able to demonstrate the feasibility of a transvaginal pure NOTES nephrectomy. During this pioneering period, a critical appraisal of results and a scrupulous determination of benefits are of utmost importance. Further studies are awaited to define the actual role of NOTES in the management of urological diseases.

Laparoscopic surgery is frequently used in urology and the introduction of the da Vinci surgical system has served to further increase the demand for these procedures. Yet, laparoscopy is not without its drawbacks including port site complications, such as bleeding, hernia, internal organ damage and scarring. To further decrease morbidity of standard laparoscopy, newer techniques such as laparoendoscopic single-site surgery (LESS) are currently being investigated. LESS is technically challenging and reduces instrument triangulation and robust retraction, and is associated with a steep learning curve. To help overcome current limitations we have introduced the da Vinci surgical system to LESS and report our experience with robotic laparoendoscopic single-site surgery.

Objective of this study is to provide an evidence-based analysis of the current status and future perspectives of scarless urological surgery. A PubMed search has been performed for all relevant urological literature regarding natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). In addition, experience with LESS and NOTES at our own institution has been considered. All clinical and investigative reports for LESS and NOTES procedures in the urological literature have been considered. A wide variety of clinical procedures in urology have been successfully completed by using LESS techniques. Thus far, experience with NOTES has largely been investigational, although early clinical reports are emerging. Further development of instrumentation and platforms is necessary for both techniques to become more widely adopted throughout the urological community.

Background Robotic technology is increasingly adopted in urologic surgery and a variety of techniques has been described for minimally invasive treatment of upper tract urothelial cancer (UTUC). Objective To describe a simplified surgical technique of robot-assisted nephroureterectomy (RANU) and to report our single-center surgical outcomes. Design, setting, and participants Patients with history of UTUC treated with this modality between April 2010 and August 2013 were included in the analysis. Institutional review board approval was obtained. Informed consent was signed by all patients. Surgical procedure A simplified single-step RANU not requiring repositioning or robot redocking. Lymph node dissection was performed selectively. Outcome measurements and statistical analysis Descriptive analysis of patients' characteristics, perioperative outcomes, histopathology, and short-term follow-up data was performed. Results and limitations The analysis included 31 patients (mean age: 72.4±10.6 yr; mean body mass index: 26.6±5.1kg/m 2 ). Twenty-six of 30 tumors (86%) were high grade. Mean tumor size was 3.1±1.8cm. Of the 31 patients, 13 (42%) had pT3 stage disease. One periureteric positive margin was noted in a patient with bulky T3 disease. The mean number of lymph nodes removed was 9.4 (standard deviation: 5.6; range: 3–21). Two of 14 patients (14%) had positive lymph nodes on final histology. No patients required a blood transfusion. Six patients experienced complications postoperatively, with only one being a high grade (Clavien 3b) complication. Median hospital stay was 5 d. Within the follow-up period, seven patients experienced bladder recurrences and four patients developed metastatic disease. Conclusions Our RANU technique eliminates the need for patient repositioning or robot redocking. This technique can be safely reproduced, with surgical outcomes comparable to other established techniques. Patient summary We describe a surgical technique using the da Vinci robot for a minimally invasive treatment of patients presenting with upper tract urothelial cancer. This technique can be safely implemented with good surgical outcomes.

Objective To compare the outcomes of robotic partial nephrectomy (RPN) for cystic and solid renal neoplasms. Methods Our RPN database was queried to identify consecutive patients who underwent RPN for cystic and solid renal masses in the period between July 2007 and July 2013. Cystic renal masses were diagnosed on cross-sectional imaging (computed tomography or magnetic resonance imaging). Matching was done between the patients with cystic renal masses and patients with solid renal masses (1:1 matching) by age, gender, tumor size, and nephrometry score. Results Of 647 cases, 55 patients with cystic masses (group 1) were matched with 55 patients with solid tumors (group 2). There was no cyst rupture or positive surgical margin observed in group 1. The volume of resected rim of healthy renal parenchyma surrounding the tumor was the same for both groups (P = .9). There was no difference between the groups in terms of percentage of glomerular filtration rate preservation postoperatively (85% vs 86%; P = .94). There was no difference in term of overall complications between the 2 groups. Thirty patients (54.5%) in group 1 and 47 patients (85.5%) in group 2 had renal cell carcinoma (P = .0001). Conclusion RPN can be safely and effectively performed when treating a suspicious cystic renal neoplasm with outcomes resembling those obtained for solid masses. Thus, when a cystic renal mass in encountered, nephron-sparing surgery can be offered and RPN represents an effective tool for this approach.

CONTEXT: Over the last decade, robot-assisted adrenalectomy has been included in the surgical armamentarium for the management of adrenal masses. OBJECTIVE: To critically analyze the available evidence of studies comparing laparoscopic and robotic adrenalectomy. EVIDENCE ACQUISITION: A systematic literature review was performed in August 2013 using PubMed, Scopus, and Web of Science electronic search engines. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria. EVIDENCE SYNTHESIS: Nine studies were selected for the analysis including 600 patients who underwent minimally invasive adrenalectomy (277 robot assisted and 323 laparoscopic). Only one of the studies was a randomized clinical trial (RCT) but of low quality according to the Jadad scale. However, the methodological quality of included nonrandomized studies was relatively high. Body mass index was higher for the laparoscopic group (weighted mean difference [WMD]: -2.37; 95% confidence interval [CI], - 3.01 to -1.74; p

Background Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to further reduce the surgical trauma associated with conventional laparoscopy. Partial nephrectomy (PN) represents a challenging indication for LESS. Objective To report a large multi-institutional series of LESS-PN and to analyze the predictors of outcomes after LESS-PN. Design, setting, and participants Consecutive cases of LESS-PN done between November 2007 and March 2012 at 11 participating institutions were included in this retrospective analysis. Intervention Each group performed LESS-PN according to its own protocols, entry criteria, and techniques. Outcome measurements and statistical analysis Demographic data, main perioperative outcome parameters, and perioperative complications were gathered and analyzed. A multivariable analysis was used to assess the factors predicting a short (≤20min) warm ischemia time (WIT), the occurrence of postoperative complication of any grade, and a favorable outcome , arbitrarily defined as a combination of the following events: short WIT plus no perioperative complications plus negative surgical margins plus no conversion to open surgery or standard laparoscopy. Results and limitations A total of 190 cases were included in this analysis. Mean renal tumor size was 2.6, and PADUA score 7.2. Median operative time was 170min, with median estimated blood loss (EBL) of 150ml. A clampless technique was adopted in 70 cases (36.8%), and the median WIT was 16.5min. PADUA score independently predicted length of WIT (low vs high score: odds ratio [OR]: 5.11 [95% confidence interval (CI), 1.50–17.41]; p =0.009; intermediate vs high score: OR: 5.13 [95% CI, 1.56–16.88]; p =0.007). The overall postoperative complication rate was 14.7%. The adoption of a robotic LESS technique versus conventional LESS (OR: 20.92 [95% CI, 2.66–164.64]; p =0.003) and the occurrence of lower (≤250ml) EBL (OR: 3.60 [95% CI, 1.35–9.56]; p =0.010) were found to be independent predictors of no postoperative complications of any grade. A favorable outcome was obtained in 83 cases (43.68%). On multivariate analysis, the only predictive factor of a favorable outcome was the PADUA score (low vs high score: OR: 4.99 [95% CI, 1.98–12.59]; p Conclusions LESS-PN can be safely and effectively performed by experienced hands, given a high likelihood of a single additional port. Anatomic tumor characteristics as determined by the PADUA score are independent predictors of a favorable surgical outcome. Thus patients presenting tumors with low PADUA scores represent the best candidates for LESS-PN. The application of a robotic platform is likely to reduce the overall risk of postoperative complications.

We evaluated the change in renal function after renal cryoablation and partial nephrectomy based on tumor complexity according to the R.E.N.A.L. nephrometry score.We retrospectively reviewed the data of patients who had a renal tumor in a solitary kidney, and underwent renal cryoablation and partial nephrectomy between December 2000 and January 2012. Renal tumor complexity was categorized into 3 groups by R.E.N.A.L. nephrometry score as low (4 to 6), intermediate (7 to 9) and high (10 to 12). All baseline demographic data, perioperative parameters and followup data including renal function were collected. Comparisons were made among similar tumor complexities.In the renal cryoablation and partial nephrectomy groups 29 patients (43 tumors) and 33 patients were identified, respectively. In all renal tumor complexities, renal cryoablation provided a better perioperative outcome in terms of median operative time, estimated blood loss, transfusion, hospital stay and complications. The median change in serum creatinine and estimated glomerular filtration rate was slightly greater in the partial nephrectomy group. However, the differences were not statistically significant for any of the tumor complexities. Three patients (10%) in the renal cryoablation group and 2 (6%) in the partial nephrectomy group required long-term dialysis.In patients with solitary kidneys, renal cryoablation is associated with superior perioperative outcomes compared to partial nephrectomy. Specifically, partial nephrectomy is not associated with greater loss of renal function than renal cryoablation regardless of the extent of tumor complexity.

Objective To evaluate the detection of near-infrared fluorescence from prostate tumors stained with a prostate-specific membrane antigen (PSMA)–targeted tracer developed in our institution with a novel robotic imaging system. Methods Prostate cancer cell lines PC3-pip (PSMA positive) and PC3-flu (PSMA negative) were implanted subcutaneously into 6 immunodeficient mice. When tumors reached 5 mm, a PSMA-targeted fluorescent conjugate was injected intravenously. The first 3 mice underwent near-infrared imaging immediately and hourly up to 4 hours after injection to determine the time necessary to obtain peak fluorescence and were killed. The last 3 mice were imaged once preoperatively and were euthanized 120 minutes later. Excision of the tumors was performed by using a novel robotic imaging system to detect near-infrared fluorescence in real time. Specimens were submitted for pathology. Results In the first 3 mice, we found 120 minutes as the time needed to observe peak fluorescence from the PSMA-positive tumors. We identified discrete near-infrared fluorescence from 2 of 3 PSMA-positive tumors with the robotic imaging system. Surgical margins were negative for all excised specimens except for one PSMA-negative tumor. Conclusions Real-time near-infrared fluorescence imaging of prostate cancer is feasible with a novel robotic imaging system. Further research is needed to optimize the signal intensity detectable from prostate cancer with our tracer. Toxicologic studies are needed before its clinical use.

We analyzed the incidence of and risk factors for complications and conversions in a large contemporary series of patients treated with urological laparoendoscopic single site surgery.The study cohort consisted of consecutive patients treated with laparoendoscopic single site surgery between August 2007 and December 2010 at a total of 21 institutions. A logistic regression model was used to analyze the risks of conversion, and of any grade and only high grade postoperative complications.Included in analysis were 1,163 cases. Intraoperatively complications occurred in 3.3% of cases. The overall conversion rate was 19.6% with 14.6%, 4% and 1.1% of procedures converted to reduced port laparoscopy, conventional laparoscopic/robotic surgery and open surgery, respectively. On multivariable analysis the factors significantly associated with the risk of conversion were oncological surgical indication (p=0.02), pelvic surgery (p0.001), robotic approach (p0.001), high difficulty score (p=0.004), extended operative time (p=0.03) and an intraoperative complication (p=0.001). A total of 120 postoperative complications occurred in 109 patients (9.4%) with major complications in only 2.4% of the entire cohort. Reconstructive procedure (p=0.03), high difficulty score (p=0.002) and extended operative time (p=0.02) predicted high grade complications.Urological laparoendoscopic single site surgery can be done with a low complication rate, resembling that in laparoscopic series. The conversion rate suggests that early adopters of the technique have adhered to the principles of careful patient selection and safety. Besides facilitating future comparisons across institutions, this analysis can be useful to counsel patients on the current risks of urological laparoendoscopic single site surgery.

Objective: To describe the evolution of robotic partial nephrectomy (PN) technique and to analyze the surgical outcomes in a large single institution experience. Materials and Methods: Retrospective review of our institutional review boardapproved, prospectively maintained, minimally invasive PN database yielded 252 robotic partial nephrectomy (RPN) procedures from June 2007 to October 2010. Our initial experience, adopted from our laparoscopic PN approach included a standard interrupted bolstered renorrhaphy, whereas our contemporary experience included a nonbolstered continuous horizontal mattress stitch for the capsular closure. Perioperative results were evaluated depending on renorrhaphy technique, length of warm ischemia time, and nephrometry scores. Results: Overall, mean tumor size was 3.1 ± 1.6 cm, operative time 190 ± 56 minutes, warm ischemia time 18.2 ± 9.4 minutes, and estimated blood loss 267 ± 275 mL. Significantly better outcomes were noted in the contemporary experience in terms of transfusion rate (8.2% vs 21.9%, P

Objective To compare the intraoperative and early postoperative outcomes of robotic partial nephrectomy (RPN) with those of laparoscopic partial nephrectomy (LPN) outcomes in patients with bilateral synchronous renal tumors. RPN is emerging as an attractive minimally invasive nephron-sparing approach for renal tumors. Methods Our ongoing institutional review board-approved, prospectively maintained, kidney cancer database was used to identify the study population. The medical records of patients who underwent minimally invasive nephron-sparing surgery at our institution from January 2001 to March 2010 were used. A cohort of 9 patients undergoing bilateral RPN was identified and compared with 17 consecutive patients who underwent sequential bilateral LPN. The demographic, intraoperative, postoperative, and short-term renal functional data were retrospectively compared between the 2 groups. Results A total of 18 procedures were performed in the RPN group and 32 in the LPN group. The median warm ischemia time was shorter in the RPN group than in the LPN group (19 vs 37 minutes, respectively; P = .059). The median tumor size was 2.85 and 2.7 cm in the RPN and LPN group, respectively ( P = .03). The final median postoperative glomerular filtration rate was 68.7 mL/min/1.73 m 2 (interquartile range 14-73) and 26.9 mL/min/1.73 m 2 (interquartile range 20-70) in the RPN and LPN groups, respectively ( P = .004). No difference was found in the complications in the RPN group (n = 2) compared with the LPN group (n = 4). Conclusion RPN is a safe and effective minimally invasive nephron-sparing treatment of bilateral synchronous kidney tumors. A trend was seen toward a shorter warm ischemia time and less effects on postoperative renal function compared with the laparoscopic approach.

Objectives To evaluate the safety and feasibility of robotic partial nephrectomy for patients with complex renal masses. Methods We reviewed the data for 164 consecutive patients who had undergone transperitoneal robotic partial nephrectomy at a tertiary care center from February 2007 to June 2010. Of the 112 patients who had available imaging studies to review, 67 were identified and classified as having a moderately or highly complex renal mass according to the R.E.N.A.L. nephrometry score (≥7) (tumor size—[R]adius, location and depth—[E]xophytic or endophytic; nearness to the renal sinus fat or collecting system [N]; anterior or posterior position [A], and polar vs non-polar location [L]). The preoperative, perioperative, pathologic, and functional outcomes data were analyzed. Results The median body mass index was 29.6 kg/m 2 (range 19.9-44.8). Of the 67 patients, 32 were men and 35 were women, with 32 right-sided masses and 35 left-sided masses. The median tumor size was 3.7 cm (range 1.2-11), and the median operative time was 180 minutes (range 150-180). The median estimated blood loss was 200 mL (range 100-375), and the warm ischemia time was 19.0 minutes (range 15-26). The median hospital stay was 3.0 days (range 3-4). The estimated glomerular filtration rate was calculated at a median decrease of 11.1 mL/min/1.73 m 2 (range 9-1.3). According to the Clavien-Dindo classification of surgical complications, 2 grade 1, 12 grade 2, and 1 grade 3 complication occurred. All margins were pathologically negative, except for 1, and, after a mean follow-up of 10 months, no recurrences had developed. Conclusions Robotic partial nephrectomy is a safe and feasible option for moderately or highly complex renal masses determined by the R.E.N.A.L. nephrometry score. The warm ischemia time, blood loss, and complications were increased with highly complex masses.

OBJECTIVES To present comparative outcomes among matched patients who underwent robotic partial nephrectomy (RPN) or laparoscopic partial nephrectomy (LPN) by a single surgeon at a single institution. METHODS Between March 2002 and August 2009, a retrospective review of 261 consecutive patients who underwent LPN (n = 186) or RPN (n = 75) by a single surgeon was performed. Patients were matched for age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and tumor size, side, and location. Perioperative outcomes were compared. RESULTS A matched cohort of 150 patients who underwent RPN (n = 75) or LPN (n = 75) were compared. There was no significant difference between the 2 cohorts with respect to patient age (P = .17), BMI (P = .68), ASA score (P = .96), preoperative estimated glomerulofiltration rate (eGFR; P = .54), or tumor size (P = .17). Mean operative time for RPN was 200 vs 197 minutes for LPN (P = .75). Mean estimated blood loss (EBL) was higher in the RPN cohort (323 vs 222 mL, P = .01). There was no significant difference with respect to warm ischemia time (18.2 minutes vs 20.3 minutes, P = .27), length of hospitalization (P = .84), percent change in eGFR (P = .80), or adverse events (P = .52). All surgical margins were negative. CONCLUSIONS Although initial surgical experience with RPN was included in this study and compared with a vast experience in LPN by the same surgeon, RPN offers at least comparable outcomes to LPN.

Aim: To provide an evidence-based analysis on the status and perspectives of laparoscopic training in urologic surgery. Methods: A thorough review of the current literature was performed as of January 31, 2009, using the Medline database through a PubMed search. The search protocol included a free-text query using the following terms: "training,'' "urologic laparoscopy,'' "urology,'' and "laparoscopy.'' Suitable articles were selected on the basis of the study content. The following issues were addressed: prediction of laparoscopic skills and transfer of training in clinical practice; homemade and commercially available laparoscopic trainers and simulators; training models for specific laparoscopic procedures; mentored training programs; formal training programs; and the impact of robotics in laparoscopic training. Results: Currently available tools predicting laparoscopic skills lack adequate validation to justify their widespread adoption. There still is not enough evidence to show definite transfer of skills from currently available simulators to the operating theater. Learning opportunities continue to evolve. Specific models have been developed for complex procedures. Various informal training programs exist, yet most urologists will not be able to complete a formal fellowship. Postgraduate urologists may possibly be more rapidly and efficiently trained using a structured mentoring program. Robotics is likely to have an increasing role in teaching urological laparoscopy. Conclusions: Despite progress in recent years and an extensive amount of data from the urological literature, the ideal training program in urological laparoscopy remains a goal to be determined objectively

The aim of this study was to review recent advances and to provide future perspectives in renal focal therapy.Most relevant available data from current literature and reports from major urological meetings as well as clinical and experimental experience at our institution have been considered.Effective treatment of incidentally detected small renal masses continues to evolve. Major recent advances have been made toward three main directions: enhancing accuracy of probe positioning, improving ablative energy efficiency, and reducing treatment-related morbidity.Renal focal therapy can offer the advantage of combining a nephron-sparing surgery together with a minimally invasive approach. Technical refinements will include emerging clinical data for radiofrequency and cryoablation. Single-port access renal cryotherapy has been shown to be feasible and safe. Although in its infancy, natural orifice translumenal endoscopic surgery might represent a further step toward scarless surgery. Radiosurgery is under investigation and oncological outcomes are awaited to determine its role. Stereotactic surgical navigation and robotic needle placement would facilitate and increase the accuracy of percutaneous probe placement.

Purpose After CMS introduced the concept of the Hospital Readmissions Reduction Program, hospitals and health care centers became financially penalized for exceeding specific readmission rates. Materials and Methods We retrospectively reviewed our institutional review board approved database of patients undergoing robotic partial nephrectomy at our institution and included in our analysis patients who were readmitted to any hospital as an inpatient stay within 30 days from discharge home after robotic partial nephrectomy. Results From March 2006 to March 2013 a total of 627 patients underwent robotic partial nephrectomy at our center and 28 (4.46%) were readmitted within 30 days of surgery. Postoperative bleeding was responsible for 8 (28.5%) readmissions. Pulmonary embolism was reported in 3 cases and retroperitoneal abscess was diagnosed in 2. Urinary leak requiring surgical intervention developed in 2 patients, pneumonia was diagnosed in 2 and 2 patients were readmitted for chest pain. Overall 9 (32.1%) patients presented with major complications requiring intervention. On multivariable analysis Charlson comorbidity index score was the only factor significantly associated with a higher 30-day readmission rate (p = 0.03). If the Charlson score was 5 or greater the chance of hospital readmission would be 2.7 times higher. Conclusions Increased comorbidity, specifically a Charlson score of 5 or greater, was the only significant predictor of a higher incidence of 30-day readmission. This information can be useful in counseling patients regarding robotic partial nephrectomy and in determining baseline rates if CMS expands the number of conditions they evaluate for excess 30-day readmissions. © 2014 by American Urological Association Education and Research, Inc.

Introduction The first laparoscopic case of ileal interposition was reported in 2000, proving the feasibility of the procedure in a minimally invasive fashion by duplicating the principles of open surgery. Robotic applications in urology are expanding worldwide, given the unique features of the robotic platform, which facilitates more advanced laparoscopic procedures. In this study, we report a case of completely intracorporeal robotic ileal ureter and thoroughly describe our technique for this complex minimally invasive procedure. Technical Considerations A 50-year-old gentleman with a history of right renal stones underwent multiple right ureteroscopies and thereafter developed 2 proximal ureteral strictures of 5 mm. Preoperative estimated glomerular filtration rate was 71 mL/min/1.73 m2. Renal scan showed preserved function. The treatment options were discussed, and the patient elected to undergo a robotic ileal ureter interposition. Total operative time was 7 hours, the estimated blood loss was approximately 50 mL, and the patient progressed to regular diet on postoperative day 4 without any problem, being discharged without complications. On the postoperative day 12, a cystogram demonstrated no extravasation, and the Foley catheter was removed. After 1 month, renal scan showed the left kidney with 60.1% and the right kidney with 39.9% of total renal function. At 2 years follow-up, his serum creatinine was 1.14 and estimated glomerular filtration rate was 70 mL/min/1.73 m2. Conclusion Robot-assisted laparaoscopic ileal ureter with a completely intracorporeal technique is feasible and appears to be safe. A larger number of procedures using this technique and longer follow-up are needed to further define its role in the treatment of ureteral strictures.

Intraoperative frozen section (FS) analysis has been regarded as a paramount tool for immediate evaluation of tumor margin status during partial nephrectomy procedures. The aim of this study was to assess the utility of FS during robot-assisted partial nephrectomy (RAPN).A retrospective review of our Institutional Review Board-approved prospectively maintained minimally invasive partial nephrectomy database yielded 342 consecutive RAPN procedures from June 2007 to September 2011. Of these, the initial 128 cases underwent FS evaluation, whereas the following 214 cases did not. Patient demographics, perioperative outcomes, and final pathology results were analyzed and compared between the two groups.Body mass index, Charleson Comorbidity Index, tumor size, renal score, preoperative creatinine level, and estimated glomerular filtration rate (eGFR) were similar between both groups. Operative time was significantly longer in the no-FS group (193 vs 180 min; P=0.04). Warm ischemia time (median 19 vs 19 min), estimated blood loss (150 vs 200 mL), postoperative creatinine level (1.0 vs 1.1 mg/dL), and postoperative eGFR (75.6 vs 75.9) were similar between the no-FS group and FS group, respectively. Complications occurred in 32 (15.0%) and 31 (24.2%) cases in no-FS and FS, respectively (P=0.06). Final pathology results demonstrated seven cases of positive margins, 1 (1%), in the FS group and 6 (3%) in the no-FS group (P=0.19). Of the cases with positive margins at final pathology analysis, a R.E.N.A.L. score of 3/3 was found on closeness to renal sinus. Overall, three intraoperative positive margins were noted in the FS group (2.3%): One patient underwent radical nephrectomy and one reresection; one case was managed with observation only.Routine application of FS analysis during RAPN seems to provide a limited benefit. FS might be advisable for tumors with sinus invasion because they seem to carry a higher likelihood of positive surgical margin at final pathology determination.

Objective To assess the feasibility of robotic transrectal hybrid natural orifice translumenal endoscopic surgery (NOTES) nephrectomy and adrenalectomy. Materials and Methods A male cadaver was used for the present investigation and placed in lithotomy position. An 8- and 12-mm port was inserted through the same periumbilical skin incision. An incision was then created in the rectum 1 cm above the pectinate line, and a submucosal tunnel was developed, through which a robotic 8-mm port was inserted under vision. The cadaver was then placed in the right side up, flank position. The laparoscope and the right robot instrument were introduced through the umbilicus while the left robot instrument was introduced through the rectal port aiding the peri-umbilical ports in kidney and adrenal dissection. After completion of the nephrectomy, the kidney was placed in a specimen bag and extracted intact through the rectum. Closure of the rectal incision was accomplished extracorporeally using 2 suture layers. Results Robotic transrectal hybrid NOTES nephrectomy and adrenalectomy were completed successfully. The total operative time was 145 minutes, of which the access and robotic docking required 20 minutes. Kidney dissection and hilar control was achieved within 60 minutes. Right adrenalectomy, specimen extraction, and rectal closure was completed in 15, 30, and 20 minutes, respectively. Conclusion We report the first investigation of a robot-assisted transrectal hybrid NOTES nephrectomy and adrenalectomy in a cadaver model to assess the range of motion and articulation of the robotic platform. Additional investigations in live animal model are needed to evaluate the safety of the transrectal approach.