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Mutations in SETD2 are among the most prevalent drivers of renal cell carcinoma (RCC). We identified a novel single nucleotide polymorphism (SNP) in SETD2, E902Q, within a subset of RCC patients, which manifests as both an inherited or tumor-associated somatic mutation. To determine if the SNP is biologically functional, we used CRISPR-based genome editing to generate the orthologous mutation within the Drosophila melanogaster Set2 gene. In Drosophila, the homologous amino acid substitution, E741Q, reduces H3K36me3 levels comparable to Set2 knockdown, and this loss is rescued by reintroduction of a wild-type Set2 transgene. We similarly uncovered significant defects in spindle morphogenesis, consistent with the established role of SETD2 in methylating α-Tubulin during mitosis to regulate microtubule dynamics and maintain genome stability. These data indicate the Set2 E741Q SNP affects both histone methylation and spindle integrity. Moreover, this work further suggests the SETD2 E902Q SNP may hold clinical relevance., Competing Interests: Conflicts of interest The author(s) declare no conflict of interest., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Genetics Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Elderly patients diagnosed with high-risk prostate cancer (PCa) present a therapeutic dilemma of balancing treatment of a potentially lethal malignancy with overtreatment of a cancer that may not threaten life expectancy., Objective: To investigate treatment patterns and overall survival outcomes in this group of patients., Design Setting and Participants: A retrospective cohort study was conducted. We queried the National Cancer Database for high-risk PCa in patients aged 80 yr or older diagnosed during 2004-2016., Intervention: Eligible patients underwent no treatment following biopsy (ie, observation), androgen deprivation therapy (ADT) alone, radiation therapy (RT) alone, RT + ADT, or surgery., Outcome Measurements and Statistical Analysis: Kaplan-Meier, log rank, and multivariate Cox proportional hazard regression was performed to compare overall survival (OS)., Results and Limitations: A total of 19 920 men were eligible for analysis, and the most common treatment approach was RT + ADT (7401 patients; 37.2%). Observation and ADT alone declined over time (59.3% in 2004 vs 47.5% in 2016). There was no observed difference in OS between observation and ADT alone (adjusted hazard ratio [HR] 1.04, 95% confidence interval [CI], 0.99-1.09; p  = 0.105). Definitive local treatment was associated with improved OS compared with ADT alone (RT alone, HR 0.54, 95% CI, 0.50-0.59, p  < 0.0001; ADT + RT, HR 0.48, 95% CI, 0.46-0.50, p  < 0.0001; surgery, HR 0.50, 95% CI, 0.42-0.59, p  < 0.0001)., Conclusions: This analysis demonstrates that the use of definitive local therapy, including surgery or RT ± ADT, is increasing and is associated with a 50% reduction in overall mortality compared with observation or ADT alone. While prospective validation is warranted, elderly men with high-risk disease eligible for definitive management should be counseled on the risks, including a possible compromise in OS, with deferring definitive management., Patient Summary: Elderly men are more often diagnosed with higher-risk prostate cancer but are less likely to receive curative treatment options than younger men. Our analysis demonstrates that for men ≥80 yr of age with high-risk prostate cancer, definitive local therapy, including surgery or radiation therapy and/or androgen deprivation therapy, is associated with a 50% reduction in overall mortality compared with observation or androgen deprivation therapy alone. We therefore recommend that life expectancy (ie, physiologic age) be taken into account, over chronologic age, and that elderly men with good life expectancy (eg, >5 yr; minimal comorbidity) should be offered definitive, life-prolonging therapy., (© 2022 The Authors.)

Objectives: To identify clear cell renal cell carcinoma-related gene mutations potentially associated with aggressive disease, sarcomatoid differentiation or poor prognosis., Methods: We carried out genomic analysis of 217 tumor foci from 25 patients with conventional clear cell renal cell carcinoma (14 patients), clear cell renal cell carcinoma with sarcomatoid differentiation (six patients) and non-clear cell renal cell carcinoma (five patients). Each tumor nodule on the tissue block that corresponded to the same focus on the slide was separated from the normal parenchyma and other histologically distinct areas of tumor. The isolated tumor foci were used for subsequent analyses and sequencing. Deoxyribonucleic acid from the formalin-fixed paraffin-embedded tissues was extracted. Multiplex bar-coded polymerase chain reaction amplification was carried out using next-generation sequencing libraries., Results: Overall, 67 protein alterations, including amino acid alterations, frame shifts and splice site mutations in seven genes were identified in the cohort of renal cell carcinoma tumors included in this study. Fewer patients with clear cell renal cell carcinoma with sarcomatoid differentiation had clear cell renal cell carcinoma-related mutations in comparison with patients with conventional clear cell renal cell carcinoma. Additionally, the average number of unique clear cell renal cell carcinoma-related protein alterations per patient was significantly lower in clear cell renal cell carcinoma with sarcomatoid differentiation than in conventional clear cell renal cell carcinoma. Mutations in PBRM1 were identified in a higher proportion of patients with high-grade tumors (World Health Organization/International Society of Urological Pathology grade 4) and in the primary tumors of six of 10 (60%) patients with metastatic disease., Conclusions: Although there are pitfalls due to intratumoral heterogeneity and sampling bias, mutations in PBRM1 may be associated with metastasis and aggressive disease in clear cell renal cell carcinoma., (© 2020 The Japanese Urological Association.)

Objective: Several inflammatory markers have been studied as potential biomarkers in renal cell carcinoma (RCC), however few reports have analyzed their prognostic value in aggregate and in non-clear cell histologies. We hypothesize that a combination of specific inflammatory markers into an RCC Inflammatory Score (RISK) could serve as a rigorous prognostic indicator of overall survival (OS) in patients with clear cell and non-clear cell RCC., Methods: Combination of preoperative C-reactive protein (CRP), albumin, erythrocyte sedimentation rate (ESR), corrected calcium, and aspartate transaminase to alanine transaminase (AST/ALT) ratio was used to develop RISK. RISK was developed using grid-search methodology, receiver-operating-characteristic (ROC) analysis, and sensitivity-specificity trade-off analysis. Prognostic value of RISK was analyzed using the Kaplan-Meier method and Cox proportional regression models. Predictive accuracy was compared with RISK to Size, Size, Grade, and Necrosis (SSIGN) score, University of California-LOS Angeles (UCLA) Integrated Staging System (UISS), and Leibovich Prognosis Score (LPS)., Results: Among 391 RCC patients treated with nephrectomy, area under the curve (AUC) for RISK was 0.783, which was comparable to SSIGN (AUC 0.776, p  = 0.82) and UISS (AUC 0.809, p  = 0.317). Among patients with localized disease, AUC for RISK and LPS was 0.742 and 0.706, respectively ( p  = 0.456). On multivariate analysis, we observed a step-wise statistically significant inverse relationship between increasing RISK group and OS (all p  < 0.001)., Conclusion: RISK is an independent and significant predictor of OS for patients treated with nephrectomy for clear cell and non-clear cell RCC, with accuracy comparable to other histopathological prognostic tools.

Objective: To evaluate the relationship between the Onodera Prognostic Nutritional Index (OPNI) and overall survival, as well as recurrence-free survival, in clear cell renal cell carcinoma (ccRCC) patients following nephrectomy., Materials and Methods: Three hundred forty-one patients who underwent nephrectomy for ccRCC were analyzed. The optimum OPNI cutoff score of 44.7 was determined by receiver operating characteristic analysis and patients were placed in either the low or high OPNI group, with OPNI values of ≤44.7 and ≥44.8, respectively. Kaplan-Meier analysis was performed to evaluate the univariate impact of the OPNI groups on overall survival and recurrence-free survival. OPNI's association with overall survival and recurrence-free survival, with adjustments for other patient and tumor qualities, was assessed with univariate and multivariate Cox regression analysis., Results: Median (95% CI) overall survival times for the low and high OPNI groups were 21.1 months and 37.9 months, respectively. OPNI was determined to be an independent prognostic factor in multivariate analysis, and after controlling for patient and tumor characteristics, the low OPNI group experienced a 1.67-fold (hazard ratio: 1.67, 95% confidence interval: 1.05-2.68) increased risk of overall mortality., Conclusion: Preoperative OPNI is a valuable independent prognostic indicator of overall survival and recurrence-free survival in patients with ccRCC following nephrectomy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To investigate the prognostic value of R.E.N.A.L. (radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior, and location relative to polar lines) nephrometry score after percutaneous ablation of renal cell carcinoma (RCC)., Materials and Methods: A retrospective 5-year study was performed. Participants were 87 consecutive patients (median age, 67.1 y; 59.7% male, 40.3% female) with 101 biopsy-proven RCCs who underwent percutaneous ablation (54.0% cryoablation, 46.0% radiofrequency ablation). Follow-up computed tomography or magnetic resonance imaging was performed in all cases (mean follow-up, 34.6 mo ± 23.5). R.E.N.A.L. scores were analyzed to determine the association of the score with treatment outcomes and complications., Results: All tumors corresponded to stage 1A disease. Mean tumor size was 2.05 cm (range, 0.7-3.9 cm), and 50.5% of the lesions measured > 2 cm. Nephrometry score was > 8 in 31.4% of lesions. Overall recurrence rate was 16.8%, first-year recurrence rate was 7.9%, and complication rate was 9.9%. A nephrometry score > 8 was associated with increased complications after percutaneous ablation (P < .0001), increased overall recurrence (P < .0001), and increased risk of first-year recurrence (P < .0001). Immediate complications were associated with tumor size > 2 cm (P < .0001) and risk of local recurrence (P < .001). Age, gender, and percutaneous ablation technique were not correlated with recurrence or immediate complications. Patients undergoing cryoablation had a higher nephrometry score with no significant differences in recurrence rate compared with RF ablation (P = .199)., Conclusions: A R.E.N.A.L. nephrometry score ≥ 8 predicts recurrence and complications after percutaneous renal ablation., (Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: Aberrant promoter methylation turns off gene expression and is involved in human malignancy. Studies show that first exon methylation has a tighter association with gene silencing compared to promoter methylation or gene mutation. However, to our knowledge the clinical importance of exonic methylation in renal cell carcinoma is unknown. We analyzed renal cell carcinoma for VHL gene exonic methylation using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry., Materials and Methods: In 48 institutionally banked renal cell carcinoma patient tissue samples VHL exon sequencing was done as well as methylation analysis of promoter and exon 1 by mass spectrometry or conventional bisulfite analysis. Methylated human lymphocytic DNA (0% and 100%), nontemplate distilled H2O, and the UOK121 and UOK171 human renal cell carcinoma cell lines served as assay controls. Samples were considered hypermethylated if a CpG site showed greater than 50% methylation., Results: Nine of the 43 patient samples read by our exon 1 assay had methylated VHL exon 1 sites, including 3 showing hypermethylation. The exon 1 methylation assay was robust and reproducible. Samples with exon 1 hypermethylation showed no exonic mutations. All samples assayed at VHL exon 2 were hypermethylated., Conclusions: To assay renal cell carcinoma tumors for VHL methylation matrix-assisted laser desorption/ionization time-of-flight mass spectrometry is robust and reproducible, and capable of quantifying the methylation status of individual DNA bases. Exon 1 methylation may be an alternate mechanism of VHL gene silencing in renal cell carcinoma in addition to mutation and promoter methylation. Applying this assay in patient populations may allow enhanced diagnosis or tumor typing in the future., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To characterise the surgical feasibility and outcomes of robot-assisted radical cystectomy (RARC) for pathological T4 bladder cancer., Patients and Methods: Retrospective evaluation of a prospectively maintained International Radical Cystectomy Consortium database was conducted for 1118 patients who underwent RARC between 2003 and 2012. We dichotomised patients based on pathological stage (≤pT3 vs pT4) and evaluated demographic, operative and pathological variables in relation to morbidity and mortality., Results: In all, 1000 ≤pT3 and 118 pT4 patients were evaluated. The pT4 patients were older than the ≤pT3 patients (P = 0.001). The median operating time and blood loss were 386 min and 350 mL vs 396 min and 350 mL for p T4 and ≤pT3, respectively. The complication rate was similar (54% vs 58%; P = 0.64) among ≤pT3 and pT4 patients, respectively. The overall 30- and 90-day mortality rate was 0.4% and 1.8% vs 4.2% and 8.5% for ≤pT3 vs pT4 patients (P < 0.001), respectively. The body mass index (BMI), American Society of Anesthesiology score, length of hospital stay (LOS) >10 days, and 90-day readmission were significantly associated with complications in pT4 patients. Meanwhile, BMI, LOS >10 days, grade 3-5 complications, 90-day readmission, smoking, previous abdominal surgery and neoadjuvant chemotherapy were significantly associated with mortality in pT4 patients. On multivariate analysis, BMI was an independent predictor of complications in pT4 patients, but not for mortality., Conclusions: RARC for pT4 bladder cancer is surgically feasible but entails significant morbidity and mortality. BMI was independent predictor of complications in pT4 patients., (© 2013 The Authors. BJU International © 2013 BJU International.)

Robot-assisted radical cystectomy (RARC) is an emerging operative alternative to open surgery for the management of invasive bladder cancer. Studies from single institutions provide limited data due to the small number of patients. In order to better understand the related outcomes, a world-wide consortium was established in 2006 of patients undergoing RARC, called the International Robotic Cystectomy Consortium (IRCC). Thus far, the IRCC has reported its findings on various areas of operative interest and continues to expand its capacity to include other operative modalities and transform it into the International Radical Cystectomy Consortium. This article summarizes the findings of the IRCC and highlights the future direction of the consortium.

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

Background: Intracorporeal urinary diversion (ICUD) has the potential benefits of a smaller incision, reduced pain, decreased bowel exposure, and reduced risk of fluid imbalance., Objective: To compare the perioperative outcomes of patients undergoing extracorporeal urinary diversion (ECUD) and ICUD following robot-assisted radical cystectomy (RARC)., Design, Setting, and Participants: We reviewed the database of the International Robotic Cystectomy Consortium (IRCC) (18 international centers), with 935 patients who had undergone RARC and pelvic lymph node dissection (PLND) between 2003 and 2011., Intervention: All patients within the IRCC underwent RARC and PLND as indicated. The urinary diversion was performed either intracorporeally or extracorporeally., Outcome Measurements and Statistical Analysis: Demographic data, perioperative outcomes, and complications in patients undergoing ICUD or ECUD were compared. All patients had at least a 90-d follow-up. The Fisher exact test was used to summarize categorical variables and the Wilcoxon rank sum test or Kruskal-Wallis test for continuous variables., Results and Limitations: Of 935 patients who had RARC and PLND, 167 patients underwent ICUD (ileal conduit: 106; neobladder: 61), and 768 patients had an ECUD (ileal conduit: 570; neobladder: 198). Postoperative complications data were available for 817 patients, with a minimum follow-up of 90 d. There was no difference in age, gender, body mass index, American Society of Anesthesiologists grade, or rate of prior abdominal surgery between the groups. The operative time was equivalent (414 min), with the median hospital stay being marginally longer for the ICUD group (9 d vs 8 d, p=0.086). No difference in the reoperation rates at 30 d was noted between the groups. The 90-d complication rate was not significant between the two groups, but a trend favoring ICUD over ECUD was noted (41% vs 49%, p=0.05). Gastrointestinal complications were significantly lower in the ICUD group (p ≤ 0.001). Patients with ICUD were at a lower risk of experiencing a postoperative complication at 90 d (32%) (odds ratio: 0.68; 95% confidence interval, 0.50-0.94; p=0.02). Being a retrospective study was the main limitation., Conclusions: Robot-assisted ICUD can be accomplished safely, with comparable outcomes to open urinary diversion. In this cohort, patients undergoing ICUD had a relatively lower risk of complications., (Copyright © 2013. Published by Elsevier B.V.)

Introduction and Objectives: There are over 65,000 new cases of renal cell carcinoma (RCC) each year, yet there is no effective clinical screening test for RCC. A single report claimed no overlap between urine levels of aquaporin-1 (AQP1) in patients with and without RCC (Mayo Clin Proc. 85:413, 2010). Here, we used archived and fresh RCC patient urine to validate this report., Methods: Archived RCC, fresh prenephrectomy RCC, and non-RCC negative control urines were processed for Western blot analysis. Urinary creatinine concentrations were quantified by the Jaffe reaction (Nephron 16:31, 1976). Precipitated protein was dissolved in 1x SDS for a final concentration of 2  μg/µL creatinine., Results: Negative control and archived RCC patient urine failed to show any AQP1 protein by Western blot analysis. Fresh RCC patient urine is robustly positive for AQP1. There was no signal overlap between fresh RCC and negative control, making differentiation straightforward., Conclusions: Our data confirms that fresh urine of patients with RCC contains easily detectable AQP1 protein. However, archival specimens showed an absence of detectable AQP1 indistinguishable from negative control. These findings suggest that a clinically applicable diagnostic test for AQP1 in fresh urine may be useful for detecting RCC.

Purpose: The modified Glasgow prognostic Score (mGPS) incorporates C-reactive protein and albumin as a clinically useful marker of tumor behavior. The ability of the mGPS to predict metastasis in localized renal cell carcinoma (RCC) remains unknown in an external validation cohort., Patients and Methods: Patients with clinically localized clear cell RCC were followed for 1 year post-operatively. Metastases were identified radiologically. Patients were categorized by mGPS score as low-risk (mGPS = 0 points), intermediate-risk (mGPS = 1 point) and high-risk (mGPS = 2 points). Univariate, Kaplan-Meier and multivariate Cox regression analyses examined Recurrence -free survival (RFS) across patient and disease characteristics., Results: Of the 129 patients in this study, 23.3% developed metastases. Of low, intermediate and high risk patients, 10.1%, 38.9% and 89.9% recurred during the study. After accounting for various patient and tumor characteristics in multivariate analysis including stage and grade, only mGPS was significantly associated with RFS. Compared with low-risk patients, intermediate- and high-risk patients experienced a 4-fold (hazard ratios [HR]: 4.035, 95% confidence interval [CI]: 1.312-12.415, P = 0.015) and 7-fold (HR: 7.012, 95% CI: 2.126-23.123 P < 0.001) risk of metastasis, respectively., Conclusions: mGPS is a robust predictor of metastasis following potentially curative nephrectomy for localized RCC. Clinicians may consider mGPS as an adjunct to identify high-risk patients for possible enrollment into clinical trials or for patient counseling.

Hemangiopericytomas are rare mesenchymal lesions arising from pericytes within the walls of capillaries. They often have an unpredictable course. We present a case of a large retroperitoneal hemangiopericytoma in a 65-year-old woman who initially presented with upper gastrointestinal discomfort. Following exptirpative surgery, pathology was consistent with hemangiopericytoma of low malignant potential. Widespread metastasis was discovered on follow up imaging, 17 months following surgery. To our knowledge, this is the first case report demonstrating a primary retroperitoneal hemangioperictoma with confirmed metastases.

Background: Complication reporting is highly variable and nonstandardized. Therefore, it is imperative to determine the surgical outcomes of major oncologic procedures., Objective: To describe the complications after robot-assisted radical cystectomy (RARC) using a standardized and validated reporting methodology., Design, Setting, and Participants: Using the International Robotic Cystectomy Consortium (IRCC) database, we identified 939 patients who underwent RARC, had available complication data, and had at least 90 d of follow-up., Outcome Measurements and Statistical Analysis: Complications were analyzed and graded according to the Memorial Sloan-Kettering Cancer Center (MSKCC) system and were defined and stratified by organ system. Secondary outcomes included identification of preoperative and intraoperative variables predicting complications. Logistic regression models were used to define predictors of complications and readmission., Results and Limitations: Forty-one percent (n=387) and 48% (n=448) of patients experienced a complication within 30 and 90 d of surgery, respectively. The highest grade of complication was grade 0 in 52%, grade 1-2 in 29%, and grade 3-5 in 19% patients. Gastrointestinal, infectious, and genitourinary complications were most common (27%, 23%, and 17%, respectively). On multivariable analysis, increasing age group, neoadjuvant chemotherapy, and receipt of blood transfusion were independent predictors of any and high-grade complications, respectively. Thirty and 90-d mortality was 1.3% and 4.2%, respectively. As a multi-institutional database, a disparity in patient selection, operating standards, postoperative management, and reporting of complications can be considered a major limitation of the study., Conclusions: Surgical morbidity after RARC is significant when reported using a standardized reporting methodology. The majority of complications are low grade. Strict reporting of complications is necessary to advocate for radical cystectomy (RC) and helps in patient counseling., (Copyright © 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Unlabelled: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Lymph node dissection and it's extend during robot-assisted radical cystectomy varies based on surgeon related factors. This study reports outcomes of robot-assisted extended lymphadenectomy based on surgeon experience in both academic and private practice settings., Objective: To evaluate the incidence of, and predictors for, extended lymph node dissection (LND) in patients undergoing robot-assisted radical cystectomy (RARC) for bladder cancer, as extended LND is critical for the treatment of bladder cancer but the role of minimally invasive surgery for extended LND has not been well-defined in a multi-institutional setting., Patients and Methods: Used the International Robotic Cystectomy Consortium (IRCC) database. In all, 765 patients who underwent RARC at 17 institutions from 2003 to 2010 were evaluated for receipt of extended LND. Patients were stratified by age, sex, clinical stage, institutional volume, sequential case number, and surgeon volume. Logistic regression analyses were used to correlate variables to the likelihood of undergoing extended LND., Results: In all, 445 (58%) patients underwent extended LND. Among all patients, a median (range) of 18 (0-74) LNs were examined. High-volume institutions (≥100 cases) had a higher mean LN yield (23 vs 15, P < 0.001). On univariable analysis, surgeon volume, institutional volume, and sequential case number were associated with likelihood of undergoing extended LND. On multivariable analysis, surgeon volume [odds ratio (OR) 3.46, 95% confidence interval (CI) 2.37-5.06, P < 0.001] and institution volume [OR 2.65, 95% CI 1.47-4.78, P = 0.001) were associated with undergoing extended LND., Conclusions: Robot-assisted LND can achieve similar LN yields to those of open LND after RC. High-volume surgeons are more likely to perform extended LND, reflecting a correlation between their growing experience and increased comfort with advanced vascular dissection., (© 2013 BJU International.)

Objective: To present our experience and outcomes with robotic mid and distal ureteral reconstruction and to compare these results with our previous laparoscopic series., Methods: In an institutional review board-approved retrospective study, 16 patients underwent robotic mid and distal ureteral repair (13 ureteral reimplantations and 3 ureteroureterostomies) at our institution from August 2008 to September 2011. Proximal ureteral stricture, extrinsic obstruction, and ureteropelvic junction obstruction cases were excluded. The demographic, perioperative, and postoperative data were reviewed in the reimplantation and ureteroureterostomy robotic groups. These data were compared with the outcomes from our previously published series on laparoscopic ureteral reimplantation., Results: The data from 16 robotic procedures were included in the present study, including 2 open conversions because of excessive scar tissue. A symptomatic bowel injury (Clavien grade IIIb) occurred in 1 case. In our previous series, 5 of the 6 laparoscopic procedures were performed completely laparoscopically with 1 open conversion for anastomosis completion. No major complications occurred. The mean robotic surgery time was 258.6 minutes (range 146-450) compared with 276.5 minutes (range 180-360) for the laparoscopic group. The mean robotic hospital stay was 2.5 days (range 1-8) compared with 2.7 days (range 2-5) for the laparoscopic group. The mean robotic estimated blood loss was 171 mL (range 30-500) compared with 150 mL (range 50-250) for the laparoscopic group. All cases were clinically and radiographically successful at the last follow-up examination., Conclusion: Although early in our experience, the robotic repair of mid and distal ureteral strictures appears to be an efficacious approach comparable to laparoscopy for such conditions., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives. To determine the relationship between preoperative erythrocyte sedimentation rate (ESR) and overall survival in localized renal cell carcinoma (RCC) following nephrectomy. Methods. 167 patients undergoing nephrectomy for localized RCC had ESR levels measured preoperatively. Receiver Operating Characteristics curves were used to determine Area Under the Curve and relative sensitivity and specificity of preoperative ESR in predicting overall survival. Cut-offs for low (0.0-20.0 mm/hr), intermediate (20.1-50.0 mm/hr), and high risk (>50.0 mm/hr) groups were created. Kaplan-Meier analysis was conducted to assess the univariate impact of these ESR-based groups on overall survival. Univariate and multivariate Cox regression analysis was conducted to assess the potential of these groups to predict overall survival, adjusting for other patient and tumor characteristics. Results. Overall, 55.2% were low risk, while 27.0% and 17.8% were intermediate and high risk, respectively. Median (95% CI) survival was 44.1 (42.6-45.5) months, 35.5 (32.3-38.8) months, and 32.1 (25.5-38.6) months, respectively. After controlling for other patient and tumor characteristics, intermediate and high risk groups experienced a 4.5-fold (HR: 4.509, 95% CI: 0.735-27.649) and 18.5-fold (HR: 18.531, 95% CI: 2.117-162.228) increased risk of overall mortality, respectively. Conclusion. Preoperative ESR values represent a robust predictor of overall survival following nephrectomy in localized RCC.

Purpose: Bilateral ureteroscopy can be done in 1 sitting, obviating the need for multiple procedures. We analyzed our experience with same session bilateral ureteroscopy to determine its safety and efficacy., Materials and Methods: In this retrospective study of a 9-year period at Emory University Hospital 1,575 consecutive ureteroscopic procedures were done, of which 95 (6.0%) were done as same session bilateral ureteroscopy, thus constituting our study cohort. Bilateral procedures were performed for urolithiasis in 71 cases, urothelial carcinoma in 9, ureteral stricture in 2 and another indication in 13. Patients were followed at least 1 month postoperatively to evaluate procedural success and assess perioperative complications., Results: Mean age of the 44 male and 40 female patients was 49.8 years. Multiple procedures were done in 9 patients and same session bilateral ureteroscopy was done in 93 of 95 (98%). Intraoperative and postoperative (greater than 1 month) bilateral stone-free rates were 86% and 64%, respectively. The mean change in serum creatinine postoperatively was 0.02 mg/dl (range -0.9 to 1.3). No patient had acute postoperative azotemia. Postoperative complications in 9.7% of patients included pain necessitating an emergency room visit in 4, pyelonephritis/urinary tract infection in 2, and urinary retention, intractable stent pain leading to early removal and urosepsis/death in 1 each., Conclusions: Same session bilateral ureteroscopy is efficacious and safe to evaluate and treat upper tract pathology. While most complications are minor, they may be higher than that typically reported for unilateral ureteroscopic procedures., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Acute flank pain is a frequent clinical presentation encountered in emergency departments, and a work-up for obstructive urolithiasis in this setting is a common indication for computed tomography (CT). However, imaging alternatives to CT for the evaluation of renal colic are warranted in some clinical situations, such as younger patients, pregnancy, patients that have undergone multiple prior CT exams and also patients with vague clinical presentations. MRI, although relatively insensitive for the direct detection of urinary calculi, has the ability to detect the secondary effects of obstructive urolithiasis. Using rapid, single shot T2-weighted sequences without and with fat saturation provides an abdominopelvic MR examination that can detect the sequelae of clinically active stone disease, in addition to alternate inflammatory processes that may mimic the symptoms of renal colic. In addition, MR nephro-urography (MRNU) has the ability to provide quantitative analysis of renal function that has the potential to direct clinical management in the setting of obstructing calculi. This review describes the potential utility and limitations of MRI in the emergency setting for diagnosing causes of flank pain and renal colic, particularly in patients with unusual presentations or when an alternative to CT may be warranted., (© 2010 Wiley-Liss, Inc.)

Purpose: To evaluate the impact of socioeconomic status (SES) on dietary habits in stones formers (SF) as there is an obvious association between dietary habits and risks of urolithiasis., Methods: SF were selected to complete the Diet History Questionnaire (DHQ) and an SES questionnaire. Meaningful dietary constituents were generated from DHQ raw data. SF were considered of lower SES if they had less than 12 years of education and lived below the poverty level., Results: Ninety-nine SF completed the DHQ and SES questionnaires. Thirty-seven SF had low education, whereas 62 high education levels. Significant mean dietary constituents by education level (lower vs higher) were calcium (1058.4 vs 705.0 mg/d), carbohydrate (394.9 vs 253.4 g/d), cholesterol (398.7 vs 253.4 mg/d), dietary fiber (24.6 vs 17.9 g/d), food energy (3307.9 vs 2051.5 kcal/d), phosphorus (1903.9 vs 1220.1 mg/d), potassium (4195.6 vs 2861.5 mg/d), and sodium (5136.8 vs 3050.5 mg/d) (P <.05). Thirty-four SF were below the poverty level and 60 above it. Significant mean dietary constituents by annual income (below vs above poverty level) were carbohydrate (397.6 vs 259.3 g/d), dietary fiber (26.1 vs 17.8 g/d), magnesium (481.8 vs 316.7 mg/d), and potassium (4141.9 vs 3031.6 mg/d), (P <.05)., Conclusions: SES impacts dietary habits and this may strongly influence stone formation and recurrence. Therefore, dietary counseling and modification as prevention for further stone formation should be more emphasized in SF of lower SES., (Copyright 2010 Elsevier Inc. All rights reserved.)

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

Introduction: Laparoscopic radical nephrectomy has become an international standard of care for medium to large renal tumors. Endovascular aneurysm repair (EVAR) has been accepted as a reasonable alternative to open abdominal aortic aneurysm (AAA) repair. We report a case of minimally invasive management of two potentially lethal diseases in a single hospitalization., Patient and Methods: The patient is a 76-year-old male who was found to have an incidental finding of an AAA and an enhancing 9 cm left central renal mass. He was deemed to be an appropriate candidate for endovascular AAA repair and laparoscopic nephrectomy based on preoperative imaging. Secondary to mild, chronic renal insufficiency, a staged approach was planned: EVAR followed by nephrectomy., Results: Successful minimally invasive treatments of the AAA and renal mass were accomplished in a staged fashion within 48 hours. The patient underwent successful EVAR for his inflammatory aneurysm and was admitted after the procedure for hydration and renal function monitoring. Two days later, a successful laparoscopic radical nephrectomy was performed. The patient was discharged postnephrectomy day 3 and hospital day 5. Pathology revealed a T2NxMx conventional renal cell carcinoma (RCC). He has been continuously followed for 4 years postoperatively with no evidence of cancer recurrence and a shrinking aneurysm sac without leak., Conclusions: We present a case of two potentially lethal disease processes previously handled in an open surgical fashion just a few short years ago. A combination of minimally invasive approaches in a staged fashion allowed a prompt patient recovery with no significant postoperative morbidity. To our knowledge, this represents the first case report of a staged minimally invasive treatment of synchronous vascular and renal pathology.

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

Purpose: Hepatic insufficiency is a medically debilitating disease state, resulting in coagulopathy, malnutrition and immunological suppression. Before and after liver transplantation patients are at increased risk for urolithiasis due to nutritional factors, acidosis and hyperoxaluria., Materials and Methods: We retrospectively reviewed our experience with endourological procedures for nephrolithiasis in hepatic compromised patients awaiting transplants and recipients. A total of 16 patients, including 13 males and 3 females, with a mean age of 52.8 years (range 46 to 59) underwent a total of 24 endoscopic stone procedures at 23 anesthesia sessions. Procedures included 18 ureteroscopies (extraction with or without lithotripsy), 5 percutaneous nephrolithotomies and 1 cystoscopic stone manipulation. Of the patients 12 patients had significant hepatic insufficiency and were evaluated for transplantation. Four patients had a prior orthotopic liver transplant at surgery. The most common causes of cirrhosis were hepatitis C and ethanol abuse. Of 22 sessions 12 were preceded by the use of fresh frozen plasma, platelets, vitamin K, desmopressin or recombinant factor VIIa for reversing severe coagulopathy. In 4 patients procedures were preceded by transfusion for anemia., Results: All 24 procedures were successfully accomplished. Average hospital stay was 2.8 days (range 0 to 8) with 5 patients treated on an outpatient basis. A total of 52 calculi with a mean size of 10.7 mm (range 2 to 40) were treated. Of the 17 evaluated stone analyses 15 revealed pure or mixed calcium oxalate calculi, while the remaining 2 were struvite. Morbidity included 2 postoperative transfusions and 1 rehospitalization for urinary tract infection. One death was due to multisystem organ failure in a pretransplant patient who underwent bilateral ureteroscopy., Conclusions: Endourological procedures may be accomplished in this morbid group of patients. Mandatory preoperative medical evaluation, selective prehospitalization with supportive services and pre-stenting patients for passive ureteral dilation have led to successful endourological outcomes. Our experience has led us to adopt protocols and apply a team approach for the successful endoscopic management of urolithiasis in this complicated group of patients.

Background and Objectives: The incidence of ureteral injuries is on the rise. Endoscopic treatment of long distal ureteral strictures is associated with poor success rates, and open ureteral reimplantation is a potentially morbid surgical procedure. The objective of this study was to review our early results with laparoscopic ureteral reimplantation., Methods: Between May 2004 and February 2007, 6 patients with ureteral strictures secondary to either gynecological surgery (4) or urolithiasis (2) presented for treatment. These patients failed traditional conservative treatment and underwent laparoscopic ureteral reimplantation., Results: Five of the 6 cases were performed completely laparoscopically, while one patient had an elective open conversion to complete the vesicoureteral anastomosis. No major intraoperative or postoperative complications were encountered. The mean operating room time was 277 minutes (range, 180 to 360). The average hospital stay was 2.7 days (range, 2 to 5). All patients had a successful outcome defined as no evidence of radiographic obstruction and no clinical complaints of persistent renal colic. Mean follow-up was 13.2 months (range, 2 to 33)., Conclusion: Our early results demonstrate that laparoscopic ureteral reimplantation is an effective minimally invasive treatment option for distal ureteral strictures.

Renal tumor classification is important because histopathological subtypes are associated with distinct clinical behavior. However, diagnosis is difficult because tumor subtypes have overlapping microscopic characteristics. Therefore, ancillary methods are needed to optimize classification. We used oligonucleotide microarrays to analyze 31 adult renal tumors, including clear cell renal cell carcinoma (RCC), papillary RCC, chromophobe RCC, oncocytoma, and angiomyolipoma. Expression profiles correlated with histopathology; unsupervised algorithms clustered 30 of 31 tumors according to appropriate diagnostic subtypes while supervised analyses identified significant, subtype-specific expression markers. Clear cell RCC overexpressed proximal nephron, angiogenic, and immune response genes, chromophobe RCC oncocytoma overexpressed distal nephron and oxidative phosphorylation genes, papillary RCC overexpressed serine protease inhibitors, and extracellular matrix products, and angiomyolipoma overexpressed muscle developmental, lipid biosynthetic, melanocytic, and distinct angiogenic factors. Quantitative reverse transcriptase-polymerase chain reaction and immunohistochemistry of formalin-fixed renal tumors confirmed overexpression of proximal nephron markers (megalin/low-density lipoprotein-related protein 2, alpha-methylacyl CoA racemase) in clear cell and papillary RCC and distal nephron markers (beta-defensin 1, claudin 7) in chromophobe RCC/oncocytoma. In summary, renal tumor subtypes were classified by distinct gene expression profiles, illustrating tumor pathobiology and translating into novel molecular bioassays using fixed tissue.

Background: Dedicated minimally invasive surgery suites are available that contain specialized equipment to facilitate endoscopic surgery. Laparoscopy performed in a general operating room is hampered by the multitude of additional equipment that must be transported into the room. The objective of this study was to compare the preparation times between procedures performed in traditional operating rooms versus dedicated minimally invasive surgery suites to see whether operating room efficiency is improved in the specialized room., Methods: The records of 50 patients who underwent laparoscopic procedures between September 2000 and April 2002 were retrospectively reviewed. Twenty-three patients underwent surgery in a general operating room and 18 patients in an minimally invasive surgery suite. Nine patients were excluded because of cystoscopic procedures undergone prior to laparoscopy. Various time points were recorded from which various time intervals were derived, such as preanesthesia time, anesthesia induction time, and total preparation time. A 2-tailed, unpaired Student t test was used for statistical analysis., Results: The mean preanesthesia time was significantly faster in the minimally invasive surgery suite (12.2 minutes) compared with that in the traditional operating room (17.8 minutes) (P=0.013). Mean anesthesia induction time in the minimally invasive surgery suite (47.5 minutes) was similar to time in the traditional operating room (45.7 minutes) (P=0.734). The average total preparation time for the minimally invasive surgery suite (59.6 minutes) was not significantly faster than that in the general operating room (63.5 minutes) (P=0.481)., Conclusion: The amount of time that elapses between the patient entering the room and anesthesia induction is statically shorter in a dedicated minimally invasive surgery suite. Laparoscopic surgery is performed more efficiently in a dedicated minimally invasive surgery suite versus a traditional operating room.

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

Purpose: In an effort to streamline a comparison of the effectiveness of a new lithotriptor with the standard HM3 lithotriptor (Dornier Medical Systems, Inc., Marietta, Georgia) we used a matched pair analysis design. A matched design often provides more efficient estimates (smaller variances) than an unmatched design given the same sample size., Materials and Methods: Patients with solitary renal or ureteral calculi treated on a LithoTron shock wave lithotriptor (HealthTronics, Marietta, Georgia) between October 1999 and February 2000 with a minimum followup of 3 months were identified. Evaluable patients treated with the LithoTron were matched using 5 parameters to a data base of patients treated with an unmodified HM3 shock wave lithotriptor between October 1997 and February 2000. Matching criteria consisted of calculus side, calculus location (1 of 7 categories), maximum stone diameter (+/-2 mm.), minimum stone diameter (+/-2 mm.) and patient body mass index (BMI +/-6). When more than 1 match was suitable, matching was directed by random numbers. Following matching, clinical charts and radiographic reports were evaluated for stone clearance and post-shock wave lithotripsy interventions. Stone treatment success was defined as residual fragments less than 2 mm. without need for further intervention., Results: A total of 94 potentially evaluable patients treated with the LithoTron were identified and 38 matched pairs were created. Average maximum stone diameter, minimum stone diameter, and BMI were 9.6 and 9.9 mm., 6.7 and 6.8 mm. and 29.3 and 28.9 kg./m. for HM3 and LithoTron cases, respectively. All calculi were radiopaque and consisted of mixed calcium oxalate monohydrate (19 and 13), calcium oxalate dihydrate (1 and 1) or calcium phosphate (2 and 2) in the HM3 and LithoTron groups, respectively. Patients were not specifically matched on stone composition because of incomplete availability. Overall intervention-free, stone treatment success rate was 79% for the HM3 and 58% for the LithoTron. OR for failure of LithoTron versus HM3 treatment was 3.004 (McNemar test p = 0.08). There were 16 discordant pairs. In 4 cases LithoTron was successful and HM3 failed, and in 12 cases LithoTron failed and HM3 was successful. Subgroup analysis revealed a trend for LithoTron treatment failure for lower pole calculi, calculi 10 mm. or greater and BMI of 30 kg./m. or greater., Conclusions: In this initial evaluation the HM3, despite a relatively small study sample size, appeared to provide superior clinical results to the LithoTron (p = 0.08). The use of matched pair analysis using a large cohort of patients treated with the HM3 for retrospective matching may allow for accurate determination of the effectiveness of new lithotripsy technology with a relatively small clinical study group.

We present a rare case of a 50-year-old woman with complete bladder, urethral, and vaginal duplication without previous urogenital system reconstruction. Our patient demonstrated a rare embryologic defect with complete bladder, urethral, and vaginal duplication without any functional dysfunction. She was able to reach adulthood without reconstructive surgery. This case allowed the unique opportunity of evaluating these urogenital anomalies at a later point in life.

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

Purpose: Hand assisted laparoscopy affords the surgeon tactile sensation and blunt dissection, which are currently limited using the standard laparoscopic technique. Therefore, we compared standard and hand assisted laparoscopic radical nephroureterectomy for localized upper tract transitional cell carcinoma., Materials and Methods: The medical records of 27 patients who underwent standard (11) or hand assisted (16) laparoscopic radical nephroureterectomy between April 1998 and January 2001 were retrospectively reviewed. The parameters of efficacy, efficiency, safety and convalescence were compared., Results: Mean patient age was 64 and 66 years (p = 0.72) in the standard and hand assisted groups, and the mean American Society of Anesthesiologists score was 2.5 and 2.7 (p = 0.64), respectively. All standard and 15 of the 16 hand assisted (94%) procedures were successfully completed via laparoscopy. Total operative time was more than 1 hour shorter for hand assisted than for laparoscopic radical nephroureterectomy (4.9 versus 6.1 hours, p = 0.055). Mean estimated blood loss was similar in the standard and hand assisted groups (190 and 201 ml., p = 0.78). In each group 1 patient required blood transfusion. Mean specimen weight was significantly higher in hand assisted cases (576 versus 335 gm., p = 0.036). Mean time to oral intake was similar in patients who underwent standard and hand assisted laparoscopic radical nephroureterectomy (13 and 20 hours, respectively, p = 0.45). The mean analgesic requirement was also similar (29 and 33 mg. morphine sulfate, respectively, p = 0.83). Mean hospital stay in uncomplicated cases was similar for standard and hand assisted surgery (2.9 and 2.5 days, respectively). Overall hospital stay in the 2 cohorts was also similar (3.3 and 4.5 days, respectively, p = 0.59). Four patients per group experienced postoperative complications. There were no deaths in the standard group but 1 patient (6%) in the hand assisted group died postoperatively. Mean time to partial and complete convalescence in the standard and hand assisted groups was 2.4 and 5.2, and 3.5 and 8.0 weeks, while mean followup was 27.4 and 9.6 months, respectively., Conclusions: Compared with standard laparoscopy hand assisted laparoscopy decreases operative time without significantly altering short-term parameters of convalescence. However, long-term convalescence after hand assisted laparoscopic radical nephroureterectomy is 1 to 3 weeks longer (p = 0.27). Longer followup in the hand assisted cohort is necessary to determine whether there are any differences in the 2 methods in regard to cancer control.

Objectives: To evaluate adhesion formation after urologic laparoscopy, a multi-institutional review was conducted among adult patients who underwent a second procedure after an initial transperitoneal laparoscopic procedure. Adhesion formation after abdominal surgery remains a major cause of postoperative morbidity. Peritoneal adhesions result in hospitalizations and interventions that result in healthcare costs of more than 1 billion dollars annually. The risk of adhesion formation from transperitoneal genitourinary laparoscopy in adults has not been previously studied., Methods: Twenty-seven patients (mean age 45.5 years, range 24 to 71) were identified who underwent a second laparoscopic procedure after their initial urologic laparoscopic procedure was performed. The mean time between the procedures was 11.4 months (range 8 days to 38 months). At the time of the repeated laparoscopy or open surgery, the peritoneal cavity was examined and mapped for type (grade), extent (length), and location of any adhesions at the operative and trocar sites. The adhesions were graded as 0, no adhesions; 1, flimsy; 2, dense; and 3, cohesive. The extent was graded as 0, no adhesions; 1, less than 2 cm; 2, 2.1 to 10 cm; 3, greater than 10.1 cm., Results: Overall, adhesions occurred in 6 (22.2%) of 27 patients. Operative site adhesions occurred in only 3 (8.2%) of 34 possible operative sites (gastric augmentation cystoplasty, renal cyst ablation, nephropexy). Trocar site adhesions occurred in 4 (3.5%) of 114 possible sites (two nephrectomies, one cyst decortication, and one orchiectomy). All adhesions were classified as grade 1 and extent 1, except for a single grade 2, extent 2 adhesion. In most patients, retroperitonealization occurred with minimal or no scarring noted. None of the patients developed symptoms as a result of the adhesion formation., Conclusions: Although intraperitoneal adhesions do occur with adult urologic laparoscopy, the incidence is low. Also, in the few patients who do form adhesions, they are flimsy and short. This evidence, when contrasted with the available data on adhesion formation after open surgery, suggests that transperitoneal laparoscopic approaches to genitourinary surgery may have advantages over traditional open transperitoneal approaches by lowering the incidence and severity of adhesion formation.

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

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

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

Purpose: We describe the use of 99mtechnetium (Tc) dimercapto-succinic acid (DMSA) renal scintigraphy to document poorly functioning and/or ectopic renal units associated with occult ectopic ureters., Materials and Methods: During the last 8 years 6 toilet-trained girls were referred for lifelong continuous urinary dribbling. Initial radiological evaluation included renal and bladder sonography in 6, excretory urography in 4, a mercaptoacetyltriglycine-3 renal scan in 1 and cystovaginoscopy in 2. Ultimately a 99mTc-DMSA renal scan was performed in all 6 girls before surgical intervention., Results: Sonography failed to establish the diagnosis of ureteral ectopia in all cases, and revealed a normal solitary kidney in 3, normal kidneys in 1, an apparently uncomplicated unilateral duplication without hydroureteronephrosis in 1 and a contralateral uncomplicated duplication in 1. Excretory urography in 4 cases was inconclusive and showed a solitary kidney in 1, ipsilateral duplication without a normal appearing upper pole collecting system in 1, contralateral uncomplicated duplication in 1 and normal kidneys in 1. A mercaptoacetyltriglycine-3 renal scan in another girl with a solitary kidney on sonography failed to demonstrate a contralateral small ectopic kidney. Cystovaginoscopy performed in 2 patients by other pediatric urologists was nondiagnostic. 99mTc-DMSA renal scintigraphy was diagnostic in all 6 cases, and revealed a small poorly functioning ectopic kidney in 3 and a poorly functioning dysplastic upper pole moiety in 3, which were consistent with a diagnosis of ureteral ectopia. An ectopic ureter was confirmed by cystoscopic and surgical findings in all girls., Conclusions: 99mTc-DMSA renal scintigraphy reliably detects and localizes hypoplastic ectopic kidneys and poorly functioning upper pole moieties associated with occult ectopic ureters in girls with continuous urinary leakage.