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We evaluated the influence of perinephric fat invasion (PFI) compared with sinus fat invasion (SFI) on disease-free survival (DFS) and cancer-specific survival (CSS) after partial nephrectomy (PN) for stage pT3a renal cell carcinoma (RCC).Data were recorded from the consecutive records of patients who had undergone underwent PN for cT1-T2 RCC from 2007 to 2016. Of these patients, 143 had stage pT3a with SFI or PFI found on final pathologic examination. The demographic, perioperative, and pathologic variables were reviewed. DFS and CSS analyses were performed. The factors predicting disease progression in this population were assessed.After a median follow-up period of 28 months (range 15-41 months), 19 patients (13.3%) had developed recurrence, including 5 local and 14 distant metastases, with 11 cancer-specific deaths (7.7%). No differences were found in DFS (5 years, 60.9% vs. 55.3%; log-rank P = .7) or CSS (5 years, 81% vs. 74.2%; log-rank P = .8) between the SFI and PFI groups. For the pT3a fat invasion population, the 2- and 5-year DFS and CSS rates were 83.6% and 58.6% and 93.6% and 78%, respectively. SFI (P = .5) and positive surgical margins (P = .1) did not predict for progression. On multivariate Cox regression, increased tumor size (hazard ratio, 1.5; 95% confidence interval, 1.1-1.9; P .01) and higher tumor grade (hazard ratio, 3.6; 95% confidence interval, 1.1-4.6; P = .04) were independent predictors of disease progression in the pT3a fat invasion population.In our series of patients with pT3a RCC after PN, SFI compared with PFI was not associated with an increased risk of progression or cancer-specific death.

Frozen sections (FS) are routinely employed to assess margin status during partial nephrectomy (PN) for clinically localized renal cell carcinoma (CLRCC); however, their oncologic benefit remains unclear. There have been no studies investigating the long-term impact of FS on local or metastatic recurrence. We wished to determine whether the utilization of FS for this purpose during PN influenced recurrence rates.We performed a retrospective review of 1090 patients with (n = 172) and without (n = 918) FS during open and robotic PN between 2006 and 2016 for CLRCC at a single tertiary care institution. Standard follow-up protocols were employed, with imaging used to guide subsequent biopsy for confirmation. Univariate and multivariate competing-risk regression analysis predicting the association of FS status and clinicodemographic characteristics with recurrence, with adjustment for all-cause mortality, were performed. Administrative data were reviewed to calculate costs of FS.Forty-five out of 1090 (4.13%) patients had recurrence. There was no difference in the cumulative incidence of recurrence between patients with and without FS (χIntraoperative FS for margins during PN did not predict decreased recurrence rates in a single-institution high-volume center. Given the lack of associated benefit, and the added cost, the utilization of FS during PN should be limited.

Introduction: Renal mass biopsy is useful in the evaluation of small renal masses. We have previously reported that office based, ultrasound guided renal mass biopsy is safe, effective and feasible when performed by urologists. This study compares office based, ultrasound guided renal mass biopsy performed by urologists and hospital based renal mass biopsy.Methods: We retrospectively studied 70 patients who underwent office based, ultrasound guided renal mass biopsy and 155 who underwent hospital based, ultrasound or computerized tomography guided renal mass biopsy for evaluation of a small renal mass (4.0 cm or less) between January 2010 and February 2016.Results: A total of 70 patients underwent office based, ultrasound guided renal mass biopsy. Median age in this group was 69.5 years, median body mass index was 29.5 kg/m2 and 61.4% of the patients (43) were male. A total of 103 patients underwent hospital based, ultrasound guided biopsy. Median age in this group was 68.0 years, median body mass...

Objectives: To compare the perioperative and functional outcomes after open and robotic partial nephrectomy performed with cold ischemia. Methods: A retrospective chart review was completed of consecutive patients who underwent partial nephrectomy with renal hypothermia between January 2011 and September 2016. The study cohort included both open (Open Cold Ischemia, OCI; n=170) and robotic (Robotic Cold Ischemia, RCI; n=31) patients with complex renal masses (R.E.N.A.L. score >7) who did not meet exclusion criteria. A modified intracorporeal technique 1 was utilized for the introduction of ice slush at the time of hilar clamping in the RCI group. Statistical testing was performed to compare key perioperative and functional outcomes after ensuring equilibration of both groups by clinicodemographic criteria. Results: Both groups were statistically equivalent with respect to baseline characteristics. Median GFR preservation postoperatively was 86.7% for the open group and 86.6% in the robotic group (p=0.49). Cold ischemia time (CIT) in the open group was 35 minutes compared to 28 minutes (p = 0.03) in the robotic group. LOS was significantly shorter by 2 days (p < 0.01) in the robotic group. Positive margins was noted to be 17 (10%) in the open group and 2 (6.5%) patients in the robotic group (p=0.48). Conclusions: We demonstrate an effective and simplified method of intracorporeal ice cooling during robotic partial nephrectomy. Our data suggests that results with this approach compare favorably to open cold ischemia technique. Intracorporeal ice cooling can be considered when performing complex partial nephrectomies with ischemia times expected to exceed 25 minutes.

We sought to identify the preoperative factors associated with conversion from robotic partial nephrectomy to radical nephrectomy. We report the incidence of this event.Using our institutional review board approved database, we abstracted data on 1,023 robotic partial nephrectomies performed at our center between 2010 and 2015. Standard and converted cases were compared in terms of patients and tumor characteristics, and perioperative, functional and oncologic outcomes. Logistic regression analysis was done to identify predictors of radical conversion.The overall conversion rate was 3.1% (32 of 1,023 cases). The most common reasons for conversion were tumor involvement of hilar structures (8 cases or 25%), failure to achieve negative margins on frozen section (7 or 21.8%), suspicion of advanced disease (5 or 15.6%) and failure to progress (5 or 15.6%). Patients requiring conversion were older and had a higher Charlson score (both p0.01), including an increased prevalence of chronic kidney disease (p = 0.02). Increasing tumor size (5 vs 3.1 cm, p0.01) and R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and hilar location) score (9 vs 8, p0.01) were also associated with an increased risk of conversion. Worse baseline renal function (OR 0.98, 95% CI 0.96-0.99, p = 0.04), large tumor size (OR 1.44, 95% CI 1.22-1.7, p0.01) and increasing R.E.N.A.L. score (p = 0.02) were independent predictors of conversion. Compared to converted cases, at latest followup standard robotic partial nephrectomy cases had similar short-term oncologic outcomes but better renal functional preservation (p0.01).At a high volume center the rate of robotic partial nephrectomy conversion to radical nephrectomy was 3.1%, including 2.2% of preoperatively anticipated nephrectomy cases. Increasing tumor size and complexity, and poor preoperative renal function are the main predictors of conversion.

We sought to identify patterns and predictors of recurrence in patients with clinically localized renal cell carcinoma managed by partial nephrectomy.We performed a retrospective study of 830 consecutive cases of partial nephrectomy done between 2007 and 2015 for clinically localized renal cell carcinoma at a single institution. Patient demographics and pathological characteristics were correlated with recurrence patterns (overall, local and distant) and overall survival using Kaplan-Meier and Cox regression analyses. Differences in the recurrence patterns were evaluated.Median patient age was 61 years and median tumor size was 3.1 cm. Overall, 11.6% of tumors were stage pT3, 39.3% were high grade, 2.9% had lymphovascular invasion and 7.1% had positive margins. Higher grade, higher stage, positive surgical margins and increased R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of deepest tumor portion to collecting system or sinus, anterior/posterior and location relative to polar line) score were associated with shorter disease-free survival on Kaplan-Meier analysis. On multivariable regression pT (p0.01), grade (p0.01) and R.E.N.A.L. score (p = 0.03) remained independent predictors of disease-free survival. Predictors of metastasis were pT stage (HR 4.5) and grade (HR 3.9, both p0.01), while R.E.N.A.L. score (HR 3.2, p = 0.03) was the single predictor of local recurrence. Five-year disease-free and overall survival probabilities were 91% and 94%, respectively. Local recurrence manifested and developed earlier than metastasis (median 13 vs 22 months, p 0.01).High pT stage, high grade and high R.E.N.A.L. score increase the risk of disease recurrence after partial nephrectomy. The pT stage and grade are predictors of metastasis, while R.E.N.A.L. score predicts local recurrence. Because relapse features and risk factors differ between the 2 recurrence patterns, they should be studied separately in the future.

Objective To evaluate the safety and efficacy of ultrasound (US)-guided percutaneous renal mass biopsy (RMB) performed in the office setting by urologists. Materials and Methods This is a retrospective study involving patients who underwent office-based US-guided percutaneous RMB between April 2010 and October 2015. Baseline vital signs and US were performed prior to the procedure. Patients were then observed for 1 hour after the procedure and repeat vital signs and US were performed. Hemodynamically stable patients who did not develop hematoma were discharged. Results In 108 patients, 70 (64.8%) were male, median age was 69.5 years, and median mass size was 3.3 cm (interquartile range: 2.5-4.6). Biopsy yield was as follows: 72 (66.7%) had renal cell carcinoma, 14 (13.0%) had benign renal parenchyma, 11 (10.2%) had oncocytoma, 6 (5.6%) had angiomyolipoma, 2 (1.9%) had lymphoma, and 3 (2.8%) had other disease. The initial nondiagnostic rate was 14 of 108 (13.0%). There were 28 of 108 (25.9%) patients observed whereas 79 of 108 (73.2%) received surgery or ablative therapy. Final pathology was concordant with biopsy results in 66 of 68 (97.1%) cases. Three patients experienced a grade I Clavien-Dindo surgical complication, all of which were managed conservatively. Conclusion Office-based US-guided RMB is safe and efficacious in the management of appropriately selected SRM. It potentially offers improved dynamic characterization of solid renal mass, greater convenience to patients, as well as cost savings. Further studies are needed to evaluate this promising technique.

To evaluate perioperative morbidity, oncological outcome and predictors of pT3a upstaging after partial nephrectomy (PN). Retrospective study of 1042 patients who underwent PN for cT1N0M0 renal cell carcinoma between 2007 and 2015. A total of 113 cT1 patients were upstaged to pT3a, while 929 were staged as pT1. Demographic, perioperative and pathological variables were reviewed. We compared the clinico-pathological characteristics, perioperative morbidity and oncological outcomes between pT3a and pT1 groups. Multivariate regression evaluates variables associated with T3a upstaging. Recurrence-free survival (RFS) and overall survival analyses were performed. Survival curves were compared using log-rank test. The pT3a tumors were high complexity tumors (median RENAL score 8 vs. 7, p

Objectives To assess the impact of approach on surgical outcomes in otherwise healthy obese patients undergoing partial nephrectomy for small renal masses. Patients and Methods Using our institutional partial nephrectomy database, we abstracted data on otherwise healthy (Charlson comorbidity score ≤1 and bilateral kidneys), obese patients (body mass index >30 kg/m2) with small renal masses (

Introduction: The surgical morbidity of ipsilateral synchronous multifocality (ISM) is poorly characterized. We assessed the impact of ISM on complications after robotic partial nephrectomy (RPN). Patients and Methods: We abstracted data on RPN cases performed between 2006 and 2015 at our institution. Multifocal disease was characterized by >1 renal mass on preoperative imaging or >1 mass excision during RPN. The primary outcome was the rate of overall postoperative complications. The association between multifocality and complications was evaluated using univariate and multivariable analyses. Results: Of 1121 cases, 59 (5.3%) had >1 ipsilateral renal mass and 50 (4.5%) required >1 excision. The overall complication rate was 20.3% (230/1121). The radiographic number of ipsilateral renal masses was not significantly associated with complications (20.2% for 1 mass vs. 25.4% for >1 mass, p = 0.338). However, the actual number of ipsilateral mass excisions performed during RPN was significantly assoc...

To identify predictors of poor discharge quality after robotic partial nephrectomy (RPN) at a large academic center. We queried our institutional RPN database for consecutive patients treated between 2011 and 2015. The primary outcome was poor discharge quality, defined as length of stay >3 days and/or unplanned readmission. The association between patient, disease, and provider factors and overall discharge quality was assessed using univariate and multivariable analyses. Of 791 cases, 219 (27.7 %) had poor discharge quality. On univariate analysis, factors associated with poor discharge quality were older age (p

Objectives To assess differences in complications after robot-assisted (RAPN) and open partial nephrectomy (OPN) among experienced surgeons. Patients and Methods We identified patients in our institutional review board-approved, prospectively maintained database who underwent OPN or RAPN for management of unifocal, T1a renal tumours at our institution between January 2011 and August 2015. The primary outcome measure was the rate of 30-day overall postoperative complications. Baseline patient factors, tumour characteristics and peri-operative factors, including approach, were evaluated to assess the risk of complications. Results Patients who underwent OPN were found to have a higher rate of overall complications (30.3% vs 18.2%; P = 0.038), with wound complications accounting for the majority of these events (11.8% vs 1.8%; P < 0.001). Multivariable logistic regression analysis showed the open approach to be an independent predictor of overall complications (odds ratio 1.58, 95% confidence interval 1.03–2.43; P = 0.035). Major limitations of the study include its retrospective design and potential lack of generalizability. Conclusions The open surgical approach predicts a higher rate of overall complications after partial nephrectomy for unifocal, T1a renal tumours. For experienced surgeons, the morbidity associated with nephron-sparing surgery may be incrementally improved using the robot-assisted approach.

Sarcomatoid and rhabdoid differentiation are associated with poor outcomes in renal cell carcinoma (RCC). We examined the impact of differentiation on cancer-specific survival (CSS) in surgically treated patients with grade 4 RCC. Using our institutional database of 1176 nephrectomies from 2005 to 2013, we identified patients with grade 4 RCC or any grade and the presence of sarcomatoid or rhabdoid differentiation. We divided the cohort based on differentiation: no differentiation, rhabdoid only, sarcomatoid only, and sarcomatoid and rhabdoid. CSS was analyzed using the Kaplan–Meier method and Cox proportional hazards modeling. Of 264 patients with grade 4 RCC, 159 (60.2 %) exhibited differentiation, including 45 (28.3 %) with rhabdoid only, 87 (54.7 %) with sarcomatoid only, and 27 (16.9 %) with rhabdoid and sarcomatoid. Sarcomatoid differentiation, either alone or with rhabdoid differentiation, was associated with worse median CSS than no differentiation (1.1 vs. 3.3 years, p

OBJECTIVE To identify preoperative factors that predict positive surgical margins in partial nephrectomy. MATERIAL AND METHODS Using our institutional partial nephrectomy database, we investigated the patients who underwent partial nephrectomy for malignant tumors between January 2011 and December 2015. Patient, tumor, surgeon characteristics were compared by surgical margin status. Multivariable logistic regression was used to identify independent predictors of positive surgical margins. RESULTS A total of 1025 cases were available for analysis, of which 65 and 960 had positive and negative surgical margins, respectively. On univariate analysis, positive margins were associated with older age (64.3 vs. 59.6, p

INTRODUCTION AND OBJECTIVE:Infectious complications following prostate biopsy remain a significant cause of patient morbidity driven by increasing antibiotic resistance. Fusion biopsy and transperi...

Introduction and objective Partial nephrectomy (PN) represents the current surgical standard for T1 tumors. Renal arterial pseudoaneurysm is a rare but potentially life-threatening complication reported after PN. The aim of this study was to identify the factors associated with the occurrence of pseudoaneurysm after PN, specifically focusing on those requiring management with selective embolization. A literature review of the topic was performed. Methods A retrospective review of the institutional PN database was performed from January 2011 to December 2016. Patients who underwent embolization for pseudoaneurysm represented a separated cohort to be compared with other patients (controls). Patients' and tumors' characteristics were considered. Univariable and multivariable analyses were used to test their eventual association with the occurrence of pseudoaneurysm. Results A total of 1417 cases were evaluated. At a median of 21 days (interquartile range = 10-34), 20 patients (1.4%) developed postoperative pseudoaneurysm. The majority of patients (70%) presented with gross hematuria. The clinical suspicion was confirmed by contrast-enhanced computed tomography scan with angiography. Selective embolization was performed using endovascular coils. Technical success and clinical success rates were 100% and 95%, respectively. No difference was found in percentage estimated glomerular filtration rate (eGFR) preserved between patients who underwent embolization versus controls (median 82.6% versus 86.3%, P = .35). No differences in age, baseline renal function (as assessed by glomerular filtration rate [GFR]), tumor size, and R.E.N.A.L. were found between patients who reported and did not report pseudoaneurysm. In patients who developed pseudoaneurysm, longer operative time (225.6 minutes versus 193 minutes, P = .04), and cold ischemia time (48 minutes versus 29 minutes, P = .03) were reported. Conclusion In our series, the occurrence of pseudoaneurysm was associated with longer operative and cold ischemia times. In patients who underwent selective embolization, renal function remained comparable with that of controls.

Understanding physician-level discrepancies is increasingly a target of US healthcare reform for the delivery of quality-focused patient care.To estimate the relative contributions of patient and surgeon characteristics to the variability in key outcomes after partial nephrectomy (PN).Retrospective review of 1461 patients undergoing PN performed by 19 surgeons between 2011 and 2016 at a tertiary care referral center.PN for a renal mass.Hierarchical linear and logistic regression models were built to determine the percentage variability contributed by fixed patient and surgeon factors on peri- and postoperative outcomes. Residual between- and within-surgeon variability was calculated while adjusting for fixed factors.On null hierarchical models, there was significant between-surgeon variability in operative time, estimated blood loss (EBL), ischemia time, excisional volume loss, length of stay, positive margins, Clavien complications, and 30-d readmission rate (all p0.001), but not chronic kidney disease upstaging (p=0.47) or percentage preservation of glomerular filtration rate (p=0.49). Patient factors explained 82% of the variability in excisional volume loss and 0-32% of the variability in the remainder of outcomes. Quantifiable surgeon factors explained modest amounts (10-40%) of variability in intraoperative outcomes, and noteworthy amounts of variability (90-100%) in margin rates and patient morbidity outcomes. Immeasurable surgeon factors explained the residual variability in operative time (27%), EBL (6%), and ischemia time (31%).There is significant between-surgeon variability in outcomes after PN, even after adjusting for patient characteristics. While renal functional outcomes are consistent across surgeons, measured and unmeasured surgeon factors account for 18-100% of variability of the remaining peri- and postoperative variables. With the increasing utilization of value-based medicine, this has important implications for the goal of optimizing patient care.We reviewed our institutional database on partial nephrectomy performed for renal cancer. We found significant variability between surgeons for key outcomes after the intervention, even after adjusting for patient characteristics.

Objective To describe our technique for performing robotic-assisted laparoscopic prostatectomy (RALP) and pelvic lymph node dissection using only 3 robotic instruments to reduce disposable costs associated with the robotic surgical platform. Methods The financial impact of robotic surgery is real. Whereas the initial capital investment of the robotic platform (including the cost of the device itself and the maintenance contract) is largely fixed, the cost of disposable instrumentation can vary depending on utilization. Herein we describe our technique for 3-instrument robotic radical prostatectomy that may decrease costs by limiting the use of disposable instruments. Results Exclusion of the high-cost energy instruments may reduce operative costs by up to 40%. In addition, using 1 robotic needle driver vs 2 may decrease overall costs by another 12%. At our institution, we have adopted these techniques in cost-efficiency and have gone further by only using 3 instruments during robotic radical prostatectomy. The only 3 instruments necessary to perform a successful RALP are a robotic needle driver, Prograsp forceps, and monopolar scissors. Conclusion To improve the value of care while utilizing robotic technology, we must be cognizant of keeping operative costs to a minimum while maintaining positive patient outcomes. We demonstrate here a method to decrease disposable operating room costs while preserving the ability to successfully perform a RALP.

Here in this chapter, we wish to outline the surgical complications specific to robotic laparoendoscopic single-site (R-LESS) surgery. This is an emerging field, and only a few centers of excellence in the world have attempted R-LESS urological procedures. Although many of the possible complications of conventional laparoscopy are inherent to R-LESS urologic surgery, they have yet to be identified by the limited number of surgical cases which have been reported in current literature. The aim of this chapter is to review the literature on R-LESS urologic surgery, describe the complications, and suggest the management strategies for each complication.

Objective To present the use of buccal mucosal graft (BMG) in a salvage robotic laparoscopic pyeloplasty as an alternative in the management of a recurrent ureteropelvic junction (UPJ) obstruction. Methods We present 2 patients with a recurrent UPJ obstruction who had previously undergone 2 prior open or robotic pyleoplasties, followed by endoscopic management. Preoperative imaging was obtained before surgical repair. The UPJ was incised and the incision extended to reveal margins of a healthy normal-caliber ureteral tissue. Single BMGs were harvested from the inner cheek of each patient. The grafts were of sufficient caliber and size to cover the entire defect as an onlay graft, and to maintain a tension-free and watertight anastomosis. Results The operative time was between 188 and 284 minutes. The estimated blood loss was 25-50 mL. The hospital stay was 2 days for each patient. Foley catheters were removed before discharge and the Jackson-Pratt drains were removed in the immediate postoperative period. The ureteral stents were removed at 6 and 9 weeks, with retrograde pyelograms confirming patency at the UPJ. Lasix renograms were obtained after 4 months and either demonstrated a resolution or were equivocal for obstruction, with a preservation of renal function. Both patients have been without complication since the stent removal. Conclusion Robotic pyeloplasty with BMG is an alternative in the management of recurrent UPJ obstructions. Short-term follow-up has demonstrated that it is an effective and attractive approach compared with more extensive and invasive surgeries such as a renal autotransplant and an ileal ureter.

Introduction and Objective We present our robotic approach and technique to manage a large left renal tumor with inferior vena cava (IVC) Level III thrombus. The superior mesenteric artery crossing the left renal vein requires robotic docking from the left, for dissection of the left kidney followed by repositioning and re-docking the robot from the right side for dissection of the right renal vein, distal and proximal IVC, and the remaining left renal vein insertion into the IVC. Methods We present a 53-year-old man with a 10.9-cm left renal mass with IVC level III tumor thrombus. A robotic left radical nephrectomy with lymph node dissection was completed using 4 ports in a midline configuration. The dissection of the left renal vein was taken medially until the superior mesenteric artery. The patient was then repositioned in the right side flank position and the robot was re-docked using the previously placed midline ports. The right renal vein, distal and proximal IVC were then controlled using modified Rummel tourniquets. Results Operative time was 530 minutes which included patient positioning, robot re-docking. The patient did not require a blood transfusion. Hospital stay was 4 days. Final pathology showed pT3bNoM1 renal cell carcinoma, clear cell type grade 4 with necrosis, and focal rhabdoid features measuring 11 cm. The tumor invaded the renal sinus and the renal vein and was metastatic to the ipsilateral adrenal gland. Margins were negative. Conclusion Herein we present a successful outcome of a left-sided robotic radical nephrectomy with IVC level III tumor thrombectomy.

Objective To compare outcomes between robot-assisted partial nephrectomy (RAPN) and open PN (OPN) for completely endophytic renal tumours. Patients and Methods We retrospectively reviewed 1 230 consecutive cases, consisting of 823 RAPNs and 407 OPNs, performed for renal mass at a single academic tertiary centre between 2011 and 2016. Of these, data on 87 RAPN and 56 OPN cases for completely endophytic renal tumours were analysed. Patient and tumour characteristics, operative, postoperative, functional, and oncological outcomes were compared between groups. Results Apart from a higher prevalence of solitary kidney among OPN cases (RAPN, 5.7% vs OPN, 21.4%; P = 0.005), demographic characteristics were similar between the groups. There were no statistically significant differences in tumour size (P = 0.07), tumour stage (P = 0.3), margin status (P = 0.48), malignant tumour subtypes (P = 0.51), and grades (P = 0.61) between the groups. Also, there were no statistically significant differences among the groups for warm ischaemia time (P = 0.15), cold ischaemia time (P = 0.28), and intraoperative (P = 0.75) or postoperative (Clavien–Dindo Grade I–V, P = 0.08; Clavien–Dindo Grade III–V, P = 0.85) complication rates. The patients in the RAPN group had a shorter length of stay (P < 0.001), less estimated blood loss (P < 0.001), and lower intraoperative transfusion rates (0% vs 7.1%, P = 0.02). No local recurrences occurred during a median (interquartile range) follow-up of 15.2 (7–27.2) and 18.1 (8.2–30.9) months in the RAPN and OPN groups, respectively. There was no difference in estimated glomerular filtration rate preservation rates between groups for the early (P = 0.26) and latest (P = 0.22) functional follow-up. Conclusion For completely endophytic renal tumours, both OPN and RAPN have excellent outcomes when performed by experienced surgeons at a high-volume centre. For skilled robotic surgeons, RAPN is a safe and effective alternative to OPN with the advantages of shorter length of stay and less blood loss.

To compare perioperative outcomes between robotic partial nephrectomy and open partial nephrectomy for localized7 cm tumors.We identified patients in our institutional review boards approved database who underwent robotic partial nephrectomy or open partial nephrectomy for treatment of renal tumors7 cm in size between January 2009 and August 2015. The operative-postoperative outcomes and complications were compared between groups.The number of patients with7 cm renal tumors treated at our center with robotic partial nephrectomy and open partial nephrectomy were 54 and 56, respectively. Patients' demographics and tumor characteristics were similar between groups. Likewise, there were no significant difference between the groups in duration of operation, positive surgical margin rates and incidence of malignant disease rates. Median ischemia time was lower in robotic partial nephrectomy group (31.5 vs. 35 min., p = 0.02). Patients undergoing robotic partial nephrectomy had significantly lower intraoperative blood transfusion rates (9.4 vs. 30.4 %, p = 0.008) and shorter length of hospital stay (3.5 vs. 5.3 days, p 0.001). The incidence of overall complications (robotic arm, 18.5 % vs. open arm, 28.6 %, p = 0.26) and major complications (robotic arm, 3.7 % vs. open arm, 12.5 %, p = 0.16) was comparable between the two groups. The readmission rate within 30-days after discharge was higher in open partial nephrectomy group (p = 0.03). There was no difference in the median percentage estimated glomerular filtration rate preservation and chronic kidney disease upstaging between groups.Localized renal tumors7 cm and amenable to partial nephrectomy can be considered suitable for robotic approach.

The use of hemostatic agents (HA) during robotic partial nephrectomy (RPN) is largely empiric. We sought to assess the impact of HA on postoperative bleeding after RPN in a contemporary cohort.Using our institutional RPN database, we identified consecutive patients treated between 2010 and 2015. HA were routinely placed in the nephrectomy bed at the time of renorrhaphy until 2014 when their use was phased out to reduce cost. We compared postoperative bleeding outcomes (blood transfusion and hemoglobin decline) between patients who did and did not receive HA, after excluding patients with preoperative anemia (hemoglobin11 g/dL) or high estimated blood loss (≥175 mL). The total inflation-adjusted costs (for 2015) of HA were calculated.Of 544 cases, HA were used in 240 (44.1%). The mean number of agents per case was 1.4 ± 0.73, including 77 (14.2%), 52 (9.6%), and 39 (7.2%) cases in which cellulose, fibrin, or gelatin-based agents were used alone, respectively, and 72 (13.2%) cases in which multiple agents were used. The mean cost of HA per case was $488 ± 421. Nearly 90% of cases were performed by surgeons who were beyond their learning curves. Overall, 13 (2.4%) patients were transfused, and the median hemoglobin decline was 2.2 g/dL (IQR, 1.4-3.0 g/dL). On univariate analysis, HA use and type of HA were not significantly associated with blood transfusion (p = 0.20 and p = 0.29, respectively), but were associated with hemoglobin decline (p = 0.01 and p = 0.02, respectively). After adjusting for covariates, HA use was no longer significantly associated with postoperative hemoglobin decline.In nonanemic patients with minimal intraoperative bleeding, HA use does not alter postoperative bleeding outcomes after RPN, suggesting that their routine use in this setting merits reconsideration. Further research is needed to determine if HA may be useful in certain high-risk situations.

using a novel three dimensional (3d) printing and silicone casting technology. METHODS: Using standard preoperative imaging, 3d reconstruction of renal parenchyma and tumor was performed to generate solid models suitable for rapid fabrication. Leveraging a novel prototyping process that utilizes 3d extrusion printing and subsequent polymer casting we generated pre-surgical models out of a silicone-based material. To determine how well these patientspecific models simulated actual operative experience, we compared enucleation times between model and actual tumor using the same robotic platform. For the final model, we performed 3d laser scans of both the enucleated model and tumor comparing their spatial characteristics. All surgical rehearsals were performed prior to the actual procedure. RESULTS: We generated patient-specific pre-surgical models for 3 patients. R.E.N.A.L. nephrometry scoring for the pre-surgical models was 7a, 8p, 8a and tumor sizes were 3.5x3.4x3.5 cm, 4.1x3.8x3.5 cm, and 1.5x1.4x1.4 cm. Time of enucleation was similar between the patient-specific pre-surgical models and the actual surgery (6:24 vs. 5:58, 3:11 vs. 3:43, 4:55 vs. 6:09 mins). For case #3, the surgical model enucleation volume measured 6.4 mm3 and the actual excised specimen 12.8 mm3. A 3d-reconstructed visual overlay demonstrated a high level of coherence in the shape of the excised tumor and allowed measurement of the difference in the volume of excised normal renal parenchyma between the model and the actual patient specimen. CONCLUSIONS: We have developed a patient-specific presurgical simulation for robotic partial nephrectomy. Our model provides accurate representation of enucleation time and volume of resected tissue. This highly reproducible simulation platform has the potential to alter surgical decision-making and allow for preoperative rehearsal in complex cases. Furthermore it may become a valuable tool for resident training.

INTRODUCTION AND OBJECTIVES: Robotic partial nephrectomy (RPN) for completely endophytic renal masses is feasible with increased robotic surgical experience. In this video we demonstrate our surgical technique for robotic partial nephrectomy, focusing on the technical variations for RPN for completely endophytic tumors. METHODS: Between June 2006 and August 2015, our institution performed 1,123 partial nephrectomies. 130 were performed for completely endophytic renal tumors. We present 2 patients with completely endophytic, central renal masses who underwent RPN, one in the left kidney and one in the right. Our approach to surgical removal of completely endophytic renal tumors includes the use of intraoperative ultrasound to delineate the margins of the mass, initial shallow angle of resection to improve visualization of the parenchymal margin and tumor base, and correction of excision trajectory at the renal sinus. This technique is described in detail in our video presentation. RESULTS: Of the 1,123 RPN performed at our institution over the last 10 years, 11.6% were performed for completely endophytic renal masses. Mean operative time, warm ischemia and estimated blood loss in this cohort were 180 minutes, 24.5 minutes, and 197 cc, respectively. Minor complicate rate in this group was 13.9%, while major complication rate was 13.9%. 7 patients in this group had positive margins (5.4%). Successfully surgical extirpation of completely endophytic renal masses is optimized by an initially shallow incision in order to obtain a clear view of the parenchymal edge and base of tumor. Once the sinus fat and collecting system are exposed, the trajectory of the excision is corrected and the sides and back of the tumor are excised in a step-wise, circumferential fashion. CONCLUSIONS: RPN for completely endophytic renal tumors is feasible and necessitates technical variations in excision in order to optimize outcomes. Excision of the tumor should be performed in a step-wise systematic fashion with a shallow initial incision to improve visualization into the renal defect and to avoid cutting into the tumor.

Since volume loss is the most important modifiable determinant of long-term renal function after partial nephrectomy, there is great interest in ways to reduce the loss of healthy parenchyma. We retrospectively reviewed 880 partial nephrectomies to identify predictors of excisional volume loss (EVL), based on pathologic assessment. After stepwise variable selection, we assessed age, sex, solitary kidney status, tumor size, endophytic property, estimated blood loss, surgical approach, and surgeon volume for association with EVL using multiple regression. Male sex (p0.01), larger tumors (p0.01), endophytic tumors (p=0.01), open approach (p0.01), increased bleeding (p0.01), and higher surgeon volume (p0.01) were independently associated with greater EVL. Approach strongly influenced EVL with open surgery having 7.8 cm(3) more EVL than robotic surgery. Negative surgical margins (95.7% vs 94.1%, p=0.32) did not differ between open and robotic approaches, respectively. EVL is associated with patient, tumor, and especially provider factors, suggesting that volume preservation may be improved with surgical optimization. Lack of percent volume loss data, which precluded assessment of EVL's impact on long-term renal function, is a limitation.We found that surgical approach affects the quantity of healthy kidney removed during cancer surgery, suggesting that there is room for further surgical improvement.

Experiments determined methanol removal and catalyst elutriation rates during photocatalytic oxidation (PCO) of fluidized and packed beds of various titania-based catalysts. The study developed elutriation-resistant catalysts in which TiO 2 was precipitated from solution (p-TiO 2 ), or was coated on an Al 2 O 3 support (TiO 2 /Al 2 O 3 ) and compared them to Degussa P-25 TiO 2 . Although Degussa P-25 TiO 2 oxidized methanol effectively, it elutriated at a rate that was two orders of magnitude greater than those of p-TiO 2 and TiO 2 /Al 2 O 3 . In addition, TiO 2 /Al 2 O 3 removed methanol at a significantly greater rate than did P-25, with p-TiO 2 being the least active. Fluidized beds produced greater PCO rates than did packed beds of P-25 and TiO 2 /Al 2 O 3 . Fluidization enhancers, such as vibration and incorporation of a static mixer, improved the performance of the P-25 fluidized bed, but did not change the effectiveness of TiO 2 /Al 2 O 3 or p-TiO 2 . The activity of TiO 2 /Al 2 O 3 decreased with increasing calcination temperature (over the temperature range 673–873 K). The optimum TiO 2 loading for TiO 2 /Al 2 O 3 was 30 wt.%.

Robotic surgery in the treatment in certain urological diseases has become a mainstay. With the increasing use of the robotic platform, some surgeries which were historically performed open have transitioned to a minimally invasive technique. Recently, the robotic approach has become more utilized for ureteral reconstruction. In this article, the authors review the surgical techniques for a number of major ureteral reconstuctive surgeries and briefly discuss the outcomes reported in the literature.

Objectives The aim of this study was to analyze the outcomes of surveillance after partial nephrectomy (PN) in a single institution and the relevance of imaging studies in detecting recurrence. Material and methods Retrospective study of 830 patients who underwent PN for localized renal cell carcinoma between 2007 and 2015 at a single institution. We studied the characteristics of recurrence according to pathological and clinical features and elaborated risk groups. The type and the total number of imaging studies performed during surveillance or until recurrence were evaluated. Outcomes of surveillance were analyzed. Results There were 48 patients (5.8%) diagnosed with recurrence during median 36 [21–52] months follow-up, including local recurrence in 18 patients (37.5%) and metastasis in 30 patients (62.5%). Totally, 17/18 patients (94.4%) with local recurrence and 26/30 patients (86.6%) with metastasis were diagnosed within the first 36 months after PN. When studying the recurrence rate, and time-to-recurrence, 2 risk groups emerged. Patients with pathological characteristics (tumors with pT1b or higher or high-grade tumor or positive surgical margin status) or patients with anatomical characteristics (high or moderate R.E.N.A.L. score) or both had high recurrence rate. Chest x-ray and abdominal ultrasound detected 7.7% and 3.4% of all recurrences, respectively, whereas computed tomography scan and magnetic resonance imaging scan detected the rest. Of the 48 patients diagnosed with recurrence, 44 (91.6%) were suitable for secondary active treatment (systemic, surgery, and radiotherapy) including 26 (54.2%) suitable for metastasectomy. The rate of relapse after secondary treatment was 43.5% (16.6% for the local recurrence group and 60.7% for metastasis group). Conclusion Local recurrence emerges earlier than distant metastasis. Patients with any adverse pathological or anatomical features should be considered as high-risk group and followed closely in the first 36 months after PN with cross-sectional studies. Secondary active treatment is suitable for most patients, while surgical treatment fits fewer patients. Local recurrence is associated with increased rates of metastatic progression.

Introduction: Augmentation ileocystoplasty is a common treatment in adults with low capacity bladders due to neurogenic bladder dysfunction. We describe here our technique for robotic assisted laparoscopic augmentation ileocystoplasty in an adult with a low capacity bladder due to neurogenic bladder dysfunction. Materials and Methods: The patient is a 35 years-old man with neurogenic bladder due to a C6 spinal cord injury in 2004. Cystometrogram shows a maximum capacity of 96cc and Pdet at maximum capacity of 97cmH2O. He manages his bladder with intermittent catheterization and experiences multiple episodes of incontinence between catheterizations. He experiences severe autonomic dysreflexia symptoms with indwelling urethral catheter. He has previously failed non operative management options of his bladder dysfunction. Our surgical technique utilizes 6 trocars, of note a 12mm assistant trocar is placed 1cm superior to the pubic symphysis, and this trocar is solely used to pass a laparoscopic stapler to facilitate the excision of the ileal segment and the enteric anastomosis. Surgical steps include: development of the space of Retzius/dropping the bladder; opening the bladder from the anterior to posterior bladder neck; excision of a segment of ileum; enteric anastomosis; detubularizing the ileal segment; suturing the ileal segment to the incised bladder edge. Results: The surgery had no intraoperative complications. Operative time was 286 minutes (4.8 hours). Estimated blood loss was 50cc. Length of hospital stay was 8 days. He did experience a postoperative complication on hospital day 3 of hematemesis, which did not require blood transfusion. Cystometrogram at 22 days post operatively showed a maximum bladder capacity of 165cc with a Pdet at maximum capacity of 10cmH2O. Conclusions: As surgeon comfort and experience with robotic assisted surgery grows, robotic surgery can successfully be applied to less frequently performed procedures. In this case we successfully performed a robotic assisted laparoscopic augmentation ileocystoplasty displaying improvement in measurable functional outcomes.

Robotic-assisted laparoscopic surgery in urology is an ever progressing field, and boundaries are constantly broken with the aid of new technology. Advancements in instrumentation have given birth to the era of robotic laparoendoscopic single-site technique (R-LESS). R-LESS however, has not gained widespread acceptance due to technical hurdles such as adequate triangulation, robotic arm clashing, decreased access for the bedside assistant, lack of wrist articulation, continued need for an axillary/accessory port, lack of robust retraction, and ergonomic discomfort. Many innovations have been explored to counter such limitations. We aim to give a brief overview of a history and development of R-LESS urologic surgery and outline the latest advancements in the realm of urologic R-LESS. By searching PubMed selectively for relevant articles, we concluded a literature review. We searched using the keywords: robotic laparoscopic single incision, robotic laparoendoscopic single-site, single incision robotic surgery, and R-LESS. We selected all relevant articles in that pertained to single-site robotic surgery in urology. We selected all relevant articles that pertained to single-site robotic surgery in urology in a table encompassed within this article. The development of the R-LESS procedures, instrumentations, and platforms has been an evolution in progress. Our results showed the history and evolution toward a purpose-built single-port robotic platform that addresses previous limitations to R-LESS. Even though previous studies have shown feasibility with R-LESS, the future of R-LESS depends on the availability of purpose-built robotic platforms. The larger concern is the demonstration of the definitive advantage of single-site over the conventional multiport surgery.