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What’s known on the subject? and What does the study add? There is little known on how to objectively measure renal ischemia during partial nephrectomy. This study clemonstrates two potentially useful methods to measure renal ischemia during partial nephrectomy. OBJECTIVE • To determine the feasibility of using near-infrared tissue oximetry (TO) and digital image analysis for assessing renal function and to quantify local renal ischaemia in a porcine model. MATERIALS AND METHODS • Tissue oximetry was performed and red/blue (R/B) colour ratios were determined on renal units of Yorkshire swine. • Interval measurements were taken before clamping the renal hilum, during warm ischaemia, and after unclamping using a ViOptix T.OxTM Tissue Oximeter and Matlab® digital image analysis. • Matlab software analysed images from the laparoscopic camera and determined an R/B ratio to track renal ischaemia. • The tissue oximeter used direct infrared light and was placed adjacent to the kidney parenchymal surface. • The data were divided into preclamp, clamp and post-clamp, and compared between methodologies. RESULTS • The R/B ratio showed a higher rate of change compared with TO during clamp time in both the 15-min experiment (R/B = 96.0 vs. TO = 52.1 unit/reference) and the 30-min experiment (R/B = 97.6 vs. TO = 45.9). • The R/B ratio showed a higher rate of change compared with TO at 1 min after clamping in the 15-min experiment (R/B = 80.1 vs. TO = 12.4). • Both detection devices showed similar changes in pre- and post-clamp measurements in the 15- min experiment (R/B = 1.6 vs. TO = 3.8) and the 30-min experiment (R/B = 4.7 vs. TO =−4.5). • In the 30-min experiment the R/B ratio showed a significant difference between preclamp, clamp, and post-clamp states (P= 0.026). CONCLUSIONS • Both TO and digital image analysis were able to calculate an ischaemic drop in tissue oxygen saturation during periods of acute renal ischaemia. • The findings suggest that the R/B ratio observed during histogram analysis shows a greater sensitivity compared with TO in quantifying renal ischaemia.

The role of laparoscopic radical nephrectomy (LRN) for very large renal tumors remains to be defined. We review our experience with LRN for very large (or =10 cm) renal malignancies.A retrospective analysis of 360 consecutive patients who underwent LRN for renal tumors between October 1999 and May 2007 in a tertiary academic center identified 11 patients with malignanciesor =10 cm.Median age was 67 years (range 48-80 y), operative time was 170 minutes (range 80-240 min), estimated blood loss was 150 mL (range 50-300 mL), and length of stay was 2 days (range 1-6 d). There were two minor postoperative complications (acute renal insufficiency and ileus). Median tumor size was 12 cm (range 10-21 cm). Pathologic stage for patients with renal cell carcinoma was T(2), T(3a), T(3b), and T(4), in five, three, two, and one patient(s), respectively. One patient died after brain metastasis developed. Two patients in whom pulmonary metastases developed were still alive at last follow-up.LRN was successfully performed in patients with renal tumors up to 21 cm. Important considerations when performing LRN include the individual clinical picture, surgeon experience, tumor location, and patient well-being. LRN for very large tumors is feasible in properly selected patients and can have significant benefits in the palliative setting.

To evaluate the efficacy and safety of a novel, continuous intravenous infusion of ketorolac, a powerful nonopioid analgesic, for postoperative pain control.A prospective, double-blind, randomized, placebo-controlled trial of a continuous infusion of ketorolac tromethamine in 1 L of normal saline vs placebo was performed in 135 patients aged 18 to 75 years after laparoscopic donor nephrectomy or percutaneous nephrolithotomy completed from October 7, 2008, through July 21, 2010. Primary study end points were the 24-hour differences in visual analog pain scores and total narcotic consumption, whereas secondary end points were differences in urine output, serum creatinine level, and hemoglobin level.The study was stopped after randomization of 135 patients (68 in the ketorolac group and 67 in the placebo group) when interim analysis indicated that the difference in mean pain scores between the 2 groups (difference, 0.6) was smaller than the 1-point threshold set forth in the power calculations. No statistically significant change was noted in hemoglobin levels from preoperative to postoperative values (P=.13) or in postoperative serum creatinine levels (P=.13).Although continuous infusion of ketorolac produced only a modest decrease in the use of narcotics, it appears to offer a safe therapeutic option for nonnarcotic pain control.clinicaltrials.gov Identifiers: NCT00765128 and NCT00765232.

Posterior reconstruction prior to anastomosis decreased anastomotic time for robotic surgeons in training., Background and Objectives: Our goal was to evaluate posterior reconstruction of the rhabdosphincter during robot-assisted radical prostatectomy and determine whether this technique decreased anastomotic time of a surgeon in training to perform vesicourethral reconstruction. Methods: We reviewed the first 25 robot-assisted prostatectomies performed by 2 urology surgeons in training (surgeon 1 and surgeon 2). The patient populations were matched for age, Gleason score, clinical stage, and PSA. Whereas surgeon 1 performed the vesicourethral anastomosis without posterior reconstruction, surgeon 2 reapproximated Denonvilliers' fascia of the posterior bladder to the rhabdosphincter. Time for each surgeon to complete the anastomosis and clinical factors was compared. Results: Surgeon 1 had a median anastomosis time of 25 minutes (range, 17 to 48), whereas surgeon 2 had a median anastomosis time of 15 minutes (range, 10 to 30) (P0.05). Pathological Gleason score (P=0.045) and total console time (surgeon 1=216 minutes, surgeon 2=176 minutes; P=0.002) were significantly different between surgeons. Conclusion: Posterior reconstruction prior to anastomosis decreases anastomosis time for robotic surgeons in training.

Historically the gold standard for the management of ureteropelvic junction obstruction (UPJO) has been open pyeloplasty. However, since laparoscopic-assisted pyeloplasty was first described by Schuessler et al. in 1993, the minimally invasive approach has gained wide popularity and acceptance among both academic and community urologists [1, 2]. The goal of correcting a UPJO is not to reverse damage which the kidney has already sustained but to prevent further deterioration of function and to relieve symptoms. Laparoscopic or robotic approaches to correction of UPJO have been well documented in the literature, including reduction in hospital stay, decreased postoperative analgesic requirements, and reduced incision size and amount of esthetically undesirable scarring [3].

Introduction: There are currently no good real-time methods to measure renal ischemic damage during hilar clamping. In this video we describe a novel technique for monitoring renal ischemi...