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Current radio frequency ablation series do not distinguish renal cell carcinoma subtypes when reporting oncologic efficacy. Papillary neoplasms may be more amenable to radio frequency ablation than clear cell carcinoma because they are less vascular, which may limit heat energy loss. We report the long-term outcomes of patients treated with radio frequency ablation for small renal masses by renal cell carcinoma subtype.The records of patients undergoing radio frequency ablation for small renal masses (cT1a) at 2 institutions from March 2007 to July 2012 were retrospectively reviewed. Patients were included in analysis if they had biopsy confirmed clear cell or papillary renal cell carcinoma histology. Patients had at least 1 contrast enhanced cross-sectional image following radio frequency ablation. Demographic data between tumor subtypes were compared using the paired t-test. Oncologic outcomes were determined by Kaplan-Meier survival analysis and survivor curves were compared with the log rank test.A total of 229 patients met study inclusion criteria. There were 181 clear cell tumors and 48 papillary tumors. Median followup was 33.2 months. There was no difference between tumor groups based on patient age, tumor size or grade, or months of followup. Five-year disease-free survival was 89.7% for clear cell tumors and 100% for papillary tumors (p = 0.041). There was no significant difference in overall survival (88.4% vs 89.6%, p = 0.764).Radio frequency ablation outcomes seem to be determined in part by renal cell carcinoma subtype with clear cell renal tumors having less favorable outcomes. We hypothesize that this is due to differences in tumor vascularity. Our experience suggests that future tumor ablation studies should consider reporting outcomes based on tumor cell types.

Nearly two-thirds of newly detected renal masses are clinical stage 1, with T1a tumours accounting for 60% of the newly detected stage 1 tumours. Guideline panels convened by the American Urological Association and the European Association of Urology recommend nephron-sparing surgery as the gold standard treatment for small renal masses, with active surveillance and thermal ablation recommended as alternative strategies in select patients. However, there is a dearth of studies directly comparing outcomes for energy-based ablation to those for traditional surgical treatments for small renal masses, and future prospective randomized trials will be invaluable in this regard. Ongoing research in renal tumour ablation targets several areas, including but not limited to achieving larger ablation sizes, decreasing morbidity, and development of novel technologies for renal tumour ablation.

Purpose: We developed a novel device to capture stones in vivo in an enclosed bag (PercSac) to prevent dispersion of stone fragments during percutaneous nephrolithotomy (PCNL) or cystolitholapaxy. We report on our initial feasibility trials of the PercSac device. Materials and Methods: PercSac consists of a specially designed polyethylene bag that is fitted over the shaft of a rigid nephroscope. The bag is used to first entrap the target stone, then tighten around it to allow fragmentation within the bag. Matched pairs of 10 canine bladder stones (2.5 cm maximum diameter) were fragmented in a human bladder model using the CyberWand™ (Olympus America, Inc.), and the procedure was assessed for markers of efficiency and effectiveness. Results: Median time to entrap the stone within the PercSac was 67 seconds (range 51–185 sec). Median time for stone fragmentation was significantly shorter with the PercSac than without (182.0 sec [range 108–221] vs 296.5 sec [range 226–398], P=0.004). Overall, howeve...

During partial nephrectomy (PN), artery-only (AO) occlusion may mitigate ischemia/reperfusion injury because of retrograde venous flow. Using digital light processing-hyperspectral imaging (DLP(®)-HSI), we compared renal oxygenation during AO vs artery and vein (AV) occlusion in patients undergoing PN.Thirty-seven patients who were undergoing complex open PN (median R.E.N.A.L. nephrometry of 8) at our institution underwent renal oxygenation assessment using DLP-HSI. Percent renal parenchymal oxyhemoglobin (%HbO2) during AO vs AV occlusion was recorded and its correlation with postoperative estimated glomerular filtration rate (eGFR) was investigated using Pearson correlation. AO and AV occlusion was performed in 12 and 25 patients, respectively.Comparing AO vs AV, mean ischemia time was 41 vs 35 minutes (P=0.02). The %HbO2 at baseline was 73.6% vs 71% (P=0.23). After hilar occlusion, %HbO2 quickly reached an "ischemic plateau" in both groups, with mean ischemic %HbO2 measures of 59.7% vs 62.2% (P=0.19). In the AV group, a lower mean ischemic %HbO2 was associated with lower eGFR at the most recent follow-up (r=0.46, P=0.02) and remained significant on multivariable analysis (odds ratio 2.31; 95% confidence interval 0.29-4.32; P=0.03).In this pilot clinical study, renal oxygenation profiles during PN as assessed by DLP-HSI were similar for AO vs AV occlusion. Significant retrograde venous oxygen delivery using an AO occlusion technique could not be demonstrated. There was also no renal functional advantage for AO occlusion in this population of difficult PN where prolonged ischemia times may have mitigated any advantage. Further study in cases with shorter ischemia times is warranted.

To compare surgeon-assessed ergonomic and workload demands of magnetic anchoring and guidance system (MAGS) laparoendoscopic single-site surgery (LESS) nephrectomy with conventional LESS nephrectomy in a porcine model.Participants included two expert and five novice surgeons who each performed bilateral LESS nephrectomy in two nonsurvival animals using either the MAGS camera or conventional laparoscope. Task difficulty and workload demands of the surgeon and camera driver were assessed using the validated National Aeronautics and Space Administration Task Load Index (NASA-TLX) questionnaire. Surgeons were also asked to score 6 parameters on a Likert scale (range 1=low/easy to 5=high/hard): procedure-associated workload, ergonomics, technical challenge, visualization, accidental events, and instrument handling. Each step of the nephrectomy was also timed and instrument clashing was quantified.Scores for each parameter on the Likert scale were significantly lower for MAGS-LESS nephrectomy. Mean number of internal and external clashes were significantly lower for the MAGS camera (p0.001). Mean task times for each procedure were shorter for experts than for novices, but this was not statistically significant. NASA-TLX workload ratings by the surgeon and camera driver showed that MAGS resulted in a significantly lower workload than the conventional laparoscope during LESS nephrectomy (p0.05).The use of the MAGS camera during LESS nephrectomy lowers the task workload for both the surgeon and camera driver when compared to conventional laparoscope use. Subjectively, it appears to also improve surgeons' impressions of ergonomics and technical challenge. Pending approval for clinical use, further evaluation in the clinical setting is warranted.

To compare the ergonomics and workload of the surgeon during single-site suturing while using the magnetic anchoring and guidance system (MAGS) camera vs a conventional laparoscope.Seven urologic surgeons were enrolled and divided into an expert group (n=2) and a novice group (n=5) according to their laparoendoscopic single-site (LESS) experience. Each surgeon performed 2 conventional LESS and 2 MAGS camera-assisted LESS vesicostomy closures in a porcine model. A Likert scale (scoring 1-5) questionnaire assessing workload, ergonomics, technical difficulty, visualization, and needle handling, as well as a validated National Aeronautics and Space Administration Task Load Index (NASA-TLX) questionnaire were used to evaluate the tasks and workloads.MAGS LESS suturing was universally favored by expert and novice surgeons compared with conventional LESS in workload (3.4 vs 4.2), ergonomics (3.4 vs 4.4), technical challenge (3.3 vs 4.3), visualization (2.4 vs 3.3), and needle handling (3.1 vs 3.9 respectively; P.05 for all categories). Surgeon NASA-TLX assessments found MAGS LESS suturing significantly decreased the workload in physical demand (P=.004), temporal demand (P=.017), and effort (P=.006). External instrument clashing was significantly reduced in MAGS LESS suturing (P.001). The total operative time of MAGS LESS suturing was comparable to that of conventional LESS (P=.89).MAGS camera technology significantly decreased surgeon workload and improved ergonomics. Nevertheless, LESS suturing and knot tying remains a challenging task that requires training, regardless of which camera is used.

We developed a polyethylene sack (the PercSac) that fits over the shaft of a rigid nephroscope and is deployed into the collecting system to capture a stone and contain fragments during percutaneous nephrolithotomy (PCNL). We previously reported our results using the PercSac in a percutaneous cystolithopaxy model. In this study, we compare the efficiency of stone fragmentation with and without the PercSac in an anatomically correct in vitro PCNL model.The PCNL model consisted of a human collecting system model created on a 3D printer. Ten BegoStones made in spherical molds of 2.0 cm diameter, matched for weight, were fragmented in the model using a 24F rigid nephroscope and an ultrasonic lithotripter, including five with and five without the PercSac. The total times for stone fragmentation and complete stone clearance, gross assessment of the stone-free status, and need for flexible nephroscopy to achieve a stone-free state were recorded.The median time for stone fragmentation was significantly shorter in the PercSac group compared with the control group (217 seconds [IQR = 169-255] vs 340 seconds [IQR = 310-356], [p = 0.028]). Likewise, the total time for complete stone clearance from the kidney was significantly shorter for the PercSac group (293 seconds [IQR = 244-347] vs 376 seconds [IQR = 375-480], [p = 0.047]). In one trial with the PercSac, residual dust remained in the kidney, while in all five trials without the PercSac small residual fragments remained. All trials without the PercSac required flexible nephroscopy with basket extraction to become stone free, while none of the trials with the PercSac required flexible nephroscopy for stone clearance.Ultrasonic lithotripsy using the novel PercSac stone entrapment device is more efficient and efficacious than traditional ultrasonic lithotripsy in an in vitro PCNL model. The advantage may be even more pronounced during clinical PCNL where residual fragments migrate into difficult-to-access calices. Further in vivo testing is underway.

Conventional laparoscopic dismembered pyeloplasty (LP) is an established alternative to open pyeloplasty given equivalent intermediate-term outcomes and decreased morbidity. Laparoendoscopic single-site (LESS) pyeloplasty has the potential to further decrease the morbidity of LP, while yielding superior cosmesis. It is, however, technically very challenging even with the use of an accessory port, largely because of the difficulty of intracorporeal suturing through a single umbilical incision. Application of the da Vinci robotic surgical platform to LESS pyeloplasty (R-LESS) has the potential to overcome these limitations. We describe our technique for R-LESS pyeloplasty using the da Vinci Si robot. We have found that use of the robotic system in conjunction with certain technique modifications helps to reduce the technical difficulty of LESS pyeloplasty and to shorten the physical learning curve associated with the procedure.

Renal ablation (RA) is no longer used exclusively in patients with limited life expectancy. There are few studies reporting a minimum follow-up of 5 years. Biases and discrepancies within the literature are abundant. The outcomes of any series must be interpreted in the context of median follow-up time, reported tumor characteristics, ablation technique and training background of the practitioner, and the definition of tumor recurrence. The long-term oncologic efficacy of radiofrequency ablation (RFA) and cryoablation appear similar, although the percutaneous RFA technique may necessitate reablation in more cases. RA is associated with slightly higher rates of local recurrence compared to surgical excision.

This report suggests that laparoscopic single-site pyeloplasty of uteropelvic junction obstruction associated with horseshoe kidney is feasible, safe, and effective in select patients., Background and Objective: Pyeloplasty in horseshoe kidneys can be challenging due to aberrant vasculature, renal malrotation, and ectopic location. Fewer than 20 cases of minimally invasive (MIS) pyeloplasty in horseshoe kidneys have been reported in the literature to date. We herein report the first 2 cases of laparoendoscopic single-site (LESS) pyeloplasty for UPJ obstruction in horseshoe kidneys. Methods: Two patients with symptomatic ureteropelvic junction obstruction in horseshoe kidneys were treated with an Anderson-Hynes LESS pyeloplasty. This was performed using three 5-mm trocars through a single umbilical incision, plus an accessory 3-mm port at the anterior axillary line to facilitate suturing and subsequent drain placement. Results: Both patients had BMI

Background: Angiomyolipoma (AML) is a benign renal neoplasm. First-line therapy includes renal preserving surgery or angioembolization (RAE), both with good outcomes in isolated studies. However, there are no comparative randomized trials and no clinical guidelines to help clinicians decide between these treatment modalities. Our study examines the patterns of AML treatment at a tertiary care centre to evaluate how local urologists have been treating this disease. Methods: This is a retrospective study of all AMLs treated at the Vancouver General Hospital (Vancouver, BC, Canada) over the past 10 years with either RAE or surgical excision. Searches were performed of the radiology and pathology dictation systems, using the following keywords: AML, angiomyolipoma, angioembolization, embolization, surgery, partial nephrectomy and nephrectomy. Results: At our institution, more AMLs were treated by surgery than angioembolization (42 vs. 17 cases). Angioembolization was more often chosen for cases of multifocal AML (35% vs. 7%) and acute hemorrhage (50% vs. 14%). In the angioembolization cases, particles were the embolic agent of choice (used 40% of the time). Conclusions: Angioembolization allows rapid patient stabilization in cases of acute hemorrhage, and provides good renal preservation in cases of multifocal AML. It may also be preferred in large masses when partial nephrectomy is not feasible. Surgery should be performed in cases of diagnostic uncertainty or complex vascular anatomy not amenable to RAE. Prospective randomized studies are needed to compare RAE and surgery to better define their indications in sporadic AML. Contexte : Un angiomyolipome (AML) est une tumeur benigne du rein. Le traitement de premiere intention comprend une chirurgie de conservation renale ou une angioembolisation renale, qui ont toutes deux donne de bons resultats dans des etudes isolees. Cependant, aucun essai comparatif randomise n’a ete mene et il n’existe pas de lignes directrices pour aider les cliniciens a choisir entre ces modalites therapeutiques. Notre etude a examine les tendances dans le traitement de l’AML a un centre de soins tertiaires pour evaluer comment les urologues y traitent cette maladie. Methodologie : Il s’agit d’une etude retrospective de tous les AML traites au Vancouver General Hospital (Vancouver, C.-B., Canada) au cours des 10 dernieres annees, soit par chirurgie de conservation renale ou par angioembolisation. Des recherches ont ete effectuees dans les systemes de dictee vocale de radiologie et de pathologie en utilisant les mots-cles anglais suivants : AML, angiomyolipoma, angioembolization, embolization, surgery, partial nephrectomy et nephrectomy. Resultats : Dans notre etablissement, plus de cas d’AML ont ete traites par chirurgie que par angioembolisation (42 cas contre 17). L’angioembolisation a ete plus souvent choisie dans les cas d’AML multifocal (35 % contre 7 %) et d’hemorragie aigue (50 % contre 14 %). Dans les cas traites par angioembolisation, les particules ont ete l’agent embolique privilegie (utilisees dans 40 % des cas). Conclusions : L’angioembolisation permet de stabiliser rapidement l’etat du patient en cas d’hemorragie aigue, et offre une bonne conservation renale en cas d’AML multifocale. Elle peut aussi etre preferable en presence de larges masses quand la nephrectomie partielle n’est pas possible. La chirurgie doit etre realisee en cas d’incertitude diagnostique ou d’anatomie vasculaire complexe ne se pretant pas a l’angioembolisation renale. Des etudes prospectives randomisees sont necessaires pour comparer l’angioembolisation renale et la chirurgie afin de mieux definir leurs indications dans les formes sporadiques d’AML.

In pre-clinical studies, acute erythropoietin (EPO) administration has been shown to mitigate the deleterious effects of ischemia/reperfusion injury. We reviewed our clinical experience with intraoperative EPO administration as a potential renoprotective agent during laparoscopic partial nephrectomy (LPN). Patients who underwent LPN at our institution between August 2008 and March 2010 received 500 IU/kg EPO 30 min prior to hilar occlusion. Those who underwent LPN between August 2006 and July 2008 without receiving EPO were selected as controls. Demographic, clinical, perioperative, and estimated glomerular filtration rate (eGFR) data were compared for the cohorts preoperatively, and during short-term (

We developed a novel device to capture stones in vivo in an enclosed bag (PercSac) to prevent dispersion of stone fragments during percutaneous nephrolithotomy (PCNL) or cystolitholapaxy. We report on our initial feasibility trials of the PercSac device.PercSac consists of a specially designed polyethylene bag that is fitted over the shaft of a rigid nephroscope. The bag is used to first entrap the target stone, then tighten around it to allow fragmentation within the bag. Matched pairs of 10 canine bladder stones (2.5 cm maximum diameter) were fragmented in a human bladder model using the CyberWand (Olympus America, Inc.), and the procedure was assessed for markers of efficiency and effectiveness.Median time to entrap the stone within the PercSac was 67 seconds (range 51-185 sec). Median time for stone fragmentation was significantly shorter with the PercSac than without (182.0 sec [range 108-221] vs 296.5 sec [range 226-398], P=0.004). Overall, however, there was no significant difference in the total time to entrap and fragment the stones between the two groups. A stone-free state was not achieved for any trial without the PercSac, while 9 of 10 trials with the PercSac resulted in a stone-free state.Use of the PercSac in conjunction with stone fragmentation has the potential to reduce the occurrence of residual fragments after PCNL or cystolitholapaxy. Further in vitro testing in a kidney model is planned.

To compare long term glomerular filtration rate (GFR) outcomes of partial nephrectomy and radiofrequency ablation performed for renal malignancy.Renal function of 347 patients undergoing radiofrequency ablation (n = 142) or partial nephrectomy (n = 205) for renal malignancy between 1994 and 2011 were compared from a retrospective database at a single tertiary care center. Minimum 1 year of follow up was required, resulting in a mean follow up of 48.2 (SD +/- 28.2) months. Renal function was estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. The primary study outcome was progression of Chronic Kidney Disease (CKD) stage, calculated using the Kaplan-Meier life table method. Multivariate analysis was also conducted to determine the level of association between GFR decline and treatment modality.The 5 year freedom from CKD stage progression for radiofrequency ablation and partial nephrectomy was 85.4% (95% CI 76.8%-91.1%) versus 82.1% (95% CI 73.7%-88.1%) (p = 0.06). A longer follow up interval was associated with greater GFR decline, although hypertension, diabetes, age, and tumor size were not.Radiofrequency ablation provides similar long term renal function preservation benefit as partial nephrectomy.

Background and Purpose Horseshoe kidney is an uncommon renal anomaly often associated with ureteropelvic junction (UPJ) obstruction. Advanced minimally invasive surgical (MIS) reconstructive techniques including laparoscopic and robotic surgery are now being utilized in this population. However, fewer than 30 cases of MIS UPJ reconstruction in horseshoe kidneys have been reported. We herein report our experience with these techniques in the largest series to date. Materials and Methods We performed a retrospective chart review of nine patients with UPJ obstruction in horseshoe kidneys who underwent MIS repair at our institution between March 2000 and January 2012. Four underwent laparoscopic, two robotic, and one laparoendoscopic single-site (LESS) dismembered pyeloplasty. An additional two pediatric patients underwent robotic Hellstrom repair. Perioperative outcomes and treatment success were evaluated. Results Median patient age was 18 years (range 2.5-62 years). Median operative time was 136 minutes (range 109-230 min.) and there were no perioperative complications. After a median follow-up of 11 months, clinical (symptomatic) success was 100%, while radiographic success based on MAG-3 renogram was 78%. The two failures were defined by prolonged t1/2 drainage, but neither patient has required salvage therapy as they remain asymptomatic with stable differential renal function. Conclusions MIS repair of UPJ obstruction in horseshoe kidneys is feasible and safe. Although excellent short-term clinical success is achieved, radiographic success may be lower than MIS pyeloplasty in heterotopic kidneys, possibly due to inherent differences in anatomy. Larger studies are needed to evaluate MIS pyeloplasty in this population.

Outcomes after laparoendoscopic single site pyeloplasty are limited to small cohort studies with short-term followup. We evaluated the clinical and renal function outcomes of what to our knowledge is the largest laparoendoscopic single site pyeloplasty cohort to date with a mean followup of 12 months.Consecutive patients diagnosed with symptomatic ureteropelvic junction obstruction who underwent robotic or conventional laparoendoscopic single site pyeloplasty were entered into the study. Patient demographics, and preoperative and postoperative renal function outcomes were recorded. Diuretic renogram was performed after stent removal, at 6 months and yearly thereafter.The cohort included 31 conventional and 22 robotic laparoendoscopic single site pyeloplasties. Four laparoendoscopic single site surgeries (7.8%) were converted to another procedure due to failure to progress. Mean ± SD followup was 12.1 ± 10.7 months and 22 patients had at least 12 months of followup. No intraoperative complications occurred. Complications developed postoperatively in 11 patients (21%), of which 9 were Clavien grade 3 or greater. Preoperative symptoms resolved in 49 of 51 cases (96%). Severe obstruction (half-time greater than 20 minutes) was seen in 32 of 44 patients (73%) at presentation and obstruction resolved (half-time 20 minutes or less) in 41 (93%). Mean preoperative and postoperative half-time was 24.6 ± 13.4 and 8.3 ± 4.1 minutes, respectively, for an improvement of 16.3 ± 12.3 minutes (p0.01).Laparoendoscopic single site pyeloplasty is safe and efficacious. The laparoscopic and robotic techniques provide excellent outcomes in terms of symptomatic relief and radiographic resolution of obstruction.

Ureteroscopy (URS) is an increasingly utilized treatment modality for a variety of upper urinary tract pathologies, including renal and ureteral calculi, ureteropelvic junction obstruction, ureteral strictures, and upper tract tumors. Although utilization patterns for the various treatment modalities can be extracted from billing records, case logs, and a variety of national datasets, the factors responsible for these practice patterns are not readily apparent from these data. The choice of treatment modality for upper tract pathology is complex, taking into account not only clinical outcomes but also patient and physician preferences, demographics of the community, and practice and economic factors. Although evidence-based clinical indications for URS should remain the focus for the practitioner, an awareness of these competing pressures may help the urologist avoid bias but also be cognizant of economic considerations in his/her choice of treatment modality.

Background and Purpose: Digital light processing-based hyperspectral imaging (DLP(®)-HSI) was adapted for use during laparoscopic surgery by coupling the spectral illumination source with a conventional laparoscopic light guide and incorporating a customized digital charge-coupled device camera for image acquisition. The system was used to characterize renal oxygenation during robot-assisted laparoscopic partial nephrectomy (RALPN) in humans.After Institutional Review Board approval, laparoscopic DLP-HSI was performed in consecutive patients undergoing RALPN at our institution. Time trends in relative tissue oxygen saturation (%HbO2) were descriptively analyzed. Associations between %HbO2 and patient age, comorbidities, and estimated glomerular filtration rate (eGFR) were investigated using the Kendall tau test.Laparoscopic DLP-HSI was performed in 18 patients between May 2011 and February 2012. Median (interquartile range; IQR) age was 55.9 (49-67.5) years. Of the patients, 10/18 (56%) were men and 12/18 (66.7%) had a history of hypertension, diabetes, and/or tobacco use. Median (IQR) %HbO2 before, during, and after ischemia was 60.8% (57.9-68.2%), 53.6% (46.8-55.1%), and 61.5% (54.9-67.6%), respectively. Baseline %HbO2 was inversely associated with preoperative eGFR (τ=-0.38; P=0.036), and eGFR at most recent follow-up (τ=-0.38; P=0.036). Baseline or ischemic %HbO2 did not correlate with hypertension, diabetes, and/or tobacco history. Younger patients (56 years) had a lower median baseline %HbO2 (P=0.07) and a higher median preoperative eGFR (P=0.038), than their older counterparts.The laparoscopic HSI system successfully characterized dynamic changes in renal oxygenation during RALPN. Intraoperative laparoscopic HSI outcomes have the potential to predict postoperative individual kidney function.

Growing evidence suggests that phosphodiesterase-5 inhibitors may mitigate ischemia-related renal damage through multiple mechanisms. We evaluated the role of tadalafil in renal function preservation during experimentally induced ischemia/reperfusion injury (IRI) in a solitary kidney porcine model.Ten adult female pigs underwent left laparoscopic nephrectomy followed by a 1 week recovery period. They were then randomized to tadalafil versus no treatment prior to cross-clamping the contralateral renal hilum for 90 minutes. The experimental group received 40 mg tadalafil in two equally divided doses, 12 hours before and just prior to surgery. Serum creatinine for each animal was obtained just prior to ischemia induction (D0) and at days 1, 3 and 7 following hilar occlusion. Median creatinine at each time point was compared between groups using the Kruskal-Wallis test.Median serum creatinine at D0 was significantly lower in the tadalafil group (after two doses of tadalafil) (123.8 µmol/L versus 168.0 µmol/L, p = 0.009). As expected, median creatinine for each group rose significantly on D1 (p = 0.04 for each). Median creatinines following hilar occlusion at D1, D3 and D7, however, were not significantly different between groups.In this porcine model, administration of perioperative tadalafil improves preoperative renal function, but it does not appear to mitigate ischemia/ reperfusion injury from hilar occlusion.

Digital light processing hyperspectral imaging (DLP® HSI) was adapted for use during laparoscopic surgery by coupling a conventional laparoscopic light guide with a DLP-based Agile Light source (OL 490, Optronic Laboratories, Orlando, FL), incorporating a 0° laparoscope, and a customized digital CCD camera (DVC, Austin, TX). The system was used to characterize renal ischemia in a porcine model.

We evaluated the long-term safety, efficacy and durability of ureteroscopic laser papillotomy for chronic flank pain associated with renal papillary calcifications.We reviewed the medical records of all patients who underwent ureteroscopic laser papillotomy in the absence of free urinary calculi at our institutions from 1998 through 2008. Success was defined as patient report of significant pain relief. The duration of response was considered the time from papillotomy to repeat papillotomy in the same renal unit, patient report of recurrent pain or final followup.Ureteroscopic Ho:YAG laser papillotomy was done a total of 176 times in 65 patients, including 147 unilateral and 29 bilateral procedures. Of the patients 39 underwent multiple procedures (2 to 12). Symptomatic followup was available in 50 patients (146 procedures) during a mean of 38 months. Significantly less pain was reported after 121 procedures (83%). The mean duration of response per procedure was 26 months and 30 patients (60%) had a mean remission duration of greater than 1 year. Postoperatively hospital admission was required after 14 procedures (8%). There was no significant change in the mean estimated glomerular filtration rate during a mean 41.3-month followup. Seven of the 65 patients (11%) had hypertension before papillotomy. In 3 of the 49 patients (6.1%) with adequate followup new hypertension developed during a mean of 38 months.Ureteroscopic laser papillotomy is safe and effective. In patients with papillary calcifications and characteristic chronic, noncolicky pain this procedure provides significant, moderately durable symptom relief.

Hernias are a rare complication following muscle-splitting dorsal lumbotomysurgery. At our centre, before the introduction of laparoscopic surgery, donornephrectomy for renal transplantation was performed via a dorsal lumbotomyapproach. We present a case of transperitoneal laproscopic repair of a dorsallumbotomy incisional hernia following donor nephrectomy using a quilted2-sided expanded polytetrafluoroethylene (ePTFE) mesh. The procedure wasuncomplicated and required 2 hours operating time to complete. A 2-daystay in hospital was observed for convalescence and the patient quickly returnedto routine activity after discharge. Advantages of the laparoscopic approachinclude excellent visualization and wide coverage of the hernia defect underdirect vision. This case illustrates the benefits of laparoscopic repair of a rarelumbotomy complication.

Background: Angiomyolipoma (AML) is a benign renal neoplasm.First-line therapy includes renal preserving surgery or angioembolization(RAE), both with good outcomes in isolated studies.However, there are no comparative randomized trials and no clinicalguidelines to help clinicians decide between these treatmentmodalities. Our study examines the patterns of AML treatment ata tertiary care centre to evaluate how local urologists have beentreating this disease.Methods: This is a retrospective study of all AMLs treated at theVancouver General Hospital (Vancouver, BC, Canada) over thepast 10 years with either RAE or surgical excision. Searches wereperformed of the radiology and pathology dictation systems, usingthe following keywords: AML, angiomyolipoma, angioembolization,embolization, surgery, partial nephrectomy and nephrectomy.Results: At our institution, more AMLs were treated by surgerythan angioembolization (42 vs. 17 cases). Angioembolization wasmore often chosen for cases of multifocal AML (35% vs. 7%) andacute hemorrhage (50% vs. 14%). In the angioembolization cases,particles were the embolic agent of choice (used 40% of the time).Conclusions: Angioembolization allows rapid patient stabilizationin cases of acute hemorrhage, and provides good renal preservationin cases of multifocal AML. It may also be preferred in largemasses when partial nephrectomy is not feasible. Surgery should beperformed in cases of diagnostic uncertainty or complex vascularanatomy not amenable to RAE. Prospective randomized studies areneeded to compare RAE and surgery to better define their indicationsin sporadic AML.Contexte : Un angiomyolipome (AML) est une tumeur bénigne durein. Le traitement de première intention comprend une chirurgiede conservation rénale ou une angioembolisation rénale, quiont toutes deux donné de bons résultats dans des études isolées.Cependant, aucun essai comparatif randomisé n’a été mené et iln’existe pas de lignes directrices pour aider les cliniciens à choisirentre ces modalités thérapeutiques. Notre étude a examiné les tendancesdans le traitement de l’AML à un centre de soins tertiairespour évaluer comment les urologues y traitent cette maladie.Méthodologie : Il s’agit d’une étude rétrospective de tous les AMLtraités au Vancouver General Hospital (Vancouver, C.-B., Canada)au cours des 10 dernières années, soit par chirurgie de conservationrénale ou par angioembolisation. Des recherches ont été effectuéesdans les systèmes de dictée vocale de radiologie et de pathologieen utilisant les mots-clés anglais suivants : AML, angiomyolipoma,angioembolization, embolization, surgery, partial nephrectomy etnephrectomy.Résultats : Dans notre établissement, plus de cas d’AML ont ététraités par chirurgie que par angioembolisation (42 cas contre 17).L’angioembolisation a été plus souvent choisie dans les cas d’AMLmultifocal (35 % contre 7 %) et d’hémorragie aiguë (50 % contre14 %). Dans les cas traités par angioembolisation, les particulesont été l’agent embolique privilégié (utilisées dans 40 % des cas).Conclusions : L’angioembolisation permet de stabiliser rapidementl’état du patient en cas d’hémorragie aiguë, et offre une bonneconservation rénale en cas d’AML multifocale. Elle peut aussi êtrepréférable en présence de larges masses quand la néphrectomiepartielle n’est pas possible. La chirurgie doit être réalisée en casd’incertitude diagnostique ou d’anatomie vasculaire complexe nese prêtant pas à l’angioembolisation rénale. Des études prospectivesrandomisées sont nécessaires pour comparer l’angioembolisationrénale et la chirurgie afin de mieux définir leurs indications dansles formes sporadiques d’AML.