Surgical decompression is associated with decreased mortality in patients with sepsis and ureteral calculi.

PURPOSE: The combination of sepsis and ureteral calculus is a urological emergency. Traditional teaching advocates urgent decompression with nephrostomy tube or ureteral stent placement, although published outcomes validating this treatment are lacking. National practice patterns for such scenarios are currently undefined. Using a retrospective study design, we defined the surgical decompression rate in patients admitted to the hospital with severe infection and ureteral calculi. We determined whether a mortality benefit is associated with this intervention. MATERIALS AND METHODS: Patient demographics and hospital characteristics were extracted from the 2007 to 2009 Nationwide Inpatient Sample. We identified 1,712 patients with ureteral calculi and sepsis. Multivariate logistic regression was performed to determine the association between mortality and surgical decompression. RESULTS: Of the patients 78% underwent surgical decompression. Mortality was higher in those not treated with surgical decompression (19.2% vs 8.82%, p <0.001). Lack of surgical decompression was independently associated with an increased OR of mortality even when adjusting for patient demographics, comorbidities and geographic region of treatment (OR 2.6, 95% CI 1.9-3.7). CONCLUSIONS: Absent surgical decompression is associated with higher odds of mortality in patients with sepsis and ureteral calculi. Further research to determine predictors of surgical decompression is necessary to ensure that all patients have access to this life saving therapy.

BioGlue surgical adhesive as a thermal reflector during laparoscopic cryoablation: effect on iceball size and ablation zone diameter.

BACKGROUND AND OBJECTIVES: Cryoablation represents an alternative for treating small renal cortical neoplasms (RCN). Previously, we demonstrated that applying BioGlue during cryoablation diminished bleeding and incidentally noted that the iceballs seemed larger than those in controls. We examined the effects of BioGlue as a thermal insulator of cryoablated tissue to determine its effect on iceball size. METHODS: Laparoscopic cryoablation (LCA) was performed in 6 female pigs (24 ablations) by using a single 1.47-mm cryoablation probe. One pole of each kidney was randomly treated with BioGlue prior to ablation, while the contralateral pole was the untreated control. The size of the iceball was measured using laparoscopic ultrasound. The tissue ablation zone was measured grossly after the specimens were harvested. We also documented the amount of bleeding on a subjective scale. RESULTS: There were no differences in the diameters of the iceballs between the BioGlue and control groups when measured with laparoscopic ultrasound (P=.85). Similarly, the ablation zones on gross measurement were not significantly different (P=.47). No difference occurred in the amount of subjective bleeding. CONCLUSIONS: In a porcine model, the application of BioGlue prior to LCA does not appear to increase the size of the iceball generated. No change was observed in the amount of subjective bleeding as a result of using BioGlue.

Post-percutaneous nephrolithotomy systemic inflammatory response: a prospective analysis of preoperative urine, renal pelvic urine and stone cultures.

PURPOSE: Prior studies suggest that renal pelvic urine culture is a more accurate predictor of urosepsis. We prospectively determined the correlation between preoperative bladder urine cultures, intraoperative renal pelvis cultures and stone cultures in patients undergoing percutaneous nephrolithotomy. We also examined post-procedure risk factors for systemic inflammatory response syndrome. MATERIALS AND METHODS: From February 2009 to February 2011 urine samples from the bladder and renal pelvis were collected from patients undergoing percutaneous nephrolithotomy. Extracted stones were also sent for culture analysis. Postoperatively patients were closely monitored for any signs of systemic inflammatory response syndrome. The concordance of urine and stone cultures across different sites was examined. Regression analysis was done to identify clinical variables associated with systemic inflammatory response syndrome. RESULTS: A total of 204 percutaneous nephrolithotomies were done in 198 patients, of whom 20 (9.8%) had evidence of systemic inflammatory response syndrome postoperatively, including 6 (30%) requiring intensive care. The concordance among stone, renal pelvic and preoperative cultures was 64% to 75% with the highest concordance between renal pelvic urine and stone cultures. In a multivariate model multiple access tracts and a stone burden of 10 cm(2) or greater were significant predictors of systemic inflammatory response syndrome postoperatively. CONCLUSIONS: Even appropriately treated preoperative urinary infections may not prevent infected urine at percutaneous nephrolithotomy. Renal pelvic urine and stone cultures may be the only way to identify the causative organism and direct antimicrobial therapy. We recommend collecting pelvic urine and stone cultures to identify the offending organism in patients at risk for sepsis, particularly those with a large stone burden requiring multiple access tracts.

Comparison of two core biopsy techniques before and after laparoscopic cryoablation of small renal cortical neoplasms.

INTRODUCTION: Cryoablation is an acceptable treatment option for small renal cortical neoplasms (RCN). Unlike extirpative interventions, intraoperative needle biopsy is the only pathologic data for ablated tumors. It is imperative that sampled tissue accurately captures pathology. We studied the optimal intraoperative needle core biopsy protocol for small RCN during laparoscopic renal cryoablation (LCA). METHODS: Patients with RCN<4cm underwent intraoperative biopsy during LCA. Four biopsy cores were taken per tumor, 2 before and 2 after LCA by using both a standard and modified technique. Standard technique: needle biopsy device was deployed after insertion into the renal tissue at a depth of 5mm. Modified technique: needle biopsy device was deployed 1mm outside of the renal tissue. Biopsies were examined and compared with reference standard pathology. Percentage agreement was calculated across biopsy types (standard vs. modified) and time points (pre- vs. postcryoablation). Logistic regression was used to identify factors impacting biopsy accuracy. RESULTS: Thirty patients with 33 RCNs underwent LCA. The mean patient age was 69.1±8.0yrs, and mean tumor size was 2.3±0.7cm. No significant bleeding resulted from biopsies. A definitive diagnosis was made in 31/33 RCNs (94.0%). Ten tumors (30.3%) were benign, 21 (63.7%) were malignant, and 2 (6.0%) were nondiagnostic. Biopsy length was significantly longer using the standard vs. modified technique with mean lengths of 9.3mm vs. 7.0mm, respectively (P=.02). Highest agreement was seen in preablation biopsies (90.3%). A significant association with agreement was seen for younger age (P=.05) and larger tumor size (P=.02). CONCLUSIONS: Younger age and larger tumor size were associated with improved accuracy. Preoperative sampling resulted in superior accuracy and the standard technique resulted in significantly longer cores. Use of preablation standard biopsy technique may result in the most accurate pathologic diagnosis for patients undergoing cryoablation for small RCNs.

Results of kidney tumor cryoablation: renal function preservation and oncologic efficacy.

INTRODUCTION: Changes in the management of minimally invasive oncologic renal surgery have introduced ablative therapies as the most recent advancement in minimally invasive technology. METHODS: The current evidence-based medicine on the topic of laparoscopic (LCA) and percutaneous (PCA) renal cryoablation was gathered and outlined in this review. The mechanism and surgical approach to performing renal cryoablation as well a focus on the oncologic and renal functional outcomes after cryoablation will be discussed. RESULTS: Although initially recommended only for patients who were at a high surgical risk, presence of a solitary kidney, or in elderly patients, renal cryoablation, has expanded to include the majority of patients being treated for a small (<3.5 cm) renal cortical neoplasm. CONCLUSION: Renal cryoablation has become a viable minimally invasive treatment option for the majority patients diagnosed with a small (≤ 3cm) renal cortical neoplasm. Cryoablation does not seem to impact post-ablative renal function regardless of surgical approach, pre-ablation renal function, or presence of a solitary kidney.

Small renal masses: current concepts regarding the natural history and reflections on the American Urological Association guidelines.

PURPOSE OF REVIEW: Although surgical resection is the current standard for treatment of small (<4 cm) renal cortical neoplasms, active surveillance remains an option in selected patients depending on tumor characteristics and surgical risk. We review the natural history of small renal masses according to the current literature, and highlight issues regarding the recent guidelines for the management of T1 renal masses put forth by the American Urological Association. RECENT FINDINGS: The natural history of small renal masses is still largely unknown; however, initial size or volume of the mass seems to predict the risk of malignancy in retrospective studies. A new study found that growth rate is inversely related to initial tumor volume, with smaller masses growing faster in the beginning and decreasing in rate of growth as they enlarge. Biomarkers such as carbonic anhydrase IX, vascular endothelial growth factor, and CD147 have demonstrated some value in predicting tumor characteristics and prognosis in renal cell carcinoma. Finally, we suggest modifications to the new American Urological Association guidelines based on the authors' experience in order to optimize the management of renal cortical neoplasms. SUMMARY: The natural history of small renal masses is not completely understood. Growth rate and tumor size are factors shown to be predictive of tumor biology. Currently, there are no specific tumor markers to determine initial risk or progression to metastatic disease; however, investigation into new molecules is being undertaken. The guidelines presented by the American Urological Association give a formal framework for the management of T1 renal cortical neoplasms; however, we site specific modifications and recommend that they be considered when evaluating patients for treatment.

Image-guided percutaneous ablation of renal tumors: outcomes, technique, and application in urologic practice.

The recent increase in detection of small (

Evaluation of 24 holmium:YAG laser optical fibers for flexible ureteroscopy.

PURPOSE: Prior study has shown that holmium:YAG laser fiber performance differs among manufacturers. We determined the performance and threshold for failure of 24 commercially available holmium:YAG laser fibers. MATERIALS AND METHODS: Single use and reusable fibers were tested in small (150 to 300 microm) and medium (300 to 400 microm) core diameter sizes. All fibers were evaluated for flexibility, failure threshold and true fiber diameter. Flexibility was measured by maximally deflecting a Stryker U-500 ureteroscope with the fiber in the working channel. The diameter of each fiber was measured by a digital micrometer. The failure threshold was assessed by bending the fibers to 180 degrees, beginning with a radius of 1.25 cm. A VersaPulse 100 W holmium:YAG laser was operated at 1.2 J and 10 Hz for 1 minute or until fiber fracture. The bend radius was decreased in 0.25 cm increments and testing was repeated until a minimum bend radius of 0.5 cm was attained or until the fiber failed. RESULTS: Of the small core fibers the SureFlex LLF-150 and LLF-273, OptiLite SMH1020F and Dornier LG Super 270 had the highest threshold for failure. The Accuflex 200 had the lowest failure threshold failing at the largest bend radius (1.75 cm). Of the medium core fibers the SureFlex LLF-365, Accuflex 365 and Lumenis SL 365 had the highest failure threshold, while the Dornier LG 400 and Lumenis EZ SL 365 were the lowest. The reusable Lumenis 365 fiber had a higher failure threshold than the single use Lumenis 365 fiber. CONCLUSIONS: Commercially available holmium:YAG laser fibers differ significantly in their performance characteristics.

Nonischemic laparoscopic partial nephrectomy using a novel wet monopolar device in a porcine model.

BACKGROUND AND PURPOSE: Laparoscopic partial nephrectomy (LPN) is the minimally invasive standard of care for the management of a cT(1a) renal mass. We evaluated a novel saline enhanced electrosurgical resection (SEER) device for performance of a nonischemic LPN. MATERIALS AND METHODS: Six pigs were used in a nonsurvival pilot study. Energy penetration was characterized by applying the SEER to the lower pole of each kidney for 30 seconds, 1 minute, and 3 minutes using pure cutting energy at 100W and a drip rate of 1 drip per second. Energy testing was performed with the hilum clamped in six kidneys and without clamping in six kidneys. Subsequently, a nonischemic upper pole LPN was performed with the SEER device, and the kidneys were harvested. The areas of necrosis were sectioned and stained with hematoxylin and eosin. Depth of necrosis was visualized grossly and microscopically for each time point. We also recorded time to perform LPN, estimated blood loss (EBL), and subjective severity of bleeding. RESULTS: The average operative time was 15.4 minutes. The mean EBL was 44.2 mL with nine (75%) cases classified as minimal, 2 (17%) moderate, and 1 (8%) severe bleeding. The mean depth of necrosis on the kidney remnants was 2.97 mm. The mean depth of necrosis for unclamped kidneys at 30 seconds, 1 minute, and 3 minutes was 0.38 mm, 0.88 mm, and 1.27 mm, respectively. The mean depths for the clamped kidneys were 2.73 mm, 3.23 mm, and 8.68 mm respectively. Depth of necrosis was significantly higher in the clamped kidneys at 3 minutes (P=0.0035). CONCLUSIONS: In the porcine model, the SEER transected parenchyma and collecting system with low resection times and minimal blood loss. Use of coagulation during resection is the main advantage of a monopolar resection compared with cold scissors. Testing performed for 3 minutes during hilar clamping demonstrated a significantly deeper level of necrosis.

Evaluation of perirenal fat as a predictor of cT 1a renal cortical neoplasm histopathology and surgical outcomes.

BACKGROUND AND PURPOSE: With the increasing detection of small renal cortical neoplasms (RCNs), the preoperative prediction of histopathology has become increasingly important. Because perirenal fat (PF) is known to be metabolically active, we evaluated PF as a predictor of renal tumor histopathology. PATIENTS AND METHODS: We retrospectively evaluated patients who underwent laparoscopic nephron-sparing procedures for cT(1a) RCN at two institutions. PF was measured using the digital measuring tool function on standard imaging software, at the level of the renal hilum as the perpendicular distance between the posterior surface of the kidney and the external margin of the psoas muscle. The Mann-Whitney test and logistic regression were used to examine PF, selected demographic, clinical, and operative parameters, and their association with tumor histopathology. RESULTS: Data from 250 patients were included in this study. There were 157 (63%) men and 93 (37%) women with a median body mass index (BMI) of 28 kg/m(2). Median tumor size was 2.4 cm, and the median PF distance was 12 mm. Significant correlations were noted between PF and sex and BMI. No significant correlations were found between PF and the operative parameters. Results of a multivariate logistic regression analysis revealed that PF (P<0.01), age (P<0.04), and tumor location (P<0.04) were significant predictors of clear-cell renal-cell carcinoma (RCC) histopathology. CONCLUSIONS: In this study, PF, location of tumor, and age were significant predictors of clear-cell RCC histopathology. The correlation of PF and histopathology may be useful in preoperative decision-making and surgical planning in the management of small RCN.

Retrospective comparison of laparoscopic partial nephrectomy versus laparoscopic renal cryoablation for small (<3.5 cm) cortical renal masses.

OBJECTIVE: We compared perioperative and short-term outcomes of renal laparoscopic partial nephrectomy (LPN) and laparoscopic cryoablation (LCA) in patients with small (<3.5 cm) renal cortical neoplasms. METHODS: A retrospective analysis from our prospectively established database was performed. We identified 92 patients with 95 lesions treated with LPN and 75 patients with 91 lesions treated with LCA. RESULTS: The LPN and LCA groups were comparable in mean tumor size and preoperative and postoperative creatinine level (P=.495, P=.953, and P=.101) respectively. Patients undergoing LPN were younger in age (58.8 versus 69.2 years, P<.001), had a higher mean estimated blood loss (168.4 versus 6 mL, P=.005), and had a prolonged mean operative time (151.6 versus 128.6 minutes, P=.01). Six complications occurred in the LCA group and 11 in the LPN group. The median follow-up time was 21.8 months for LPN and 14 months for LCA (P<.001). Two recurrences were detected in the LCA group, and 1 recurrence was reported after LPN. CONCLUSIONS: In the treatment of small renal cortical neoplasms with short-term follow-up, LPN and LCA seem to be equally effective. LCA offers decreased blood loss, shorter operative time, and less morbidity. Longer follow-up is required to establish oncologic efficacy.

The effect of extralumenal safety wires on ureteral injury and insertion force of ureteral access sheaths: evaluation using an ex vivo porcine model.

OBJECTIVE: To evaluate the effect that a safety wire (SW) had on insertion force and direct ureteral trauma using ureteral access sheaths (UAS) in an ex vivo porcine model. MATERIAL AND METHODS: UASs were advance into 20 fresh ex vivo porcine kidney-ureters, either with or without SWs. The average and max force of insertion were recorded. Retrograde saline injection was used to identify the presence of lacerations. RESULTS: For SW vs no SW, the mean insertion force (1.79 vs 0.67, P = .0003, respectively) and max insertion force (2.29 kg vs 1.00, P = .0007) was greater in the SW group. There were 9 lacerations, 6 of which were partial and 3 complete. Of the partial injuries, 2 were in the no SW group and 4 were in the SW group. Of the complete lacerations, 2 occurred in the no SW group and 1 in the SW group. However, there was no significant difference in the total number of lacerations (P = 1.00), the number of partial lacerations (P = .628), or the number of complete lacerations (P = 1.00) between the 2 groups. CONCLUSIONS: The use of an SW significantly increases the force required to insert a UAS; however, it does not appear to affect the force or the degree of ureteral injury.

Independent diagnostic and post-treatment prognostic models for prostate cancer demonstrate significant correlation with disease progression end points.

BACKGROUND AND PURPOSE: A major advance in the standard practice of tissue-based pathology is the new discipline of systems pathology (SP) that uses computational modeling to combine clinical, pathologic, and molecular measurements to predict biologic activity. Recently, a SP-based prostate cancer (PCa) predictive model for both preoperative (Px+) and postoperative (Px) prostatectomy has been developed. The purpose of this study is to calculate the percent agreement and the concordance between the Px+ and Px end points. PATIENTS AND METHODS: Fifty-three patients underwent robot-assisted prostatectomy for PCa, and had Px+ and Px testing performed. Data were collected on Px+ end points and Px end points along with pathologic specimen results. The percent agreement and the degree of correlation between the Px+ and Px end points were then calculated. RESULTS: The percent agreement (PA) between Px+ end points and Px end points ranged from 77% to 87%. The PA between a high Px+ favorable pathology (FP) classification and dominant Gleason score ≤ 3 and Gleason sum ≤ 6 was 71.7% and 37.4%, respectively. On univariate analysis, Px+ disease progression (DP) score significantly correlated with Px prostate-specific antigen recurrence (PSAR) score (P<0.001), while Px+ DP probability significantly correlated with PxPSAR probability (P<0.001). Px+ FP probability significantly correlated with postprostatectomy dominant Gleason grade ≤ 3 (P<0.001) and Gleason sum (P<0.001). CONCLUSION: The PA between Px+ and Px testing end points for radical prostatectomy patients was very good. Furthermore, there was a direct correlation between most Px+ and Px end points. While the Px+FP classification and Gleason sum demonstrated a poor PA, Px+FP score still maintained a direct correlation to prostatectomy Gleason sum.

Clinical, pathologic, and functional outcomes after nephron-sparing surgery in patients with a solitary kidney: a multicenter experience.

BACKGROUND AND PURPOSE: Surgical management of a renal neoplasm in a solitary kidney is a balance between oncologic control and preservation of renal function. We analyzed patients with a renal mass in a solitary kidney undergoing nephron-sparing procedures to determine perioperative, oncologic, and renal functional outcomes. PATIENTS AND METHODS: A multicenter study was performed from 12 institutions. All patients with a functional or anatomic solitary kidney who underwent nephron-sparing surgery for one or more renal masses were included. Tumor size, complications, and recurrence rates were recorded. Renal function was assessed with serum creatinine level and estimated glomerular filtration rate. RESULTS: Ninety-eight patients underwent 105 ablations, and 100 patients underwent partial nephrectomy (PN). Preoperative estimated glomerular filtration rate (eGFR) was similar between the groups. Tumors managed with PN were significantly larger than those managed with ablation (P<0.001). Ablations were associated with a lower overall complication rate (9.5% vs 24%, P=0.01) and higher local recurrence rate (6.7% vs 3%, P=0.04). Eighty-four patients had a preoperative eGFR ≥60 mL/min/1.73 m(2). Among these patients, 19 (23%) fell below this threshold after 3 months and 15 (18%) at 12 months. Postoperatively, there was no significant difference in eGFR between the groups. CONCLUSIONS: Extirpation and ablation are both reasonable options for treatment. Ablation is more minimally invasive, albeit with higher recurrence rates compared with PN. Postoperative renal function is similar in both groups and is not affected by surgical approach.

Robotic instrument insulation failure: initial report of a potential source of patient injury.

OBJECTIVES: To report our experience with failures in the accessory tip covers that insulate the monopolar robotic cautery scissor instruments and the patient injuries that have resulted. Currently, there is no data in the literature regarding the failure rate of robotic instruments or their accessory components. METHODS: All robotic surgeries performed at our institution were recorded from July 2008 to January 2009. Instrument tip cover failures were recorded at the time of failure regardless of whether a patient complication occurred. Failure was identified by the arching of the electrical current from the insulated portion of the monopolar scissors or by an intraoperative injury. RESULTS: Four-hundred fifty-four robotic procedures were recorded. A total of 12 accessory tip cover failures were discovered, demonstrating a failure rate of 2.6%, with a patient complication rate of 0.6% (25% of all failures). CONCLUSIONS: Failure in robotic accessory tip covers can lead to patient complications. The cause for failure can be attributed to a variety of electrical and mechanical causes. All centers and surgeons performing robotic surgery should be aware of the potential for this problem to occur, and the possible interventions that may reduce tip cover failure.

Laparoscopic ablation of renal neoplasms.

As a result of the widespread application of cross sectional imaging, there has been a significant rise in the incidence of small renal cortical neoplasms. The current standard of care in the management of these lesions is nephron-sparing extirpative surgery. In the last decade, however, image-guided or ablative therapies have garnered significant attention as nephron-sparing alternatives to partial nephrectomy. Although initially laparoscopic ablation was predominately intended for use as active treatment in those patients in whom more invasive therapy was contraindicated, as experience with laparoscopic ablation has become more robust, the indications for the procedure continue to evolve. The current article reviews the indications and contraindications, preoperative preparation, surgical technique, and postoperative follow-up for laparoscopic ablative procedures. Also discussed are techniques and patient selection criteria to avoid complications, as well as the management of complications that do occur.

Minimally invasive percutaneous ablation of parapelvic renal cysts and caliceal diverticula using bipolar energy.

BACKGROUND AND PURPOSE: The use of bipolar electrocautery has proven advantages over monopolar energy during transurethral surgery by limiting hyponatremia and its clinical sequelae. Percutaneous ablation of caliceal diverticula and parapelvic renal cysts has been shown to be an effective surgical approach for the management of these conditions when clinically indicated. We present single center results of percutaneous ablation of renal cysts and caliceal diverticula using a bipolar energy technique and compare the results with a cohort of patients undergoing the procedure using monopolar energy. PATIENTS AND METHODS: Between July 2006 and June 2010, 30 patients with caliceal diverticula and renal cysts underwent percutaneous ablation using the bipolar resection system with saline irrigation (group 1). This group was compared with a cohort of 19 patients who underwent traditional ablation using a standard resectoscope, monopolar energy, and glycine irrigation (group 2). We evaluated operative times, change in hematocrit and serum sodium levels from preoperative levels, complication rates, as well as symptomatic and radiographic success rates. RESULTS: The mean operative times were 87 minutes and 63 minutes for groups 1 and 2, respectively (P = 0.07). The mean percent decrease in hematocrit was 3.27 ± 1.93 in group 1 and 3.82 ± 2.09 in group 2 (P = 0.16), and the mean decrease in serum sodium level was -0.21 ± 2.24 mEq/L in group 1 and 3.78 ± 2.18 mEq/L in group 2 (P < 0.001). There were no intraoperative complications. One patient needed ureteral stent placement for persistent urine leak. All patients with symptomatic renal cysts reported resolution of their discomfort, with radiographic success confirmed in 89% in group 1 and 79% in group 2 (P = 0.41). CONCLUSIONS: Percutaneous ablation of caliceal diverticula and renal cysts using a bipolar resection system is feasible and appears to have efficacy similar to that of the monopolar system. In addition, use of isotonic saline as the irrigation medium appears to reduce the risk of postoperative hyponatremia.

Contemporary experience with laparoscopic partial nephrectomy.

INTRODUCTION: We evaluated our contemporary outcomes with laparoscopic partial nephrectomy (LPN) for renal cortical neoplasms (RCN) by an experienced single surgeon in our last 100 consecutive patients. METHODS: We reviewed a prospectively established database and identified 378 patients who underwent LPN for RCN. Data from the most recent 100 consecutive patients (June 2007 to August 2009) were evaluated for oncologic, functional, and recovery outcomes, and tumors were stratified by size. There were 57 men and 43 women. The mean tumor size was 2.8 cm (range 0.9-9.0 cm). RESULTS: The mean operative time was 132 minutes (range 95-350 minutes) and the mean blood loss was 175 mL (range 25-1000 mL). There were 13 (13%) complications. Seventy-seven tumors were ≤4 cm (group 1) and 23 tumors were >4 cm (group 2). The groups were similar in terms of demographics, perioperative data, and complications. The mean warm ischemia time in groups 1 and 2 were 25.9 and 29.5 minutes, respectively (P=.04). Overall, 79% of the tumors were malignant renal cell carcinoma variants with a positive margin rate of 2%. With a median follow-up of 8 months, there was 1 local recurrence. The median change between preoperative estimated glomerular filtration rate and 3 months' follow-up estimated glomerular filtration rate was 10.1 mL per minute per 1.73 m(2) (P>.001). CONCLUSIONS: LPN is a safe and effective treatment option for RCN. With extensive experience and a well-developed surgical technique, patient outcomes are improved and postoperative complications are reduced. LPN may be applied to more complex cases including larger and hilar tumors.

Active surveillance of renal cortical neoplasms: a contemporary review.

INTRODUCTION: Over the past 2 decades, there has been a significant increase in the number of incidentally found small renal cortical neoplasms (RCNs). As more RCNs are being discovered in the elderly and infirmed patient populations, there has been a growing interest in the role of active surveillance (AS). Active surveillance is recommended for high surgical-risk patients and those with a reduced life expectancy. It is also an option for patients wishing to avoid surgery. We review the current literature on AS and highlight the natural history of disease, the important factors to evaluate during AS, and the contemporary role of biopsy. METHODS AND MATERIALS: The MEDLINE database was searched using PubMed. Search terms included active surveillance, renal mass, natural history, and renal mass histology. From 1966 to present, 17 AS series were identified, all of which have been included in this summary. A summary was performed by compiling all available data and performing a weighted mean where applicable. RESULTS: Initial tumor size does not correlate with growth rate or malignancy. The mean growth rate in large published series is low (0.28-0.34 cm/year). Tumors with high growth rates usually represent malignant lesions and typically undergo delayed intervention. Progression to metatatic disease is a low-probability event for tumors on AS (1.4%); however, this is still a risk that patients must be willing to accept. Larger tumors (cT1b and cT2) also demonstrate relatively low growth (0.57 cm/year); however, these tumors should be monitored carefully. Tumors followed for > 5 years demonstrate a low growth rate (0.15 cm/year), will not likely require intervention, and have a low chance of progression to metastatic disease. CONCLUSION: For highly selected patients with RCN, AS is a reasonable treatment option. Age, surgical risk, comorbidities, and patient opinion must all factor into the final decision when considering a patient for AS.

Polyglyconate unidirectional barbed suture for posterior reconstruction and anastomosis during robot-assisted prostatectomy: effect on procedure time, efficacy, and minimum 6-month follow-up.

BACKGROUND AND PURPOSE: With widespread implementation of posterior rhabdosphincter reconstruction (RSR) followed by urethrovesical anastomosis (UVA), reconstruction has become a significant portion of robot-assisted laparoscopic prostatectomy (RALP). Successful anastomosis can be measured by time for reconstruction and the absence of urinary leak. We prospectively evaluated the experience of a single surgeon (KKB) in using the V-Loc™ wound closure device for the posterior RSR and UVA, and compared it with a standard reconstruction and anastomosis. PATIENTS AND METHODS: A total of 84 patients divided into two groups underwent RALP, undergoing RSR and UVA using a Van Velthoven technique with the V-Loc or with a standard 3-0 monofilament suture. The primary end point was the time to complete RSR, UVA, and the total reconstruction. As a secondary end point, the clinical evidence of an anastomotic leak was also documented. RESULTS: The mean RSR, UVA, and total times were 9, 18, and 27 minutes for the control group, and 6, 12 and 18 minutes for the V-Loc group, respectively. The time differences between the two groups for RSR, UVA, and total time were 3 minutes (P<0.01), 6 minutes (P<0.01), and 9 minutes (P<0.001), respectively. There was no clinical evidence of anastomotic leak in either group. Continence recovery was equivalent between the groups at 6 weeks and 6 months. At a 9-month follow-up, no patients in either group had a clinical UVA stricture necessitating intervention. CONCLUSIONS: The V-Loc suture is associated with a significantly shorter time for the RSR and UVA compared with the traditional suture and is not associated with a higher incidence of clinical urinary leak; however, a larger randomized study with long-term follow-up is necessary to confirm these results.