NCCN Guidelines® Insights: Prostate Cancer Early Detection, Version 1.2023.

The NCCN Guidelines for Prostate Cancer Early Detection provide recommendations for individuals with a prostate who opt to participate in an early detection program after receiving the appropriate counseling on the pros and cons. These NCCN Guidelines Insights provide a summary of recent updates to the NCCN Guidelines with regard to the testing protocol, use of multiparametric MRI, and management of negative biopsy results to optimize the detection of clinically significant prostate cancer and minimize the detection of indolent disease.

The Impact of Ureteral Access Sheath Use on the Development of Abnormal Postoperative Upper Tract Imaging after Ureteroscopy.

PURPOSE: Ureteral access sheaths are commonly used during ureteroscopy to facilitate stone removal, improve visibility and maintain low intrarenal pressures. However, the use of a ureteral access sheath can cause ureteral wall ischemia and ureteral tears, potentially increasing the risk of postoperative ureteral stricture and obstruction. We studied the impact of ureteral access sheath use on postoperative imaging studies. Secondary objectives included studying the impact of other intraoperative parameters on postoperative imaging studies. MATERIALS AND METHODS: A retrospective chart review was conducted of cases that underwent ureteroscopy for nephroureterolithiasis across 2 high volume institutions between January 2012 and September 2016. Patient demographics, cumulative stone size, operative time, use of ureteral access sheath, laser lithotripsy, basket extraction, preoperative ureteral stent and postoperative ureteral stent placement were extracted from the electronic medical record. Findings of followup renal ultrasound, kidney-ureter-bladder x-ray and/or computerized tomography at approximately 8 weeks after surgery were recorded. RESULTS: A total of 1,332 ureteroscopies were performed with 1,060 cases (79.6%) returning for routine upper tract imaging after ureteroscopy. Postoperative hydronephrosis was noted following 127 cases (12.0%). Factors predicting presence of hydronephrosis after ureteroscopy include lower body mass index (p=0.0016), greater cumulative stone size (p=0.0003), increased operative time (p <0.0001), preoperative ureteral stent (OR 1.49, p=0.0299) and postoperative ureteral stent placement (OR 6.43, p=0.0031). Postoperative hydronephrosis was not associated with use of ureteral access sheath, age, laser lithotripsy or basket extraction. CONCLUSIONS: Use of ureteral access sheath did not have a significant impact on development of postoperative hydronephrosis, suggesting ureteral access sheath is safe for use during ureteroscopy. Ureteral strictures remain rare following ureteroscopy, seen in only 1.0% of our cohort. With an observed prevalence of hydronephrosis of 12.0% on followup imaging at 8 weeks, routine upper tract imaging after ureteroscopy remains a valuable prognostic tool.

Clinicopathologic analysis of renal cell carcinoma containing Intratumoral fat with and without osseous metaplasia.

BACKGROUND: There is minimal information regarding the prevalence of intratumoral adipose in renal cell carcinoma (RCC), and no study has assessed the impact of intratumoral adipose on the preoperative imaging diagnosis. The aim of this study was to investigate the prevalence and histopathologic characteristics of entrapped adipose with or without osseous metaplasia in RCC nephrectomy specimens and to determine if this finding impacted the preoperative imaging interpretation. METHODS: 704 RCC specimens were prospectively evaluated for entrapped adipose and osseous metaplasia (423 partial nephrectomies, 281 total nephrectomies; 327 pT1a, 377 ≥ pT1b; 510 clear cell, 119 papillary, 30 chromophobe, 22 clear cell papillary, 23 other). Imaging reports were obtained, and the presence of intratumoral fat or calcification and the radiologic diagnostic impression were recorded. RESULTS: 3% (n = 21) contained microscopically identified intratumoral adipose, with a similar frequency in the main histologic subtypes (p = 0.76). Mean metaplastic deposit size was 0.4 cm, mean deposit to capsule distance 0.2 cm, and 29% involved the tumor capsule. Histologically identified adipose was infrequently noted via imaging (13%), and only 1 case with histologically identified metaplasia had a radiologic diagnostic differential of angiomyolipoma (1/704, 0.1%). CONCLUSION: While intratumoral adipose and/or osseous metaplasia can be observed within RCC, it is extremely rare for the radiologic diagnostic impression to have been confounded by histologically identified entrapped adipose. Awareness that metaplastic deposits are usually near the tumor capsule and may be minute could help prevent errors in diagnosis or staging.

Supracostal access tubeless percutaneous nephrolithotomy: minimizing complications.

INTRODUCTION AND OBJECTIVE: Supracostal access in percutaneous nephrolithotomy (PCNL) may be avoided due to concern for thoracic complications. The objective of the study is to report the safety and efficacy of supracostal access utilizing a tubeless (stent only) PCNL technique. PATIENTS AND METHODS: Retrospective review of perioperative outcomes of 70 patients (76 renal units) who underwent a supracostal tubeless PCNL. No nephrostomy tubes were left. All patients had a 7F ureteral stent and Foley catheter placed. The nephrostomy sheath was removed with the patient held in end-expiration, and the incision closed. RESULTS: Median (IQR) age was 62 (48.3-67) years. Median stone size was 20 × 21 mm, and 14 (18%) patients had complete staghorn stones. The upper calyx was the site of access in 52 (68.4%) cases. Access was above the 12th and 11th rib in 63 (83%) and 12 (16%) cases, respectively. Median (IQR) length of stay was 30 (28-32) hours. Fifty (68.5%) patients had no residual fragments (< 2 mm) on postoperative imaging. Eight (11%) patients underwent an ancillary procedure (7 URS and 1 ESWL), with an additional seven patients becoming stone free after this procedure (78%). Thoracic complications occurred in two (2.6%) patients: one small pneumothorax, and one pleural effusion, both managed conservatively. Other complications occurred in nine patients (11.8%): bleeding requiring transfusion (1), fever (4), urinary retention (2), and syncope (2). CONCLUSION: Compared to historical controls, our approach to upper tract PCNL utilizing a nephrostomy tube-free approach resulted in an overall low thoracic complication rate and facilitated hospital discharge.

Holmium-YAG laser: impact of pulse energy and frequency on local fluid temperature in an in-vitro obstructed kidney calyx model.

During laser lithotripsy, energy is transmitted to both the stone and the surrounding fluid. As the energy is delivered, the temperature will rise. Temperatures ≥60 ° C can cause protein denaturation. The objective of this study is to determine the time it takes from body temperature (37°C) to 60°C at various laser power settings. A Flexiva TracTip 200 optical fiber was submerged alongside a negative temperature coefficient-type thermistor in 4 mL of saline in a glass test tube. A Lumenis VersaPulse Powersuite 100-W holmium:yttrium aluminum garnet laser was activated at 0.2- to 1.5-J pulse energies, 6- to 50-Hz frequencies, and 2- to 22.5-W average power. Temperature readings were recorded every second from 37°C until 60°C. Time and heating rate were measured. The procedure was repeated three times for each setting. Average time from 37°C to 60°C for settings (1) 0.2 J/50 Hz, (2) 0.6 J/6 Hz, (3) 1 J/10 Hz, and (4) 1.5 J/10 Hz was 60.3, 172.7, 58, and 43.3 s, respectively. Time from 37°C to 60°C decreased as frequency increased for every given pulse energy. Average heating rate increased proportionally to power from 0.06°C/s at 2 W to 0.74°C/s at 22.5 W. During laser lithotripsy, there is a rapid increase in the temperature of its surrounding fluid and temperatures ≥60 ° C may be reached. This could have local tissue effects and some caution with higher power settings should be employed especially where irrigation is limited. Further studies incorporating irrigation and live tissue models may aid to further define the risks.

Perinephric Hematoma and Hemorrhagic Shock as a Rare Presentation for an Acutely Obstructive Ureteral Stone with Forniceal Rupture: A Case Report.

BACKGROUND: Spontaneous perinephric hematoma (SPH) secondary to a forniceal rupture as the first presenting sign for an obstructive ureteral stone in a patient without history of urolithiasis has not been described previously. CASE PRESENTATION: We report a 70-year-old Caucasian male patient who presented to our emergency room with fever, altered mental status, and left flank pain. He had a temperature of 103.3°F, tachycardia, but stable blood pressure. He had left flank tenderness. A computed tomography scan of the abdomen/pelvis with intravenous contrast revealed an intracapsular hematoma (13.3 × 10.0 × 6.4 cm) with an active bleeding and a 1.1 cm left proximal ureteral stone. The patient became quickly hemodynamically unstable and was taken for emergent exploratory laparotomy and left nephrectomy. An active bleeding was encountered secondary to a (2.4 × 2.0 cm) lateral capsular defect in the kidney. CONCLUSION: Hemorrhagic/septic shock as a presenting sign for an obstructive ureteral stone may require an emergent nephrectomy in a hemodynamically unstable patient.

Crowd-Sourced Assessment of Technical Skills for Validation of Basic Laparoscopic Urologic Skills Tasks.

PURPOSE: The BLUS (Basic Laparoscopic Urologic Skills) consortium sought to address the construct validity of BLUS tasks and the wider problem of accurate, scalable and affordable skill evaluation by investigating the concordance of 2 novel candidate methods with faculty panel scores, those of automated motion metrics and crowdsourcing. MATERIALS AND METHODS: A faculty panel of surgeons (5) and anonymous crowdworkers blindly reviewed a randomized sequence of a representative sample of 24 videos (12 pegboard and 12 suturing) extracted from the BLUS validation study (454) using the GOALS (Global Objective Assessment of Laparoscopic Skills) survey tool with appended pass-fail anchors via the same web based user interface. Pre-recorded motion metrics (tool path length, jerk cost etc) were available for each video. Cronbach's alpha, Pearson's R and ROC with AUC statistics were used to evaluate concordance between continuous scores, and as pass-fail criteria among the 3 groups of faculty, crowds and motion metrics. RESULTS: Crowdworkers provided 1,840 ratings in approximately 48 hours, 60 times faster than the faculty panel. The inter-rater reliability of mean expert and crowd ratings was good (α=0.826). Crowd score derived pass-fail resulted in 96.9% AUC (95% CI 90.3-100; positive predictive value 100%, negative predictive value 89%). Motion metrics and crowd scores provided similar or nearly identical concordance with faculty panel ratings and pass-fail decisions. CONCLUSIONS: The concordance of crowdsourcing with faculty panels and speed of reviews is sufficiently high to merit its further investigation alongside automated motion metrics. The overall agreement among faculty, motion metrics and crowdworkers provides evidence in support of the construct validity for 2 of the 4 BLUS tasks.

Validation of the AUA BLUS Tasks.

PURPOSE: Standardized assessment of laparoscopic skill in urology is lacking. We investigated whether the AUA (American Urological Association) BLUS (Basic Laparoscopic Urologic Skills) skill tasks are valid to address this need. MATERIALS AND METHODS: This institutional review board approved study included 27 medical students, 42 urology residents, 18 fellows and 37 faculty urologists across 8 sites. Using the EDGE (Electronic Data Generation and Evaluation) device (Simulab, Seattle, Washington) 454 recordings were collected on peg transfer, pattern cutting, suturing and clip applying tasks, which together comprise the expert determined BLUS tasks. We collected synchronized video and tool motion data for each trial. For each task errors, time, path length, economy of motion, peak grasp force and EDGE score were collected. An expert panel of 5 faculty members performed GOALS (Global Objective Assessment of Laparoscopic Skills) evaluations on a representative subset of peg transfer and suturing skill tasks performed by 24 participants (IRR = 0.95). RESULTS: Demographically derived skill levels proved unsuitable to evaluate construct validity. Separation of mean scores by grouped skill levels was strongest for the suturing task. Objective motion metrics and errors supported construct validity vis-à-vis correlation with blinded expert video ratings (motion metrics R(2) = 0.95, p <0.01). Expert scores appeared to reward errors in suturing but not in block transfer. CONCLUSIONS: BLUS skill task performance scoring can discriminate among basic laparoscopic technical skill levels. Self-reported demographics are an unreliable source of determining laparoscopic technical skill.

Multi-Institutional Validation of an OSATS for the Assessment of Cystoscopic and Ureteroscopic Skills.

PURPOSE: We evaluated the internal and construct validity of an assessment tool for cystoscopic and ureteroscopic cognitive and psychomotor skills at a multi-institutional level. MATERIALS AND METHODS: Subjects included a total of 30 urology residents at Ohio State University, Columbus, Ohio; Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Mayo Clinic, Rochester, Minnesota. A single external blinded reviewer evaluated cognitive and psychomotor skills associated with cystoscopic and ureteroscopic surgery using high fidelity bench models. Exercises included navigation, basketing and relocation; holmium laser lithotripsy; and cystoscope assembly. Each resident received a total cognitive score, checklist score and global psychomotor skills score. Construct validity was assessed by calculating correlations between training year and performance scores (both cognitive and psychomotor). Internal validity was confirmed by calculating correlations between test components. RESULTS: The median total cognitive score was 91 (IQR 86.25, 97). For psychomotor performance residents had a median total checklist score of 7 (IQR 5, 8) and a median global psychomotor skills score of 21 (IQR 18, 24.5). Construct validity was supported by the positive and statistically significant correlations between training year and total cognitive score (r = 0.66, 95% CI 0.39-0.82, p = 0.01), checklist scores (r = 0.66, 95% CI 0.35-0.84, p = 0.32) and global psychomotor skills score (r = 0.76, 95% CI 0.55-0.88, p = 0.002). The internal validity of OSATS was supported since total cognitive and checklist scores correlated with the global psychomotor skills score. CONCLUSIONS: In this multi-institutional study we successfully demonstrated the construct and internal validity of an objective assessment of cystoscopic and ureteroscopic cognitive and technical skills, including laser lithotripsy.

Laparoscopic partial nephrectomy: six degrees of haemostasis.

OBJECTIVE: • To describe six steps for haemostasis and collecting system closure ('six degrees of haemostasis') that are reproducible and that minimize the two most concerning complications of laparoscopic partial nephrectomy: haemorrhage and urine leakage. METHODS: • A retrospective study of 23 consecutive laparoscopic partial nephrectomy cases performed by a single surgeon between 2005 and 2008 using the 'six degrees of haemostasis' was carried out. RESULTS: • There were no cases of intraoperative, postoperative or delayed bleeding. • There were no cases of urine leakage. CONCLUSION: • The 'six degrees of haemostasis' technique for laparoscopic partial nephrectomy described in the present study provides a reliable and reproducible method to reassure the surgeon of haemostasis and provide a decreased risk of urine leakage.

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.

Bovine serum albumin glutaraldehyde for completely sutureless laparoscopic heminephrectomy in a survival porcine model.

INTRODUCTION: Laparoscopic partial nephrectomy (LPN) has not received widespread clinical application because of its technical challenge. Bovine serum albumin glutaraldehyde (BSAG) is a hemostatic agent that is independent of the clotting cascade. We evaluated the use of BSAG as the sole agent for parenchymal and collecting system closure during LPN in a survival porcine model. METHODS: Eighteen pigs underwent hilar clamping and LPN by longitudinal excision of the lateral one-third of the right kidney. The opened collecting system was covered with oxidized cellulose to prevent BSAG seepage into the urinary tract. BSAG was allowed to set for 10 or 5 minutes. Twelve animals underwent survival LPN BSAG only closure; six control pigs were acutely studied using saline. Urinary extravasation was evaluated by injection of furosemide and indigo carmine, and then evaluating the renal surface and bladder catheter drainage for dye. A subjective bleeding score was assigned after hilum unclamping. At 6 weeks, BSAG kidneys were harvested for burst pressure testing and histopathological analysis. RESULTS: All 12 pigs survived for 6 weeks. No pigs had urinary extravasation. Mean percentage of kidney removed by weight was 19%. Mean warm ischemia time was 29 minutes. Five pigs required a second BSAG application to achieve a bleeding score of 0. Mean arterial and collecting system burst pressures were 301.8 and 322.4 mm Hg, respectively. Mean postoperative creatinine increase was 0.07 mg/dL. CONCLUSION: BSAG for completely sutureless LPN in a survival porcine model was feasible.

Sacrifice of accessory pudendal arteries in normally potent men during robot-assisted radical prostatectomy does not impact potency.

AIM: Whether or not sacrificing accessory pudendal arteries (APAs) during radical prostatectomy affects potency has been an ongoing source of concern. Herein, we present our potency results relative to sacrificing APAs in normally pre-potent men following robot-assisted radical prostatectomy (RARP). METHODS: The distribution of APAs and clinical characteristics were prospectively recorded in 200 consecutive patients undergoing RARP with a cautery-free technique. Sexual function was assessed using the International Index of Erectile Function 5-item questionnaire (IIEF-5). All APAs were sacrificed due to stapling the dorsal vein complex. MAIN OUTCOME MEASURES: Postoperatively, potency was defined by an affirmative answer to the following two questions: "Were erections adequate for penetration?" and "were the erections satisfactory?" Postoperative IIEF-5 scores and quality of erections (% of preoperative firmness: 0%, 25%, 50%, 75%, 100%) were also obtained. Subgroup analysis of patients age < or =65 years with IIEF-5 score of 22-25 was performed. RESULTS: Eighty patients (40%) had APAs. Preoperatively, there was no association with having an APA and normal/abnormal sexual function. Preoperatively, 58/200 were < or =65 years with self-administered IIEF-5 scores of 22-25. Postoperatively, 53/58 (91%) were potent at 24 months follow-up. Nineteen of 58 patients had a sacrificed APA; 39 patients had no APA. Eighteen of 19 (95%) patients with sacrificed APAs were potent vs. 35/39 (90%) with no APA present (P = 0.53). Multivariate analysis showed no significant correlation between sacrificing an APA and time of potency recovery, quality of postoperative erections (94% vs. 90% P = 0.80) or mean IIEF-5 score (22.4 vs. 20.8, P = 0.13). CONCLUSION: We found no correlation between the presence or absence of APAs and preoperative sexual function. Furthermore, after sacrificing all APAs, we found no correlation with potency return, time to return of potency, quality of erections, or mean IIEF-5 scores at 24 months.

Preliminary study of virtual reality and model simulation for learning laparoscopic suturing skills.

PURPOSE: Repetitive practice of laparoscopic suturing and knot tying can facilitate surgeon proficiency in performing this reconstructive technique. We compared a silicone model and pelvic trainer to a virtual reality simulator in the learning of laparoscopic suturing and knot tying by laparoscopically naïve medical students, and evaluated the subsequent performance of porcine laparoscopic cystorrhaphy. MATERIALS AND METHODS: A total of 20 medical students underwent a 1-hour didactic session with video demonstration of laparoscopic suturing and knot tying by an expert laparoscopic surgeon. The students were randomized to a pelvic trainer (10) or virtual reality simulator (10) for a minimum of 2 hours of laparoscopic suturing and knot tying training. Within 1 week of the training session the medical students performed laparoscopic closure of a 2 cm cystotomy in a porcine model. Objective structured assessment of technical skills for laparoscopic cystorrhaphy was performed at the procedure by laparoscopic surgeons blinded to the medical student training format. A video of the procedure was evaluated with an objective structured assessment of technical skills by an expert laparoscopic surgeon blinded to medical student identity and training format. The medical students completed an evaluation questionnaire regarding the training format after the laparoscopic cystorrhaphy. RESULTS: All students were able to complete the laparoscopic cystorrhaphy. There was no difference between the pelvic trainer and virtual reality groups in mean +/- SD time to perform the porcine cystorrhaphy at 40 +/- 15 vs 41 +/- 10 minutes (p = 0.87) or the objective structured assessment of technical skills score of 8.8 +/- 2.3 vs 8.2 +/- 2.2 (p = 0.24), respectively. Bladder leak occurred in 3 (30%) of the pelvic trainer trained and 6 (60%) of the virtual reality trained medical student laparoscopic cystorrhaphy procedures (Fisher exact test p = 0.37). The only significant difference between the 2 groups was that 4 virtual reality trained medical students considered the training session too short compared to none of those trained on the pelvic trainer (p = 0.04). CONCLUSIONS: There is no significant difference between the pelvic trainer and virtual reality trained medical students in proficiency to perform laparoscopic cystorrhaphy in a pig model, although both groups require considerably more training before performing this procedure clinically. The pelvic trainer training may be more user-friendly for the novice surgeon to begin learning these challenging laparoscopic skills.

Preliminary evaluation of a genitourinary skills training curriculum for medical students.

PURPOSE: Basic urology training in medical school is considered important for many medical and surgical disciplines. We developed a 2-day intensive genitourinary skills training curriculum for medical students beginning their clinical clerkship training years and evaluated the initial experience with this program. MATERIALS AND METHODS: All 94 third-year medical students at the University of California, Irvine were required to participate in a 5.5-hour genitourinary examination skills training program. The teaching course included 1.5 hours of didactic lecture and video presentation with questions and answers, followed by 5, 45-minute hands-on stations including male Foley catheter placement, female Foley catheter placement, testicular examination and digital rectal examination training with a standardized patient, virtual reality cystourethroscopy and, lastly, a urologist led tutorial of abnormal genitourinary findings. The students completed questionnaires before and after the course concerning their experience. At the end of the course the students rated the usefulness of each part of the curriculum and evaluated the faculty. In addition, they were required to complete a multiple choice examination that included 4 genitourinary specific questions. RESULTS: All 94 medical students completed the genitourinary skills training course. Before the course less than 10% of students reported comfort with genitourinary skills, including testicular examination (5%), digital rectal examination (10%), male Foley catheter placement and female Foley catheter placement (2%). Following the course the comfort level improved in all parameters of digital rectal examination (100%) and testicular examination, male Foley catheter placement and female Foley catheter placement (98%). The students rated in the order of most to least useful training 1) standardized patient for testicular examination and digital rectal examination teaching, 2) male Foley catheter placement and female Foley catheter placement training, 3) didactic lecture, 4) tutorial of abnormal genitourinary examination findings and 5) virtual reality cystourethroscopy. On the examination questions following the course 80% to 98% of the class answered each urology content question correctly. CONCLUSIONS: An intensive skills training curriculum significantly improved medical student comfort and knowledge with regard to basic genitourinary skills including testicular examination, rectal examination, and Foley catheter placement in the male and female patient. Further followup will be performed to determine the application of these skills during clinical clerkship rotations.

Transvaginal access: current experience and potential implications for urologic applications.

Natural orifice translumenal endoscopic surgery (NOTES) has been introduced as a less invasive approach to performing intra-abdominal surgery. Any natural orifice may be used, although the ideal portal remains to be determined. Transvaginal surgery has been performed by gynecologists for decades and there is abundant literature supporting the efficacy and safety using this approach. Surgeons have also used the vagina for specimen removal after laparoscopic surgery to minimize the transabdominal incision. More recently, several animal NOTES experiments have used the transvaginal approach to complete a variety of gastrointestinal and urologic surgeries. Given the success with animal experiments, the transition to clinical surgery has begun, with several groups reporting their success with transvaginal cholecystectomy. At present, it appears that the transvaginal approach may be the best suited NOTES portal in those patients in whom it is possible. Future studies are needed to address NOTES' specific concerns, and these potentially less invasive techniques will ultimately need to be compared with standard laparoscopic surgery before their true value can be ascertained.

Retroperitoneal transdiaphragmatic robotic-assisted laparoscopic resection of a left thoracolumbar neurofibroma.

OBJECTIVE: Robotic technology has been used in a variety of surgical procedures for its 3D magnification and precision. Minimally invasive techniques have already become common in neurosurgery; however, robotic-assisted procedures in neurosurgery are still a relatively new frontier. This report describes the first use of robotic technology to resect a left thoracolumbar neurofibroma. CASE REPORT: A 19-year-old male with a family history of neurofibromatosis was diagnosed with a suspected 3-cm x 4-cm neurofibroma in the T12-L1 left paraspinal area. His only complaint was back pain requiring narcotic analgesics. He had no other findings on physical examination or laboratory/radiologic workup. METHODS: After consulting urologic robotic surgeons, it was agreed to use the da Vinci robot (Intuitive Surgical, Sunnyvale, CA) for the resection of this mass. Following retroperitoneal laparoscopic access, the urologic surgeons opened the diaphragm and began the initial mobilization of the mass laparoscopically. The robot was docked, and the neurosurgeon operated the robot at the console to resect the mass from its nerve origin. There were no complications, and the mass, a confirmed neurofibroma, was completely removed. The patient was discharged on postoperative day 2; his back pain resolved, requiring no analgesia by the end of the first postoperative week. CONCLUSION: This case provides early evidence that robotic assistance can be successfully used for the resection of a paraspinal neurofibroma.