Surgical correction of multiple renoduodenal fistulas due to chronic pyelonephritis: a case report and literature review.

Renoduodenal fistulas are a rare and uncommon phenomenon that account for ˂1% of those found between the urinary and intestinal tracts. Precipitation of this pathologic tract can be caused by chronic inflammation, necrosis, or ischemia. This case illustrates a 72-year-old man presenting with flank pain discovered to have multiple renoduodenal fistulas and our approach that led to the resolution of his symptoms. We review the pathophysiology, management, and effects of these fistulous tracts on renal function. Patients with staghorn calculi should undergo immediate evaluation for removal of the stone. In cases complicated by fistula formation, need for radical nephrectomy should be investigated and surgical repair should be pursued.

A Fatal Case of Penile Calciphylaxis.

Calciphylaxis is a rare and serious complication of chronic renal failure characterized by vascular calcium overload. It has a high mortality rate. Penile calciphylaxis is an extremely rare condition of penile necrosis due to calciphylaxis of the penile arterioles. Presented here is a severe case of systemic calciphylaxis initially presented as penile necrosis treated with sodium thiosulfate and amputation.

Successful body flossing via indwelling nephrostomy allowing for primary realignment of bladder rupture and placement of a foley catheter into the urinary bladder.

Vesicourethral anastomosis leaks are one of the most common short-term complications following radical prostatectomy. We present a case of a 67-year-old Caucasian male who presented to our Emergency Department (ED) with abdominal pain and urinary incontinence 10 days after a robotic-assisted laparoscopic prostatectomy. Interventional radiology initially performed successful nephrostomy placement for bilateral hydronephrosis. Vesicourethral disruption was managed via a multidisciplinary approach with urology and interventional radiology in which a novel approach to realign a bladder rupture and appropriately place a foley catheter in the bladder. Vesicourethral leaks are often managed conservatively. In a few cases, such as this one, mini-invasive intervention is often required to repair the disruption.

A Case of Recurrent Bacterial Meningitis Due to Retained 54-Year-Old Ureterodural Anastomosis.

Ventriculoperitoneal shunts are the current treatment of choice for congenital hydrocephalus. It is rare for physicians to see patients with alternative types of shunting devices. Lumboureteral shunts, once popular from the 1940s to 1960s, decompress via the genitourinary system. Immediate complications were dehydration, electrolyte imbalances, infection, and the sacrifice of a functional kidney. Long-term complications include retrograde meningitis due to urinary tract infections. Three shunt types have been documented: polyethylene, silicone rubber, and ureterodural anastomosis. Routine imaging cannot detect a ureterodural anastomosis, and if suspected, computed tomography myelogram is needed for confirmation. This article presents the case of a man with long-standing ureterodural anastomosis that required ligation after recurrent episodes of acute meningitis secondary to urinary retention.

Robot-assisted partial nephrectomy for hilar tumors: perioperative outcomes.

OBJECTIVE: To compare perioperative outcomes of robot-assisted partial nephrectomy (RAPN) for hilar vs nonhilar tumors. MATERIALS AND METHODS: The study retrospectively reviewed 364 patients with available computed tomography scans undergoing RAPN. Demographic data and perioperative outcomes results were compared between the hilar (group 1, n = 70) and nonhilar tumors (group 2, n = 294). Multivariate analysis was used to identify predictors of warm ischemia time (WIT), estimated blood loss (EBL), major perioperative complications, and postoperative renal function. RESULTS: There were no differences with respect to demographic variables. Hilar tumors had higher RENAL (radius, exophytic/endophytic properties of the tumor, nearness of tumor deepest portion to the collecting system or sinus, anterior/posterior descriptor and the location relative to polar lines) scores (P <.001) and were larger (3.9 vs 2.6 cm, P <.001). Surgeries for hilar tumors were associated with greater operative time (210 vs 180 minutes, P <.001), longer WIT (27 vs 17 minutes, P <.001), and increased EBL (250 vs 200 mL, P = .04). No differences were noted in transfusion rate, length of stay, complications (overall and major) and positive margins. Postoperative estimated glomerular filtration rate showed no significant difference between hilar vs nonhilar patients on postoperative day 3 (70.12 vs 74.71 mL/min/1.73 m(2), P = .31) or at last follow-up (72.62 vs 75.78 mL/min/1.73 m(2), P = .40), respectively. Multivariate analysis found hilar location was independently associated with increased WIT without significant changes in EBL, major complications, or postoperative renal function. CONCLUSION: RAPN represents a safe and effective procedure for hilar tumors. Hilar location for patients undergoing RAPN in a high-volume institution seems not be associated with an increased risk of transfusions, major complications, or decline of early postoperative renal function.

Perioperative complications of robot-assisted partial nephrectomy: analysis of 886 patients at 5 United States centers.

OBJECTIVE: To review complications of robot-assisted partial nephrectomy (RAPN) at 5 centers, as classified by the Clavien system. MATERIALS AND METHODS: A multi-institutional analysis of prospectively maintained databases assessed RAPN complications. From June 2007 to November 2011, 886 patients at 5 United States centers underwent RAPN. Patient demographics, perioperative outcomes, and complications data were collected. Complication severity was classified by Clavien grade. RESULTS: Mean (standard deviation) data were patient age, 59.4 (11.4) years; age-adjusted Charlson Comorbidity Index, 3.0 (1.9); radiographic tumor size, 3.0 (1.6) cm; nephrometry score, 6.9 (2.0); and warm ischemia time, 18.8 (9.0) minutes. Median blood loss was 100 mL (interquartile range, 100-250 mL). Of the 886 patients, intraoperative complications occurred in 23 patients (2.6%) and 139 postoperative complications occurred in 115 patients (13.0%) for a total complication rate of 15.6%. Among the 139 postoperative complications, 43 (30.9%) were classified as Clavien 1, 64 (46.0%) were Clavien 2, 21 (15.1%) were Clavien 3, and 11 (7.9%) were Clavien 4. No complication-related deaths occurred. Intraoperative hemorrhage occurred in 9 patients (1.0%) and postoperative hemorrhage in 51 (5.8%). Forty-one patients (4.6%) required a perioperative blood transfusion, 10 (1.1%) required angioembolization, and 2 (0.2%) required surgical reexploration for postoperative hemorrhage. Urine leaks developed in 10 patients (1.1%): 3 (0.3%) required ureteral stenting, and 2 (0.2%) required percutaneous drainage. Acute postoperative renal insufficiency or renal failure developed in 7 patients (0.8%), 2 of whom required hemodialysis. The RENAL (radius, exophytic/endophytic properties of the tumor, nearness of tumor deepest portion to the collecting system or sinus, anterior/posterior descriptor and the location relative to polar lines) nephrometry scoring system accurately predicted RAPN complication rates. CONCLUSION: Complication rates in this large multicenter series of RAPN appear to be acceptable and comparable with other nephron-sparing modalities. Most complications (77.0%) are Clavien 1 and 2 and can be managed conservatively.

Robot-assisted transrectal hybrid natural orifice translumenal endoscopic surgery nephrectomy and adrenalectomy: initial investigation in a cadaver model.

OBJECTIVE: To assess the feasibility of robotic transrectal hybrid natural orifice translumenal endoscopic surgery (NOTES) nephrectomy and adrenalectomy. MATERIALS AND METHODS: A male cadaver was used for the present investigation and placed in lithotomy position. An 8- and 12-mm port was inserted through the same periumbilical skin incision. An incision was then created in the rectum 1 cm above the pectinate line, and a submucosal tunnel was developed, through which a robotic 8-mm port was inserted under vision. The cadaver was then placed in the right side up, flank position. The laparoscope and the right robot instrument were introduced through the umbilicus while the left robot instrument was introduced through the rectal port aiding the peri-umbilical ports in kidney and adrenal dissection. After completion of the nephrectomy, the kidney was placed in a specimen bag and extracted intact through the rectum. Closure of the rectal incision was accomplished extracorporeally using 2 suture layers. RESULTS: Robotic transrectal hybrid NOTES nephrectomy and adrenalectomy were completed successfully. The total operative time was 145 minutes, of which the access and robotic docking required 20 minutes. Kidney dissection and hilar control was achieved within 60 minutes. Right adrenalectomy, specimen extraction, and rectal closure was completed in 15, 30, and 20 minutes, respectively. CONCLUSION: We report the first investigation of a robot-assisted transrectal hybrid NOTES nephrectomy and adrenalectomy in a cadaver model to assess the range of motion and articulation of the robotic platform. Additional investigations in live animal model are needed to evaluate the safety of the transrectal approach.

Single institutional cost analysis of 325 robotic, laparoscopic, and open partial nephrectomies.

OBJECTIVE: To compare costs associated with partial nephrectomy (PN) using robotic, laparoscopic (LPN), and open (OPN) approaches. METHODS: An Investigational Review Board-approved prospectively maintained database was reviewed for 325 patients who underwent PN at our institution from January 2009 to December 2010. Costs for each surgical technique were itemized, including hospitalization, operating room (OR), anesthesia, medication, laboratory and pathology, professional fees, and blood bank. Continuous variables were analyzed with Kruskal-Wallis and Wilcoxon tests, and categoric variables were analyzed with χ(2) and Fisher exact tests. RESULTS: Median costs of RPN were higher than LPN ($632, P = .005), but not significantly higher than OPN ($313, P = .14). The major cause of this difference was OR instrumentation and supplies. OR costs for LPN and OPN were equivalent (P = .11). The cost associated with anesthesia was significantly lower for RPN and LPN than for OPN (P = .002). RPN and LPN had lower hospitalization costs than OPN (P <.0001), which was largely due to the shorter hospital stay (P <.0001) and lower laboratory cost (P <.0001). Pharmacy costs and blood bank costs were not significantly different among groups (P = .09 and P = .48, respectively). CONCLUSION: RPN had higher operating room costs than LPN and OPN, primarily due to instrumentation and supplies. This higher cost was offset by decreased cost of hospitalization in compared with the OPN group. Modification of practices aimed at lowering RPN instrumentation and supply costs may enable cost equivalence.

Correlation of the RENAL nephrometry score with warm ischemia time after robotic partial nephrectomy.

PURPOSE: The RENAL nephrometry score (RNS) was developed to quantify complexity of renal tumors in a reproducible manner. We aim to determine whether individual categories of the RNS have different impact on the warm ischemia time (WIT) for patients undergoing robotic partial nephrectomy (RPN). METHODS: In a retrospective analysis of a prospectively maintained database, we identified 251 consecutive patients who underwent RPN between January 2007 and June 2010. RNS was determined in 187 with available imaging. Univariable analysis and multivariable linear regression analysis were performed to identify which factors were more significantly associated with WIT. RESULTS: Overall RNS was of low (4-6), moderate (7-9), and high complexity (10-12) in 84 (45 %), 80 (43 %), and 23 (12 %) patients, respectively. There was no association between gender (p = 0.6), BMI (p = 0.3), or anterior/posterior location (A) (p = 0.8), and WIT. On univariable analysis, longer WIT was associated with size (R) >4 cm (p < 0.0001), entirely endophytic properties (E) (p = 0.005), tumor <4 mm from the collecting system/sinus (N) (p < 0.0001), and location between the polar lines (L) (p = 0.004). Total RNS and WIT were highly correlated (Spearman correlation coefficient = 0.54, p < 0.0001). There was a significant trend of higher WIT with increased tumor complexity (p for trend <0.0001). After multivariable analysis, only R (p = 0.0003), E (p = 0.003), and N (p = 0.00002) components of the RNS were significantly associated with WIT. CONCLUSIONS: The A and L subcategories of the RNS have no significant impact on the WIT of patients undergoing RPN. WIT is significantly dependent upon the other subcategories, as well as the overall RNS. These findings can be used to preoperatively predict which tumor characteristics will likely affect WIT and may be useful in preoperative counseling as well as planning of approach.

Probe ablation as salvage therapy for renal tumors in von Hippel-Lindau patients: the Cleveland Clinic experience with 3 years follow-up.

BACKGROUND: To evaluate the efficacy and safety of probe ablative therapy as salvage treatment for renal tumor in von Hippel-Lindau (VHL) patients after previous partial nephrectomy (PN). METHODS: Medical records of VHL patients undergoing probe ablative treatment for renal tumors from March 2003 to January 2010 at our institution were retrospectively analyzed. RESULTS: Fourteen VHL patients who were submitted to salvage probe ablative therapy were included in the analysis. Twelve patients (85%) had a solitary kidney. Overall, 33 tumors were ablated by either percutaneous cryoablation (P-Cryo) (n of procedures = 13), radiofrequency ablation (RFA) (n = 14), and laparoscopic cryoablation (L-Cryo) (n = 3). Average maximal renal tumor diameter was 2.6 ± 1 cm. Average ablation time was 18.3 ± 2.1 minutes for P-Cryo, 36.7 ± 17 minutes for RFA, and 17.3 ± 4 minutes for L-Cryo. All procedures were successfully completed without transfusions and intraoperative complications. No early postoperative complications were recorded. Postoperative decline in renal function was minimal and not clinically significant. With a mean follow-up of 37.6 months (range 12-82), 4 patients had a suspicious recurrence on computed tomography/magnetic resonance imaging (CT/MRI) scan and in 3 of them a re-ablation was performed. Actuarial overall and cancer-specific survivals were 92% and 100%, respectively. CONCLUSIONS: Probe ablative therapy seems to represent a suitable treatment option for VHL patients with a previous history of PN as it offers a repeatable operation, with a high technical success rate and causing minor changes in renal function.

Robot-assisted ureteroneocystostomy: technique and comparative outcomes.

BACKGROUND AND PURPOSE: Ureteroneocystostomy can be used for the treatment of patients with a wide variety of ureteral pathology. Over the last decade, robot-assisted surgery has become more commonly used as a minimally invasive approach for reconstructive upper urinary tract procedures. The aim of this study is to present our experience with robot-assisted ureteroneocystosctomy (RUNC) with a comparison with that of open ureteroneocystostomy (OUNC). PATIENTS AND METHODS: Medical records of 25 patients who underwent RUNC and 41 patients who underwent OUNC or at our institution between 2000 and 2010 were retrospectively analyzed. Perioperative and postoperative data including demographics, surgical outcomes, and clinical and radiographic findings at postoperative follow-up were considered in the comparative analysis. Descriptive statistics were used to present the data. The significance of the difference between variables was evaluated using the Wilcoxon rank sum test for continuous and Fisher exact test for categorical variables. RESULTS: No significant differences were detected in terms of baseline patient characteristics between the two groups. The OUNC procedures were performed with a shorter median operative time (200 vs 279 min., P=0.0008), whereas RUNC patients had a shorter hospital stay (median 3 vs 5 days, P=0.0004), less narcotic pain requirement (morphine equivalent, mg 104.6 vs 290, P=0.0001), and less estimated blood loss (100 vs 150 mL, P=<0.0002). There as no significant difference in the rate of reoperation between groups: RUNC 2/25 (7.6 %) vs OUNC 4/41 (9.7%) P=0.8. Limitations include the retrospective nature of the study and the difference in indications for surgery. CONCLUSION: RUNC provides excellent outcomes with shorter hospital stay, less narcotic pain requirement, and decreased blood loss when compared with the open procedure. Advantages of the robotic platform for dissection and suturing can be useful for complex minimally invasive urologic reconstructive procedures.

Robotic partial nephrectomy for solitary kidney: a multi-institutional analysis.

OBJECTIVE: To evaluate the outcomes of robotic partial nephrectomy (RPN) for solitary kidney in a large multicenter series. MATERIALS AND METHODS: Medical records of 886 consecutive patients who underwent RPN at 5 academic institutions from May 2007 to May 2012 were retrospectively analyzed. Data were prospectively collected in an Investigational Review Board-approved protocol. Experienced robotic surgeons performed all operations. Patient demographics, functional, perioperative, and early oncologic outcomes were analyzed. RESULTS: A total of 26 patients with a solitary kidney were identified and included in the analysis; of these, 16 (62%) had solitary kidneys secondary to a previous malignancy. Perioperative outcomes included a median warm ischemia time of 17 minutes (interquartile range, 12, 28 minutes). Only 2 intraoperative complications occurred. One was a renal vein injury and one an aortic vessel tear, and both patients required intraoperative blood transfusions. No conversions to laparoscopy or open surgery occurred. There were 3 postoperative complications (11.5%). Median follow-up was 6 months (interquartile range, 5, 9.7 months). Postoperative renal function did not change significantly as measure by estimated glomerular filtration rate (-15.8%; P=.13). None of the patients required dialysis. Positive margins occurred in 1 patient, with 73% of patients having a renal cell carcinoma. CONCLUSION: We report a multi-institutional series of RPN in patients with solitary kidney presenting with small renal masses. Our findings suggest that RPN represents a feasible treatment option in this specific population by offering reliable preservation of renal function, low surgical morbidity, and early oncologic safety in the hands of experienced robotic surgeons.

Off-clamp robot-assisted partial nephrectomy preserves renal function: a multi-institutional propensity score analysis.

BACKGROUND: Ongoing efforts are focused on minimizing or eliminating renal ischemia during robot-assisted partial nephrectomy (RPN). Although various techniques allowing the elimination of renal hilar clamping have been described, large multi-institutional studies assessing perioperative and functional outcomes of this approach are lacking. OBJECTIVE: To evaluate perioperative and functional outcomes of RPN without hilar clamping and to assess comparative effectiveness relative to clamped RPN. DESIGN, SETTING, AND PARTICIPANTS: A multi-institutional data analysis of prospectively collected records of 886 RPNs performed by high-volume surgeons across five academic institutions between 2007 and 2011 was carried out. A total of 66 patients who underwent RPN without hilar clamping were identified. After the exclusion of 17 patients, perioperative results of 49 patients were compared against propensity score matched clamped controls. INTERVENTION: RPN without hilar clamping. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Descriptive statistics and propensity score matching. RESULTS AND LIMITATIONS: Patients undergoing off-clamp RPN had a mean tumor size of 2.5 cm (standard deviation [SD]: ± 2.1) and a mean RENAL nephrometry score of 5.3 (SD: ± 1.5). The mean preoperative estimated glomerular filtration rate (eGFR) was 81 (SD: ± 29). The mean estimated blood loss (EBL) was 210 ml (SD: ± 212), and the mean operative time was 155 min (SD: ± 46). No Clavien 3-5 complications were recorded. The mean postoperative change in eGFR was 3% at first follow-up (1-3 mo), and no patient required postoperative dialysis. The positive surgical margin rate was 3% (n=2), with no disease recurrence reported at a mean follow-up of 21 mo. In propensity score matched analyses, the off-clamp RPN patients had a significantly shorter mean operative time (156 min compared with 185 min, p<0.001), a higher EBL (228 ml compared with 157 ml, p=0.009), and a smaller decrease in eGFR (2% compared with -6%, p=0.008). The retrospective analysis was the main limitation of this study. CONCLUSIONS: With appropriately selected patients and adequate surgeon experience, off-clamp RPN is safe and feasible. Off-clamp RPN was associated with higher EBL, shorter operative times, and smaller decrease in renal function.

Comparative outcomes and assessment of trifecta in 500 robotic and laparoscopic partial nephrectomy cases: a single surgeon experience.

PURPOSE: We report a comparative analysis of a large series of laparoscopic and robotic partial nephrectomies performed by a high volume single surgeon at a tertiary care institution. MATERIALS AND METHODS: We retrospectively reviewed the medical charts of 500 patients treated with minimally invasive partial nephrectomy by a single surgeon between March 2002 and February 2012. Demographic and perioperative data were collected and statistically analyzed. R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in mm, anterior/posterior and location relative to polar lines) nephrometry score was used to score tumors. Those scored as moderate and high complexity were designated as complex. Trifecta was defined as a combination of warm ischemia time less than 25 minutes, negative surgical margins and no perioperative complications. RESULTS: Two groups were identified, including 261 patients with robotic and 231 with laparoscopic partial nephrectomy. Demographics were similar in the groups. The robotic group was significantly more morbid (Charlson comorbidity index 3.75 vs 1.26), included more complex tumors (R.E.N.A.L. score 5.98 vs 7.2), and had lower operative (169.9 vs 191.7 minutes) and warm ischemia (17.9 vs 25.2 minutes) time, intraoperative (2.6% vs 5.6%, each p <0.001) and postoperative (24.53% vs 32.03%, p = 0.004) complications, and positive margin rate (2.9% vs 5.6%, p <0.001). Thus, a higher overall trifecta rate was observed for robotic partial nephrectomy (58.7% vs 31.6%, p <0.001). The laparoscopic group had longer followup (3.43 vs 1.51 years, p <0.001) and no significant difference in postoperative changes in renal function. Main study limitations were the retrospective nature, arbitrary definition of trifecta and shorter followup in the RPN group. CONCLUSIONS: Our large comparative analysis shows that robotic partial nephrectomy offers a wider range of indications, better operative outcomes and lower perioperative morbidity than laparoscopic partial nephrectomy. Overall, the quest for trifecta seems to be better accomplished by robotic partial nephrectomy, which is likely to become the new standard for minimally invasive partial nephrectomy.

Utility of intraoperative frozen section during robot-assisted partial nephrectomy: a single institution experience.

BACKGROUND AND PURPOSE: Intraoperative frozen section (FS) analysis has been regarded as a paramount tool for immediate evaluation of tumor margin status during partial nephrectomy procedures. The aim of this study was to assess the utility of FS during robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS: A retrospective review of our Institutional Review Board-approved prospectively maintained minimally invasive partial nephrectomy database yielded 342 consecutive RAPN procedures from June 2007 to September 2011. Of these, the initial 128 cases underwent FS evaluation, whereas the following 214 cases did not. Patient demographics, perioperative outcomes, and final pathology results were analyzed and compared between the two groups. RESULTS: Body mass index, Charleson Comorbidity Index, tumor size, renal score, preoperative creatinine level, and estimated glomerular filtration rate (eGFR) were similar between both groups. Operative time was significantly longer in the no-FS group (193 vs 180 min; P=0.04). Warm ischemia time (median 19 vs 19 min), estimated blood loss (150 vs 200 mL), postoperative creatinine level (1.0 vs 1.1 mg/dL), and postoperative eGFR (75.6 vs 75.9) were similar between the no-FS group and FS group, respectively. Complications occurred in 32 (15.0%) and 31 (24.2%) cases in no-FS and FS, respectively (P=0.06). Final pathology results demonstrated seven cases of positive margins, 1 (1%), in the FS group and 6 (3%) in the no-FS group (P=0.19). Of the cases with positive margins at final pathology analysis, a R.E.N.A.L. score of 3/3 was found on closeness to renal sinus. Overall, three intraoperative positive margins were noted in the FS group (2.3%): One patient underwent radical nephrectomy and one reresection; one case was managed with observation only. CONCLUSION: Routine application of FS analysis during RAPN seems to provide a limited benefit. FS might be advisable for tumors with sinus invasion because they seem to carry a higher likelihood of positive surgical margin at final pathology determination.

Robotic versus laparoscopic partial nephrectomy for tumor in a solitary kidney: a single institution comparative analysis.

OBJECTIVES: To compare the outcomes of robot-assisted laparoscopic partial nephrectomy and laparoscopic partial nephrectomy for renal tumor in patients with a solitary kidney. METHODS: We retrospectively reviewed data of patients with solitary kidney who underwent laparoscopic (n = 52) and robot-assisted (n = 15) partial nephrectomy for renal tumor at Cleveland Clinic, Cleveland, Ohio, USA, between June 2000 and April 2012. Patient demographic data, perioperative parameters and follow-up data were compared. RESULTS: The two groups were similar in terms of patients and tumor characteristics, including preoperative renal function and etiology of solitary kidney. The median operative time (225 vs 171 min, P = 0.02), warm ischemia time (19 vs 15 min, P = 0.04) and hospital stay (4 vs 3 days, P = 0.03) were significantly shorter in the robotic group. No significant differences were found in terms of estimated blood loss, transfusion, complications, pathological results and margin status. The median percentage change of renal function was not significantly different between two groups. Long-term hemodialysis was required for three patients in the laparoscopic group (6%) and none of the patients in the robotic group. Median follow up was 15.6 and 5.9 months in the laparoscopic and robotic group, respectively. CONCLUSIONS: Robot-assisted partial nephrectomy represents a safe and effective minimally-invasive treatment option for renal masses in patients with a solitary kidney. Early comparative outcomes suggest that it offers a significant benefit over the laparoscopic approach in terms of operative time, warm ischemia time and hospital stay. Further studies with a longer follow up are required to confirm the likelihood of better long-term functional and oncological outcomes.

Cryoablation versus minimally invasive partial nephrectomy for small renal masses in the solitary kidney: impact of approach on functional outcomes.

PURPOSE: We evaluated the change in renal function after renal cryoablation and partial nephrectomy based on tumor complexity according to the R.E.N.A.L. nephrometry score. MATERIALS AND METHODS: We retrospectively reviewed the data of patients who had a renal tumor in a solitary kidney, and underwent renal cryoablation and partial nephrectomy between December 2000 and January 2012. Renal tumor complexity was categorized into 3 groups by R.E.N.A.L. nephrometry score as low (4 to 6), intermediate (7 to 9) and high (10 to 12). All baseline demographic data, perioperative parameters and followup data including renal function were collected. Comparisons were made among similar tumor complexities. RESULTS: In the renal cryoablation and partial nephrectomy groups 29 patients (43 tumors) and 33 patients were identified, respectively. In all renal tumor complexities, renal cryoablation provided a better perioperative outcome in terms of median operative time, estimated blood loss, transfusion, hospital stay and complications. The median change in serum creatinine and estimated glomerular filtration rate was slightly greater in the partial nephrectomy group. However, the differences were not statistically significant for any of the tumor complexities. Three patients (10%) in the renal cryoablation group and 2 (6%) in the partial nephrectomy group required long-term dialysis. CONCLUSIONS: In patients with solitary kidneys, renal cryoablation is associated with superior perioperative outcomes compared to partial nephrectomy. Specifically, partial nephrectomy is not associated with greater loss of renal function than renal cryoablation regardless of the extent of tumor complexity.

Transvaginal hybrid natural orifice transluminal surgery robotic donor nephrectomy: first clinical application.

OBJECTIVE: To report a novel surgical approach of transvaginal hybrid natural orifice transluminal surgery (NOTES) living donor nephrectomy. We conceptualized this approach by incorporating 2 existing concepts: laparoendoscopic single-site surgery and NOTES. MATERIALS AND METHODS: After thorough consent and under institutional review board approval, a 61-year-old woman volunteered to donate her kidney through hybrid transvaginal NOTES. Under general anesthesia, she was placed in a modified right lateral decubitus position. A SILS port and an 8-mm trocar were placed through the same umbilical incision. The GelPoint port was placed transvaginally via the posterior fornix, and the robot was docked. After dissection of the left kidney in preparation for extraction, the robot was undocked, and the retrieval bag was inserted through the GelPoint port. The graft was bagged before vessel stapling and extracted without breaching the bag. The kidney was delivered to the perfusion table with a clean pair of gloves without contamination with the bag exterior. RESULTS: Donor nephrectomy was successfully completed without conversion or perioperative complications. The total operative time was 240 minutes, the warm ischemic time was 5.8 minutes, and the estimated blood loss was 75 mL. No complications occurred and extra ports were not needed. The patient was discharged after an uneventful 48-hour stay. Her creatinine was 1.0 mg/dL at 4 weeks of follow-up. The recipient was given pulse steroids for biopsy-proven acute rejection, and her serum creatinine was 1.16 mg/dL at 4 weeks postoperatively. CONCLUSION: Transvaginal hybrid NOTES robotic donor nephrectomy is feasible. Additional advances in robotic technology are awaited for development of this approach and to foster its clinical application.

The impact of body mass index on surgical outcomes of robotic partial nephrectomy.

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. "What's known on the subject?" and "What does the study add?" Obesity is associated with higher incidence of renal cell carcinoma. Laparoscopic and robotic partial nephrectomy (RPN) was shown to be technically feasible in the obese population. In the present study we evaluated the impact of obesity on outcome of RPN, in a large cohort of patients. In the present study, obese patients had a higher American Society of Anesthesiologists score and larger tumour size. We evaluated obesity as a categorical and a continuous variable, and we adjusted for confounding factors. We categorized obesity based according to the WHO classification of obesity. We described our technical modifications to overcome difficulties that can be encountered during the surgery. Obese patients had a higher estimated blood loss, but no difference in blood transfusion rate, operation duration or warm ischaemia time. OBJECTIVE: • To assess the impact of body mass index (BMI) on the surgical outcomes of robotic partial nephrectomy (RPN). PATIENTS AND METHODS: • Medical charts of 250 consecutive patients who underwent RPN at our institution between 2006 and 2010 were reviewed. • Patients were categorized based on their BMI into four groups per international classification of obesity into: normal (BMI < 25 kg/m(2)), overweight (25-29.9), obese (30-39.9) and morbidly obese (≥ 40). • Preoperative characteristics as well as perioperative and postoperative outcomes were analysed and compared between the groups. RESULTS: • Of the 250 patients, 43 (17.2% of the entire cohort) were non-obese, 104 (41.6%) were overweight, 75 (30%) were obese, and 28 (11.2%) were morbidly obese. • Groups were similar in terms of age, gender, history of previous surgery and nephrometry score (P = 0.5). • Patients with higher BMI had a higher American Society of Anesthesiologists (ASA) score (median 3 for obese and morbidly obese groups vs 2 for non-obese groups; P = 0.002) and tumour size (median 3.6, 2.9, 2.5 and 2.3 cm in those who were morbidly obese, obese, overweight and with normal BMI, respectively; P = 0.005). • Patients within the morbidly obese group had a higher estimated blood loss (median 250 mL) than other groups (median: 200, 200, 150 mL, respectively) (P = 0.03). • No significant difference was detected between the groups in terms of operation duration, warm ischaemia time, transfusion rate and postoperative complications. CONCLUSION: • Robotic partial nephrectomy represents an effective treatment modality for renal tumours providing equivalent surgical outcomes even for patients with BMI up to 60 kg/m(2).