Efficacy of testosterone replacement therapy plus alternate-day tadalafil for patients with late-onset hypogonadism: An open-label, randomized, crossover study.

OBJECTIVE: To examine the efficacy and safety of combination treatment with testosterone replacement therapy plus alternate-day tadalafil (10 mg) in patients with late-onset hypogonadism. METHODS: In this open-label, randomized, crossover study, 29 patients with late-onset hypogonadism were randomly assigned to receive testosterone replacement therapy for 12 weeks followed by combination treatment for 12 weeks (Group 1) or combination treatment for 12 weeks followed by testosterone replacement therapy (Group 2). Symptom questionnaires were administered and blood tests were performed prior to and following each treatment to assess safety and efficacy. At the end of the study, participants were asked about their treatment preferences. RESULTS: An adverse effect, a rheum symptom, occurred in only one participant, and 26 participants completed the study without any toxicity. Scores on the Aging Male Symptoms scale and the modified short version of the International Index of Erectile Function, and Overactive Bladder Symptom scores were significantly improved in the combination treatment phase of Group 2, whereas no significant difference between the phases were observed in Group 1. In total, 12 out of the 14 participants in Group 1 and 11 out of the 12 participants in Group 2 preferred combination treatment, which reached statistical significance (P = 0.008 and 0.004 for Groups 1 and 2, respectively). CONCLUSIONS: Testosterone replacement therapy with add-on alternate-day tadalafil is a safe and satisfactory treatment for patients with late-onset hypogonadism.

Efficacy of combined treatment of intramuscular testosterone injection and testosterone ointment application for late-onset hypogonadism: an open-labeled, randomized, crossover study.

INTRODUCTION: The best method for administering testosterone replacement therapy (TRT) for late-onset hypogonadism (LOH) remains controversial. This study aimed to compare the efficacy and safety of a combined treatment (CT) involving intramuscular testosterone injection and testosterone ointment application [Glowmin® (GL)] with intramuscular injection monotherapy (IMIM). MATERIALS AND METHODS: Patients were randomly assigned as follows: Group 1 received IMIM for 12 weeks and CT for 12 weeks and Group 2 received CT for 12 weeks and IMIM for 12 weeks. Patients were then asked about their treatment preferences: (A) IMIM, (B) a combination of IMIM and ointment, or (C) either A or B. RESULTS: Patients (n = 43) completed the study without any adverse effects. No significant differences between each treatment period were found. In Group 1, most patients chose B (n = 13) while in Group 2, most chose A (n = 10). In each group, patients preferred the second treatment phase; however, statistical significance was not reached between A and B (Group 1, p = 0.11 and Group 2, p = 0.47, respectively). CONCLUSION: TRT by CT is compatible with TRT by IMIM. Patients who cannot continue TRT because of polycythemia from IMIM may be suited to CT.

Mevalonate pathway blockage enhances the efficacy of mTOR inhibitors with the activation of retinoblastoma protein in renal cell carcinoma.

Renal cell carcinoma (RCC) is the most common malignancy of kidney and remains largely intractable once it recurs after resection. mTOR inhibitors have been one of the mainstays used against recurrent RCC; however, there has been a major problem of the resistance to mTOR inhibitors, and thus new combination treatments with mTOR inhibitors are required. We here retrospectively showed that regular use of antilipidemic drug statins could provide a longer progression free survival (PFS) in RCC patients prescribed with an mTOR inhibitor everolimus than without statins (median PFS, 7.5 months vs. 3.2 months, respectively; hazard ratio, 0.52; 95% CI, 0.22-1.11). In order to give a rationale for this finding, we used RCC cell lines and showed the combinatorial effects of an mTOR inhibitor with statins induced a robust activation of retinoblastoma protein, whose mechanisms were involved in statins-mediated hindrance of KRAS or Rac1 protein prenylation. Finally, statins treatment also enhanced the efficacy of an mTOR inhibitor in RCC xenograft models. Thus, we provide molecular and (pre)clinical data showing that statins use could be a drug repositioning for RCC patients to enhance the efficacy of mTOR inhibitors.

Effects of Sex Steroids on the Spinal Gastrin-Releasing Peptide System Controlling Male Sexual Function in Rats.

The gastrin-releasing peptide (GRP) system in the lumbosacral spinal cord controls male sexual function in rats. In contrast, in female rats, GRP neurons could scarcely be detected around puberty when circulating ovarian steroid hormones such as estradiol and progesterone levels are increasing. However, little information is available on feminizing or demasculinizing effects of ovarian steroids on the central nervous system in female puberty and adulthood. In this study, to visualize the spinal GRP neurons in vivo, we generated a GRP-promoter-Venus transgenic (Tg) rat line and studied the effects of the sex steroid hormones on GRP expression in the rat lumbar cord by examining the Venus fluorescence. In these Tg rats, the sexually dimorphic spinal GRP neurons controlling male sexual function were clearly labeled with Venus fluorescence. As expected, Venus fluorescence in the male lumbar cord was markedly decreased after castration and restored by chronic androgen replacement. Furthermore, androgen-induced Venus expression in the spinal cord of adult Tg males was significantly attenuated by chronic treatment with progesterone but not with estradiol. A luciferase assay using a human GRP-promoter construct showed that androgens enhance the spinal GRP system, and more strikingly, that progesterone acts to inhibit the GRP system via an androgen receptor-mediated mechanism. These results demonstrate that circulating androgens may play an important role in the spinal GRP system controlling male sexual function not only in rats but also in humans and that progesterone could be an important feminizing factor in the spinal GRP system in females during pubertal development.

[Spontaneous Subcapsular Renal Hemorrhage of Papillary Renal Cell Carcinoma].

A 75-year-old man with a history of chronic kidney disease (CKD) visited our emergency room after the sudden onset of severe right lower abdominal pain and nausea. Computed tomography (CT) showed right perirenal hematoma and renal tumor, which was diagnosed as a spontaneous rupture of the right renal tumor. It was difficult to correctly diagnose the tumor as benign or malignant with magnetic resonance imaging (MRI). Because of CKD, a shunt was implanted, and dynamic enhanced CT was performed. Dynamic enhanced CT showed a slightly enhanced area of the tumor, and it was diagnosed as renal cell carcinoma (RCC). Radical nephrectomy was performed, and he has not experienced recurrence within 7 months after the surgery. Pathological diagnosis was papillary renal carcinoma. Spontaneous renal hemorrhage is relatively uncommon, but the most common cause of spontaneous renal hemorrhage is renal cell carcinoma (26.1%). CT is useful for diagnosis, but it is not highly accurate. Therefore, it is necessary to discuss surgical indication carefully.

Nephrolithotomy performed concurrently with laparoendoscopic single-site pyeloplasty.

INTRODUCTION: The objective of the present study was to evaluate the results of laparoendoscopic single-site (LESS) pyeloplasty and pyelolithotomy, which were performed concurrently in patients with pelviureteric junction obstruction (PUJO) and renal stones. TECHNICAL CONSIDERATIONS: Four patients with PUJO and renal stones underwent pyelolithotomy performed concurrently with LESS pyeloplasty. In 3 patients, a 2.5-cm incision was made in the umbilical region. In the fourth patient, the 2.5-cm vertical incision was made at a site 7 cm below the umbilical region because of a stone in the right lower calyx. After dissection of the pelviureteric junction, an incision of approximately 1 cm was made along the presumed transection line of the renal pelvis. The pyelolithotomy was performed using a 24F rigid nephroscope through a SILS port. Dismembered pyeloplasty was performed after extraction of the renal stones was completed. The mean operation time was 277 minutes (range, 225-373), and the mean lithotomy time was 31 minutes (range, 20-50). No intraoperative or postoperative complications were observed. For all 4 patients, discharge from the hospital was possible after a mean of 3.4 postoperative days (range, 3-4). All patients became stone free. Postoperative ultrasound revealed that hydronephrosis improved in all patients. In all patients, resolution of the symptoms was confirmed. CONCLUSION: LESS nephrolithotomy with pyeloplasty is a safe and effective procedure with a good cosmetic result for patients with PUJO and renal stones.

Hemostatic effect of new surgical glue in animal partial nephrectomy models.

OBJECTIVE: To evaluate the hemostatic effect of newly developed medical adhesive in animal partial nephrectomy models. MATERIALS AND METHODS: A total of 30 experimental rabbits were used in the first study. After clamping the renal vessels, partial nephrectomy was performed up to the opening of the calices. Bioglue was applied to the resection stumps using the new glue (group 1, n = 10) or fibrin glue (group 2, n = 10) for 2 minutes, and the blood loss was measured after unclamping the vessels. Simple unclamping without glue (group 3, n = 10) was also evaluated. For the second study, we used 9 dogs with blood pressure monitoring. After preparation similar to that for the first study, the new glue was applied in 3 dogs (group 4), fibrin glue in 3 dogs (group 5) and no glue in 3 dogs (group 6). Histologic evaluation was performed at 7 days and 1 month after surgery. RESULTS: The mean blood loss was significantly less in group 1 (1.45 g) than in groups 2 (6.59 g) and 3 (19.77 g; P <.001 for both). It was also significantly less in group 4 (12.5 g) than in group 5 (182.5 g; P <.001). Group 4 maintained their initial blood pressure throughout the study, but a significant decrease was observed in group 5. No hematoma was observed at day 7. CONCLUSION: The new glue showed acceptable hemostasis when applied to the resection stumps after partial nephrectomy in both the rabbit and the dog models. These findings indicate that it could be useful for hemostasis after partial nephrectomy.

Health related quality of life for monosymptomatic enuretic children and their mothers.

PURPOSE: There have been few reports addressing how nocturnal enuresis affects the health related quality of life of patients and their mothers. Thus, we evaluated the health related quality of life of enuretic children and their mothers. MATERIALS AND METHODS: The health related quality of life of 139 patients with nocturnal enuresis and that of their mothers were evaluated before and after treatment. The children's health related quality of life was evaluated with the Kid-KINDL® protocol. The mothers' health related quality of life was evaluated using the SF-36®, the SDS (Self-Rating Depression Scale) for rating depression and the STAI (State-Trait Anxiety Inventory) for assessing anxiety. RESULTS: In the health related quality of life of enuretic children, the family domain score was significantly lower than that of controls (p = 0.02). In the health related quality of life of the mothers as shown by SF-36, the vitality domain score was significantly lower compared to controls (p = 0.01). The evaluation of the STAI score demonstrated a higher state anxiety score (p = 0.003), which represents current suffering from anxiety, and a similar trait anxiety score (p = 0.22), which represents a similar level of underlying tendency to anxiety. There was no significant difference between the mothers of enuretic children and the controls in the SDS evaluation. After treatment for enuresis the health related quality of life score was improved not only for the enuretic children as assessed by the Kid-KINDL protocol, but also for the mothers of enuretic children as assessed by the SF-36 and STAI. CONCLUSIONS: Similar to other pediatric chronic diseases, nocturnal enuresis is a condition that negatively affects the health related quality of life of children and their mothers. Impaired health related quality of life can be improved after the successful treatment of nocturnal enuresis.

Percutaneous drainage with a one-step technique under real-time computed tomography fluoroscopic guidance.

BACKGROUND/AIMS: The goal of our study was to determine the usefulness of the percutaneous placement of a drainage catheter using a one-step technique under guidance of computed tomography (CT) fluoroscopy. METHODOLOGY: Subjects were 11 patients (3 women, 8 men; mean age 65 years) who underwent percutaneous thoracic, abdominal, and pelvic drainage procedures for fluid collections between August 2010 and June 2011. The mean maximum diameter of the lesions was 53.8mm (range 30 to 82 mm) and the mean depth was 37.6mm (range 18 to 70mm). A drainage catheter that can be inserted by a one- step technique without a guide wire was used. The procedures were guided by use of a helical CT scanner that provided real-time fluoroscopic reconstruction. RESULTS: Percutaneous drainage was successfully achieved in every procedure. Use of real-time CT-fluoroscopy and a drainage catheter that can be inserted with a one-step technique allowed rapid assessment of catheter placement. No patient had a serious complication related to the drainage procedure. The mean procedure time required to drain one lesion was 21.1 minutes (range 12 to 41 minutes). CONCLUSIONS: Thoracic, abdominal, and pelvic drainage procedures using the one-step technique under CT-fluoroscopy guidance were accurate, safe and easy.

Nicardipine vs. saline injection as treatment for Peyronie's disease: a prospective, randomized, single-blind trial.

INTRODUCTION: Various conservative treatments for Peyronie's disease (PD) have been attempted over the years. Intralesional verapamil injection has been tested in prospective randomized studies, but the effect of this treatment seems insufficient. Nicardipine is a calcium antagonist alternative to verapamil and is reportedly more effective in vitro. AIM: The objective of our study was to evaluate the usefulness of intralesional nicardipine injection as a conservative treatment for PD in the transition period of acute and chronic phase. METHODS: Eighty-six patients (age: 38-72 years, mean: 52) were enrolled in this study. A total of 74 patients were assigned randomly to nicardipine group (10 mg diluted in 10 mL of distilled water daily, N=37) and control group (10 mL of saline water, N=37). A total of six injections were administrated biweekly. MEAN OUTCOME MEASURE: The subjects were assessed by International Index of Erectile Function (IIEF)-5 and international pain scale. The plaque size was measured by ultrasonography after 20 µg intracavernosal injection of alprostadil (prostaglandin E1). The penile curvature was also measured by taking a photograph at maximum rigidity. RESULTS: A reduction of pain score was seen throughout the course of treatment in both groups with a significant difference between the nicardipine and control groups (multiple analysis of variance test, P=0.019). A significant improvement of IIEF-5 score occurred only in the nicardipine group at 48 weeks after the initiation of treatment (P<0.01). The plaque size was significantly reduced at 48 weeks only in the nicardipine group (12 points, P=0.0004 by paired t-test). The penile curvature was significantly improved in both groups (P<0.01) without significant difference between them (P=0.14). There were no severe side effects, such as hypotension or other cardiovascular events. CONCLUSION: Our findings indicate that intralesional nicardipine injection is clinically effective as a conservative treatment for PD in the transition period of acute and chronic phase.

Laparoendoscopic single-site urological surgery: initial experience in Japan.

The objective of this paper is to report our initial experience in laparoendoscopic single-site surgery (LESS). One patient underwent LESS varicocelectomy and another patient underwent LESS pyeloplasty. The Triport was inserted into the abdomen through the umbilical incision. In the varicocelectomy, testicular vessels were coagulated by a vessel-sealing system, and transected. In the pyeloplasty, a 2-mm needlescopic port was added to facilitate the procedure, and a dismembered procedure was performed. Total operative duration was 60 min for the varicocelectomy and 240 min for the pyeloplasty. Blood loss was minimal and no perioperative complications occurred. At the 3-month follow up, no postoperative complications were observed and there was no complaint of pain. LESS varicocelectomy and pyeloplasty were successfully performed with excellent cosmetic results and no complications.

Experimental study for electrovaporization of renal cell carcinoma using a new shape memory alloy probe.

OBJECTIVES: To develop a new shape memory alloy probe for percutaneous treatment of renal cell carcinoma (RCC) by electrovaporization, and investigate its efficacy and safety in experimental models. METHODS: The shape memory alloy electrode can be manipulated to any shape at room temperature and regains its original shape at >or=65 degrees C. By adding a high-frequency electric current to the probe, the electrodes quickly regain their original shape and vaporize tissues into a spherical defect. The performance of this probe was tested using agar, dog kidney, and rat RCC models. The treatment effect was evaluated by magnetic resonance imaging and histologic examination. RESULTS: In the agar model, the electrovaporization inside the spherical electrode was successfully achieved in several seconds, with all power outputs tested. The area of >or=60 degrees C extended about 5 mm beyond the periphery of the vaporized part and corresponded with the histologic findings on the dog kidney that an irreversible heat denaturation occurred to the same extent. The study on the RCC model also confirmed that about 5-mm extent of heat denaturation was seen in the muscular tissue adjacent to the tumor. In the study using the RCC model, some remaining tissues close to the tumor were observed after vaporization. However, dynamic magnetic resonance imaging demonstrated no enhancement in this area and no viable tumor cells were documented by histologic examination. CONCLUSIONS: This novel tissue ablation system has potential as a viable option for percutaneous treatment of renal tumors.

Radiofrequency ablation for renal tumors: our experience.

OBJECTIVES: To report our results of percutaneous radiofrequency ablation (RFA) for renal tumors and to assess predictors of therapeutic efficacy. METHODS: Forty patients (median age 73 years) with renal tumors were treated with RFA under local or epidural anesthesia. All of them had high surgical risk or refused radical surgery. Tumors were punctured percutaneously using the Radionics Cool-tip RF System under computed tomography or ultrasonographic guidance. Median tumor diameter was 24 mm. After RFA, contrast-enhanced computed tomography or magnetic resonance imaging was performed within 1 month. Complete response (CR) was defined as no enhancement inside the tumor. Factors related to the outcome and to renal function were assessed. RESULTS: Median follow up was 16 months. CR was observed in 34 cases (85.0%). A significant difference in CR rate was observed between tumors < or =30 mm and those >30 mm. Outcomes tended to be better for tumors in the mid to lower kidney, and those away from the renal hilum. Recurrence was observed in one case (2.9%), but a CR was obtained again by additional RFA. Out of a total of 77 RFA procedures, complications occurred in only three cases (3.9%), and conservative treatment was possible in all cases. Serum creatinine levels 3 months after RFA did not differ from those before RFA. CONCLUSIONS: Percutaneous RFA is a safe and effective treatment for small renal tumors in patients with high surgical risk or who refuse radical surgery.

Transvesical laparoscopic cross-trigonal ureteral reimplantation for correction of vesicoureteral reflux: initial experience and comparisons between adult and pediatric cases.

PURPOSE: Transvesical laparoscopic cross-trigonal ureteral reimplantation (TLCUR) has been reported as an alternative procedure for vesicoureteral reflux mainly in pediatric cases. We review our initial experience with TLCUR and evaluate its feasibility in adult patients. PATIENTS AND METHODS: We performed TLCUR in 30 patients (22 females and 24 bilateral cases) with a median age of 14.5 years. RESULTS: The median operating time was 145 minutes in the unilateral cases and 230 minutes in the bilateral cases. Blood loss was minimal in all cases. No intraoperative complications were observed. The urethral catheter was removed at day 2 to 3. One persistence of reflux and one uretero-vesico anastomosis stricture were observed. The total success rate of 49 ureters in 27 patients, in whom postoperative cystography was performed, was 96% (47/49). Comparing the first 15 and last 15 cases, patient age was similar, the operation time was significantly shorter in the last 15 cases, and both operative failures were found in the first 15 cases. Comparing the 15 pediatric and 15 adult cases, the operation time did not differ between the two groups and one operative failure was observed in each group. CONCLUSION: This procedure was an effective and safe alternative minimally invasive procedure for both adult and pediatric patients with reflux.

A comparison of cooling methods for laparoscopic partial nephrectomy.

OBJECTIVES: To evaluate appropriate cooling methods in laparoscopic partial nephrectomy. METHODS: Under general anesthesia, 21 porcine kidneys were exposed retroperitoneoscopically. Ice slush (500 g) was put into the retroperitoneal cavity after renal vascular clamping. Renal parenchymal temperature was measured by a thermometer. Seven kidneys were cooled only by ice slush (group I). In seven kidneys, 200 mL of 4 degrees C saline was infused around the kidney 45 minutes after vascular clamping (group II). In seven kidneys, 4 degrees C saline was irrigated continuously through a 5F ureteral catheter, which was inserted into the ureter (group III). RESULTS: In group I, 21 minutes after vascular clamping, the lowest temperature achieved was 13.2 degrees C, and at 47 minutes the temperature exceeded 20 degrees C. In group II, the lowest temperature achieved was 13.0 degrees C 23 minutes after vascular clamping, and at 59 minutes the temperature exceeded 20 degrees C. In group III, the lowest temperature of 10.6 degrees C was achieved at 27 minutes, and at 79 minutes the temperature exceeded 20 degrees C. CONCLUSIONS: In complicated cases of laparoscopic partial nephrectomy, cooling with both ice slush and ureteral catheter irrigation was thought to be effective. When the renal collecting system is opened, an additional infusion of cooled water may also be effective.

Localization of increased insulin-like growth factor binding protein-3 in diabetic rat penis: implications for erectile dysfunction.

OBJECTIVES: Diabetes-induced erectile dysfunction (ED) is assumed to result from neurovascular abnormalities. However, the entire picture of the molecular mechanisms underlying ED has not yet been clarified. To elucidate the possible elements involved in ED in diabetes mellitus, we performed broad-scale gene expression profiling using cDNA array in the penis of streptozotocin-induced diabetic rats. METHODS: Northern blot analysis was performed to examine the course of the mRNA expression encoded by the identified gene. Immunohistochemistry was performed to identify the cellular localization of the encoded protein. RESULTS: Of the genes investigated, the expression level of insulin-like growth factor binding protein 3 (IGFBP-3) was greatly increased at 12 weeks after streptozotocin treatment. The levels of ErbB3 epidermal growth factor receptor-related proto-oncogene, G1/S-specific cyclin D2, hepatic neutral cholesteryl ester hydrolase precursor, UDP-galactose ceramide galactosyltransferase, and serine protease RNK-Met-1 were markedly decreased. Increased levels of IGFBP-3 mRNA were demonstrated as early as 2 weeks after induction of hyperglycemia. Increased IGFBP-3 protein was localized to the epithelium of the urethra, penile endothelium, and smooth muscle in the corpus cavernosum. Significant depletion of the smooth muscle density relative to the connective tissue was first observed in the penis of the 8-week diabetic rats, and a significant reduction in the intracavernous pressure was demonstrated only at 12 weeks after the induction of hyperglycemia. CONCLUSIONS: These results suggest that the increased expression of IGFBP-3 during hyperglycemia might play an important role in the development of ED.

Low serum testosterone concentration in middle-aged men with type 2 diabetes.

Low concentrations of endogenous androgens have been linked with insulin resistance and atherosclerosis. Men with diabetes have been reported to have lower serum testosterone concentration than non-diabetic men; however, there has never been a large study. The aim of this study was to investigate if endogenous androgen concentration is certainly lower in a relatively large number of Japanese patients with type 2 diabetes compared with healthy men, and to identify what factors may be associated with low serum testosterone concentrations in men with type 2 diabetes. Serum free testosterone concentrations were measured in 524 healthy men and in 331 consecutive Japanese men with type 2 diabetes between 40 and 69 years old. In addition, we investigated the relationships between serum free testosterone concentration and luteinizing hormone (LH) concentration as well as major cardiovascular risk factors including age, blood pressure, plasma lipid concentration, glycemic control (HbA(1c)), and BMI. Serum free testosterone concentrations were lower in men with type 2 diabetes than in healthy men in the 40-49 years group (10.9 +/- 3.3 vs. 14.0 +/- 3.6 pg/ml, P<0.0001), in the 50-59 years group (10.4 +/- 3.2 vs. 12.1 +/- 2.9 pg/ml, P<0.0001), and in the 60-69 years group (9.5 +/- 2.6 vs. 10.5 +/- 2.9 pg/ml, P = 0.0104). A negative correlation was found between serum free testosterone and LH concentrations (r = -0.326, P<0.0001). In conclusion, serum free testosterone concentration is certainly lower in a relatively large number of Japanese patients with type 2 diabetes compared with healthy men with each decade of life between 40 and 69 years old.

[A case of urethral stricture diagnosed by transrectal ultrasonography (TRUS) at voiding].

Subcapsral prostatectomy was performed in a 75-year-old male, with the diagnosis of benign prostatic hyperplasia. Total prostate volume was 105 ml by transrectal ultrasonography (TRUS) and the excised prostate weighed in 90 g. After the surgery, he recovered from urinary disturbance once, but, he again complained of severe dysuria 12 days after the surgery. With the aim of non-invasive examination, we performed TRUS at voiding. Urethral stricture was definitely diagnosed using TRUS during micturition. Thus voiding TRUS was very effective in diagnosing urethral stricture.

Oncologic outcome of hand-assisted laparoscopic radical nephrectomy.

OBJECTIVES: To evaluate and compare the oncologic outcome of hand-assisted retroperitoneoscopic radical nephrectomy (HALS) with that of open radical nephrectomy. METHODS: The clinical and follow-up data of 123 patients with localized renal cell carcinoma who underwent HALS were retrospectively compared with those of 70 patients who underwent open radical nephrectomy. RESULTS: No significant differences were found in operating time, complication rates, or transfusion rates between the HALS and open groups. The estimated blood loss was significantly less in the HALS group. The median follow-up period was 41.0 months for the HALS group, significantly shorter than that for the open group (74.5 months). The 3 and 5-year disease-free survival rate for the HALS and open groups was 94% and 92% and 93% and 91%, respectively. The 3 and 5-year cancer-specific survival rate for the HALS and open groups was 96% and 92% and 98% and 94%, respectively. No significant differences were found in the disease-free and cancer-specific survival rates between the two groups. In the HALS group, no significant differences were found in the disease-free survival rate between those undergoing surgery by less-experienced surgeons who had performed laparoscopic nephrectomy on 10 cases or less and those undergoing surgery by more experienced surgeons. CONCLUSIONS: The oncologic outcome of HALS did not differ much from that of the open approach. Also, the experience of the surgeon did not affect the oncologic outcome. However, extended follow-up is necessary to assess the true oncologic efficacy of HALS.