Robot-assisted ureteral reconstruction using a tubularized peritoneal flap: a novel technique in a chronic porcine model.

OBJECTIVE: To evaluate the feasibility and functional outcomes in porcine models of a novel robotic surgical technique for the treatment of complex ureteral injuries and strictures. MATERIALS AND METHODS: Six pigs underwent robotic ureteral reconstruction using a long tabularized peritoneal flap and followed for 6-9 weeks after the surgery. Ureteral flap vascularity, intra-renal pressure, patency of the conduct, endoscopic aspect of the flap, renal function and histopathology were evaluated. RESULTS: All animals successfully underwent ureteral reconstruction using a tubularized peritoneal flap. Median operative time was 223 min (162-360). Flap tubularization suture took 31 min (19-47), and proximal anastomosis took 20 min (15-38). Bladder mobilization with psoas hitch and distal anastomosis took 9 min (7-12) and 23 min (13-46), respectively. On follow-up, significant shrinkage of the ureteral flap in both length and width was observed. Antegrade pyelograms confirmed dilation and tortuosity of the proximal ureter, dilation of the renal pelvis, and major and minor calyxes without any definitive strictures. Microscopically, focal urothelial lining was seen in the neoureter. Creatinine level was significantly higher at the end of the follow-up period (p = 0.003). CONCLUSIONS: Robot-assisted ureteral reconstruction using a tubularized peritoneum flap is technically feasible and reproducible. The flap sustained abundant vascular supply after different intervals of follow-up and the peritoneal mesenchymal cells differentiated into urothelium and myofibroblasts. Further studies are needed to address the issue of functional obstruction to improve long-term renal function outcomes.

Severity of erectile dysfunction is highly correlated with the syntax score in patients undergoing coronariography.

OBJECTIVE: To investigate the association between the severity of erectile dysfunction (ED) and coronary artery disease (CAD) in men undergoing coronary angiography for angina or acute myocardial infarct (AMI). MATERIAL AND METHODS: We studied 132 males who underwent coronary angiography for first time between January and November 2010. ED severity was assessed by the international index of erectile function (IIEF-5) and CAD severity was assessed by the Syntax score. Patients with CAD (cases) and without CAD (controls) had their IIEF-5 compared. In the group with CAD, their IIEF-5 scores were compared to their Syntax score results. RESULTS: We identified 86 patients with and 46 without CAD. The IIEF-5 score of the group without CAD (22.6±0.8) was significantly higher than the group with CAD (12.5±0.5; p<0.0001). In patients without ED, the Syntax score average was 6.3±3.5, while those with moderate or severe ED had a mean Syntax score of 39.0±11.1. After adjustment, ED was independently associated to CAD, with an odds ratio of 40.6 (CI 95%, 14.3-115.3, p<0.0001). The accuracy of the logistic model to correctly identify presence or absence of CAD was 87%, with 92% sensitivity and 78% specificity. The average time that ED was present in patients with CAD was 38.8±2.3 months before coronary symptoms, about twice as high as patients without CAD (18.0±5.1 months). CONCLUSIONS: ED severity is strongly and independently correlated with CAD complexity, as assessed by the Syntax score in patients undergoing coronariography for evaluation of new onset coronary symptoms.

Ipsilateral renal function preservation after robot-assisted partial nephrectomy (RAPN): an objective analysis using mercapto-acetyltriglycine (MAG3) renal scan data and volumetric assessment.

OBJECTIVE: To objectively assess ipsilateral renal function (IRF) preservation and factors influencing it after robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS: Our database was queried to identify patients who had undergone RAPN from 2007 to 2013 and had complete pre- and postoperative mercapto-acetyltriglycine (MAG3) renal scan assessment. The estimated glomerular filtration rate (eGFR) for the operated kidney was calculated by multiplying the percentage of contribution from the renal scan by the total eGFR. IRF preservation was defined as a ratio of the postoperative eGFR for the operated kidney to the preoperative eGFR for the operated kidney. The percentage of total eGFR preservation was calculated in the same manner (postoperative eGFR/preoperative eGFR × 100). The amount of healthy rim of renal parenchyma removed was assessed by deducting the volume of tumour from the volume of the PN specimen assessed on pathology. Multivariable linear regression was used for analysis. RESULTS: In all, 99 patients were included in the analysis. The overall median (interquartile range) total eGFR preservation and IRF preservation for the operated kidney was 83.83 (75.2-94.1)% and 72 (60.3-81)%, respectively (P < 0.01). On multivariable analysis, volume of healthy rim of renal parenchyma removed, warm ischaemia time (WIT) > 30 min, body mass index (BMI) and operated kidney preoperative eGFR were predictive of IRF preservation. CONCLUSIONS: Using total eGFR tends to overestimate the degree of renal function preservation after RAPN. This is particularly relevant when studying factors affecting functional outcomes after nephron-sparing surgery. IRF may be a more precise assessment method in this setting. Operated kidney baseline renal function, BMI, WIT >30 min, and amount of resected healthy renal parenchyma represent the factors with a significant impact on the IRF preservation. RAPN provides significant preservation of renal function as shown by objective assessment criteria.

Laparoendoscopic single-site (LESS) vs laparoscopic living-donor nephrectomy: a systematic review and meta-analysis.

The aim of this study was to provide a systematic review and meta-analysis of reports comparing laparoendoscopic single-site (LESS) living-donor nephrectomy (LDN) vs standard laparoscopic LDN (LLDN). A systematic review of the literature was performed in September 2013 using PubMed, Scopus, Ovid and The Cochrane library databases. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Weighted mean differences (WMDs) were used to measure continuous variables and odds ratios (ORs) to measure categorical ones. Nine publications meeting eligibility criteria were identified, including 461 LESS LDN and 1006 LLDN cases. There were more left-side cases in the LESS LDN group (96.5% vs 88.6%, P < 0.001). Meta-analysis of extractable data showed that LLDN had a shorter operative time (WMD 15.06 min, 95% confidence interval [CI] 4.9-25.1; P = 0.003), without a significant difference in warm ischaemia time (WMD 0.41 min, 95% CI -0.02 to 0.84; P = 0.06). Estimated blood loss was lower for LESS LDN (WMD -22.09 mL, 95% CI -29.5 to -14.6; P < 0.001); however, this difference was not clinically significant. There was a greater likelihood of conversion for LESS LDN (OR 13.21, 95% CI 4.65-37.53; P < 0.001). Hospital stay was similar (WMD -0.11 days, 95% CI -0.33 to 0.12; P = 0.35), as well as the visual analogue pain score at discharge (WMD -0.31, 95% CI -0.96 to 0.35; P = 0.36), but the analgesic requirement was lower for LESS LDN (WMD -2.58 mg, 95% CI -5.01 to -0.15; P = 0.04). Moreover, there was no difference in the postoperative complication rate (OR 1.00, 95% CI 0.65-1.54; P = 0.99). Renal function of the recipient, as based on creatinine levels at 1 month, showed similar outcomes between groups (WMD 0.10 mg/dL, -0.09 to 0.29; P = 0.29). In conclusion, LESS LDN represents an emerging option for living kidney donation. This procedure offers comparable surgical and early functional outcomes to the conventional LLDN, with a lower analgesic requirement. However, it is more technically challenging than LLDN, as shown by a greater likelihood of conversion. The role of LESS LDN remains to be defined.

30-day hospital readmission after robotic partial nephrectomy--are we prepared for Medicare readmission reduction program?

PURPOSE: After CMS introduced the concept of the Hospital Readmissions Reduction Program, hospitals and health care centers became financially penalized for exceeding specific readmission rates. MATERIALS AND METHODS: We retrospectively reviewed our institutional review board approved database of patients undergoing robotic partial nephrectomy at our institution and included in our analysis patients who were readmitted to any hospital as an inpatient stay within 30 days from discharge home after robotic partial nephrectomy. RESULTS: From March 2006 to March 2013 a total of 627 patients underwent robotic partial nephrectomy at our center and 28 (4.46%) were readmitted within 30 days of surgery. Postoperative bleeding was responsible for 8 (28.5%) readmissions. Pulmonary embolism was reported in 3 cases and retroperitoneal abscess was diagnosed in 2. Urinary leak requiring surgical intervention developed in 2 patients, pneumonia was diagnosed in 2 and 2 patients were readmitted for chest pain. Overall 9 (32.1%) patients presented with major complications requiring intervention. On multivariable analysis Charlson comorbidity index score was the only factor significantly associated with a higher 30-day readmission rate (p = 0.03). If the Charlson score was 5 or greater the chance of hospital readmission would be 2.7 times higher. CONCLUSIONS: Increased comorbidity, specifically a Charlson score of 5 or greater, was the only significant predictor of a higher incidence of 30-day readmission. This information can be useful in counseling patients regarding robotic partial nephrectomy and in determining baseline rates if CMS expands the number of conditions they evaluate for excess 30-day readmissions.

Robot-assisted partial nephrectomy (RAPN) for completely endophytic renal masses: a single institution experience.

OBJECTIVE: To analyse the outcomes of robot-assisted partial nephrectomy (RAPN) for completely endophytic renal tumours. PATIENTS AND METHODS: Medical records of patients who had undergone RAPN for a completely endophytic (i.e. 3 points for the 'E' domain of the R.E.N.A.L. nephrometry score) enhancing renal mass at our Centre from 2006 to 2012 were retrieved from our prospectively maintained RAPN database and used for this analysis. Demographics, surgical and early postoperative outcomes were compared with those of patients with exophytic masses (i.e. 1 point for the 'E' domain) and those of patients with mesophytic masses (i.e. 2 points for the 'E' domain). RESULTS: In all, 65 patients (mean age 56 years; mean body mass index 29.4 kg/m(2) ; mean Charlson comorbidity index 3.2) were included in the study group, accounting for 16.7% of RAPN cases over the study period. The main surgical outcomes were: mean operative time 175 min, mean estimated blood loss 225 mL, and mean warm ischaemia time 21.7 min. Pathology showed a malignant histology in 48 cases (74%), mostly clear cell renal cell carcinoma. Two positive margins (3%) were found. Patients with a completely endophytic mass had smaller tumours on preoperative imaging (mean 2.6 vs 3.3 for mesophytic vs 3.7 cm for exophytic; P < 0.001), and higher overall R.E.N.A.L. score (mean 8.7 vs 7.6 vs 6.4; P < 0.001). There was a lower rate of unclamped cases in the endophytic group (3.1% vs 4.8% vs 18%; P < 0.001). There were no differences in intraoperative complications, length of hospital stay, positive margin rate, postoperative change in estimated glomerular filtration rate, given a similar length of follow-up (mean 12.6 vs 15.7 vs 14.5 months; P = 0.3). CONCLUSION: RAPN for completely intraparenchymal renal tumours can be safely and effectively performed in centres with significant robotic expertise, with surgical outcomes resembling those obtained in the general RAPN population.

Step-by-Step robotic heminephrectomy for duplicated renal collecting system.

INTRODUCTION: A duplicated renal collecting system is a relatively common congenital anomaly rarely presenting in adults. AIM: In this video we demonstrate our step-by-step technique of Robotic heminephrectomy in a patient with non-functioning upper pole moiety. MATERIALS AND METHODS: Following cystoscopy and ureteral catheter insertion the patient was placed in 60° modified flank position with the ipsilateral arm positioned at the side of the patient. A straight-line, three arm robotic port configuration was employed. The robot was docked at a 90-degree angle, perpendicular to the patient. Following mobilization the colon and identifying both ureters of the duplicated system, the ureters were followed cephalically toward, hilar vessels where the hilar anatomy was identified. The nonfunctioning pole vasculature was ligated using hem-o-lok clips. The ureter was sharply divided and the proximal ureteral stump was passed posterior the renal hilum. Ureteral stump was used as for retraction and heminephrectomy is completed along the line demarcating the upper and lower pole moieties. Renorrhaphy was performed using 0-Vicryl suture with a CT-1 needle. The nonfunctioning pole ureter was then dissected caudally toward the bladder hiatus, ligated using clips, and transected. RESULTS: The operating time was 240 minutes and blood loss was 100 cc. There was no complication post-operatively. CONCLUSIONS: Wrist articulation and degree of freedom offered by robotic platform facilitates successful performance of minimally invasive heminephrectomy in the setting of an atrophic and symptomatic renal segment.

Urine leak in minimally invasive partial nephrectomy: analysis of risk factors and role of intraoperative ureteral catheterization.

PURPOSE: To investigate risk factors for urine leak in patients undergoing minimally invasive partial nephrectomy (MIPN) and to determine the role of intraoperative ureteral catheterization in preventing this postoperative complication. MATERIALS AND METHODS: MIPN procedures done from September 1999 to July 2012 at our Center were reviewed from our IRB-approved database. Patient and tumor characteristics, operative techniques and outcomes were analyzed. Patients with evidence of urine leak were identified. Outcomes were compared between patients with preoperative ureteral catheterization (C-group) and those without (NC-group). Univariable and multivariable analyses were performed to identify factors predicting postoperative urine leak. RESULTS: A total of 1,019 cases were included (452 robotic partial nephrectomy cases and 567 laparoscopic partial nephrectomy cases). Five hundred twenty eight patients (51.8%) were in the C-group, whereas 491 of them (48.2%) in the NC-group. Urine leak occurred in 31(3%) cases, 4.6% in the C-group and 1.4% in the NC-group (p<0.001). Tumors in NC-group had significantly higher RENAL score, shorter operative and warm ischemic times. On multivariable analysis, tumor proximity to collecting system (OR=9.2; p<0.01), surgeon's early operative experience (OR=7.8; p<0.01) and preoperative moderate to severe CKD (OR=3.1; p<0.01) significantly increased the odds of the occurrence of a postoperative urine leak. CONCLUSION: Clinically significant urine leak after MIPN in a high volume institution setting is uncommon. This event is more likely to occur in cases of renal masses that are close to the collecting system, in patients with preoperative CKD and when operating surgeon is still in the learning curve for the procedure. Our findings suggest that routine intraoperative ureteral catheterization during MIPN does not reduce the probability of postoperative urine leak. In addition, it adds to the overall operative time.

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.

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.

Repeat robot-assisted partial nephrectomy (RAPN): feasibility and early outcomes.

OBJECTIVE: To demonstrate the feasibility, and to report our single-centre perioperative outcomes of repeat robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS: From June 2006 to June 2012, 490 patients underwent RAPN for a renal mass at our centre. Of these patients, nine who had undergone previous ipsilateral nephron-sparing surgery (NSS) were included in the analysis. Patient charts were reviewed to obtain demographic data, preoperative surgical history, operative details, and postoperative outcomes and follow-up data. RESULTS: In all, 12 tumours were removed in nine patients (median age 69 years; six female). A third of the operations were performed on patients with a solitary kidney. The median (range) R.E.N.A.L. nephrometry score for the resected masses was 7 (4-8). The warm ischaemia time was 17.5 min and in three of the nine patients an unclamped procedure was performed. No intraoperative complications were registered, whereas only two minor complications occurred postoperatively. There were no renal unit losses. All surgical margins were negative. There was no significant difference between mean preoperative and latest postoperative mean estimated glomerular filtration rates (70.5 vs 63.5 mL/min/1.73 m(2) , P > 0.05). At a mean (sd) follow-up of 8.3 (13) months, eight of the nine patients with a pathology diagnosis of malignant neoplasm were alive and free from disease at the latest follow-up. CONCLUSION: Although technically more demanding, repeat RAPN can be safely and effectively performed in patients presenting with local recurrence after primary NSS for kidney cancer.

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.

Androgenetic alopecia and risk of prostate cancer: a systematic review and meta-analysis.

BACKGROUND: Androgenetic alopecia (AGA) is a genetically determined skin condition strongly age dependent and androgens are assumed to play an important role in its development. A link between AGA and prostate cancer has been hypothesized because of their similar risk factors. OBJECTIVE: We sought to systematically review the evidence available on the association between AGA and risk of prostate cancer. METHODS: We searched the electronic databases MEDLINE and Cochrane for studies examining the association between AGA and risk of prostate cancer. We estimated pooled odds ratios (OR) and 95% confidence intervals. We also analyzed the OR for individual hair loss patterns, as defined by the Hamilton scale. RESULTS: A total of 7 case-control studies including 8994 patients-4078 cases and 4916 controls-were reviewed. One cohort study was identified but did not meet our inclusion criteria. There was statistically significant association between vertex baldness and prostate cancer (OR 1.25; 95% confidence interval 1.09-1.44; Z = 3.13; P = .002). No statistically significant association between AGA (any pattern) and prostate cancer was identified (OR 1.03; 95% confidence interval 0.93-1.13; Z = 0.55; P = .58). LIMITATIONS: Only case-control studies, which may be subject to bias, met the inclusion criteria for this meta-analysis. CONCLUSIONS: Vertex pattern AGA was associated with a significant increased risk of prostate cancer. Any pattern AGA did not show a significant increase in the risk of prostate cancer.

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.

Laparoendoscopic single site reconstructive procedures in urology: medium term results.

PURPOSE: Despite numerous retrospective series of laparoendoscopic single site surgery, cohorts have generally been small and followup largely short-term. Therefore, we report intermediate term outcomes for patients undergoing reconstructive laparoendoscopic single site procedures at a single institution. MATERIALS AND METHODS: Upon review of our prospectively maintained laparoendoscopic single site urological database of 185 cases, 32 reconstructive procedures were identified including pyeloplasty (25), ileal interposition (3), ureteroneocystostomy (3) and retrocaval ureter repair (1). Perioperative data were reviewed, and clinical and radiographic success was noted. RESULTS: Median followup was 24.4 months for pyeloplasty, 35 months for ileal interposition, 29.4 months for ureteroneocystostomy and 20 months for retrocaval ureter repair. At last followup 24 of 25 patients treated with pyeloplasty, 2 of 3 with ileal ureter, 3 of 3 with ureteroneocystostomy and 1 of 1 with retrocaval ureter reported being asymptomatic or improved after the procedure. Delayed incisional hernia repair was required in 1 patient. One death occurred during the followup period, remote from the date of surgery. No other complications were noted. CONCLUSIONS: Intermediate term results after laparoendoscopic single site reconstructive procedures remain promising. Further followup of this patient population is required to ensure the durability of results. Prospective evaluation is also needed to assess if advantages exist for laparoendoscopic single site reconstructive procedures compared to standard minimally invasive approaches.

Robot-assisted partial nephrectomy for sporadic ipsilateral multifocal renal tumours.

OBJECTIVE: To report our short-term results of robot-assisted partial nephrectomy for treating sporadic multiple ipsilateral renal tumours. METHODS: Over a 3-year period, eight patients with two or more ipsilateral renal masses underwent nine robotic partial nephrectomies in our institution. We evaluated the PADUA and R.E.N.A.L. nephrometry scores, intraoperative outcomes, histopathological characteristics, complications according to Clavien classification and renal function outcomes. RESULTS: In total, 19 tumours were removed from eight patients in nine procedures. Mean operative time was 199 ± 47 min (median 200; range 150-300). Mean size of the dominant lesion was 3.0 ± 1.1 cm (2.7; 1.6-4.8) and overall mean tumour size was 2.2 ± 1.2 cm (1.9; 0.4-4.8). Mean number of tumours removed per patient was 2.4. Median PADUA and R.E.N.A.L. scores were 7 and 6 (with the predominance of an anterior, non-hilar position), respectively. Excluding the six off-clamp resected tumours, the mean warm ischaemia time was 21 ± 9.2 min (21; 10-35). Mean estimated blood loss was 250 ± 154 mL (200; 100-500) and no patient required transfusion. There were no intraoperative complications or conversion to open surgery. One patient had atrial fibrillation, resolved with anti-arrhythmic drugs. Mean length of stay was 4.2 ± 0.97 days. Sixteen of the nineteen tumours were malignant, most of papillary type and Fuhrman grade II. The mean decrease in glomerular filtration rate was 4%, with a mean follow-up of 14 months. CONCLUSIONS: Robotic partial nephrectomy for sporadic ipsilateral multifocal renal tumours is feasible and safe. Off-clamp resection of multiple tumours can also be safely performed in carefully selected lesions.

LESS pyeloplasty & other reconstructive procedures.

OBJECTIVES: To review and synthesize the evidence available in the literature on laparoendoscopic single-site (LESS) pyeloplasty and other reconstructive procedures. METHODS: A literature search was performed to capture original articles related to LESS urological reconstructive procedures. We outlined the differences in technique and clinical outcomes related to their safety and efficacy. RESULTS: We found 28 retrospective studies, with a total of 146 patients. Procedures included pyeloplasty (91), ureterolithotomy (44), sacrocolpopexy (4), bladder diverticulectomy (4), partial cystectomy (2), one of which associated to augmentation cystoplasty, ureteroneocystostomy (1), ileal ureter (1), and retrocaval ureter (1). Mean operative time was 215 minutes for LESS pyeloplasty and 186 minutes for LESS ureterolithotomy. The mean estimated blood loss was 73 milliliters for pyeloplasty and 108 milliliters for ureterolithotomy. Mean length of stay was 2.7 days for pyeloplasty and 3.8 days for ureterolithotomy. CONCLUSION: Urological LESS reconstructive surgery is feasible and safe for different procedures. A solid laparoscopic experience is strongly advised prior attempting LESS reconstructive procedures due to its technical complexity. Future studies should prioritize prospective and randomized designs comparing LESS with standard laparoscopy.

Image guided percutaneous probe ablation for renal tumors in 65 solitary kidneys: functional and oncological outcomes.

PURPOSE: We evaluated the oncological and functional outcomes of computerized tomography guided percutaneous cryotherapy or radio frequency ablation of kidney tumors in patients with a solitary kidney. MATERIALS AND METHODS: We reviewed the medical charts of patients with a solitary kidney who underwent percutaneous probe ablation for renal masses at our institution from April 2002 through March 2010. Followup consisted of computerized tomography or magnetic resonance imaging 1 day postoperatively, at 3, 6 and 12 months, and annually thereafter. Serum creatinine and estimated glomerular filtration rate were used to measure renal function. The cryotherapy and radio frequency ablation groups were compared for demographics, the 2-year actuarial survival rate and renal function. RESULTS: Overall 65 patients were included in this retrospective analysis, of whom 29 (44.6%) underwent cryotherapy and 36 (55.4%) underwent radio frequency ablation. Median followup was 15.1 (IQR 4.4 to 32.9) and 38.8 months (13.8 to 50.7), respectively. The 2 groups were comparable in median age, body mass index, American Society of Anesthesiologists score, tumor size and preoperative estimated glomerular filtration rate. The 3 primary treatment failures, including 1 after cryotherapy and 2 after radio frequency ablation, were successfully re-treated with thermal ablation. There were 14 recurrences after radio frequency ablation and 3 after cryotherapy. Two-year actuarial overall, cancer specific, recurrence-free and metastasis-free survival rates for cryotherapy vs radio frequency ablation were 89% vs 93%, 100% vs 96%, 69% vs 58% and 86% vs 91%, respectively. For each group no significant decrease in renal functional parameters was found at the latest followup visit. CONCLUSIONS: Computerized tomography guided percutaneous probe ablation represents a safe treatment option in surgical patients at high risk with a solitary kidney. It provides low morbidity, acceptable short-term cancer control and minimal clinical impact on postoperative renal function.

Phosphodiesterase 5 inhibitors for lower urinary tract symptoms secondary to benign prostatic hyperplasia: a systematic review.

OBJECTIVE: • To review the evidence in support of the effectiveness of phosphodiesterase 5 inhibitors in lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). METHODS: • Relevant studies were identified by performing a literature search using MEDLINE® and The Cochrane Library®. The criteria used during the search included randomized, placebo-controlled trials of treatment for LUTS secondary to BPH using the International Prostate Symptom Score as an outcome measure. RESULTS: • Four trials that included a total of 1928 patients met the inclusion criteria. All four studies showed a statistically significant difference in the International Prostate Symptom Score, quality of life and erectile function in favour of phosphodiesterase 5 inhibitors. • No study showed a statistically significant improvement of the maximum urinary flow. • Meta-analysis of the results was not possible because of heterogeneity across the studies. CONCLUSIONS: • Phosphodiesterase 5 inhibitors used in the clinical setting can significantly improve LUTS secondary to BPH, erectile function and quality of life. Maximum urinary flow improvement is not statistically significant. • Future research should focus on pathophysiological principles and cost analysis.

Selection of a port for use in laparoendoscopic single-site surgery.

Laparoendoscopic single-site surgery (LESS) is a novel technique that aims to perform abdominal surgery through a single incision. Various access techniques and ports exist. This review will attempt to describe the currently available ports as well as highlight their advantages and disadvantages.