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.

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.

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.

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.

Robotic laparoendoscopic single site urological surgery: analysis of 50 consecutive cases.

PURPOSE: We present our cumulative experience with robotic laparoendoscopic single site urological surgery at a single institution. MATERIALS AND METHODS: Medical records of patients undergoing robotic laparoendoscopic single site procedures between May 2008 and December 2010 were analyzed. The da Vinci® S or Si systems and 3 different multichannel single port devices were used. Demographic, intraoperative and postoperative data were assessed. RESULTS: Overall, 50 patients were scheduled to undergo robotic laparoendoscopic single site urological surgery during the study period, representing 36% of the total patients undergoing laparoendoscopic single site surgery at our institution. Mean ± SD patient age was 60.2 ± 13.6 years. Mean body mass index was 27.0 ± 4.5 kg/m(2). Specifically, 24 patients underwent robotic laparoendoscopic single site renal surgery and the same method was used in 26 patients undergoing pelvic surgery. Mean operative time was 207 ± 74 minutes and mean estimated blood loss was 140 ± 111 ml. Four cases were converted to laparoscopy (2 standard, 2 robotic assisted) and 6 cases required at least 1 additional trocar outside of the single site incision. A rectal injury occurred during radical cystectomy, which was recognized intraoperatively and closed primarily without sequelae. Postoperative complications occurred in 8 cases and 1 was Clavien grade IV. Mean length of hospital stay was 2.9 ± 1.7 days. CONCLUSIONS: Our preliminary experience with robotic laparoendoscopic single site surgery has demonstrated feasibility and safety in the realm of urological surgery. Widespread adoption of this new approach will likely require redesign of the robotic system or development of a task specific robotic platform, and should be limited to centers with significant robotic, laparoscopic and laparoendoscopic single site surgery experience.

Functional recovery after partial nephrectomy: effects of volume loss and ischemic injury.

PURPOSE: We used what is to our knowledge a new method to estimate volume loss after partial nephrectomy to assess the relative contributions of ischemic injury and volume loss on functional outcomes. MATERIALS AND METHODS: We analyzed the records of 301 consecutive patients who underwent conventional partial nephrectomy between 2007 and 2010 with available data to meet inclusion criteria. Percent functional volume preservation was measured at a median of 1.4 years after surgery. Modification of diet in renal disease-2 estimated glomerular filtration rate was measured preoperatively and perioperatively, and a median of 1.2 years postoperatively. Statistical analysis was done to study associations. RESULTS: Hypothermia or warm ischemia 25 minutes or less was applied in 75% of cases. Median percent functional volume preservation was 91% (range 38%-107%). Percent glomerular filtration rate preservation at nadir and late time points was 77% and 90% of preoperative glomerular filtration rate, respectively. On multivariate analysis percent functional volume preservation and warm ischemia time were associated with nadir glomerular filtration rate while only percent functional volume preservation was associated with late glomerular filtration rate (each p <0.001). Late percent glomerular filtration rate preservation and percent functional volume preservation were directly associated (p <0.001). Recovery of function to 90% or greater of percent functional volume preservation predicted levels was observed in 86% of patients. In patients with de novo postoperative stage 3 or greater chronic kidney disease, percent functional volume preservation and Charlson score were associated with late percent glomerular filtration rate preservation. Warm ischemia time was not associated with late functional glomerular filtration rate decreases in patients considered high risk for ischemic injury. CONCLUSIONS: In this cohort volume loss and not ischemia time was the primary determinant of ultimate renal function after partial nephrectomy. Technical modifications aimed at minimizing volume loss during partial nephrectomy while still achieving negative margins may result in improved functional outcomes.

Diameter-axial-polar nephrometry: integration and optimization of R.E.N.A.L. and centrality index scoring systems.

PURPOSE: The R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior) and centrality index nephrometry scores enable systematic, objective assessment of anatomical tumor features. We systematically compared these systems using item analysis test theory to optimize scoring methodology. MATERIALS AND METHODS: Analysis was based on 299 patients who underwent partial nephrectomy from 2007 to 2011 and met study inclusion criteria. Percent functional volume preservation, and R.E.N.A.L. and centrality index scores were measured. Late percent glomerular filtration rate preservation was calculated as the ratio of the late to the preoperative rate. Interobserver variability analysis was done to assess measurement error. All data were statistically analyzed. RESULTS: A novel scoring method termed DAP (diameter-axial-polar) nephrometry was devised using a data based approach. Mean R.E.N.A.L., centrality index and DAP scores for the cohort were 7.3, 2.5 and 6 with 84%, 90% and 95% interobserver agreement, respectively. The DAP sum score and all individual DAP scoring components were associated with the clinical outcome, including percent functional volume preservation, warm ischemia time and operative blood loss. DAP scoring criteria allowed for the normalization of score distributions and increased discriminatory power. DAP scores showed strong linear associations with percent functional volume preservation (r(2) = 0.97) and late percent glomerular filtration rate preservation (r(2) = 0.81). Each 1 unit change in DAP score equated to an average 4% change in kidney volume. CONCLUSIONS: DAP nephrometry integrates the optimized attributes of the R.E.N.A.L. and centrality index scoring systems. DAP scoring was associated with simplified methodology, decreased measurement error, improved performance characteristics, improved interpretability and a clear association with volume loss and late function after partial nephrectomy.

Nephrometry score is associated with volume loss and functional recovery after partial nephrectomy.

PURPOSE: Functional volume preservation after partial nephrectomy is a primary determinant of kidney function. We identified tumor features, including R.E.N.A.L. (radius for tumor size as maximal diameter, exophytic/endophytic tumor properties, nearness of deepest portion of tumor to collecting system or sinus, anterior/posterior descriptor and location relative to polar line) and centrality index nephrometry scores, associated with volume loss after partial nephrectomy. MATERIALS AND METHODS: A chart and imaging review was done for 237 patients who underwent partial nephrectomy from 2007 to 2010 and met study inclusion criteria. R.E.N.A.L. and centrality index nephrometry scores were measured in all patients. Percent functional volume preservation was estimated a median of 1.4 years after surgery using the cylindrical volume ratio method. Statistical analysis was done to study associations. RESULTS: Independent tumor features associated with percent functional volume preservation included tumor diameter (p < 0.001) and the distance from tumor periphery to kidney center (p = 0.02). R.E.N.A.L. and centrality index scores were associated with percent functional volume preservation (each p < 0.001). Nephrometry scores were also associated with nadir and late percent glomerular filtration rate preservation. Tumors classified as highly complex, with a centrality index score of 1.5 or less and a R.E.N.A.L. score of 10 or greater, were associated with an average 28% to 30% functional parenchymal volume loss of operated kidneys. A mean 8% difference in percent functional volume preservation was observed among low, intermediate and high tumor complexity categories for R.E.N.A.L. and centrality index scores. CONCLUSIONS: R.E.N.A.L. and centrality index nephrometry scores were associated with changes in the percent functional volume preservation and the perioperative functional decrease. Nephrometry scores performed better than diameter alone on statistical analysis. Nephrometry scores may be useful to estimate the likelihood of operative volume loss and by proxy the functional outcome.

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.

Tumor complexity predicts malignant disease for small renal masses.

PURPOSE: Approximately 20% to 30% of suspicious small renal tumors are benign. A significant proportion of malignant tumors are low grade and potentially indolent. We evaluated whether preoperative patient and tumor characteristics are associated with adverse pathological features. MATERIALS AND METHODS: A total of 886 patients underwent robot-assisted partial nephrectomy, as done by 1 of 5 high volume surgeons. Demographic and clinical data were compared between patients with benign/malignant disease, clear cell/nonclear cell renal cell carcinoma and high/low grade tumors. Tumor complexity was quantified by R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior, hilar and location relative to polar lines) nephrometry score and described as low--4 to 6, intermediate--7 to 9 or high--10 or greater. Logistic regression analyses were performed to test the association between tumor and patient characteristics, and high grade renal cell carcinoma. Subanalyses were done for patients with renal tumors 4 cm or less. RESULTS: High grade renal cell carcinoma was larger and more likely to develop in men. Patients with malignant tumors and with clear cell histology were more likely to have intermediate or high complexity tumors. Increasing tumor complexity independently predicted malignancy, high grade malignancy and clear cell histology on multivariate regression analysis (each p <0.05). Male gender was independently associated with malignancy and high grade renal cell carcinoma. When considering tumors 4 cm or less, tumor complexity predicted malignancy but not tumor grade. CONCLUSIONS: High R.E.N.A.L nephrometry score and male gender are associated with an increased risk of malignancy and high grade malignancy in tumors treated with partial nephrectomy.

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).

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.

Prospective multi-center study of oncologic outcomes of robot-assisted partial nephrectomy for pT1 renal cell carcinoma.

BACKGROUND: Partial nephrectomy has been increasingly recommended over radical nephrectomy for the management of small renal masses based on improved renal functional outcomes without sacrifice of oncologic effectiveness. Robot-assisted partial nephrectomy (RAPN) has been introduced in an effort to offer another minimally invasive option for nephron-sparing surgery. However, reports of RAPN have been limited to short-term perioperative outcomes. The goal of this study is to report and evaluate the initial oncologic outcomes of RAPN. Utilizing prospectively obtained data on RAPN performed by four surgeons at four separate tertiary care centers, we selected patients with unilateral, localized, non-familial, pathologically-confirmed pT1 renal cell carcinoma and a minimum post-operative follow-up of 12 months. METHODS: Utilizing prospectively obtained data on RAPN performed by four surgeons at four separate tertiary care centers, we selected patients with unilateral, localized, non-familial, pathologically-confirmed pT1 renal cell carcinoma and a minimum post-operative follow-up of 12 months. Survival analysis (disease-free, cancer-specific, and overall survival) was performed, and Kaplan-Meier curves were generated. RESULTS: RAPN was performed in 124 patients with a median tumor size of 3.0 cm (IQR 2.2-4.2 cm). Median follow-up was 29 months (range 12-46 months). Positive parenchymal surgical margins occurred in two patients (1.6 %), both of whom were recurrence-free at 30 and 34 months after surgery. The three-year Kaplan-Meier estimated disease-free survival was 94.9 %, cancer-specific survival was 99.1%, and overall survival was 97.3 %. CONCLUSIONS: In our cohort of patients with small renal carcinomas who were followed for a median of 29 months, recurrence and survival outcomes were similar to those reported for open and laparoscopic partial nephrectomy. Further long-term outcomes will be needed to definitively claim that RAPN is oncologically equivalent to other surgical approaches.

Laparoendoscopic single site pelvic surgery: is there any room?

OBJECTIVES: Our purpose was to summarize the current status of Laparo-endocopic single site surgery (LESS) in the pelvis. METHODS: A comprehensive literature search was conducted in May 2011 using the medline database to identify publications relating to LESS surgery in the pelvis. RESULTS: LESS can be safely performed in the pelvis with comparable outcomes to standard minimally invasive approaches. Small series have demonstrated good outcomes in the hands of experienced surgeons in a number of urological settings in the pelvis. Challenges in LESS surgery are continual being overcome by advancing technologies such as with the robotic platform;however, significant improvements are necessary to reduce the difficulty with LESS surgery and dispersion amongst urological surgeons. CONCLUSION: LESS pelvic procedures are evolving. Wide ranges of procedures have been described using LESS approach, however, in small series and short follow-up. Further examination of LESS pelvic approach with well-designed studies will be crucial to determine the future role of such an approach.

Robotic laparoendoscopic single-site surgery: the way forward.

OBJECTIVES: LaparoEndoscopic Single-Site (LESS) surgery presents many technical and ergonomic obstacles. The solution to these current limitations may lie within emerging technologies, primarily the daVinci robotic platform. The purpose of this review was to examine the available literature as it pertains to robotic laparoendoscopic single-site surgery (R-LESS) and detail our experience with this approach at our institution. METHODS: An electronic literature search was conducted using the Medline database to identify all publications relating to R-LESS and/Mor robotic single port surgery in urology. Additionally, a retrospective review of our single center experience was completed. RESULTS: Fifteen original articles and two abstracts were identified in the literature and included dry lab investigation, animal experiments, single case reports, cumulative series, and two retrospective comparative analyses. Most detailed technique, perioperative outcomes, and associated procedural nuances. CONCLUSIONS: R-LESS urologic surgery is feasible and can be performed using several approaches. R-LESS reduces difficulties encountered with conventional LESS urologic surgery. An ideal robotic system is needed and would be task specific, deployable through a single incision, possess articulating instruments, and have reduced external housings.

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.

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.

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.

[Robot assisted laparoscopic partial nephrectomy: techniques and outcomes]. / Nefrectomía parcial laparoscópica asistida por robot: técnicas y resultados.

Nephron-sparing surgery is currently considered the gold standard treatment for T1 renal tumors. As laparoscopic partial nephrectomy (LPN) represents a technically challenging procedure, robotic surgery has been increasingly used during the last few years in the field of nephron-sparing surgery. The aim of this review is to analyze the techniques and outcomes of robotic partial nephrectomy (RPN). Currently available evidence shows that RPN is a feasible and safe procedure for small localized renal tumors and also for selected complex renal tumors. Early comparative studies have demonstrated similar perioperative outcomes between RPN and LPN, with a trend towards a shorter ischemia time for RPN. However, oncological follow-up remains limited and further prospective trials are awaited to confirm the benefits of robotic approach for partial nephrectomy.