Using a stress reservoir to improve urine leakage after artificial urinary sphincter implantation.

INTRODUCTION: Although the longest efficacy record, some patients report about urinary leakage during higher intra-abdominal pressure after Artificial Urinary Sphincter (AUS) implantation. To improve the continent results, we placed in addition to the occluding cuff and the pressure regulating balloon, in a second procedure a stress-relief reservoir in lower abdomen, for additional passive pressure transmission to the occluding cuff. METHODS: In this retrospective monocentric data analysis between 2011 and 2018, 80 patients with persistence incontinence after AUS implantation were included. Stress-relief reservoir was indicated in 12 patients with involuntary leakage of urine, that occurred when intra-abdominal pressure raised. RESULTS: In all 12 cases, the stress reservoir was easily implanted and there were no intraoperative complications. In a mean follow-up time of 53 months, the pad per day usage (p/d) improved from 3 (± 1.2) to 1.7 (± 1.5) (p = 0.001). Two patients with multiple previous abdominal surgeries used an equal number of pads after SRR; however, an improvement during physical exertion was reported. Continence situation was evaluated with a questionnaire and was rated as "excellent", "good", or "satisfactory" by 11 (92%) patients. CONCLUSION: The persistence of urinary incontinence after AUS is a challenging topic. Implantation of a stress reservoir in carefully selected patients with urinary leakage during higher intra-abdominal pressure is minimally invasive and offers new options to improve the proven long-term record of AUS. Certainly, more investigations are needed to determine the clinical relevance of this approach.

Superficial penile cancer treated with complete excision of the glans epithelium and coverage with a tissue sealant matrix (TachoSil®).

INTRODUCTION: The aim of our work was to demonstrate the feasibility and clinical outcomes after partial excision of the epithelial and subepithelial layer of the glans with subsequent tissue sealant matrix coverage (TachoSil®). MATERIAL AND METHODS: We enrolled 11 consecutive patients with superficial penile cancer. Under the microscopic guidance, the tumor in the glans area was excised continuously with a minimal lateral margin of 5 mm. The cosmetic result was accessed using a 5-graded scale ranging from very dissatisfied to very satisfied. RESULTS: The median patient's age at the presentation was 46 years (range 38-53). Histopathological examination of the specimen confirmed squamous cell carcinoma and tumor-free surgical margins were obtained in all cases. Overall, the tumors were TaG1 in 3 patients, TaG2 in 1 patient, TisG1 in 2 patients, TisG2 in 2 patient, T1aG1 in 2 patients, and T1aG2 in 1 patient. All patients had clinically negative lymph-node status - cN0 (confirmed by aabdominopelvic computed tomography (CT) scan with contrast). During the follow-up of 6 to 36 months (median 18), local recurrence occurred in 1 patient with carcinoma in situ six months after surgery, which was managed by a second glans-preserving surgery without recurrence. The others showed no signs of local recurrence or metastasis during the period of observation. CONCLUSIONS: These preliminary data suggests that glans-preserving surgical technique using TachoSil® as a defect coverage is technically feasible, functionally safe and cosmetically satisfying. However, well-designed prospective-randomized trial is warranted, to further confirm the clinical utility of our approach.

Neo-glans reconstruction for penile cancer: Description of the primary technique using autologous testicular tunica vaginalis graft.

Partial penectomy (glansectomy with/or without distal corporectomy) is an acceptable alternative for smaller distal pT3 penile carcinoma lesions in highly motivated and compliant patients. The authors describe a novel technique of neo-glans reconstruction using a tunica vaginalis (TV) testis allograft. However, due to an unclear resection margin on final histology, the patient underwent re-do surgery with a neo-glans revision using the well-established mesh split-thickness skin graft (STSG) technique. The penile length was preserved and the penile and bulbar part of the urethra was additionally mobilised in order to obtain a natural and aesthetic result for the meatus. Neo-glans reconstruction with TV coverage may be another promising alternative, which certainly requires further evaluation. We believe that the donor-site associated morbidity is minimal when compared to other harvesting sites. However, this is just an assumption, because direct comparison data on grafting techniques and neo-glans reconstruction are not available. Nevertheless, we think that for re-do procedures a standardised approach using a STSG technique should be the treatment method of choice.

A practical guide and decision-making protocol for the management of complex renal cystic masses.

OBJECTIVES: To analyse the management, pathology and outcomes of complex renal cystic masses (CRCM) and to develop a decision-making tool for daily clinical care using the Bosniak classification system for CRCM. PATIENTS AND METHODS: A comprehensive dataset of 185 patients with 188 CRCM and a minimum follow-up of 3 years were analysed for management, pathology and outcomes. RESULTS: We analysed 35 Bosniak II, 34 Bosniak IIF, 58 Bosniak III, and 61 Bosniak IV lesions. The overall incidence of renal cell carcinoma was 8.6%, 29.4%, 62.1%, and 78.7% for each category. Based on our surveillance strategy of Bosniak IIF masses, we recommend computed tomography (CT)/magnetic resonance imaging (MRI) every 2 years after the initial examination. We also recommend performing one MRI (as an adjunct to CT) during the early follow-up period (<4 years). The use of MRI correlation for differential diagnostic purposes has proven useful for marginal Bosniak II, IIF and III cases. CONCLUSIONS: From our data, we have created a decision-making protocol to guide urologists in planning a safe and effective diagnostic and treatment strategy for CRCM. The Bosniak classification is a useful tool for clinical decision-making. Uncertainties still remain for Bosniak IIF and III lesions. Our protocol shows that individualised decision-making is necessary in a significant proportion of CRCM.

Construct, content and face validity of the camera handling trainer (CHT): a new E-BLUS training task for 30° laparoscope navigation skills.

PURPOSE: Assessing construct, face and content validity of the camera handling trainer (CHT), a novel low-fidelity training device for 30° laparoscope navigation skills. METHODS: We developed a custom-designed box trainer with clinically based graphic targets. A total of 117 participants, stratified according to their previous experience (novice, competent, expert), took part to a CHT session and subsequently were asked to fill out a survey to assess the impact of the CHT on their 30° laparoscope navigation skills. Sixty of them were also studied for task performance during a 1-h session, with multiple time measurements. RESULTS: All participants, regardless of the previous experience, significantly improved their performance after the CHT session. Regarding construct validity, the mean task performance on the last measurement for novice group was found to be comparable to the mean first attempt of both competent (p = 0.12) and expert (p = 0.24) participants. All participants agreed that "the CHT is a valid training tool" and that "the CHT should be part of the regular dry laboratory training sessions", assessing both face and content validity. Limitations include the need for assessment of predictive validity. CONCLUSIONS: The CHT is a valid training tool for 30° laparoscope navigation and thus should be considered as one of the fundamental exercises during basic laparoscopic hands-on training sessions for urologists.

Partial nephrectomy driven by cavitron ultrasonic surgical aspirator under zero ischemia: a pilot study.

PURPOSE: To investigate the efficacy and technical applicability of cavitron ultrasonic surgical aspirator (CUSA)-driven zero-ischemia open partial nephrectomy in patients with renal tumors. MATERIALS AND METHODS: We prospectively collected data of 13 consecutive patients, who underwent open partial nephrectomy under non-ischemic conditions. Tumor resection was done using an ultrasonic device (CUSA/SONOCA 300). Demographic and laboratory data, tumor characteristics, perioperative, and postoperative variables were evaluated. RESULTS: The median age was 60.0 years (range 40-76); body mass index 28.0 kg/m(2) (range 22.9-43.3); tumor size 37.0 mm (range 11-110 mm). Patient were stratified according to the PADUA score into low- (score 6-7; n - 4), intermediate- (score 8-9; n - 5), and high-risk (score of >10; n - 4) groups, and the median score was 9.0 (range 6-13; SD +2.3). The vast majority of kidney tumors were diagnosed incidentally (n - 11; 84.6 %). Median operative time was 175 min (55-270 min); median time of tumor extirpation was 12 min (6-25 min); and median blood loss was 250 ml. Serum creatinine, glomerular filtration rate, and hemoglobin were nearly unaltered before and after surgery in 11 cases (84.6 %). Three patients received a blood transfusion (Clavien-Dindo Grade II); one had Grade IIIa complication (insertion of double J stent without general anesthesia); and three had Grade IIIb complications (insertion of double J under general anesthesia). CONCLUSIONS: The ultrasonic device demonstrated acceptable hemostatic and resection properties during open partial nephrectomy without ischemia. Our series showed promising perioperative and postoperative outcomes that may help in maximizing preservation of renal function in partial nephrectomy candidates.

Patient's and physician's behavior on the management of benign prostatic hyperplasia among the patients at the risk of clinical progression. A multicenter noninterventional trial in Slovakia by "Prostate and Expectations of Treatment: Epidemiology Research" (PETER) study group.

OBJECTIVES: The aim of the survey was to assess physician's behavior and the global knowledge about patient's preferences and their psychological burden linked to lower urinary tract symptoms (LUTS) in an outpatient setting in Slovakia. METHODS: The study included 36 outpatient urological clinics. Overall, 1132 newly diagnosed LUTS patients were screened within 1 month. A total of 454 questionnaires were obtained from 459 LUTS patients with risk of progression (RP). Inclusion criteria were: age > 50 years, IPSS > 8, prostate volume ≥ 30 cm3, and PSA ≥ 1.5 to ≤ 10 ng/ml. RESULTS: The digital rectal examination, PSA testing, and urinalysis were used in all the centers as first visit examinations. The least frequently performed diagnostic procedure was uroflowmetry (74 %). The physician's preferred therapy for patients with RP was standard combined treatment in (52.6 %); followed by α-blocker alone (45 %) and monotherapy with 5-α-reductase inhibitors (5-ARI) only in 3 % of all asked urologists. Patient's mean age was 63.3 years (SD ± 7.4); baseline PSA value 2.2 ng/ml (SD + 3.2); prostate volume was 38.0 ml (SD ± 16.7 ml); Qmax was 11.5 ml/s (SD ± 4.6); and IPSS score 12.5 (SD ± 6.3). The most bothersome symptoms were nocturia (prevalence of ≥ 75 %), weak urinary stream (61 %), and retarded voiding (43 %). Patient's expectations of treatment were rapid improvement of symptoms (36.0 %), stabilization of symptoms (35.5 %), and reduction of potential risk of surgical intervention (25.8 %). CONCLUSIONS: Our research reflects the physician's behavior, patient's self-perception of the disease and therapeutic priorities in the current outpatient practice in Slovakia.

Patient's behavior and attitudes toward the management of benign prostatic hyperplasia among patients with the risk of disease progression: prospective study by "Prostate and Expectations of Treatment Epidemiology Research (PETER) study group".

BACKGROUND: The aim of the study was to evaluate patients attitudes with benign prostatic hyperplasia at the risk of progression during a 12-month period of observation. MATERIALS AND METHODS: A total of 426 patients from 45 outpatients centers were included and prospectively followed. Inclusion criteria were: age > 50 years, International Prostate Symptom Score (IPSS) > 8, prostate volume > 30 cm(3) (transabdominal ultrasound) and PSA > 1.5 to < 10 ng/ml. RESULTS: In all, 28.6% patients were naive, 62.9% used monotherapy (alpha-blocker), and 8.5% combined treatment (alpha-blocker/5alpha-reductase inhibitor/dutasteride). The most bothersome symptoms were the weak urine stream (60.8%) and nocturia (59.2%). Patients expectations from the treatment were stabilization of the disease and reducing the risk of surgery rather than rapid resolution of symptoms. Despite the presence of symptoms, 2.3% patients claimed that benign prostatic hyperplasia/lower urinary tract symptoms had no impact on their quality of life (QoL), in 48.1 % only little impact on QoL, and 47.9% patients percepted their symptoms as severe. Out of 71.4% patients treated previously, 26.5% patients were indecisive about the satisfaction of present treatment. Visual analog score was percepted more optimistically rather than the IPSS. Pearson's correlation r = 0.68 at the beginning and r = 0.83 at the end of the study. CONCLUSIONS: Prostate and Expectations of Treatment Epidemiology Research study highlights and reflects on patients behavior and self-perception, patients self-perception of the disease and therapeutic priorities during the 1 year of observation.

Management, pathology and outcomes of Bosniak category IIF and III cystic renal lesions.

OBJECTIVE: To analyze the management, pathology and outcomes of Bosniak category IIF and III cystic renal lesions. METHODS: This retrospective study included 85 consecutive patients with Bosniak category IIF and III lesions, who were actively surveilled or surgically treated at three academic urology centers between 2003 and 2012. Outcomes of interest included the rates of cyst progression and pathology. RESULTS: Overall, 27 patients with Bosniak category IIF lesions were initially managed by active surveillance, from which eighteen (67 %) did not progress after a median interval of 64 months, while 9 (33 %) underwent surgery within a median interval of 18 months. There were 58 patients with Bosniak category III lesions, 54 (93 %) of which were managed by surgery. Compared with Bosniak category IIF, Bosniak category III lesions had more frequently proven RCC (64 vs. 30 %, p = 0.005). Of the tumors that underwent surgical extirpation, the T stage, grade (p = 0.65) and subtype distribution (p = 0.36) did not differ between the Bosniak categories. The majority of RCCs were low-stage and low-grade tumors. One patient developed a local recurrence. There were no RCC-specific deaths. CONCLUSIONS: As only a minority of Bosniak IIF lesions are malignant and the majority are low-stage and low-grade tumors, initial active surveillance is the standard of care for these lesions. Progressive Bosniak IIF lesions may undergo later RCC treatment without seemingly loosing the window of cure. Bosniak III lesions harbor a high risk of malignancy and should be managed as solid renal tumors according to contemporary guidelines.

A prospective evaluation of pain associated with stone passage, stents, and stent removal using a visual analog scale.

OBJECTIVE: To investigate the perception of colicky pain due to ureteral stones and double-J (DJ)-associated discomfort and to evaluate the role of clinical parameters that might influence the perception of pain. MATERIALS AND METHODS: From November 2011 to May 2012, 124 consecutive patients with colicky pain due to ureteral stones and ureteroscopic stone extraction underwent DJ stent placement. A visual analog scale (VAS) was used to assess the pain at ureteral colic, during indwelling DJ stent, and at DJ stent removal. The association of clinical data with pain scores was also analyzed. RESULTS: Pain perception at the time of colic did not vary according to sex (P = .804), age (P = .674), or DJ stent length (P = .389). Stone size (<4 mm) was a predictor of a high VAS score (P = .001). Patients with recurrent stone formation had significantly less pain at the time of colic (P = .004), and DJ stent removal (P = .004) than those with the first instance of stone formation. The clinical experience at cystoscopic DJ stent removal influenced pain perception (P <.001). CONCLUSION: Using a VAS for the evaluation of pain perception is a valid method for the objectification of subjective discomfort. The VAS is an easy to administer scale and provides accurate information on the patients' status. Additional studies with larger cohorts focusing on pain perception using the VAS and other validated questionnaires are recommended to produce more consistent data.

Validation of serum C-reactive protein (CRP) as an independent prognostic factor for disease-free survival in patients with localised renal cell carcinoma (RCC).

OBJECTIVE: To validate high-sensitivity C-reactive protein (hs-CRP) serum levels as an independent marker for disease-free survival (DFS) in clinically localised clear cell renal cell carcinoma (ccRCC). PATIENTS AND METHODS: In all, 403 consecutive patients with clinically localised (T1-3N0M0) ccRCC treated by radical or partial nephrectomy were enrolled. Preoperative serum levels of hs-CRP were evaluated as both a continuous and categorical variables. Associations with clinical (age, gender) and pathological variables (T classification, grade, tumour necrosis) were assessed with the chi-square and Kruskal-Wallis tests. Univariable and multivariable Cox proportional hazards models were fitted. The prognostic accuracy (PA) was assessed with Harrell's C-index. RESULTS: The mean hs-CRP level was 1.32 mg/dL. The hs-CRP levels were associated with T classification (P = 0.05), high-grade disease (P < 0.001) and tumour necrosis (P = 0.003). After a median follow-up of 43 months, 41 patients (10.1%) had developed disease recurrence. With each unit increase in hs-CRP levels, the risk of recurrence increased by 10% (hazard ratio 1.10, P = 0.015). The thresholds of 0.5 and 0.75 mg/dL showed the best discrimination for stratification of patients according to the probability of recurrence. These categorically coded hs-CRP levels were identified as independent prognostic factors in multivariable analyses (P < 0.001) and led to a significant increase in the PA of a multivariable base model containing the variables of the 'Stage, Size, Grade and Necrosis' (SSIGN) score. CONCLUSIONS: This study validates preoperative serum hs-CRP levels as independent prognostic factor after surgery for localised ccRCC. Hs-CRP may be included in standard prognostic modelling after surgery and may guide surveillance and inclusion in adjuvant clinical trials.

Predictive power of objectivation of phimosis grade on outcomes of topical 0.1% betamethasone treatment of phimosis.

OBJECTIVE: To evaluate the predictive power of the objectivation of the phimosis grade according to the classification defined by Kikiros and Woodward, with regard to the expected efficacy of 0.1% betamethasone cream as a treatment option. METHODS: From October 2010 to May 2011, a total of 55 boys (aged <10 years) were treated for phimosis at our department. An assessment of the category of phimosis and the retractability of the foreskin, according to the classification of Kikiros and Woodward, was performed. The proposed treatment options included complete circumcision or topical treatment with steroid cream (0.1% betamethasone-17-valerate). RESULTS: Of the 55 patients, 19 (34.5%) underwent conventional circumcision, and 36 (65.5%) were treated with an 8-week course of topical steroid cream. The mean age was 3.9 years (range 0.6-10). Grade 1, 2, 3, 4, and 5 phimosis was seen in 1 (2.8%), 4 (11.1%), 8 (22.2%), 16 (44.4%), and 7 (19.4%) of the cases in the topical steroid cream group, respectively. The success rate for the topical steroid cream was 69.4% and 63.9% at 3 and 8.3 months, respectively. The objectivation of the phimosis grade did not predict the outcome (P > .05). No side effects were associated with the topical steroid treatment. CONCLUSION: The pretreatment classification of phimosis did not allow the prediction of success with the topical steroid treatment. We believe that topical steroid therapy with foreskin retraction and daily cleansing is a valid therapy modality that should be offered before any surgical intervention, regardless of the degree of phimosis.

Multidetector computed tomography virtual cystoscopy: an effective diagnostic tool in patients with hematuria.

OBJECTIVE: To evaluate the efficacy and the potential use of multidetector computed tomography virtual cystoscopy (MDCT-VC) in patients with gross hematuria. METHODS: A total of 32 patients underwent MDCT-VC, cystoscopy, and a cytologic examination. The slice thickness of MDCT was 1 mm. Bladder distension was done with room air. The data were converted into 3-dimensional virtual reconstructive models. The data sets were reviewed independently by 2 experienced radiologists. Tumors confined to the mucosa, infiltrating the muscularis, and transmural tumors were distinguished. RESULTS: VC showed a sensitivity and specificity of 100%. The radiologic accuracy regarding T stage correlated in 87.5%. MDCT-VC identified 21 bladder lesions suspicious for bladder cancer in 18 patients. The histologic results showed 22 patients with bladder lesions, 18 were diagnosed with transitional cell carcinoma of the bladder, 3 had bladder endometriosis, and 1 had an infiltrating colon cancer. Four patients had concomitant carcinoma in situ lesions, which were not seen completely with MDCT-VC. However, cytology was positive in those cases. Ten patients did not have any tumor signs on VC and the subsequent conventional cystoscopy did not bring any change to the initial tumor-free diagnosis of VC. CONCLUSION: MDCT-VC combined with urine cytology is a good alternative to conventional cystoscopy for patients with painless gross hematuria. It should be used as a decision-making aid to identify patients who will benefit from additional cystoscopic examination. Future developments should focus on the visibility of sessile and carcinoma in situ lesions.

Complex renal cystic masses: current standards and controversies.

Bosniak classification system is the only preoperative diagnostic tool that has proven its efficiency in the management of complex renal cystic masses. However, it is reader dependent, despite its clear definition of each category. The overall incidence of malignancy in each category did not change significantly over the past 20 years. Current limitations are interobserver variability among readers and a fact that a significant proportion of Bosniak III masses have benign character. The goal is to depict these masses preoperatively and spare the patients of unnecessary surgeries, which raises the question: What particular findings will help in differentiating a Bosniak IIF lesion from a Bosniak III lesion? Do we need to define critical variables that could improve accuracy of Bosniak classification by developing a future nomogram or risk calculator? Some radiologists and urologists erroneously tend to group Bosniak II and IIF in one category and observe them regularly. It seems that radiographic growth itself is insufficient factor for intervention. The change of internal architecture and presence of enhancement play the most important role in depicting malignant lesions during the time frame of active surveillance.

Peyronie's Disease: Nonsurgical Therapy Options.

Peyronie's disease (PD) is a fibrous inelastic scar of the tunica albuginea, leading to penile deformity, penile curvature, shortening, narrowing, and painful erections that subsequently lead to painful or unsatisfying sexual intercourse. No consensus exists yet on the ideal management of PD. This fact is a result of our limited knowledge of its etiology and causative factors. The acute presentation of PD is treated conservatively, and surgical approaches are only attempted if severe curvature, narrowing, or indentation persists for more than 1 year; PD stability exists for at least 3 months; curvature impedes sexual intercourse; and severe penile shortening occurs. This review focuses on new developments for conservative treatment strategies for PD.

Laparoscopic cryoablation versus partial nephrectomy for the treatment of small renal masses: systematic review and cumulative analysis of observational studies.

CONTEXT: For small renal masses (SRMs), partial nephrectomy (PN) represents the therapeutic standard of care. Laparoscopic cryoablation (LCA) could be regarded as an alternative to surgical excision in selected patients, if perioperative complication rates and oncologic results are comparable. OBJECTIVE: To perform a cumulative analysis of observational studies regarding oncologic outcomes and perioperative complications of both procedures. EVIDENCE ACQUISITION: Medline, Embase, and Web of Science searches were performed for clinically localized sporadic SRMs that were treated with PN or LCA. A total of 6785 lesions were analyzed for local and metastatic tumor progression and 10 906 procedures for perioperative complications. EVIDENCE SYNTHESIS: Patients undergoing LCA were significantly older, mean tumor sizes were lower, and mean follow-up duration was shorter (each p<0.001). Following LCA and PN, 8.5% and 1.9% developed local tumor progression, respectively (p<0.001). In multivariable analysis, the relative risk for local tumor progression of LCA versus PN was 5.24-fold increased (p<0.001); the risk of metastatic progression was similar. The overall complication rate was higher following PN (23.5% vs 17.0%; p<0.001), especially the rate of major complications (19.2% vs 10.2%; p<0.001). In multivariable analysis, the total risk for complications and major complications for PN versus LCA was 4.6-fold (p=0.004) and 9.71-fold (p<0.001) increased, respectively. Limitations of this analysis include follow-up and selection bias, and lack of standardization reporting complications and outcomes. CONCLUSIONS: Both PN and LCA are viable options for the management of SRMs. Compared with PN, LCA results in a higher risk of local tumor progression. The risk of perioperative complications appears to be lower following LCA; however, this difference is strongly influenced by selection bias, and thus limited conclusions can be made regarding true differences in complications. Therefore, PN is the gold standard for SRMs, but LCA may be indicated in selected patients with significant comorbidity.

Perioperative, oncologic, and functional outcomes of laparoscopic renal cryoablation and open partial nephrectomy: a matched pair analysis.

PURPOSE: To directly compare perioperative, oncologic, and functional outcomes of laparoscopic renal cryoablation and open partial nephrectomy using a matched pair analysis. PATIENTS AND METHODS: A total of 41 patients who underwent laparoscopic cryoablation for an incidental, solid clinical T(1a)N(0)M(0) renal tumor were matched with 82 patients who received partial nephrectomy in cold ischemia, using optimal matching based on propensity scores, which were created on the basis of preoperative aspects and dimensions used for an anatomic classification of renal tumors (PADUA) score, preoperative glomerular filtration rate, age-adjusted Charlson comorbidity index, and sex. Median follow-up was 33.6 months. RESULTS: No differences in the overall incidence of complications (cryoablation, 20%; partial nephrectomy, 17%; P=0.739) and grade of complications (P=0.424) were observed. After cryoablation, local recurrence developed in four patients with renal-cell carcinoma (n=35) after a median duration of 14 months (range 6-18 mos), but none after partial nephrectomy. The 3-year recurrence-free survival probabilities after laparoscopic renal cryoablation vs open partial nephrectomy were 83% vs 100%, respectively (P=0.015). The average decrease of estimated glomerular filtration rate during follow-up was 7.8±3.1 mL/min/1.73 m(2) after laparoscopic cryoablation and 9.8±2.3 mL/min/1.73 m(2) after open partial nephrectomy, which was not statistically significant (P=0.602). CONCLUSIONS: Perioperative complications and renal functional outcomes of laparoscopic cryoablation and open partial nephrectomy are similar; however, laparoscopic cryoablation confers a substantially higher local recurrence risk of about 17% after 3 years. Therefore, laparoscopic renal cryoablation should be reserved for high-risk patients with decreased life expectancy. Careful patient counseling is advocated. Study limitations include the small sample size, the lack of randomization, and the short follow-up.

Interpersonal variability and present diagnostic dilemmas in Bosniak classification system.

OBJECTIVE: The purpose of the study was to evaluate the management and interpersonal variability of Bosniak classification and demonstrate the present diagnostic dilemmas. MATERIAL AND METHODS: One-hundred and four patients with 113 complex renal cystic masses (26 Bosniak II,15 IIF,28 III and 44 IV) were included and analysed between April 1996 and May 2009.In total, 71 cystic masses were characterized by two radiologists in consensus initially as the first diagnosis (group 1), and then by a radiologist (group 2) and a urologist (group 3) independently in a blinded fashion. RESULTS: Only 11 patients (10.6%) were symptomatic (one Bosniak IIF, six III and four IV). Only one had renal cell carcinoma (RCC) on final histology, whereas the others (n = 10) had benign lesions. An overall pathological result was obtained in 71 masses (62.8%) (two Bosniak II, three IIF, 27 III and 39 IV). The overall incidence of RCC in surgically treated patients was 0%, 20%, 55.6% and 76.9% for each category, respectively. The interpersonal variability was significant among the three groups (especially in Bosniak II, IIF), and the overall category was changed in 54%, 20% and 41%, respectively (p < 0.001). After correlation with final histology and presumed benign character of Bosniak II/IIF lesions (all patients having reached 5-year follow-up) the differences were not significant. CONCLUSION: It is challenging to minimize unnecessary surgical procedures in Bosniak category III. According to these results, it may make practical sense to group Bosniak II and IIF masses in one category.

External validation of the preoperative anatomical classification for prediction of complications related to nephron-sparing surgery.

PURPOSE: Ficarra et al. (Eur Urol 56:786-793, 2009) published a preoperative anatomical classification (PADUA) to assess the impact of anatomical parameters of renal tumors on complication rate of nephron-sparing surgery (NSS). The objective of this study is to provide a bi-center external validation of this classification using the technique of hilar arterial clamping during open and laparoscopic NSS and to correlate the PADUA score to the ischemia time. METHODS: 240 consecutive tumors treated with open and laparoscopic NSS were reclassified according to the PADUA classification. Complications were graded according to the modified Clavien system (Dindo et al. in Ann Surg 240:205-213, 2004). Chi-square tests and multivariate logistic regression models addressed the predictive value of PADUA classification on overall complication rate and grade. RESULTS: Mean patient age was 62.2 +/- 13.3 years. Eastern Cooperative Oncology Group performance was 0 in 76%, 1 in 22% and 2 in 2%. 61 (25%) were treated laparoscopically. The median PADUA score was 7.5 (range 6-13). Mean surgery and ischemia time was 189 +/- 95 and 24 +/- 22 min, respectively. Overall complication rate was 23% (n = 54). On univariate analysis, the PADUA score correlated with complication rate (p < 0.001) of open and laparoscopic NSS. On multivariate, only the PADUA score correlated with complication rate (p = 0.0056). Ischemic time correlated with the PADUA score and was significantly higher in PADUA score > or = 10 (p = 0.034). CONCLUSIONS: The PADUA score is a reliable tool to preoperatively predict the risk of complications. In addition, it might be beneficial for a more objective patient selection for laparoscopic surgery and teaching NSS.