Update of the Standard Operating Procedure on the Use of Multiparametric Magnetic Resonance Imaging for the Diagnosis, Staging and Management of Prostate Cancer.

PURPOSE: We update the prior standard operating procedure for magnetic resonance imaging of the prostate, and summarize the available data about the technique and clinical use for the diagnosis and management of prostate cancer. This update includes practical recommendations on the use of magnetic resonance imaging for screening, diagnosis, staging, treatment and surveillance of prostate cancer. MATERIALS AND METHODS: A panel of clinicians from the American Urological Association and Society of Abdominal Radiology with expertise in the diagnosis and management of prostate cancer evaluated the current published literature on the use and technique of magnetic resonance imaging for this disease. When adequate studies were available for analysis, recommendations were made on the basis of data and when adequate studies were not available, recommendations were made on the basis of expert consensus. RESULTS: Prostate magnetic resonance imaging should be performed according to technical specifications and standards, and interpreted according to standard reporting. Data support its use in men with a previous negative biopsy and ongoing concerns about increased risk of prostate cancer. Sufficient data now exist to support the recommendation of magnetic resonance imaging before prostate biopsy in all men who have no history of biopsy. Currently, the evidence is insufficient to recommend magnetic resonance imaging for screening, staging or surveillance of prostate cancer. CONCLUSIONS: Use of prostate magnetic resonance imaging in the risk stratification, diagnosis and treatment pathway of men with prostate cancer is expanding. When quality prostate imaging is obtained, current evidence now supports its use in men at risk of harboring prostate cancer and who have not undergone a previous biopsy, as well as in men with an increasing prostate specific antigen following an initial negative standard prostate biopsy procedure.

AUA Policy Statement on the Use of Multiparametric Magnetic Resonance Imaging in the Diagnosis, Staging and Management of Prostate Cancer.

PURPOSE: We summarize the available data about the clinical and economic effectiveness of magnetic resonance imaging in the diagnosis and management of prostate cancer, and provide practical recommendations for its use in the screening, diagnosis, staging and surveillance of prostate cancer. MATERIALS AND METHODS: A panel of clinicians with expertise in the diagnosis and management of prostate cancer evaluated the current published literature on the use and effectiveness of magnetic resonance imaging for this disease. When adequate studies were available for analysis, recommendations were made on the basis of data and when adequate studies were not available, recommendations were made on the basis of expert consensus. RESULTS: At this time the data support the use of magnetic resonance imaging in patients with a previous negative biopsy and ongoing concerns about increased risk of prostate cancer. The data regarding its usefulness for initial biopsy suggest a possible role for magnetic resonance imaging in some circumstances. There is currently insufficient evidence to recommend magnetic resonance imaging for screening, staging or surveillance of prostate cancer. CONCLUSIONS: Although it adds cost to the management of prostate cancer, magnetic resonance imaging offers superior anatomic detail, and the ability to evaluate cellular density based on water diffusion and blood flow based on contrast enhancement. Imaging targeted biopsy may increase the diagnosis of clinically significant cancers by identifying specific lesions not visible on conventional ultrasound. The clinical indications for the use of magnetic resonance imaging in the management of prostate cancer are rapidly evolving.

The 4 Questions to Ask and Answer Regarding ICD-10: Second of a 2-Part Series.

INTRODUCTION: On October 1, 2015 the United States will transition from the decades-old 9th revision of the International Classification of Diseases (ICD-9) set of diagnoses for coding medical encounters and inpatient procedure codes to the far more contemporary, vastly larger and much more detailed 10th revision of those code sets (ICD-10). In this second part of a 2-part series we will address the 2 remaining questions about this transition, namely why you should check your codes to ensure correct coding and how to best prepare for the transition. METHODS: A search was undertaken to determine how ICD-10 codes are organized and the best techniques to choose correct codes, and how to best prepare for the transition. Results were based on this search, and on input and expertise from coding experts as well as personal experience. RESULTS: Due to the significant change in the code set and rules, ICD-10 codes should be double-checked for accuracy, especially early in the transition, as finding the most accurate code involves challenges. Detailed preparation of all aspects of the practice potentially affected by ICD-10 codes is vital. CONCLUSIONS: The transition from ICD-9 to ICD-10 will have a major impact on anyone who uses health care information. Proper preparation is vital to a smooth transition.

The 4 Questions to Ask and Answer Regarding ICD-10: First of a 2-Part Series.

INTRODUCTION: On October 1, 2015 the International Classification of Diseases and Related Health Problems, 9th revision (ICD-9) will be replaced by the 10th revision (ICD-10) for coding medical encounters in the United States. This transition will fundamentally change how medical care is documented, how health care is delivered and how delivery systems operate. We will shed light on the ICD-10 transition and answer 4 questions we believe to be important to this transition. We first wanted to know 1) how ICD-10 differs from ICD-9 and 2) why we need to do this/what frustrations we might expect. METHODS: A search was undertaken regarding the transition from ICD-9 to ICD-10, and included input and expertise from coding experts as well as personal experience. RESULTS: ICD-10 differs from ICD-9 in a number of ways, not just in the extreme expansion in the number of codes and specificity. ICD-10 has a new structure and rules that must be understood. The proposed advantages of transitioning to ICD-10 include a better analysis of disease patterns, improved treatment outcomes, streamlined claims submissions and reduced overall health care costs. These "advantages" have been debated and not yet proved. The transition could be very expensive and very frustrating. CONCLUSIONS: The transition to ICD-10 presents a significant implementation challenge for every health care provider and practice, and could be financially devastating to those who are unprepared. There is a significant cost to implementation, much of which is seemingly placed directly on health care providers. We must be prepared.

How Will the Transition to ICD-10 Affect Urology Coding? An Analysis of ICD-9 Code Use from a Large Group Practice.

INTRODUCTION: On October 1, 2015 the ICD (International Classification of Diseases)-10-CM (10th Revision, Clinical Modification) code set replaced ICD-9 (9th Revision) for coding medical encounters in the United States. The introduction of this unique, expanded code set will change the way medical encounters are coded, and may affect specialties and subspecialists to different degrees. METHODS: A retrospective review was performed evaluating ICD-9 codes used at a large urology group. The most commonly used codes were evaluated in the office and hospital settings, and also from 3 individual subspecialists including a men's health/infertility subspecialist, a pelvic floor/reconstruction subspecialist and a pediatric subspecialist. RESULTS: The top 30 ICD-9 codes comprised 82.5% and 80.7% of the codes chosen in the office and hospital settings, with a 1:1 conversion from ICD-10 in 60% (18 of 30) and 36.7% (11 of 30), respectively. The top 25 codes from the 3 subspecialists (men's health/infertility, pelvic floor/reconstruction and pediatric) comprised 86.8%, 88.7% and 88.1% of the ICD-9 codes chosen, with a 1:1 correlation in 48% (12 of the top 25), 56% (14 of 25) and 40% (10 of 25), respectively. A significant number of unspecified codes was used across all of the aspects of practice. CONCLUSIONS: Urologists need to be aware of their practice patterns when converting from ICD-9 to ICD-10. The high percentage of codes concentrated in the top 25 of a practice may allow urologists to focus on their individual needs. Improved documentation and coding education may decrease the number of unspecified codes chosen, leading to improved coding accuracy.

Effect of body position on renal parenchyma perfusion as measured by nuclear scintigraphy.

OBJECTIVES: To compare differential renal perfusion in various body positions in healthy volunteers, to help postulate factors responsible for recurrent unilateral stone formation. METHODS: Ten volunteers with normal renal function and no history of urinary disease were evaluated with diuretic renography using mercaptoacetyl-triglycine. Scintigraphy was performed 1 week apart in each of three typical sleep positions (supine, left lateral decubitus, right lateral decubitus), and renal perfusion was measured. RESULTS: Symmetric renal perfusion was noted in all volunteers in the supine position. Subjects positioned in the left lateral decubitus position had a mean renal perfusion of 61.3% in the dependent (left) kidney, compared with 38.7% in the nondependent (right) kidney (P <0.05). In the right lateral decubitus position, the mean renal perfusion in the right kidney was 63.3%, whereas that in the left kidney measured 36.7% (P <0.05). Renal perfusion in the dependent kidney was increased when compared with the same kidney in the supine position in both the left and right kidneys. CONCLUSIONS: Body position had a significant effect on renal perfusion as measured by nuclear renal scintigraphy. If altered renal blood flow contributes to urinary calculogenesis, these data suggest that the urinary and vascular milieu in the decubitus position may contribute to risk factors for stone formation.

The effect of kidney morcellation on operative time, incision complications, and postoperative analgesia after laparoscopic nephrectomy.

INTRODUCTION: Compare the outcomes between kidney morcellation and two types of open specimen extraction incisions, several covariates need to be taken into consideration that have not yet been studied. MATERIALS AND METHODS: We retrospectively reviewed 153 consecutive patients who underwent laparoscopic nephrectomy at our institution, 107 who underwent specimen morcellation and 46 with intact specimen removal, either those with connected port sites with a muscle-cutting incision and those with a remote, muscle-splitting incision. Operative time, postoperative analgesia requirements, and incisional complications were evaluated using univariate and multivariate analysis, comparing variables such as patient age, gender, body mass index (BMI), laterality, benign versus cancerous renal conditions, estimated blood loss, specimen weight, overall complications, and length of stay. RESULTS: There was no significant difference for operative time between the 2 treatment groups (p = 0.65). Incision related complications occurred in 2 patients (4.4%) from the intact specimen group but none in the morcellation group (p = 0.03). Overall narcotic requirement was lower in patients with morcellated (41 mg) compared to intact specimen retrieval (66 mg) on univariate (p = 0.03) and multivariate analysis (p = 0.049). Upon further stratification, however, there was no significant difference in mean narcotic requirement between the morcellation and muscle-splitting incision subgroup (p = 0.14). CONCLUSION: Morcellation does not extend operative time, and is associated with significantly less postoperative pain compared to intact specimen retrieval overall, although this is not statistically significant if a remote, muscle-splitting incision is made. Morcellation markedly reduces the risk of incisional-related complications.

The effect of kidney morcellation on operative time, incision complications, and postoperative analgesia after laparoscopic nephrectomy

INTRODUCTION: Compare the outcomes between kidney morcellation and two types of open specimen extraction incisions, several covariates need to be taken into consideration that have not yet been studied. MATERIALS AND METHODS: We retrospectively reviewed 153 consecutive patients who underwent laparoscopic nephrectomy at our institution, 107 who underwent specimen morcellation and 46 with intact specimen removal, either those with connected port sites with a muscle-cutting incision and those with a remote, muscle-splitting incision. Operative time, postoperative analgesia requirements, and incisional complications were evaluated using univariate and multivariate analysis, comparing variables such as patient age, gender, body mass index (BMI), laterality, benign versus cancerous renal conditions, estimated blood loss, specimen weight, overall complications, and length of stay. RESULTS: There was no significant difference for operative time between the 2 treatment groups (p = 0.65). Incision related complications occurred in 2 patients (4.4 percent) from the intact specimen group but none in the morcellation group (p = 0.03). Overall narcotic requirement was lower in patients with morcellated (41 mg) compared to intact specimen retrieval (66 mg) on univariate (p = 0.03) and multivariate analysis (p = 0.049). Upon further stratification, however, there was no significant difference in mean narcotic requirement between the morcellation and muscle-splitting incision subgroup (p = 0.14). CONCLUSION: Morcellation does not extend operative time, and is associated with significantly less postoperative pain compared to intact specimen retrieval overall, although this is not statistically significant if a remote, muscle-splitting incision is made. Morcellation markedly reduces the risk of incisional-related complications.

Novel everting urologic access sheath: potential advantages of decreased cellular advancement.

BACKGROUND AND PURPOSE: Axial forces are imposed on the urothelium during advancement of instruments across the urinary tract, potentially transferring cellular debris, bacteria, or urothelial carcinoma from one anatomic location to another. A prototype access sheath (Cystoglide; Percutaneous Systems, Mountain View, CA) was created that everts and radially dilates but does not provide axial forces during deployment that can be used in a variety of anatomic systems. We created a urinary-tract model to evaluate the in-vitro advancement of cells to compare this technology with using instruments alone. MATERIALS AND METHODS: Blocks of sterile agar were created with 17F tracts of three lengths (2.7, 5.5, and 11 cm) with 5 mL of Luria-Bertani broth/ampicillin solution in a well at the end. The tips of a Cystoglide sheath and a traditional urologic instrument of the same diameter were dipped into a suspension of ampicillin-resistant Escherichia coli and advanced through the tracts. After a 10-second exposure, 4 mL of broth was collected and cultured. Bacterial growth was compared by measuring the optical density (OD) of the broth at multiple time points. RESULTS: The mean overall OD of the broth was significantly lower (P < 0.001) in the novel-sheath cultures than with a traditional instrument for all advancements at all tract lengths. CONCLUSION: The Cystoglide sheath significantly reduces the advancement of cells within an artificial urinary tract compared with a non-everting instrument. Clinical studies are needed to assess the utility of this technology in vivo.

Novel everting urologic access sheath: decreased axial forces during insertion.

BACKGROUND: Advancement of urologic instruments through the genitourinary tract is associated with significant axial forces that likely contribute to patient discomfort, even after injection of a local anesthetic, and may lead to mucosal trauma, postprocedural dysuria and hematuria, and increased susceptibility to infection and strictures. Placing an everting urethral sheath prior to instrumentation may decrease these problems. MATERIALS AND METHODS: Two 7-cm-long, 5-mm diameter urethral luminal models were created, one with and one without an artificial stricture. We measured the forces generated during advancement of a novel everting access sheath (Cystoglide; Percutaneous Systems, Mountain View, CA) through the models in comparison with a representative cystoscope and a urologic dilator simulating a traditional access sheath. RESULTS: The mean force generated during advancement of the everting sheath was significantly less than that of both the representative cystoscope (P<0.01) and the traditional access sheath (P<0.01). This held true for the urethral models both with and without an artificial stricture (P<0.01) and with and without lubrication (P<0.01). CONCLUSIONS: This novel introduction sheath markedly decreased the axial forces applied to an artificial urethral luminal wall. It is possible that the clinical use of this technology will decrease the discomfort and potential complications associated with lower urinary-tract endoscopy.

Laparoscopic appreciation of the adrenal artery: fact or fiction?

BACKGROUND: It is well accepted that identification and control of the adrenal vein is a critical step in laparoscopic adrenalectomy. The surgical and anatomic literature propagates the notion of a dominant or multiple dominant adrenal arteries that should likewise be controlled during surgical extirpation. MATERIALS AND METHODS: We assessed the frequency of adrenal-artery identification and the need for formal ligation in an extensive series of laparoscopic adrenalectomies. RESULTS: In our experience, even using a magnified laparoscopic view, we found it possible to identify and necessary to formally ligate an adrenal artery in only 3 of 265 cases (1.1%). Further, in this series, only the inferior adrenal artery was ever seen definitively to require formal clip ligation, while a discrete middle or superior adrenal artery was almost never seen, and the vasculature in these areas could be controlled with electrocautery or ultrasonic energy alone during routine dissection. CONCLUSIONS: The need to search for and ligate the arterial supply during laparoscopic adrenalectomy is not as clinically significant as once thought, and formal control appears unnecessary unless the vessels are serendipitously encountered during the routine dissection.

Failed percutaneous balloon dilation for renal access: incidence and risk factors.

OBJECTIVES: To present our experience using balloon dilation and discuss secondary techniques to establish a percutaneous tract when balloon dilation fails. Balloon dilation is a safe and effective method to achieve percutaneous renal access, but it is not uniformly successful. Also, the failure rate and risk factors have not been well documented. METHODS: We retrospectively reviewed our last 99 consecutive percutaneous renal procedures using a balloon system as our initial dilation modality. In all cases, the urologist achieved needle access. We determined the balloon failure rate, relationship to prior renal surgery and other patient-related factors, and success rate using secondary techniques of tract dilation. RESULTS: The balloon did not adequately dilate a tract in 17 (17% failure rate) of 99 cases. The risk factors for failure included a history of prior ipsilateral renal surgery (25% failure rate versus 8% without surgery) and subcostal compared with supracostal puncture (18% versus 9% failure rate). The failure rate was not increased when stratified by laterality, stone composition, stone size and location, or history of ipsilateral renal infection. Amplatz dilators were used in 16 refractory cases and were successful in 15. Metal Alken dilators were successfully used in 2 patients. CONCLUSIONS: The balloon dilation system is commonly used as the primary modality to establish percutaneous renal access. Although safe and effective (83%), the success rate drops dramatically in patients with prior ipsilateral renal surgery. Knowledge and skill with alternative dilation systems, such as Amplatz or metal Alken dilators, are necessary to successfully gain entry into all renal collecting systems.

Laparoscopic management of peripelvic renal cysts: University of California, San Francisco, experience and review of literature.

OBJECTIVES: To report our experience and review published reports on the laparoscopic management of peripelvic renal cysts. Peripelvic renal cysts represent a unique subset of renal cysts, as they are rare, commonly symptomatic, and more difficult to treat than simple peripheral renal cysts. Minimally invasive methods for the treatment of peripelvic renal cysts, including laparoscopic decortication, have recently become more common. METHODS: Four patients who presented with symptomatic peripelvic cysts underwent laparoscopic decortication at our institution. All four were men aged 47 to 65 years. One patient had undergone an unsuccessful prior cyst aspiration. All patients underwent preoperative computed tomography and retrograde pyelography. The mean number of peripelvic cysts per patient was 3.0, and the mean cyst size was 7.1 cm. RESULTS: The mean operative time was 259 minutes (range 240 to 293), and the mean estimated blood loss was 30 mL (range 10 to 50). No evidence of cystic renal cell carcinoma was found on aspiration cytology or cyst wall pathologic examination. The mean hospital stay was 1.3 days. No inadvertent collecting system injuries and no intraoperative or postoperative complications occurred. All 4 patients achieved symptomatic relief and were determined to have radiologic success as determined by the 6-month postoperative computed tomography findings. CONCLUSIONS: Laparoscopic ablation of peripelvic renal cysts is more difficult than that of simple peripheral renal cysts and demands a heightened awareness of potential complications and, therefore, more advanced surgical skills. In addition to our experience, a thorough review of published reports found this procedure to be safe and effective with appropriate patient selection.

Insensitivity to transforming growth factor-beta results from promoter methylation of cognate receptors in human prostate cancer cells (LNCaP).

Prostate cancers often develop insensitivity to TGF-beta to gain a growth advantage. In this study, we explored the status of promoter methylation of TGF-beta receptors (TbetaRs) in a prostate cancer cell line, LNCaP, which is insensitive to TGF-beta. Sensitivity to TGF-beta was restored in cells treated with 5-Aza-2'-deoxycytidine (5-Aza), as indicated by an increase in the expression of phosphorylated Smad-2, type I (TbetaRI), and type II (TbetaRII) TGF-beta receptors, and a reduced rate of proliferation. The same treatment did not significantly affect a benign prostate cell line, RWPE-1, which is sensitive to TGF-beta. Mapping of methylation sites was performed by screening 82 potential CpG methylation sites in the promoter of TbetaRI and 33 sites in TbetaRII using methylation-specific PCR and sequence analysis. There were six methylation sites (-365, -356, -348, -251, -244, -231) in the promoter of TbetaRI. The -244 site was located in an activator protein (AP)-2 box. There were three methylated sites (-140, +27, +32) in the TbetaRII promoter and the -140 site was located in one of the Sp1 boxes. Chromatin immunoprecipitation analysis demonstrated DNA binding activity of AP-2 in the TbetaRI promoter and of Sp1 in the TbetaRII promoter after treatment with 5-Aza. To test whether promoter methylation is present in clinical specimens, we analyzed human prostate specimens that showed negative staining for either TbetaRI or TbetaRII in a tissue microarray system. DNA samples were isolated from the microarray after laser capture microdissection. Methylation-specific PCR was performed for TbetaRI (six sites) and TbetaRII (three sites) promoters as identified in LNCaP cells. A significant number of clinical prostate cancer specimens lacked expression of either TbetaRI and/or TbetaRII, especially those with high Gleason's scores. In those specimens showing a loss of TbetaR expression, a promoter methylation pattern similar to that of LNCaP cells was a frequent event. These results demonstrate that insensitivity to TGF-beta in some prostate cancer cells is due to promoter methylation in TbetaRs.

Restoration of expression of transforming growth factor-beta type II receptor in murine renal cell carcinoma (renca) cells by 5-Aza-2'-deoxycytidine.

The murine renal cell carcinoma (Renca) cells are insensitive to TGF-beta due to a lack of TGF-beta type II receptor (TbetaR-II). The objective of the present study is to determine the mechanism of this loss of sensitivity to TGF-beta in Renca cells. Renca cells were cultured and treated with 5-Aza-2'-Deoxycytidine (5-Aza), a specific inhibitor of methylation. Expression of TGF-beta type I receptor (TbetaRI) and TbetaRII was determined by RT-PCR and Western blot analysis before and after the treatment of Renca cells with 5-Aza. The expression of phosphorylated Smad2 (P-Smad2) was determined by Western blot analysis. TGF-beta levels in the conditioned medium were measured by ELISA. Renca cells did not express TbetaR-II prior to 5-Aza treatment. After 5-Aza treatment, these cells expressed TbetaR-II at both mRNA and protein levels, which corresponded to the restoration of sensitivity to TGF-beta by an increase in P-Smad2. Levels of TGF-beta1 were similar before and after 5-Aza treatment. Results of the present study indicated that, in Renca cells, the loss of sensitivity to TGF-beta is likely due to a promoter hypermethylation in the TbetaR-II gene.

Safety and efficacy of percutaneous nephrolithotomy in patients with neurogenic bladder dysfunction.

OBJECTIVES: To review our experience performing percutaneous nephrolithotomy (PNL) on patients with neurogenic bladder dysfunction with special attention paid to the risks of surgical complications and stone recurrence. Patients with neurogenic bladder dysfunction with or without urinary diversion are at increased risk of urolithiasis, surgical complications, and recurrent stone disease. METHODS: We retrospectively reviewed the 23 patients with neurogenic bladder dysfunction who underwent PNL at our institution. Neurologic lesions included spina bifida, traumatic spinal cord injury, exstrophy/epispadias, neonatal meningitis, stroke, and spine chondrosarcoma. Bladder management included ileal conduit (n = 8), intermittent catheterization (n = 7), indwelling catheter (n = 7), and ureterosigmoidostomy (n = 1). RESULTS: We performed 100 procedures on 47 renal units (17 bilateral, 7 with recurrent stones). Urinary tract infection/colonization was seen in 21 of 23 patients, most of whom had more than one organism. The stone-free rate was 96%. Six patients required three or more procedures, each had a complete staghorn calculus. In an average of 36 months of follow-up, 10 patients (46%) had recurrent stone disease requiring intervention, and 5 patients (23%) underwent repeat PNL. The stone composition analysis revealed mainly infection-related stones. CONCLUSIONS: PNL in patients with neurogenic voiding dysfunction is safe and effective, with outcomes comparable to that of patients without such lesions. The complication rate is small but statistically significant. It is important to obtain adequate urine cultures, because renal pelvis and bladder culture data may differ and affect the outcome. Risk factors for recurrent stone disease include a high spinal cord lesion, indwelling urinary catheter, and ureterosigmoidostomy.

Laparoscopic renal cryosurgery: the Northwestern experience.

PURPOSE: Laparoscopic renal cryosurgery provides a minimally invasive alternative for the treatment of small renal lesions of undefined malignant potential. We report on our series of patients treated with laparoscopic renal cryosurgery. MATERIALS AND METHODS: Fifteen patients underwent laparoscopic renal cryoablation of peripheral, exophytic unifocal renal lesions. Patients were managed with a 4-port transperitoneal approach for anteromedial tumors and 3 to 4-port retroperitoneal approach for posterolateral tumors. All lesions were biopsied and sent to pathology for permanent section. A 4.8 mm cryoprobe (CMS cryoprobe, 4.8 mm x 2 cm x 40 cm, Cryomedical Sciences Inc., Ewing, New Jersey) was placed into the tumor using visual and ultrasonographic guidance, and a double freeze-passive thaw cycle was performed. The iceball was extended at least 1 cm beyond the tumor margin under ultrasound guidance. Followup biopsies were performed on all consenting patients with renal cell carcinoma at least 3 months after cryosurgery was performed. RESULTS: Laparoscopic renal cryosurgery was successfully performed on all 15 patients (6 male and 9 female). Of the 15 patients 10 had renal cell carcinoma. Mean age was 68.5 years (range 49 to 86). Mean tumor size was 2.15 cm (range 1.2 to 3.2) and mean estimated blood loss was 67 cc (range 15 to 125). There were 2 perioperative complications. Mean hospital stay was 3.5 days (range 1 to 11). Patients returned to work after 16.5 days (range 7 to 28). Radiographic followup revealed stable cryoablative lesions in all patients. Mean radiographic followup was 453 days (range 147 to 816). Mean preoperative creatinine was 1.25 mg/dl (range 0.8 to 4.3) and mean postoperative creatinine obtained 1 month postoperatively was 1.36 (range 0.8 to 4.8). There was 1 treatment failure, although another patient had a positive biopsy outside the ablated area. The failure occurred in the largest tumor treated (3.2 cm) and was due to incomplete treatment of the periphery of the lesion. The other patient had a successfully treated tumor but a positive followup biopsy due to multifocal papillary renal cell carcinoma and required nephrectomy. CONCLUSIONS: Laparoscopic renal cryosurgery appears to be a safe and effective minimally invasive alternative for the treatment of small renal masses. Careful selection of patients with lesions that are less than 3.0 cm and close monitoring of the iceball is necessary to treat these patients successfully.