Predictors of Recurrence, and Progression-Free and Overall Survival following Open versus Robotic Radical Cystectomy: Analysis from the RAZOR Trial with a 3-Year Followup.

PURPOSE: The RAZOR (Randomized Open versus Robotic Cystectomy) trial revealed noninferior 2-year progression-free survival for robotic radical cystectomy. This update was performed with extended followup for 3 years to determine potential differences between the approaches. We also report 3-year overall survival and sought to identify factors predicting recurrence, and progression-free and overall survival. MATERIALS AND METHODS: We analyzed the per protocol population of 302 patients from the RAZOR study. Cumulative recurrence was estimated using nonbladder cancer death as the competing risk event and the Gray test was applied to assess significance in differences. Progression-free survival and overall survival were estimated by the Kaplan-Meier method and compared with the log rank test. Predictors of outcomes were determined by Cox proportional hazard analysis. RESULTS: Estimated progression-free survival at 36 months was 68.4% (95% CI 60.1-75.3) and 65.4% (95% CI 56.8-72.7) in the robotic and open groups, respectively (p=0.600). At 36 months overall survival was 73.9% (95% CI 65.5-80.5) and 68.5% (95% CI 59.8-75.7) in the robotic and open groups, respectively (p=0.334). There was no significant difference in the cumulative incidence rates of recurrence (p=0.802). Patient age greater than 70 years, poor performance status and major complications were significant predictors of 36-month progression-free survival. Stage and positive margins were significant predictors of recurrence, and progression-free and overall survival. Surgical approach was not a significant predictor of any outcome. CONCLUSIONS: This analysis showed no difference in recurrence, 3-year progression-free survival or 3-year overall survival for robotic vs open radical cystectomy. It provides important prospective data on the oncologic efficacy of robotic radical cystectomy and high level data for patient counseling.

Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial.

BACKGROUND: Radical cystectomy is the surgical standard for invasive bladder cancer. Robot-assisted cystectomy has been proposed to provide similar oncological outcomes with lower morbidity. We aimed to compare progression-free survival in patients with bladder cancer treated with open cystectomy and robot-assisted cystectomy. METHODS: The RAZOR study is a randomised, open-label, non-inferiority, phase 3 trial done in 15 medical centres in the USA. Eligible participants (aged ≥18 years) had biopsy-proven clinical stage T1-T4, N0-N1, M0 bladder cancer or refractory carcinoma in situ. Individuals who had previously had open abdominal or pelvic surgery, or who had any pre-existing health conditions that would preclude safe initiation or maintenance of pneumoperitoneum were excluded. Patients were centrally assigned (1:1) via a web-based system, with block randomisation by institution, stratified by type of urinary diversion, clinical T stage, and Eastern Cooperative Oncology Group performance status, to receive robot-assisted radical cystectomy or open radical cystectomy with extracorporeal urinary diversion. Treatment allocation was only masked from pathologists. The primary endpoint was 2-year progression-free survival, with non-inferiority established if the lower bound of the one-sided 97·5% CI for the treatment difference (robotic cystectomy minus open cystectomy) was greater than -15 percentage points. The primary analysis was done in the per-protocol population. Safety was assessed in the same population. This trial is registered with ClinicalTrials.gov, number NCT01157676. FINDINGS: Between July 1, 2011, and Nov 18, 2014, 350 participants were randomly assigned to treatment. The intended treatment was robotic cystectomy in 176 patients and open cystectomy in 174 patients. 17 (10%) of 176 patients in the robotic cystectomy group did not have surgery and nine (5%) patients had a different surgery to that they were assigned. 21 (12%) of 174 patients in the open cystectomy group did not have surgery and one (1%) patient had robotic cystectomy instead of open cystectomy. Thus, 302 patients (150 in the robotic cystectomy group and 152 in the open cystectomy group) were included in the per-protocol analysis set. 2-year progression-free survival was 72·3% (95% CI 64·3 to 78·8) in the robotic cystectomy group and 71·6% (95% CI 63·6 to 78·2) in the open cystectomy group (difference 0·7%, 95% CI -9·6% to 10·9%; pnon-inferiority=0·001), indicating non-inferiority of robotic cystectomy. Adverse events occurred in 101 (67%) of 150 patients in the robotic cystectomy group and 105 (69%) of 152 patients in the open cystectomy group. The most common adverse events were urinary tract infection (53 [35%] in the robotic cystectomy group vs 39 [26%] in the open cystectomy group) and postoperative ileus (33 [22%] in the robotic cystectomy group vs 31 [20%] in the open cystectomy group). INTERPRETATION: In patients with bladder cancer, robotic cystectomy was non-inferior to open cystectomy for 2-year progression-free survival. Increased adoption of robotic surgery in clinical practice should lead to future randomised trials to assess the true value of this surgical approach in patients with other cancer types. FUNDING: National Institutes of Health National Cancer Institute.

Whole-mount evaluation of penectomies for penile cancer: feasibility, cost and comparison to routine sectioning.

AIMS: Pathological staging in penectomies may be difficult due to the anatomical complexity of penile anatomy, and may be additionally challenging due to the low volume at most institutions. Our study aimed to assess the feasibility of whole-mount processing for penectomy specimens. METHODS AND RESULTS: A 7-year retrospective search for partial or radical penectomies identified 55 specimens, which were processed routinely (n = 31) from 2006 to 2009 and whole-mounted (n = 24) from 2010 to 2012. Routine cases used more slides per case compared to whole mounts (mean 10.4 versus 7.2). Recuts occurred more often in routine cases (12.9% versus 0%). More routine cases had additional blocks grossed (19.4% versus 4.2%). Upon review, five discrepancies that impacted pT staging were identified in the routine group, with none in the whole-mount group. The average estimated additional cost for each whole-mount case compared to routine processing was $40.74, with an increased turnaround time of 1 day. CONCLUSIONS: Whole-mounting is a feasible technique for penectomy that can be utilized with minimal increased cost and turnaround time, and may improve staging. Institutions in which whole-mounting is already established for other organs, such as prostate, may wish to consider utilizing this format for penectomy specimens.

Multimodal imaging and detection strategy with 124 I-labeled chimeric monoclonal antibody cG250 for accurate localization and confirmation of extent of disease during laparoscopic and open surgical resection of clear cell renal cell carcinoma.

Renal cell carcinoma (RCC) accounts for approximately 85% to 90% of all primary kidney malignancies, with clear cell RCC (ccRCC) constituting approximately 70% to 85% of all RCCs. This study describes an innovative multimodal imaging and detection strategy that uses (124)I-labeled chimeric monoclonal antibody G250 ((124)I-cG250) for accurate preoperative and intraoperative localization and confirmation of extent of disease for both laparoscopic and open surgical resection of ccRCC. Two cases presented herein highlight how this technology can potentially guide complete surgical resection and confirm complete removal of all diseased tissues. This innovative (124)I-cG250 (ie, (124)I-girentuximab) multimodal imaging and detection approach, which would be clinically very useful to urologic surgeons, urologic medical oncologists, nuclear medicine physicians, radiologists, and pathologists who are involved in the care of ccRCC patients, holds great potential for improving the diagnostic accuracy, operative planning and approach, verification of disease resection, and monitoring for evidence of disease recurrence in ccRCC patients.

Urologist's Impact on Needle Core Prostate Biopsy Histopathologic Variables Within a Single Institution.

OBJECTIVE: To assess the urologist's impact on prostate needle core biopsy variables including number of containers submitted, total core length, longest core length, and individual core length threshold values, and to elucidate the relationship between these variables and cancer detection rate within a recent cohort. METHODS: A retrospective search was performed to identify patients who had an extended transrectal ultrasound-guided prostate needle core biopsy between 2008 and 2013. RESULTS: One thousand one prostate biopsies were analyzed. Total core length (mean 13.2-22.9 cm, P < .001) significantly varied by submitting urologist but did not impact cancer detection rate per case. Increased core length per container impacted the cancer detection per container (P < .001). The number of cores that met threshold values of 0.5, 1.0, and 1.5 cm as well as longest individual core length (mean 1.7-2.2 cm) significantly varied between urologist (P < .001), although there was no association between these variables and cancer detection. Container number differed significantly between urologists (P < .001) but did not correlate with cancer detection. For the single urologist with a change in his submission protocol during the study period, a nonsignificant change in cancer detection was noted when comparing 12-14 containers vs 6-9 containers. CONCLUSION: Submitting urologist significantly impacts prostate biopsy metrics. An increased amount of tissue per container was associated with higher rates of cancer per container. A nonsignificant change in cancer detection rate was observed when container number was reduced from 12-14 to 6-9.

Does the Renal Parenchyma Adjacent to the Tumor Contribute to Kidney Function? A Critical Analysis of Glomerular Viability in Partial Nephrectomy Specimens.

OBJECTIVE: To evaluate the viability of glomeruli in the peritumor parenchyma of partial nephrectomy specimens removed for renal cell carcinoma (RCC) and relate it to kidney function, to better understand the contribution of peritumor parenchyma to renal function. MATERIALS AND METHODS: A retrospective analysis of 53 partial nephrectomies containing RCC was performed. Glomeruli within 0.25-cm increments from the tumor were quantified and histologically assessed for viability. Tumor size, minimum and maximum margin size, and pre- and postoperative estimated glomerular filtration rate (eGFR) were obtained. RESULTS: Glomerular viability positively correlated with distance from tumor with mean viable glomeruli in successive 0.25-cm increments of 0-0.25 cm, 58%; 0.25-0.5 cm, 80%; 0.5-0.75 cm, 90%; and 0.75-1.0 cm, 92%. Glomerular viability near the tumor did not correlate with preoperative eGFR, whereas decreased viability further from the tumor did correlate with worse preoperative eGFR. Tumor size showed a nonstatistically significant positive trend with minimum (median 0.15 cm) and maximum margin (median 0.7 cm) sizes. Percent change of glomerular filtration rate did not correlate with margin size (P = .190). CONCLUSION: Renal parenchyma immediately adjacent to RCC contains fewer viable glomeruli compared with the parenchyma further from the tumor. Based on this information, attempts to preserve all non-neoplastic renal parenchyma via a surgical margin approaching zero may not necessarily result in clinically relevant differences in the amount of viable glomeruli remaining or the renal function preserved.

Dismembered percutaneous endopyeloplasty: a new procedure.

PURPOSE: We recently described a novel technique of percutaneous non-dismembered endopyeloplasty (Fenger type). Herein, we extend this transrenal technique further and report percutaneous dismembered endopyeloplasty (Anderson-Hynes type). MATERIALS AND METHODS: In five pigs with unilateral ureteropelvic junction (UPJ) obstruction created 3 to 6 weeks earlier, percutaneous dismembered endopyeloplasty was performed. Percutaneous transrenal access to the UPJ was obtained, and the UPJ was completely dismembered from within the renal pelvis through the solitary percutaneous tract. The dismembered proximal ureter was circumferentially mobilized, and in two animals, the UPJ segment was completely excised and removed. A spatulated end-to-end endopyeloplasty anastomosis (Anderson-Hynes) was created transrenally with 5 to 10 interrupted sutures using a novel nephroscopic suturing device (Sew-Right SR-5; LSI Solutions, Rochester, NY). In two animals, the entire percutaneous procedure was performed with CO2 insufflation instead of fluid irrigation. RESULTS: The technique was developed in three pigs. Subsequently, two pigs were treated and sacrificed at 2 and 5 weeks. All UPJs were dismembered successfully, and a precisely sutured mucosa-to-mucosa anastomosis was created. Intraoperative bleeding was negligible, and the operative time ranged from 3 to 5 hours, with the majority of the time dedicated to transrenal retroperitoneal dissection of the scarred, fibrotic UPJ. Carbon dioxide insufflation was efficacious because it minimized fluid extravasation and tissue edema and additionally enhanced visibility. Postoperative pyelograms revealed an adequately funneled UPJ, with good flow into the distal ureter. The two survival animals had minimal apparent morbidity from the procedure, and retrograde pyelograms at euthanasia revealed a patent anastomosis without extravasation. A 6F catheter easily crossed the reconstructed UPJ at autopsy in all animals. CONCLUSIONS: Dismembered percutaneous Anderson-Hynes endopyeloplasty is technically feasible and is promising. Further technical experience and additional functional outcome analysis in the survival model are necessary. With the technique described herein, we introduce the concept of percutaneous intrarenal reconstructive surgery (PIRS), wherein advanced intrarenal and retroperitoneal dissection with reconstruction can be performed endourologically, further broadening the horizons of conventional percutaneous techniques.

Management of the residual post-chemotherapy retroperitoneal mass in germ cell tumors.

The management of the residual mass in the retroperitoneum following induction chemotherapy for metastatic testicular cancer has evolved over the past three decades. A multidisciplinary approach involving cisplatin-based chemotherapy and postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) has increased long-term survival rates above 80%. Advances into the appropriate patient selection and timing of surgery have lowered morbidity while improving oncologic outcomes. However, areas of controversy still exist within the field. Management of the small residual mass, predictors of the histology of the residual mass, the extent of PC-RPLND, the role of PC-RPLND in the setting of elevated serum tumor markers, and the role of positron-emission tomography are all topics of ongoing research and debate. We will discuss these issues and review the current guidelines for the management of the residual postchemotherapy retroperitoneal mass in this review.

Urachal carcinoma: a clinicopathologic analysis of 24 cases with outcome correlation.

BACKGROUND: Urachal carcinomas occur mostly in the bladder dome, comprising 22% to 35% of vesical adenocarcinomas, and are generally treated by partial cystectomy with en bloc resection of the median umbilical ligament and umbilicus. Detailed pathologic studies with clinical outcome correlation are few. DESIGN: We reviewed histologic material and clinical data from 24 cases selected from a database of 67 dome-based tumors diagnosed and treated at our institution from 1984 to 2005. Follow-up information was available for all 24 patients. RESULT: The mean age at diagnosis was 52 years (range: 26 to 68 y). Fifteen patients were male and 9 were female. Location was the dome in 23 and dome and anterior wall in 1. Thirteen cases were pure adenocarcinoma, not otherwise specified, 9 were enteric type adenocarcinoma, and 2 were adenocarcinoma with focal components of lymphoepithelioma-like carcinoma and urothelial carcinoma with cytoplasmic clearing. Signet ring cell features were focally seen in 2 cases. Cystitis cystica and cystitis glandularis were seen in 4 and 2 cases, respectively. In all instances but 1, cystitis cystica/glandularis was focal and predominantly in the bladder overlying the urachal neoplasm. Urachal remnants were identified in 15 cases: the urachal epithelium was benign urothelial-type in 6 cases and showed adenomatous changes in 9. The overlying bladder urothelium was colonized by adenocarcinoma in 3 cases. In all 3, urachal remnants were identified and showed transition from benign to adenomatous epithelium. On immunohistochemistry, these tumors were positive for CK20 and variably positive for CK7 and 34BE12. The majority showed a cytoplasmic membranous staining pattern for beta-catenin, although in 1 case, focal nuclear immunoreactivity was identified. The Sheldon pathologic stage was pT1 in 0, pT2 in 2, pT3a in 8, pT3b in 11, pT3c in 1, pT4a in 1, and pT4b in 1 patient. One patient had a positive soft tissue margin. The mean follow-up period was 40 months (range: 0.3 to 157.6 mo). Seven of 24 (29%) cases recurred locally. The incidence of local recurrence was higher in patients who underwent a partial cystectomy alone (37.5%) versus those who had a more radical surgery (27%). Distant metastases occurred in 9 (37.5%) patients, 4 of whom had no prior local recurrence. Seven patients (29%) died of the disease. All cases with locally recurrent and metastatic disease belonged to stage pT3 or higher. CONCLUSIONS: Pathologic stage is an important prognostic factor in urachal carcinoma. Surface urothelial involvement by carcinoma and presence of cystitis cystica/glandularis do not necessarily exclude the diagnosis of urachal carcinoma. Immunostains do not unequivocally discriminate a urachal from a colorectal carcinoma, but diffuse positivity for 34BE12 would support, and diffuse nuclear immunoreactivity for beta-catenin would militate against, a diagnosis of urachal carcinoma. Local recurrence may be owing to seeding within the distal urothelial tract, particularly in tumors with a configuration that is polypoid and which open into the bladder cavity. The type of surgery performed may have an effect on local recurrence despite negative margins of resection.

Clinical outcome and predictors of survival in late relapse of germ cell tumor.

PURPOSE: Late relapse (LR) of germ cell tumor (GCT) is a well recognized entity associated with poor survival. We report on our experience with LR and determine predictors of survival. PATIENTS AND METHODS: From 1990 to 2004, 75 patients were managed for LR of GCT at our institution. Clinical and pathologic parameters were reviewed. Estimates of cancer-specific survival were generated using the Kaplan-Meier method, and a Cox proportional hazards model was used to assess potential predictors of outcome. RESULTS: The median time to LR was 6.9 years (range, 2.1 to 37.7 years). Overall, 56 patients (75%) had LR in the retroperitoneum, including 25 (93%) of 27 patients initially managed without retroperitoneal lymph node dissection. The 5-year cancer-specific survival (CSS) was 60% (95% CI, 46% to 71%). Patients who underwent complete surgical resection at time of LR (n = 45) had a 5-year CSS of 79% versus 36% for patients without complete resection (n = 30; P < .0001). The 5-year CSS for chemotherapy-naive patients was significantly greater than patients with a prior history of chemotherapy as part of their initial management (5-year CSS, 93% v 49%, respectively). In multivariable analysis of pretreatment parameters available at the time of LR, the presence of symptoms (hazard ratio [HR] = 4.9) and multifocal disease (HR = 3.0) were associated with an inferior CSS. CONCLUSION: The data suggest that meticulous control of the retroperitoneum is critical to prevent LR in the retroperitoneum. In multivariable analysis, patients with a symptomatic presentation and those with multifocal disease have a significantly decreased survival. Survival is greatly improved if complete surgical excision of disease is attained.

Incidence of disease outside modified retroperitoneal lymph node dissection templates in clinical stage I or IIA nonseminomatous germ cell testicular cancer.

PURPOSE: We evaluated the incidence, sites and histology of disease outside 5 modified retroperitoneal lymph node dissection templates for patients with low stage nonseminomatous germ cell tumors of the testis. MATERIALS AND METHODS: Our cohort consisted of 500 consecutive patients with clinical stage I to IIA nonseminomatous germ cell tumors who underwent primary retroperitoneal lymph node dissection from 1989 to 2004. We analyzed 191 patients with pathological stage II disease and defined the incidence of disease outside 5 modified retroperitoneal lymph node dissection templates, 3 described for open surgery (Testicular Tumor Study Group, Indiana University and Memorial Sloan-Kettering Cancer Center) and 2 for laparoscopic surgery (University of Innsbruck and The Johns Hopkins University). RESULTS: Of 191 patients with pathological stage II disease, 111 (58%) had clinical stage I disease and 80 (42%) had clinical stage IIA disease. Depending on the template applied, extra-template disease ranged from 3% to 23% of all patients and was 1% to 11% of patients with pN1 disease. Regardless of template, histological distribution of extra-template disease was not significantly different from in-template disease with approximately 90% viable germ cell tumor, 10% teratoma only and 20% with any teratoma. For right side templates inclusion of para-aortic, preaortic and right common iliac regions decreased the incidence of extra-template disease to 2%. For left side templates inclusion of interaortocaval, precaval, paracaval and left common iliac regions decreased the incidence of extra-template disease to 3%. CONCLUSIONS: A significant number of men with clinical stage I to IIA nonseminomatous germ cell tumors and retroperitoneal metastases have disease present outside the limits of modified templates, including 20% to 30% with chemoresistant teratomatous elements. The data suggest that more extensive nerve sparing templates optimize oncological efficacy and ejaculation preservation, and minimize overall treatment morbidity.

Tumor location does not affect long-term renal function after partial nephrectomy.

OBJECTIVES: To study the effect of central tumor location on the glomerular filtration rate (GFR) after partial nephrectomy for renal cortical tumor. METHODS: We reviewed our institutional database to identify patients who had undergone partial nephrectomy from January 1995 to July 2005. Central tumors were defined as those encroaching on the collecting system or renal sinus or that did not distort the renal contour; all others were categorized as peripheral on preoperative abdominal imaging. We calculated the GFR preoperatively, during the hospital stay, and at 1 and 12 months after surgery. Linear regression models were fit to determine the association of tumor location with the changes in GFR at each period, after controlling for age, sex, operative and ischemic times, comorbidities, and blood loss. RESULTS: A total of 248 central and 333 peripheral tumors were available for analysis. Patients with central tumors were younger than those with peripheral tumors (62 versus 59 years, P = 0.014) and experienced longer intraoperative renal ischemia times (40 versus 29 minutes, P <0.001) and longer operations (195 versus 179 minutes, P = 0.004). On multivariate analysis, tumor location was not significantly associated with the change in GFR at any of the intervals, after adjusting for the covariates. CONCLUSIONS: The results of our study have indicated that tumor location does not appear to affect long-term renal function. Thus, partial nephrectomy should not be withheld from this subset of patients.

Nerve-sparing laparoscopic radical cystectomy: technique and initial outcomes.

OBJECTIVES: To report the technique and early outcomes of nerve-sparing laparoscopic radical cystectomy with continent orthotopic ileal neobladder in selected male and female patients with bladder cancer. METHODS: Since 2000, 52 patients have undergone laparoscopic radical cystectomy at our institution, with nerve-sparing laparoscopic radical cystectomy performed in 5 patients. In the nerve-sparing technique, transection of the lateral vascular pedicle and the posterior dissection proceeds closer to the bladder, at some distance from the rectum. Hem-o-lock clips were used for hemostasis, avoiding the need for any energy source near the neurovascular bundle (NVB). In the male, the identification and complete release of the NVB before division of the urethra minimizes damage to the NVB along the prostatic apex. In the female, preservation of the uterus, fallopian tubes, ovaries, and vagina, maintenance of the endopelvic fascia, and minimal mobilization distal to the urethra facilitates nerve sparing. RESULTS: The median operative time was 10 hours, blood loss was 400 mL, and the length of stay was 5 days. No patient required blood transfusion, and one had a postoperative complication. All patients were free of recurrence at a median follow-up of 30 months. At 12 months, nocturnal and daytime continence was preserved in 100% and 75% of patients, respectively. Sexual function was preserved in the female patient and 2 of the 4 male patients. CONCLUSIONS: With careful attention to the anatomic location of the NVBs and a precise operative technique, nerve-sparing laparoscopic radical cystectomy can be performed in appropriately selected male and female patients with organ-confined bladder cancer.

Attitudes of pediatric urologists regarding sports participation by children with a solitary kidney.

PURPOSE: Little data are available regarding sports participation and appropriate long-term followup of children with a solitary kidney. We determine the current practice patterns and recommendations among pediatric urologists regarding sports participation and followup of these patients. MATERIALS AND METHODS: A survey was mailed to the 231 active members of the American Academy of Pediatrics, Section on Urology. The survey included questions regarding counseling of patients with a solitary kidney and physician estimates of long-term risk to overall renal function. RESULTS: Of the 231 surveys 182 were returned for an overall response rate of 79%. Of the respondents 68% recommend that patients with a solitary kidney avoid contact sports. Recommendations in regard to participation in contact sports were further stratified as strongly against participation (27%), against participation with rare exceptions (30%), no recommendation either way (14%), allow participation (25%) and no restrictions be made (4%). Of the respondents 88% agreed that the estimated risk of renal loss from a child participating regularly in contact sports is less than 1% and 60% recommended special medical followup. CONCLUSIONS: Despite the consensus that the risk of renal injury in contact sports is low, a significant number of pediatric urologists advise avoidance. There appears to be a lack of consensus regarding long-term medical surveillance of these patients. Studies designed to obtain accurate clinical data regarding these issues are warranted to establish evidence based guidelines for the long-term treatment of children with a solitary kidney.

Thoracic complications during urological laparoscopy.

PURPOSE: We documented thoracic related complications during urological laparoscopic surgery. MATERIALS AND METHODS: A total of 1129 patients underwent major urological laparoscopic procedures in a 5-year period. Operative reports and postoperative radiographic reports were retrospectively reviewed to identify patients with thoracic related medical and surgical sequelae. Of the patients 619 (55%) underwent at least 1 chest x-ray in the immediate or early postoperative period. In the remaining 510 patients (45%) there was no clinical indication to perform chest x-ray. RESULTS: Of 619 patients undergoing chest x-ray 438 (71%) were completely normal. Medical pulmonary complications, surgical thoracic complications and subclinical, incidentally detected gas collections in the chest were identified in 12.6%, 0.5% and 5.5% of patients, respectively. Medical complications in 12.6% of cases included pulmonary infiltrate/atelectasis in 9.7%, pleural effusion in 4.8% and pulmonary embolus in 0.3%. Surgical complications included symptomatic pneumothorax in 4 patients (0.35%), hemothorax in 1 (0.08%) and chylothorax in 1 (0.08%). Subclinical abnormal thoracic gas collections were radiographically noted in 34 of the 619 patients (5.5%) on chest x-ray, including pneumomediastinum in 19 (3.1%), pneumothorax in 10 (1.6%) and pneumopericardium in 5 (0.8%). Overall 36 of 40 (90%) thoracic surgical complications (3) and subclinical, incidentally detected gas collections (33) occurred during retroperitoneal laparoscopy. Re-intervention was necessary in 6 patients (0.5%), namely pulmonary embolus requiring vena caval filter placement in 3 (0.3%), pneumothorax requiring a chest tube in 2 (0.17%) and hemothorax requiring emergency open thoracotomy in 1 (0.08%). No patient underwent open conversion to complete the initial proposed operation. CONCLUSIONS: Due to its high solubility the expectant management of incidental CO2 pneumothorax, pneumopericardium and pneumomediastinum is recommended initially in the clinically stable patient. Inadvertent diaphragmatic entry can be satisfactorily repaired laparoscopically without open conversion. Although it is rare, surgical thoracic complications are potentially life threatening, requiring prompt identification and management.