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Benign prostatic hyperplasia and lower urinary tract symptoms are very common among men. Transurethral resection of the prostate continues to be the gold standard for treatment, but men can often be treated with other less invasive modalities. In this roundtable discussion, the participants share their expertise and offer their opinions on the wide variety of treatment options currently available. [ABSTRACT FROM AUTHOR]

The management of ureteral stones has changed dramatically in the past decade. In this environment of constant change, urologists must keep informed about the efficacy, safety, and economics of contemporary management techniques to aid their patients in making appropriate decisions. Our panel of experts was convened to discuss the new armamentarium aril share their personal tricks of the trade. [ABSTRACT FROM AUTHOR]

Our panel of experts debates and discusses diagnosis, endoscopic and percutaneous evaluation, and proper patient selection as part of minimally invasive management of upper tract TCC. [ABSTRACT FROM AUTHOR]

Histopathology, which is the gold-standard for prostate cancer diagnosis, faces significant challenges. With prostate cancer ranking among the most common cancers in the United States and worldwide, pathologists experience an increased number for prostate biopsies. At the same time, precise pathological assessment and classification are necessary for risk stratification and treatment decisions in prostate cancer care, adding to the challenge to pathologists. Recent advancement in digital pathology makes artificial intelligence and learning tools adopted in histopathology feasible. In this review, we introduce the concept of AI and its various techniques in the field of histopathology. We summarize the clinical applications of AI pathology for prostate cancer, including pathological diagnosis, grading, prognosis evaluation, and treatment options. We also discuss how AI applications can be integrated into the routine pathology workflow. With these rapid advancements, it is evident that AI applications in prostate cancer go beyond the initial goal of being tools for diagnosis and grading. Instead, pathologists can provide additional information to improve long-term patient outcomes by assessing detailed histopathologic features at pixel level using digital pathology and AI. Our review not only provides a comprehensive summary of the existing research but also offers insights for future advancements., Competing Interests: None., (AJCEU Copyright © 2024.)

Robotic surgery has expanded globally across various medical specialties since its inception more than 20 years ago. Accompanying this expansion were significant technological improvements, providing tremendous benefits to patients and allowing the surgeon to perform with more precision and accuracy. This review lists some of the different types of platforms available for use in various clinical applications. We performed a literature review of PubMed and Web of Science databases in May 2023, searching for all available articles describing surgical robotic platforms from January 2000 (the year of the first approved surgical robot, da Vinci® System, by Intuitive Surgical) until May 1st, 2023. All retrieved robotic platforms were then divided according to their clinical application into four distinct groups: soft tissue robotic platforms, orthopedic robotic platforms, neurosurgery and spine platforms, and endoluminal robotic platforms. Robotic surgical technology has undergone a rapid expansion over the last few years. Currently, multiple robotic platforms with specialty-specific applications are entering the market. Many of the fields of surgery are now embracing robotic surgical technology. We review some of the most important systems in clinical practice at this time., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Management of residual or recurrent disease following thermal ablation of renal cortical tumors includes surveillance, repeat ablation, or surgical extirpation. We present a multicenter experience with regard to the management of this clinical scenario. Prospectively maintained databases were reviewed to identify 1265 patients who underwent cryoablation (CA) or radiofrequency ablation (RFA) for enhancing renal masses. Disease persistence or recurrence was classified into one of the three categories: (i) residual disease in ablation zone; (ii) recurrence in the ipsilateral renal unit; and (iii) metastatic/extra-renal disease. Seventy seven patients (6.1%) had radiographic evidence of disease persistence or recurrence at a median interval of 13.7 months (range, 1-65 months) post-ablation. Distribution of disease included 47 patients with residual disease in ablation zone, 29 with ipsilateral renal unit recurrences (all in ablation zone), and one with metastatic disease. Fourteen patients (18%) elected for surveillance, and the remaining underwent salvage ablation (n = 50), partial nephrectomy (n = 5), or radical nephrectomy (n = 8). Salvage ablation was successful in 38/50 (76%) patients, with 12 failures managed by observation (3), tertiary ablation (6), and radical nephrectomy (3). At a median follow-up of 28 months, the actuarial cancer-specific survival and overall survival in this select cohort of patients was 94.8 and 89.6%, respectively., Competing Interests: The authors declare no potential conflicts of interest with respect to research, authorship, and/or publication of this article., (Copyright: Loloi J et al.)

Introduction: Microwave ablation (MWA) uses heat to ablate undesired tissue. Development of pre-planning algorithms for MWA of small renal masses requires understanding of microwave-tissue interactions at different operating parameters. The objective of this study was to compare the performance of two MWA systems in in-vivo porcine kidneys., Methods: Five ablations were performed using a 902-928 MHz system (24 W, 5 min) and a 2450 MHz system (180 W, 2 min). Nonlinear regression analysis of temperature changes measured 5 mm from the antenna axis was completed for the initial 10 s of ablation using the power equation Δ T = a t b and after the inflection point using an exponential equation. Thermal damage was calculated using the Arrhenius equation. Long and short axis ablation diameters were measured., Results: The average 'a' varied significantly between systems (902-928 MHz: 0.0299 ± 0.027, 2450 MHz: 0.1598 ± 0.158), indicating proportionality to the heat source, but 'b' did not (902-928 MHz: 1.910 ± 0.372, 2450 MHz: 2.039 ± 0.366), signifying tissue type dependence. Past the inflection point, average steady-state temperature increases were similar between systems but reached more quickly with the 2450 MHz system. Complete damage was reached at 5 mm for both systems. The 2450 MHz system produced significantly larger short axis ablations (902-928 MHz: 2.40 ± 0.54 cm, 2450 MHz: 3.32 ± 0.41cm)., Conclusion: The 2450 MHz system achieved similar steady state temperature increases compared to the 902-928 MHz system, but more quickly due to higher output power. Further investigations using various treatment parameters and precise thermal sensor placement are warranted to refine equation parameters for the development of an ablation model.

The diagnosis of incidental small renal masses (SRM) has increased during the past two decades secondary to the increased use of various abdominal imaging modalities. In the past decade there has been a shift from radical nephrectomy to nephron sparing surgery techniques where partial nephrectomy has become the standard of care. Thermal ablation (TA) modalities such as freezing or heating delivered percutaneously for the treatment of small renal masses (SRM) is now offered in many Institutions as a treatment option. Clinical guidelines have indicated that TA is appropriate for select patients that are medically high risk or elderly. In our institution and in select centers, TA is discussed and often offered for all patients with SRM as equivalent treatment without respect to age or co-morbidities. As provider experience improves and long-term outcome studies become available, TA is becoming increasingly accepted as a potential new standard of care for solid SRM. This review will highlight the role of image guided radiofrequency ablation (RFA) techniques and their application focusing on the different imaging modalities for RFA application which, most commonly, include percutaneous (Magnetic Resonance Imaging (MRI) and computerized tomographic (CT). Our aim is to summarize those studies along with long term follow up., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

In pursuit of improving the quality of residents' education, the Southeastern Section of the American Urological Association (SES AUA) hosts an annual robotic training course for its residents. The workshop involves performing a robotic live porcine nephrectomy as well as virtual reality robotic training modules. The aim of this study was to evaluate workload levels of urology residents when performing a live porcine nephrectomy and the virtual reality robotic surgery training modules employed during this workshop. Twenty-one residents from 14 SES AUA programs participated in 2015. On the first-day residents were taught with didactic lectures by faculty. On the second day, trainees were divided into two groups. Half were asked to perform training modules of the Mimic da Vinci-Trainer (MdVT, Mimic Technologies, Inc., Seattle, WA, USA) for 4 h, while the other half performed nephrectomy procedures on a live porcine model using the da Vinci Si robot (Intuitive Surgical Inc., Sunnyvale, CA, USA). After the first 4 h the groups changed places for another 4-h session. All trainees were asked to complete the NASA-TLX 1-page questionnaire following both the MdVT simulation and live animal model sessions. A significant interface and TLX interaction was observed. The interface by TLX interaction was further analyzed to determine whether the scores of each of the six TLX scales varied across the two interfaces. The means of the TLX scores observed at the two interfaces were similar. The only significant difference was observed for frustration, which was significantly higher at the simulation than the animal model, t (20) = 4.12, p = 0.001. This could be due to trainees' familiarity with live anatomical structures over skill set simulations which remain a real challenge to novice surgeons. Another reason might be that the simulator provides performance metrics for specific performance traits as well as composite scores for entire exercises. Novice trainees experienced substantial mental workload while performing tasks on both the simulator and the live animal model during the robotics course. The NASA-TLX profiles demonstrated that the live animal model and the MdVT were similar in difficulty, as indicated by their comparable workload profiles.

Background and Purpose: Radiofrequency ablation (RFA) is an effective technique for the treatment of patients with small renal tumors, although it is often limited to tumors at least 2 cm from the renal pelvis or ureter. Retrograde pyeloperfusion (PPF) of the pelvis with cold saline during RFA may protect the pelvis and ureter. We designed a mathematical and ex vivo model of RFA to investigate the effects of PPF., Methods: Our theoretical model uses heat transfer principles simplifying the RFA probe to a heat-emitting cylinder within a material. In the ex vivo model, an RFA probe was placed 18 mm from the pelvis in porcine kidneys and with temperature probes on either side of the RFA probe. Control trials with no PPF were compared with either cold saline (2°C), warm saline (38°C), or antifreeze (-20°C) pumped into the renal calix at a rate of 60 mL/min. Ablated volumes were measured and confirmed histologically., Results: The average steady state temperatures at each probe were highest with no PPF, followed by warm saline, cold saline, then antifreeze. Compared with no PPF, temperatures were significantly (P<0.05) colder with warm saline (-8.4°C), cold saline (-18°C), and significantly colder at the calix (warm -14°C, cold -27°C). While RFA output a constant voltage, significantly lower resistances in warm (171Ω) and cold (124Ω) PPF vs no PPF (363Ω) translated to significantly greater power outputs in warm (40 W) and cold (42 W) vs no PPF (14 W). The ablated volumes were significantly higher in warm saline (2.3 cm(3)) vs cold saline (0.84 cm(3)) and no PPF (1.1 cm(3)). Mathematical modeling produced a predictive temperature curve with R2=0.44., Conclusion: PPF lowers temperatures throughout the entire kidney during RFA, most notably near the collecting system and is dependent on the temperature of the liquid used. In addition, PPF may cause less charring of the tissue around the probe resulting in lower resistance and higher power outputs.

Objective: Few studies report long-term follow-up of renal cancer treated by radiofrequency ablation (RFA), thus limiting the comparison of this modality to well-established long-term follow-up series of surgically resected renal masses. Herein, we report long-term oncologic outcomes of renal cancer treated with RFA in a single institution., Methods and Materials: We retrospectively reviewed patients treated between November 2001 and October 2012 with laparoscopic-guided or computed tomography-guided RFA. All treatments were performed with real-time thermometry ensuring target ablation temperature (>60°C) was adequately reached. Only patients with biopsy-confirmed T1a-category cancer and a follow-up period>48 months were included in our analysis. Follow-up included office visits, laboratory work, and periodic contrast-enhanced imaging. Survival was calculated using the Kaplan-Meier analysis. Overall complications were reported using the Clavien-Dindo scale., Results: Of 434 RFA cases, 53 treatments in 50 patients met the inclusion criteria. Of these, 29 were treated with computed tomography-guided RFA and 24 with laparoscopic-guided RFA. The mean follow-up interval was 65.6 months (48.5-120.2), and the mean renal mass size was 2.3 cm (0.3-4.0). There were 4 (7.5%) local recurrences and 1 case of distant metastases with no local recurrence. The 5-year overall survival was 98%, cancer-specific survival was 100%, and recurrence-free survival was 92.5%. The complication rate was 26.4%, which included 71% of Clavien-Dindo grade I and 29% of grade II. Mean estimated glomerular filtration rate preoperatively and at the most recent follow-up visit was 77 and 66 ml/min, respectively., Conclusions: When performed on selected patients, while monitoring real-time temperatures to ensure adequate treatment end points, RFA offers favorable long-term oncologic outcomes approaching those reported for partial nephrectomy., (Copyright © 2014 Elsevier Inc. All rights reserved.)

To discuss the use of renal mass biopsy (RMB) for small renal masses (SRMs), formulate technical aspects, outline potential pitfalls and provide recommendations for the practicing clinician. The meeting was conducted as an informal consensus process and no scoring system was used to measure the levels of agreement on the different topics. A moderated general discussion was used as the basis for consensus and arising issues were resolved at this point. A consensus was established and lack of agreement to topics or specific items was noted at this point. Recommended biopsy technique: at least two cores, sampling different tumour regions with ultrasonography being the preferred method of image guidance. Pathological interpretation: 'non-diagnostic samples' should refer to insufficient material, inconclusive and normal renal parenchyma. For non-diagnostic samples, a repeat biopsy is recommended. Fine-needle aspiration may provide additional information but cannot substitute for core biopsy. Indications for RMB: biopsy is recommended in most cases except in patients with imaging or clinical characteristics indicative of pathology (syndromes, imaging characteristics) and cases whereby conservative management is not contemplated. RMB is recommended for active surveillance but not for watchful-waiting candidates. We report the results of an international consensus meeting on the use of RMB for SRMs, defining the technique, pathological interpretation and indications., (© 2013 The Authors. BJU International © 2013 BJU International.)

Objectives: To examine resident performance on the Mimic dV-Trainer (MdVT; Mimic Technologies, Inc., Seattle, WA) for correlation with resident trainee level (postgraduate year [PGY]), console experience (CE), and simulator exposure in their training program to assess for internal bias with the simulator., Design: Residents from programs of the Southeastern Section of the American Urologic Association participated. Each resident was scored on 4 simulator tasks (peg board, camera targeting, energy dissection [ED], and needle targeting) with 3 different outcomes (final score, economy of motion score, and time to complete exercise) measured for each task. These scores were evaluated for association with PGY, CE, and simulator exposure., Setting: Robotic skills training laboratory., Participants: A total of 27 residents from 14 programs of the Southeastern Section of the American Urologic Association participated., Results: Time to complete the ED exercise was significantly shorter for residents who had logged live robotic console compared with those who had not (p = 0.003). There were no other associations with live robotic console time that approached significance (all p ≥ 0.21). The only measure that was significantly associated with PGY was time to complete ED exercise (p = 0.009). No associations with previous utilization of a robotic simulator in the resident's home training program were statistically significant., Conclusions: The ED exercise on the MdVT is most associated with CE and PGY compared with other exercises. Exposure of trainees to the MdVT in training programs does not appear to alter performance scores compared with trainees who do not have the simulator., (© 2013 Published by Association of Program Directors in Surgery on behalf of Association of Program Directors in Surgery.)

Purpose of Review: Thermal ablation of urologic tumors in the form of freezing (cryoablation) and heating (radiofrequency ablation) have been utilized successfully to treat and ablate soft tissue tumors for over 15 years. Multiple studies have demonstrated efficacy nearing that of extirpative surgery for certain urologic conditions. There are technical limitations to their speed and safety profile because of the physical limits of thermal diffusion., Recent Findings: Recently, there has been a desire to investigate other forms of energy in an effort to circumvent the limitations of cryoblation and radiofrequency ablation. This review will focus on three relatively new energy applications as they pertain to tissue ablation: microwave, irreversible electroporation, and water vapor. High-intensity-focused ultrasound nor interstitial lasers are discussed, as there have been no recently published updates., Summary: Needle and probe-based ablative treatments will continue to play an important role. As three-dimensional imaging workstations move from the advanced radiologic interventional suite to the operating room, surgeons will likely still play a pivotal role in the +-application of these probe ablative devices. It is essential that the surgeon understands the fundamentals of these devices in order to optimize their application.

Objectives: Urothelial carcinomas (UC) from the upper urinary tract represent 7%-10% of all kidney malignancies. With current ureteroscopic (URS) techniques, small tissue samples are usually the only available histopathologic material for evaluation, representing a diagnostic challenge. Precision in diagnosis is essential for treatment decision making. There has been much debate as to whether tumor grade and stage found on biopsy agree with final pathology. The purpose of this study is to evaluate whether URS biopsy volume affects tumor grading and staging agreement between biopsy and nephroureterectomy (NU) specimens., Materials and Methods: We reviewed 137 URS biopsies in 81 patients with suspected upper urinary tract UC performed from April 2002 to April 2011. Of those, 54 patients had both the URS biopsy and NU performed at our institution and were available for review. Biopsy dimensions were recorded to calculate estimated ellipsoid volume, and 2 urological pathologists independently evaluated histologic grade (ISUP/WHO 2004), (based on pleomorphism and mitosis) and depth of invasion. Statistical analysis was performed to evaluate URS biopsy and NU specimen grade and stage concordance. In addition, univariable and multivariable analyses was performed to assess the effect of biopsy volume on agreement., Results: Of the 54 patients studied, low grade and high grade UC biopsy were found in 8 (15%) and 46 (85%), URS biopsies, respectively. Regarding biopsy stage, 51 (94%), 1 (2%), and 2 (4%) were stage Ta, T1, T2, respectively. Grade concordance was 92.6%, (95% CI: 82.4%-98.0%). Stage concordance was 43% (95% CI: 28.7%-55.9%). Multivariable analysis showed biopsy volume did not affect tumor assessment of grade (P = 0.81) or stage (P = 0.44)., Conclusions: Histologic grade assigned on the URS biopsy sample accurately predicts histologic grade in the resected specimen (92.6%), even when the biopsy volume is small. Grading in URS biopsies provides sufficient information for clinical decision making that is independent of sample volume., (Copyright © 2013. Published by Elsevier Inc.)

Objectives: Treatment options for small renal tumors have evolved from radical nephrectomy (RN) to partial nephrectomy (PN), thermal ablation, or active surveillance. With the advancement of techniques, costs differences are unclear. The objective of this study is to compare the 6-month costs associated with nephron-sparing procedures for cT1a renal tumors., Materials and Methods: We performed a review of patients diagnosed with a solitary cT1a renal mass who underwent surgical treatment from June 2008 to May 2011. Open partial nephrectomy (OPN), robot-assisted partial nephrectomy (RLPN), laparoscopic radio-frequency ablation (LRFA), or computed tomography guided radio frequency ablation (CTRFA) was performed on 173 patients. Cost data were collected for surgical costs, associated hospital stay, and the 6-month postoperative period., Results: Patients underwent surgery, including 52 OPN, 48 RLPN, 44 LRFA, and 29 CTRFA. Median total costs associated were $17,018, $20,314, $13,965, and $6,475, for OPN, RLPN, LRFA, and CTRFA, respectively. When stratified by approach differences were noted for total cost (P < 0.001), operating room (OR) time (P < 0.001), surgical supply (P < 0.001), and room and board (P < 0.001) in univariable analysis. Multivariable linear regression (R(2) = 0.966) showed surgical approach (P = 0.007), length of stay (P < 0.001), and OR time (P < 0.001) to be significant predictors of total cost. However, tumor size (P = 0.175), and Charlson comorbidity index (P = 0.078) were not statistically significant., Conclusions: Six-month cost of nephron-sparing surgery is lowest with radio frequency ablation (RFA) by either laparoscopic or computed tomography (CT)-guided approach compared to RLPN and OPN. As oncologic and safety outcomes improve and become comparable in all nephron-sparing surgery (NSS) approaches, cost of each procedure will start to play a stronger role in the clinical and healthcare policy setting., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To identify preoperative factors associated with surgical complications and successful diagnostic renal biopsy in both laparoscopic and percutaneous radiofrequency ablation (RFA) of renal masses in order to help aid in preoperative patient counseling for renal RFA., Methods: We reviewed our Institutional Review Board approved database from November 2001 to January 2011, containing 335 tumors treated with either laparoscopic (LRFA) or percutaneous RFA (CTRFA). Preoperative patient demographics, tumor characteristics, and intraoperative surgical data were collected along with biopsy results and clinicopathologic outcomes., Results: RFA was performed on 335 renal tumors (124 LRFA, 211 CTRFA). Non-diagnostic biopsy occurred in 18 (5.5%) tumors. Of the 317 procedures performed, 121 complications occurred in 103 (30.7%) procedures. Multivariate analysis only showed CTRFA (vs LRFA) to increase the likelihood of non-diagnostic biopsy (OR 5.1, 95% CI 1.2-22, p = 0.032). Increased tumor size (p = 0.007) and synchronous ablations (p = 0.019) increased the risk for major complications, while decreased surgeon experience (p = 0.003) and tumors close to the collecting system (p = 0.005) increased the risk of any complication., Conclusions: Preoperative recommendations can be made to patients in the future. We suggest counseling patients that when undergoing RFA, percutaneous approach increases the risk of non-diagnostic biopsy, increased tumor size increases the risk of major complications, having more than 1 tumor ablated increases the risk of a major complication, and tumors close to the collecting system may increase the risk of complications.

Objectives: To assess the Southeast Section of the American Urological Association (SESAUA) trainee exposure to and thoughts on robotic simulation., Design: Questionnaire-based study of SESAUA residency trainees to determine their access to robotic simulation, live robotic experience to date, and opinion regarding the adequacy of current robotic training., Setting: Three trainees from each SESAUA training program were invited to Orlando, Florida for a formal 2-day robotic training course. Day 1 was a 3-component didactic session. Day 2 involved faculty directing the trainees in set tasks on a live porcine model for 4 hours and another 4 hours on the Mimic dV-Trainer (Mimic Technologies, Inc, Seattle, WA) for directed exercises., Participants: Thirty-two trainees from 14 programs in the SESAUA participated in the course and filled out a 1-page, 8-item questionnaire following their simulator exposure., Results: Seventeen (53.1%) trainees, including 5 urology year-3 trainees, reported never having had robotic console time. Of the trainees, 65.6% (21 of 32) had access to the Mimic dV-Trainer or Mimic "backpack" whereas 10 had no exposure to robotic simulation; 84.4% (27 of 32) felt that the simulator replicated real-life robotic console surgery and 90.6% (29 of 32) felt the simulator was helpful or would be helpful for training in their program. Trainees felt the "tubes 2" drill, which mimics a vesicourethral anastomosis, was the most difficult drill to perform., Conclusions: A majority of trainees in the SESAUA have had limited to no robotic console time. A high number of resident trainees in the SESAUA have exposure to virtual reality robotic simulation. Trainees believe that the simulator replicates real-life robotic console movements and almost all believe they would be benefit from having access to robotic simulation., (Copyright © 2013 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Improvements in imaging technology have resulted in an increase in detection of small renal masses (SRMs). Minimally invasive ablation modalities, including cryoablation, radiofrequencey ablation, microwave ablation and irreversible electroporation, are currently being used to treat SRMs in select groups of patients. Cryoablation and radiofrequency ablation have been extensively studied. Presently, cryoablation is gaining popularity because the resulting ice ball can be visualized easily using ultrasonography. Tumour size and location are strong predictors of outcome of radiofrequency ablation. One of the main benefits of microwave ablation is that microwaves can propagate through all types of tissue, including desiccated and charred tissue, as well as water vapour, which might be formed during the ablation. Irreversible electroporation has been shown in animal studies to affect only the cell membrane of undesirable target tissues and to spare adjacent structures; however, clinical studies that depict the efficacy and safety of this treatment modality in humans are still sparse. As more experience is gained in the future, ablation modalities might be utilized in all patients with tumours <4 cm in diameter, rather than just as an alternative treatment for high-risk surgical patients.

Background and Purpose: With the increased incidence of low-stage renal cancers, thermal ablation technology has emerged as a viable treatment option for extirpation in selected persons and is supported by the current American Urological Association guidelines. We present a 9-year, single institution experience with radiofrequency ablation (RFA) using real-time peripheral temperature monitoring of small renal masses focusing on oncologic outcomes., Patients and Methods: We reviewed our prospectively collected database of patients with renal masses who were treated between November 2001 and January 2011 with laparoscopic (LRFA) or CT-guided percutaneous RFA (CTRFA) with simultaneous real-time peripheral fiberoptic thermometry. Patients were followed radiographically at 1 month, 6 months, 1 year, and then annually. Clinicopathologic outcomes were collected and analyzed., Results: A total of 274 patients (211 male) aged 18 to 88 years (mean 67 years) with 292 renal tumors underwent LRFA (112) or CTRFA (180). Mean tumor size was 2.5 cm (0.7-5.3 cm). An intraoperative preablation biopsy showed 197 (67.4%) renal-cell carcinomas (RCC), and 77 (26.4%) benign tumors. Mean follow-up was 26 months (1-98 mos). The single ablation treatment radiographic success rate was 96% for all tumors and 94% for RCC. Metastatic RCC developed in one patient, who died. The Kaplan-Meier (KM) 3-year and 5-year cancer-specific survival was 100% and 98.6%, respectively. The KM 3-year and 5-year overall survival was 90.4% and 74.2%, respectively., Conclusion: RFA is a clinically effective and safe nephron-sparing treatment of patients with small renal masses. Our large cohort and intermediate-term experience adds to the building evidence for the efficacy of RFA for small renal cancers.

Unlabelled: Abstract Background and Purpose: Multiple renal volumetric assessment studies have correlated parenchymal volume with the glomerular filtration rate. The objective of this study was to compare renal volumes before and after treatment of renal masses with either partial nephrectomy or radiofrequency ablation (RFA)., Patients and Methods: We reviewed our prospectively collected database of patients with renal masses who were treated between November 2001 and January 2011 with robot-assisted laparoscopic partial nephrectomy (RALPN), laparoscopic RFA (LRFA), or CT-guided percutaneous RFA (CTRFA). Digital Imaging and Communications in Medicine CT imaging data were analyzed in an open-source viewer. Volumetric calculations were used to measure the normal, enhancing bilateral renal parenchyma and tumor volumes. Normal parenchymal volume loss was compared among treatments., Results: There were 96 patients (68 men) with an average age of 68.0 (36-84) years who met our inclusion criteria. The average tumor diameter, tumor volume, and nephrometry score (NS) was 3.5 cm, 32.0 cm(3), and 7.1 in RALPN (n=26), 2.6 cm, 9.8 cm(3), and 7.1 in CTRFA (n=47), and 2.9 cm, 14.3 cm(3), and 7.2 in LRFA (n=23) groups. The percent change in the operated kidney volume was similar in RALPN (-12%±15), CTRFA (-13%±16), and LRFA (-17%±18) groups. NS was the only variable in a multivariate linear regression model that correlated with the amount of volume lost in the ipsilateral kidney., Conclusions: Our retrospective volumetric analysis of renal parenchyma before and after partial nephrectomy or RFA of renal masses revealed that all treatments produce similar volume of collateral damage.

Purpose: The purpose of this guideline is to provide a clinical framework for the diagnosis, evaluation and follow-up of asymptomatic microhematuria., Materials and Methods: A systematic literature review using the MEDLINE® database was conducted to identify peer reviewed publications relevant to the definition, diagnosis, evaluation and follow-up for AMH. The review yielded 191 evidence-based articles, and these publications were used to create the majority of the guideline statements. There was insufficient evidence-based data for certain concepts; therefore, clinical principles and consensus expert opinions were used for portions of the guideline statements., Results: Guideline statements are provided for diagnosis, evaluation and follow-up. The panel identified multiphasic computed tomography as the preferred imaging technique and developed guideline statements for persistent or recurrent AMH as well as follow-up., Conclusions: AMH is only diagnosed by microscopy; a dipstick reading suggestive of hematuria should not lead to imaging or further investigation without confirmation of three or greater red blood cells per high power field. The evaluation and follow-up algorithm and guidelines provide a systematic approach to the patient with AMH. All patients 35 years or older should undergo cystoscopy, and upper urinary tract imaging is indicated in all adults with AMH in the absence of known benign causation. The imaging modalities and physical evaluation techniques are evolving, and these guidelines will need to be updated as the effectiveness of these become available. Please visit the AUA website at http://www.auanet.org/content/media/asymptomatic&#95;microhematuria&#95;guideline.pdf to view this guideline in its entirety., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Gender, smoking history, patient age, and tumor size have been found to impact the likelihood of benign histology at the time of nephron-sparing surgery (NSS). Providing external validation of these variables and evaluating the relationship between body mass index (BMI) and tumor location on the likelihood of benign histology during NSS for T1 tumors were the objectives of this study., Methods: Data were analyzed for consecutive patients undergoing NSS for T1 disease. Central tumors either were completely encircled by renal parenchyma, descended below the cortico-medullary junction, or were in direct opposition to the collecting system, renal sinus, or the hilar structures. Categorical variables were evaluated with chi-square test, and continuous variables were analyzed with independent sample t test. Logistic regression identified independent predictors of final pathology., Results: NSS was performed in 316 patients, of whom 79 (24 %) had benign tumors. Patients with benign tumors were more likely to be female, to have a lower BMI, and to have peripheral tumors. On multivariate analysis, female gender (hazard ratio, 3.97; 95 % CI, 2.92-4.53, p < 0.001), peripheral tumor location (hazard ratio, 2.27; 95 % CI, 1.73-3.21, p = 0.014), and lower BMI (hazard ratio, 1.5; 95 % CI, 1.12-1.94, p = 0.015) were independently associated with benign histopathology at the time of surgical resection., Conclusions: Prospectively identifying which T1 tumors are benign would have tremendous implications for the patient. Ours is the first study that has identified the impact of tumor location and BMI on the risk of benign histology. Additional studies are needed to corroborate these findings and incorporate these data into future nomograms.

Background: The aim of this report is to describe our surgical technique for robot-assisted laparoscopic bladder diverticulectomy. In this technique, methylene blue is instilled into the bladder to aid in intra-abdominal identification of the diverticular neck., Subjects and Methods: We retrospectively reviewed the records of patients who underwent robot-assisted bladder diverticulectomy by a single surgeon., Results: Between September 2008 and January 2011, 5 patients successfully underwent robot-assisted laparoscopic bladder diverticulectomy using 1% intravesical methylene blue. All cases were completed without intraoperative complication or need for open conversion. Mean operative time was 216 minutes, with a mean estimated blood loss of 45 mL. Patients were discharged 1-2 days following surgery. No patient experienced a perioperative complication., Conclusions: The robot-assisted approach for bladder diverticulectomy is a viable alternative to both open and laparoscopic surgery. The use of intravesical methylene blue greatly aids in identification of the diverticular neck during this procedure.

Nephropexy remains standard for symptomatic nephroptosis, and several minimally-invasive techniques have been described. Triangulation sutures placed between the abdominal wall and the renal capsule are often difficult to tie tightly due to the confined working space. We propose a technique modification to fixate the kidney utilizing the da Vinci Surgical System robot and Lapra-Ty absorbable suture clips. Four female patients with symptomatic nephroptosis diagnosed via kidney hypermobility demonstrated on intravenous urography (IVU) underwent robotic-assisted laparoscopic nephropexy (RALNP) from February 2008 to April 2010. After complete mobilization and stripping of perirenal fat, several 0 Vicryl sutures were placed in a "figure of eight" fashion and tied loosely. Subsequently we utilized a Lapra-Ty to tighten the stitch serially and fixate the kidney. The mean age was 46 years (43-52); one patient underwent simultaneous pyeloplasty and one underwent partial nephrectomy in the ipsilateral kidney. There were no intraoperative complications and two postoperative complications, both Clavien grade I. All patients were asymptomatic postoperatively at a mean follow-up of 9.2 months (1-28), and had no evidence of kidney hypermobility on upright IVU or diuretic renal scintigraphy (RS) scan at 6 weeks postoperatively. RALNP is a viable option in the treatment of symptomatic nephroptosis. Secure placement of several "pexing" sutures helps to ensure appropriate security of these itinerant kidneys. Our technique modification corrects kidney hypermobility while improving symptoms related to nephroptosis.

This manuscript reviews the history of laparoscopic nephrectomy and addresses the future trends of this minimally invasive operation.

Purpose: With the increased incidence of low stage renal cancers, thermal ablation technology has emerged as a viable treatment option. Current AUA (American Urological Association) guidelines include thermal ablation as a treatment modality for select individuals. We compared the laparoscopic and percutaneous approach for the radio frequency ablation of renal tumors under the guidance of urological surgeons., Materials and Methods: We reviewed our radio frequency ablation database of patients with renal masses undergoing laparoscopic or computerized tomography guided percutaneous radio frequency ablation with simultaneous peripheral fiberoptic thermometry from November 2001 to January 2011 at a single tertiary care center. Data were collected on patient demographics, and surgical and clinicopathological outcomes stratified by approach., Results: A total of 298 patients with 316 renal tumors underwent laparoscopic (122 tumors) or computerized tomography guided (194 tumors) radio frequency ablation. There were no statistically significant differences between the laparoscopic and computerized tomography guided radio frequency ablation groups with respect to patient demographics, complication rates and renal functional outcomes (p>0.05). The 3-year Kaplan-Meier estimation of radiographic recurrence-free probability was 95% for computerized tomography guided radio frequency ablation and 94% for laparoscopic radio frequency ablation (p=0.84). Subanalysis of the 212 (67%) renal cell carcinoma tumors showed a 3-year Kaplan-Meier estimation of oncologic recurrence-free probability (post-ablation biopsy proven viable tumor) of 94% for computerized tomography guided radio frequency ablation and 100% for laparoscopic radio frequency ablation (p=0.16). Median followup was 21 months for laparoscopic radio frequency ablation) and 19 months for computerized tomography guided radio frequency ablation., Conclusions: Laparoscopic and computerized tomography guided radio frequency ablation appear safe and effective with statistically equivalent rates of complications and recurrence., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: To show that radiofrequency ablation (RFA) is safe and effective treatment for renal angiomyolipoma (AML). Current treatments to reduce the risk of haemorrhage include tumour extirpation, angio-embolization, or ablative therapy., Patients and Methods: Review of our prospective database revealed 15 patients with intraoperative biopsy confirmed renal AML undergoing RFA from February 2002 to March 2010. Patients underwent either laparoscopic or computed tomography (CT)-guided percutaneous RFA using either the Cool-tip™ (Covidien, Inc. Boulder, CO, USA) or RITA™ (Angiodynamics(®), Latham, NY, USA) RFA probe. CT at 1 month, 6 months, 1 year, and annually thereafter., Results: In all, two male and 13 female patients with seven left-sided and eight right-sided tumours with a mean (range) size of 2.6 (1.0-3.7) cm underwent laparoscopic (five) or CT-guided (10) RFA. No intraoperative complications occurred. Minor complications included transient haematuria and intercostals nerve transection. Surgical complications included pneumonia and myocardial infarction. There was no radiographic evidence of persistent AML (CT enhancement) at a mean follow-up of 21 months., Conclusions: The haemostatic effect of RFA allows renal lesions suspicious for AML to be treated without bleeding complications. Avoids surgical risk of extirpation or embolization. RFA for renal AML is safe and effective., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Purpose: We compared laparoscopic and robotic pyeloplasty to identify factors associated with procedural efficacy., Materials and Methods: We conducted a retrospective multicenter trial incorporating 865 cases from 15 centers. We collected perioperative data including anatomical and procedural factors. Failure was defined subjectively as pain that was unchanged or worse per medical records after surgery. Radiographic failure was defined as unchanged or worsening drainage on renal scans or worsening hydronephrosis on computerized tomography. Bivariate analyses were performed on all outcomes and multivariate analysis was used to assess factors associated with decreased freedom from secondary procedures., Results: Of the cases 759 (274 laparoscopic pyeloplasties with a mean followup of 15 months and 465 robotic pyeloplasties with a mean followup of 11 months, p <0.001) had sufficient data. Laparoscopic pyeloplasty, previous endopyelotomy and intraoperative crossing vessels were associated with decreased freedom from secondary procedures on bivariate analysis, with a 2-year freedom from secondary procedures of 87% for laparoscopic pyeloplasty vs 95% for robotic pyeloplasty, 81% vs 93% for patients with vs without previous endopyelotomy and 88% vs 95% for patients with vs without intraoperative crossing vessels, respectively. However, on multivariate analysis only previous endopyelotomy (HR 4.35) and intraoperative crossing vessels (HR 2.73) significantly impacted freedom from secondary procedures., Conclusions: Laparoscopic and robotic pyeloplasty are highly effective in treating ureteropelvic junction obstruction. There was no difference in their abilities to render the patient free from secondary procedures on multivariate analysis. Previous endopyelotomy and intraoperative crossing vessels reduced freedom from secondary procedures., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: Thermal ablation is a well established treatment option for the management small renal masses. Increasingly, renal ablation is performed via a percutaneous approach. However, most urologists are not formally trained in image-based deployment of ablation needles. To address this need, we created a novel training model to teach urologists to perform precise and accurate percutaneous needle placement. This teaching model was implemented as part of a recent training course on tissue ablation organized by the American Urological Association., Methods: Two fresh frozen human cadavers (Anatomic Gifts Registry, Hanover, Maryland) were used in the model. Plumber's Putty (Oatey, Cleveland, Ohio) and nonpitted olives soaked in Isovue (Bracco Dianostics, Inc, New York, New York) were used to create ablation targets. Course participants underwent a tutorial on the computed tomography (CT)-guided deployment of a 19-gauge Yueh Needle (Cook Medical, Bloomington, Indiana) or Cool-tip radio-frequency ablation (RFA) probe (Covidien, Inc, Boulder, Colorado). After each needle placement, a CT scan was performed to assess successful deployment. Participants were then queried regarding their experience., Results: A total of 18 urologists performed needle or radio-frequency ablation probe placement on 2 cadavers. A mean of 3.39 (range 2-5) attempts was required to hit targets. Subjectively, participants noted an increase in confidence performing percutaneous needle deployment. The cadaver laboratory exposed participants to pretreatment planning, tactile feel of needle placement, needle readjustment, and 3-D spatial relationships of a percutaneous approach., Conclusions: The presented cadaveric model is an effective tool for teaching percutaneous needle placement. All urologists evaluated noted increased confidence in this technique after training on the model., (Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Nephron-sparing surgery is currently the standard of care for the management of small renal masses. While both neoadjuvant and adjuvant conventional external beam radiotherapy have failed to demonstrate an oncologic benefit for the treatment of renal cell carcinoma, more recent work aims to explore the utility of stereotactic radiotherapy. We present the case of a 70-year-old woman who failed primary treatment of a small renal mass with the CyberKnife radiotherapy system and describe her successful salvage treatment with robot-assisted partial nephrectomy. This case demonstrates the safety of robotic surgery for the management of renal tumors following failed stereotactic radiotherapy.

Radiofrequency ablation (RFA) is a minimally invasive, energy-based, needle-ablative treatment modality that is currently being used to treat small renal masses (SRMs) and offers advantages over extirpative techniques. RFA treats SRM with heat induced by the tissue impedance to radiofrequency current emitted from a needle probe within the SRM. Currently available RFA systems use either an impedance- or temperature-based treatment algorithm to reach treatment end point while minimizing risk of carbonization. Physical limitations, such as electrical property heterogeneity and convective heat loss due to blood flow, and technical considerations should be addressed when performing RFA. Nonetheless, investigations with intermediate follow-up have demonstrated single-treatment radiographic recurrence-free rates of >90%. Future trends include the use of noninvasive imaging thermometry, electromagnetic targeting and adjuvant techniques.

Partial nephrectomy is the current gold-standard treatment of small renal masses. The articulated instruments of the surgical robot have made the laparoscopic approach more feasible. We present our experience with 50 robot-assisted laparoscopic partial nephrectomy (RALPN) surgeries and attempt to validate a recently reported nephrometry score. From July 2008 to July 2010, 50 (53 planned) elective RALPNs were performed utilizing the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). All patients had an enhancing renal mass on CT scan pre-operatively. Clinicopathologic, surgical, and renal functional (Cockcroft-Gault formula) outcomes were recorded prospectively and analyzed. Mean tumor size, length of surgery (LS), warm ischemia time (WIT), and nephrometry scores were 3.6 cm (1-8), 303 min (133-610), 29.1 min (11-42), and 6.8 (4-11) respectively. Renal cell carcinoma was found in 39 (78%) patients. When evaluating the nephrometry score, comparison of low, medium, and high complexity tumors for length of surgery, WIT, and estimated blood loss (EBL) showed no difference (p > 0.05). Nearness to the collecting system (N score 1 vs. N score 3) showed increased EBL (195 ml vs. 510 mL, p = 0.005), and location relative to polar lines (L score 1 and L score 2) increased mean LS (265 vs. 359 min, p = 0.02). RALPN is safe and effective. Nephrometry scores are a method of standardizing tumor complexity and can be utilized in comparing tumor cohorts but may not be predictive of intra-operative outcomes.

Flat-panel detector CT (FD-CT) provides cross-sectional CT-images while offering an improved workspace using fluoroscopic guidance for thermal probe placement such as for radiofrequency ablation (RFA) needles and thermal sensors. The purpose of this article is to test the feasibility of FD-CT in the application of renal tumor ablation in a "hybrid operating room" environment. Eleven patients with renal masses diagnosed preprocedurally with contrast-enhanced CT scan underwent core biopsy and simultaneous CT-RFA under general anesthesia with FD-CT guidance in the cardiac catheterization laboratory. Scans were taken preablation for tumor targeting, intermittently for probe placement and guidance of temperature sensors, and postablation. Perioperative and postoperative outcomes, pathologic results, and radiographic follow-up were recorded for each patient. Target temperatures >60°C to guide treatment end point were reached for each tumor periphery. Biopsy pathology showed 6/11 (55%) to be renal-cell carcinoma, and 2/11 (18%) to be benign; 3/11 (27%) had an indeterminate biopsy result. Three Clavien grade I complications occurred. One patient showed evidence of recurrent disease on postoperative CT scan. In our experience, we have found FD-CT-guided ablation of small renal tumors to be feasible using this advanced targeting system.

Purpose: The goal of this report is to describe our initial clinical experience performing a simple nephrectomy with the SPIDER (Single Port Instrument Delivery Extended Reach) laparoendoscopic single-site (LESS) surgical system., Patient and Methods: One patient with a nonfunctioning kidney secondary to a ureteropelvic junction obstruction underwent a simple nephrectomy through a single incision performed using the SPIDER surgical system. We assessed the technical feasibility, efficiency, and perioperative outcomes., Results: The SPIDER-LESS nephrectomy was performed successfully without additional skin incisions for laparoscopic ports, instrument clashing, or open conversion. Total operative time was 210 minutes with blood loss of 50  mL. The patient experienced no intraoperative or postoperative complications. Pathologic evaluation confirmed atrophic renal parenchyma., Conclusions: The SPIDER surgical system LESS nephrectomy is feasible and safe. Future refinements of the technology and prospective studies are needed to further optimize its application in urology.

Unlabelled: Abstract Background and Purpose: The Single Port Instrument Delivery Extended Reach (SPIDER) surgical system was developed for true continuous instrument triangulation during laparoendoscopic single site (LESS) surgery. We present our initial preclinical experience with the SPIDER surgical system during renal surgery., Material and Methods: Bilateral laparoscopic nephrectomies were performed in a live adult porcine animal model using the SPIDER device. A standard surgical approach was used via direct video guidance., Results: The procedure was successfully performed without surgical error or complication. The SPIDER system proved easy to use with only a minimal learning curve. Intracorporeal surgical knots were tied without difficulty using this single site system., Conclusions: Our initial experience with the SPIDER surgical system during renal surgery is promising. SPIDER allows for true single port instrument triangulation offering a superior operative experience to currently available LESS surgical systems.

Multiple modalities exist for the management of small renal tumors, including active surveillance, extirpation (radical nephrectomy and partial nephrectomy), and ablative therapies. Radiofrequency ablation (RFA) is an alternative to extirpative surgery for renal tumors. This article presents the current literature on RFA for renal tumors. We reviewed 28 RFA series in the English literature from 2003 to 2010 to assess patient selection, biopsy, renal outcomes, and oncologic outcomes.

Objectives: To assess efficacy and morbidity of microwave ablation (MWA) for small renal tumors in an initial cohort of patients. MWA is a recently introduced thermal needle ablation treatment modality with theoretical advantages compared with radiofrequency ablation, such as greater intratumoral temperatures, lack of a grounding pad, and superior convection profile. However, experience has been limited in the human kidney., Methods: Ten patients with a single, solid-enhancing renal tumor from June 2008 to November 2008 received laparoscopic or computed tomography-guided percutaneous MWA at a tertiary referral center with ≥14 months of follow-up. MWA was performed using the Valleylab Evident, 915-MHz MWA system at 45 W with intraoperative biopsy before ablation, and peripheral fiberoptic thermometry to determine the treatment endpoints. The patients were followed up with contrast-enhanced computed tomography at 1 month, 6 months to 1 year, and annually to monitor for tumor recurrence., Results: The follow-up duration for the 6 male and 4 female patients (mean tumor size 3.65 cm, range 2.0-5.5; mean age 69.8 years) was 17.9 months. The recurrence rate, defined by persistent enhancement, was 38% (3 of 8). The intraoperative and postoperative complication rate was 20% and 40%, respectively., Conclusions: MWA resulted in poor oncologic outcomes with a significant complication rate at an intermediate level of follow-up. However, MWA has promising theoretical advantages and should not be discarded. Additional studies should be considered to better understand the microwave-tissue interaction and treatment endpoints for different size renal masses before widespread use., (Copyright © 2011. Published by Elsevier Inc.)

Objectives: To describe our initial experience with the laparoscopic technique of sliding-clip renorrhaphy applied to open surgery for small renal masses., Methods: Knotless renorrhaphy with the sliding-clip technique is performed by securing suture with Hem-o-lok clips slid under tension against the renal capsule and locked in place with Lapra-Ty clips. This approach was initially described by laparoscopic surgeons to aid with hemostasis, prevent urine leaks, and shorten warm ischemia time. We evaluated the utility of this technique during open partial nephrectomy., Results: From February 2009 to June 2010, 9 patients, with mean age of 54 years, underwent open partial nephrectomy using the sliding-clip technique. Mean ischemia time was <20 minutes, with a mean blood loss of approximately 280 mL. No intraoperative complications were reported. One clinically significant complication of a urinoma was found in the perioperative period. No bleeding complications developed., Conclusions: The results of our study have shown that the sliding-clip technique is safe and effective in the open surgical management of small renal masses. We recommend this approach over traditional knot tying for renal reconstruction., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives: To compare conventional laparoscopic pyeloplasty (C-LPP) and robotic-assisted laparoscopic pyeloplasty (RA-LPP), which are both used for correction of ureteropelvic junction obstruction. Robotic assistance may further expedite dissection and reconstruction; however it is unclear whether this has an impact on results., Methods: Between 1999 and 2009, 172 conventional or robotic-assisted transperitoneal laparoscopic pyeloplasties were performed by 2 surgeons. Data were obtained from our prospective database, patient charts, and radiographic reports. Statistical analysis was performed for the groups., Results: A total of 98 patients underwent R-LPP, and 74 underwent C-LPP. Mean age, body mass index, and gender distribution were similar for the groups. Of the patients, 22 (12.8%) had secondary ureteropelvic junction obstruction. Operative time in minutes was 189.3 ± 62 for RA-LPP, and 186.6 ± 69 for C-LPP (P = .69) respectively. Intraoperative and postoperative complication rates for RA-LPP and C-LPP were 1%, 5.1% and 0, 2.7% (P = .83 and .85) respectively. There was no significant difference in mean suturing time: 48.3 ± 30 and 60 ± 46 (P = .30) for RA-LPP and C-LPP, respectively. Long-term follow up (minimum 6 months; available for 136 patients) showed 93.4% and 95% radiographic success rate based upon diuretic scintirenography for RA-LPP and C-LPP respectively., Conclusions: Operative time, perioperative outcome and success rates are similar for C-LPP and RA-LPP. Mean suturing time for RA-LPP was shorter; however, there was no significant time difference in total operative time. Complications for both procedures are infrequent. Success rates, as measured by diuretic scintirenography, are high for the 2 procedures., (Copyright © 2011 Elsevier Inc. All rights reserved.)

The advancement of imaging modalities in the past two decades has led to the increased incidence of small renal masses. This same technology is making nephron-sparing treatment of small renal masses much more feasible and precise. The goal of this manuscript is to review the currently available imaging modalities utilized in focal treatment and follow-up of small renal masses.

Objectives: Radiofrequency ablation (RFA) is increasingly finding a place in the treatment of small renal masses (SRM). RFA may be able to provide better renal preservation, while achieving appropriate cancer control. This investigation takes a critical look at pertinent aspects of RFA principles and reviews oncological and renal function outcomes., Methods: A review of the most current English literature using a PubMed search was done. Oncological and renal function outcomes were reviewed from selected articles published between 2003 and 2009. Oncological outcome was determined by "single treatment" success rate at first follow-up and "After single treatment" success rate after first follow-up. Renal function outcome was determined by either change in creatinine, creatinine clearance, or GFR after RFA., Results: The mean tumor size was 2.5 cm for 16/17 studies. Average mean and median follow-up was 23.3 months in 13/17 studies and 19.8 months for 4/17 studies. "Single Treatment" success rates of 90-100% (average = 97.2%) were noted in 13 studies. Average increase in serum creatinine was +0.14 mg/dL in four studies. Serum creatinine and creatinine clearance change in one solitary kidney study was +11 mmol/L and -8 mL/min., respectively., Conclusions: RFA is fast emerging as a safe and efficacious treatment for small renal masses. Compared to extirpative treatment options, RFA seems to provide the lowest rate of renal impairment, while providing acceptable rates of tumor ablation. As long-term results emerge, this may become one of the treatment modalities for renal tumors in patients with solitary kidneys and renal impairment.

The techniques for management of small renal masses (SRMs) have evolved over the past several years. Radical nephrectomy can lead to an increased risk of chronic kidney disease, and the emphasis is now shifting to nephron-conserving techniques. Partial nephrectomy is now considered a standard of care for the management of SRMs, and laparoscopic techniques are becoming popular because they are minimally invasive. The kidneys are extremely vascular organs, and renal hemorrhage is a major cause of morbidity after laparoscopic partial nephrectomies. Control of bleeding and management of calyceal injuries can be difficult and make the procedure technically challenging. This review looks at the various modalities that are available to reduce bleeding and reviews some advances in the area of hemostatic maneuvers during laparoscopic partial nephrectomies.

Focal renal therapy for small renal masses (T(1a) or T(1b)) has been used as primary treatment for patients with comorbidities who are considered poor candidates for surgical resection. With a continuing effort toward optimization of minimally invasive nephron-sparing modalities, the effort to expand the patient pool will continue. As long-term results of renal ablative therapies become available and the safety, precision, and efficacy become well established, renal ablation may be used with increasing frequency for a wider group of patients. When this happens, high-quality imaging for localization and targeting of these renal lesions will become the central core of the treatment, with emphasis on superior results, accurate positioning of the probe, precise localization of the tumor, and real-time intraoperative monitoring of outcomes.

Owing to an increased use of diagnostic imaging for evaluating patients with other abdominal conditions, incidentally discovered kidney masses now account for a majority of renal tumors. Renal ablative therapy is assuming a more important role in patients with borderline renal impairment. Renal ablation uses heat or cold to bring about cell death. Radiofrequency ablation and cryoablation are two such procedures, and 5-year results are now emerging from both modalities. Renal biopsy at the time of ablation is extremely important in order to establish tissue diagnosis. Real-time temperature monitoring at the time of radiofrequency ablation is very useful to ensure adequacy of ablation.