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Abstract: Background: Low morbidity has been advocated for cryoablation of small renal masses. Objectives: To assess negative perioperative outcomes of laparoscopic renal cryoablation (LRC) with ultrathin cryoprobes and patient, tumour, and operative risk factors for their development. Design, setting, and participants: Prospective collection of data on LRC in five centres. Intervention: LRC. Measurements: Preoperative morbidity was assessed clinically and the American Society of Anaesthesiologists (ASA) score was assigned prospectively. Charlson Comorbidity Index (CCI) and Charlson-Age Comorbidity Index (CACI) scores were retrospectively assigned. Negative outcomes were prospectively recorded and defined as any undesired event during the perioperative period, including complications, with the latter classed according to the Clavien system. Patient, tumour, and operative variables were tested in univariate analysis as risk factors for occurrence of negative outcomes. Significant variables (p <0.05) were entered in a step-forward multivariate logistic regression model to identify independent risk factors for one or more perioperative negative outcomes. The confidence interval was settled at 95%. Results and limitations: There were 148 procedures in 144 patients. Median age and tumour size were 70.5 yr (range: 32–87) and 2.6cm (range: 1.0–5.6), respectively. A laparoscopic approach was used in 145 cases (98%). Median ASA, CCI, and CACI scores were 2 (range: 1–3), 2 (range: 0–7), and 4 (range: 0–11), respectively. Comorbidities were present in 79% of patients. Thirty negative outcomes and 28 complications occurred in 25 (17%) and 23 (15.5%) cases, respectively. Only 20% of all complications were Clavien grade ≥3. Multivariate analysis showed that tumour size in centimetres, the presence of cardiac conditions, and female gender were independent predictors of negative perioperative outcomes occurrence. Receiver operator characteristic curve confirmed the tumour size cut-off of 3.4cm as an adequate predictor of negative outcomes. Conclusions: Perioperative negative outcomes and complications occur in 17 % and 15.5%, respectively, of cases treated by LRC with multiple ultrathin needles. Most of the complications are Clavien grade 1 or 2. The presence of cardiac conditions, female gender, and tumour size are independent prognostic factors for the occurrence of a perioperative negative outcome. [Copyright &y& Elsevier]

Objective To determine whether the use of 3-dimensional (3D) imaging translates into a better surgical performance of naïve urologic laparoscopic surgeons during pyeloplasty (PY) and partial nephrectomy (PN) procedures. Materials and Methods Eighteen surgeons without any previous laparoscopic experience were randomly assigned to perform PY and PN in a porcine model using initially 2-dimensional (2D) and 3D laparoscopy. A surgical performance score was rated by an “expert” tutor through a modified 5-item global rating scale contemplating operative field view, bimanual dexterity, efficiency, tissue handling, and autonomy. Overall surgical time, complications, subjective perception of participating surgeons, and inconveniences related to the 3D vision were recorded. Results No difference in terms if operative time was found between 2D or 3D laparoscopy for both the PY ( P = .51) and the PN ( P = .28) procedures. A better rate in terms of surgical performance score was noted by the tutors when the study participants were using 3D vs 2D, for both PY (3.6 [0.8] vs 3.0 [0.4]; P = .034) and PN (3.6 [0.51] vs 3.15 [0.63]; P = .001). No complications occurred in any of the procedures. Most (77.2%) of the participating naïve laparoscopic surgeons had the perception that 3D laparoscopy was overall easier than 2D. Headache (18.1%), nausea (18.1%), and visual disturbance (18.1%) were the most common issues reported by the surgeons during 3D procedures. Conclusion Despite the absence of translation in a shorter operative time, the use of 3D technology seems to facilitate the surgical performance of naïve surgeons during laparoscopic kidney procedures on a porcine model. [ABSTRACT FROM AUTHOR]

Abstract: Context: Thermal ablation of small renal tumours is an established treatment modality in selected cases. Many groups have published their experiences. However, a major drawback of most of the previously published reviews and meta-analyses is their retrospective nature, the heterogeneity of included studies, and the limitations of a short-term oncologic follow-up. For those reasons, firm conclusions are still lacking. Objective: To assess the best combination of ablation technique and approach in those renal tumours deemed suitable for ablation. Evidence acquisition: A PubMed search was performed (up to December 2010) of the world literature on thermal ablation of renal tumours. To assess oncologic outcomes, we selected reports with a minimum follow-up of 36 mo and with appropriately documented pathologic results specifying the number of biopsy-proven renal cell carcinomas (RCCs). To assess perioperative complications we selected series with substantial caseloads of at least 70 cases and comparative series among techniques. Evidence synthesis: All long-term series of thermal ablation for small renal masses show a recurrence-free survival (RFS) of 84–94% with a cancer-specific survival (CSS) of 89–100%. Some cases with previous (partial) nephrectomy for RCC are included in the series with lowest RFS and CSS. No distinct differences exist between radiofrequency ablation (RFA) and cryoablation (CA). Initial failure and overall complication rates are higher for the percutaneous approach compared with laparoscopy. The major complication rate is slightly lower, ultimate survival is comparable, and length of stay and patient convalescence are favourable for the percutaneous approach, regardless of the modality. Conclusions: Low-quality evidence shows that CA or RFA modalities have a low major-complication rate, preserve renal function, and provide acceptable, oncologic, long-term outcomes. The percutaneous approach has a high rate of initial failure, but seems to be less costly. [Copyright &y& Elsevier]

Abstract: Context: The increasing incidence of localised renal cell carcinoma (RCC) over the last 3 decades and controversy over mortality rates have prompted reassessment of current treatment. Objective: To critically review the recent data on the management of localised RCC to arrive at a general consensus. Evidence acquisition: A Medline search was performed from January 1, 2004, to May 3, 2011, using renal cell carcinoma, nephrectomy (Medical Subject Heading [MeSH] major topic), surgical procedures, minimally invasive (MeSH major topic), nephron-sparing surgery, cryoablation, radiofrequency ablation, surveillance, and watchful waiting. Evidence synthesis: Initial active surveillance (AS) should be a first treatment option for small renal masses (SRMs) <4cm in unfit patients or those with limited life expectancy. SRMs that show fast growth or reach 4cm in diameter while on AS should be considered for treatment. Partial nephrectomy (PN) is the established treatment for T1a tumours (<4cm) and an emerging standard treatment for T1b tumours (4–7cm) provided that the operation is technically feasible and the tumour can be completely removed. Radical nephrectomy (RN) should be limited to those cases where the tumour is not amenable to nephron-sparing surgery (NSS). Laparoscopic radical nephrectomy (LRN) has benefits over open RN in terms of morbidity and should be the standard of care for T1 and T2 tumours, provided that it is performed in an advanced laparoscopic centre and NSS is not applicable. Open PN, not LRN, should be performed if minimally invasive expertise is not available. At this time, there is insufficient long-term data available to adequately compare ablative techniques with surgical options. Therefore ablative therapies should be reserved for carefully selected high surgical risk patients with SRMs <4cm. Conclusions: The choice of treatment for the patient with localised RCC needs to be individualised. Preservation of renal function without compromising the oncologic outcome should be the most important goal in the decision-making process. [Copyright &y& Elsevier]