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Renal oncocytoma (RO) accounts for 5% of renal cancers and generally behaves as a benign tumor with favorable long-term prognosis. It is difficult to confidently distinguish between benign RO and other renal malignancies, particularly chromophobe renal cell carcinoma (chRCC). Therefore, RO is often managed aggressively with surgery. We sought to identify molecular biomarkers to distinguish RO from chRCC and other malignant renal cancer mimics. In a 44-patient discovery cohort, we identified a significant differential abundance of nine genes in RO relative to chRCC. These genes were used to train a classifier to distinguish RO from chRCC in an independent 57-patient cohort. The trained classifier was then validated in five independent cohorts comprising 89 total patients. This nine-gene classifier trained on the basis of differential gene expression showed 93% sensitivity and 98% specificity for distinguishing RO from chRCC across the pooled validation cohorts, with a c-statistic of 0.978. This tool may be a useful adjunct to other diagnostic modalities to decrease the diagnostic and management uncertainty associated with small renal masses and to enable clinicians to recommend more confidently less aggressive management for some tumors. PATIENT SUMMARY: Renal oncocytoma is generally a benign form of kidney cancer that does not necessarily require surgical removal. However, it is difficult to distinguish renal oncocytoma from other more aggressive forms of kidney cancer, so it is treated most commonly with surgery. We built a classification tool based on the RNA levels of nine genes that may help avoid these surgeries by reliably distinguishing renal oncocytoma from other forms of kidney cancer., (Copyright © 2020. Published by Elsevier B.V.)

Objective: To determine the negative predictive value of multiparametric magnetic resonance imaging (mpMRI), we evaluated the frequency of prostate cancer detection by 12-core template mapping biopsy in men whose mpMRI showed no suspicious regions., Methods: Six hundred seventy patients underwent mpMRI followed by transrectal ultrasound (TRUS)-guided systematic prostate biopsy from December 2012 to June 2016. Of this cohort, 100 patients had a negative mpMRI. mpMRI imaging sequences included T2-weighted and diffusion-weighted imaging, and dynamic contrast enhancement sequences., Results: The mean age, prostate-specific antigen, and prostate volume of the 100 men included were 64.3 years, 7.2 ng/mL, and 71 mL, respectively. Overall cancer detection was 27% (27 of 100). Prostate cancer was detected in 26.3% (10 of 38) of patients who were biopsy-naïve, 12.1% (4 of 33) of patients who had a prior negative biopsy, and in 44.8% (13 of 29) of patients previously on active surveillance; Gleason grade ≥7 was detected in 3% of patients overall (3 of 100). The negative predictive value of a negative mpMRI was 73% for all prostate cancer and 97% for Gleason ≥7 prostate cancer., Conclusion: There is an approximately 3% chance of detecting clinically significant prostate cancer with systematic TRUS-guided biopsy in patients with no suspicious findings on mpMRI. This information should help guide recommendations to patients about undergoing systematic TRUS-guided biopsy when mpMRI is negative., (Published by Elsevier Inc.)

Objective: To describe and illustrate the evolution of surgical technique, emphasizing technical modifications of laparoscopic donor nephrectomy (LDN) and the impact on complication outcome., Methods: This is a retrospective observational study of prospectively collected data on all consecutive purely LDN surgeries performed at a tertiary academic medical center (n = 1325), performed between March 2000 and October 2013., Results: Over time, LDN was performed on older patients, changing from a mean of 35.7 years in 2000 to 41.2 years in 2013 (P <.001). Additionally, mean blood loss decreased from 75 mL in 2000 to 21.6 mL in 2013 (P <.001). However, body mass index, operative time, and length of stay remained similar. Overall, there were 105 (7.9%) complications: Clavien grade 1 (n = 81, 6.1%) and grade 2 or higher (n = 23, 1.8%). Procedure duration, blood loss, surgeon, year of procedure, laterality, body mass index, age, and gender did not significantly predict complications. There was no significant difference for Clavien complication rates between the early learning period (first 150 cases) and the rest of the series., Conclusion: With continual refinement with LDN techniques based on intraoperative observations and technological advances, complication rates remain consistently low, despite increasing donor age., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Pure laparoscopic donor nephrectomy (LDN) is a unique intervention because it carries known risks and complications, yet carries no direct benefit to the donor. Therefore, it is critical to continually examine and improve quality of care., Objective: To identify factors affecting LDN outcomes and complications., Design, Setting, and Participants: A retrospective analysis of prospectively collected data for 1204 consecutive LDNs performed from March 2000 through August 2012., Intervention: LDN performed at an academic training center., Outcome Measurements and Statistical Analysis: Using multivariable regression, we assessed the effect of age, sex, body mass index (BMI), laterality, and vascular variation on operative time, estimated blood loss (EBL), complications, and length of stay., Results and Limitations: The following variables were associated with longer operative time (data given as parameter estimate plus or minus the standard error): female sex (9.09 ± 2.43; p<0.001), higher BMI (1.03 ± 0.32; p=0.001), two (7.87 ± 2.70; p=0.004) and three or more (22.45 ± 7.13; p=0.002) versus one renal artery, and early renal arterial branching (5.67 ± 2.82; p=0.045), while early renal arterial branching (7.81 ± 3.85; p=0.043) was associated with higher EBL. Overall, 8.2% of LDNs experienced complications, and by modified Clavien classification, 74 (5.9%) were grade 1, 13 (1.1%) were grade 2a, 10 (0.8%) were grade 2b, and 2 (0.2%) were grade 2c. There were no grade 3 or 4 complications. Three or more renal arteries (odds ratio [OR]: 2.74; 95% CI, 1.05-7.16; p=0.04) and late renal vein confluence (OR: 2.42; 95% CI, 1.50-3.91; p=0.0003) were associated with more complications. Finally, we did not find an association of the independent variables with length of stay. A limitation is that warm ischemia time was not assessed., Conclusions: In our series, renal vascular variation prolonged operative time and was associated with more complications. While complicated donor anatomy is not a contraindication of LDN, surgical decision-making should take into consideration these results., (Copyright © 2013. Published by Elsevier B.V.)

Background: External shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PNL) have been the standard of care for the treatment of intrarenal calculi., Objective: We sought to determine the safety and efficacy of flexible ureteroscopy and holmium laser lithotripsy for the treatment of multiple intrarenal calculi and further stratify the efficacy by stone burden less than and greater than 20mm., Design, Setting, and Participants: Patients with multiple unilateral renal calculi treated between 2000 and 2006 at a single tertiary academic center were retrospectively evaluated., Intervention: All patients underwent retrograde flexible ureteroscopy and holmium laser lithotripsy., Measurements: Stone-free status was determined by ureteroscopy 15 d after the last procedure and was defined as the absence of stones in the kidney or residual fragments <1mm. A renal ultrasound was performed 30 d after the last treatment to confirm the absence of stones and hydronephrosis., Results and Limitations: Fifty-one patients were identified for a total of 161 intrarenal calculi with a mean stone size per patient of 6.6+/-3mm (range: 2-15). The mean number of stones per patient was 3.1+/-1 (range: 2-6). The mean number of primary procedures was 1.4+/-0.6 (range: 1-3). The overall stone-free rates after one and two procedures were 64.7% and 92.2%, respectively. The stone-free rates for patients with a stone burden greater than and less than 20mm were 85.1% and 100%, respectively. The overall complication rate was 13.6%; 97.6% of cases were performed as outpatient procedures. There are some limitations to this study, however: This is a retrospective review from a single institution, and our results are based on a relatively small sample size., Conclusions: For select patients with multiple intrarenal calculi, flexible ureteroscopy with holmium laser lithotripsy may represent an alternative therapy to ESWL or PNL, with acceptable efficacy and low morbidity.

Objectives: Laparoscopic partial nephrectomy (LPN) is a technically challenging procedure for the management of renal tumours. Major complications of LPN include bleeding and urine leakage. Haemostatic agents (HAs) and/or glues may reduce haemorrhage and urine leakage. We sought to examine the current practice patterns for urologists performing LPN with regard to HA use and its relationship with bleeding and urine leakage., Materials and Methods: A survey was sent via e-mail to urologists currently performing LPN in centres in the United States and Europe. We queried the indications for HA/glue usage, type of HAs/glues used, and whether concomitant suturing/bolstering was performed. In addition, the total number of LPNs performed, laparoscopic tools used to resect the tumour, tumour size, and tumour position were queried., Results: Surveys suitable for analysis were received from 18 centres (n=1347 cases). HAs and/or glues were used in 1042 (77.4%) cases. Mean tumour size was 2.8cm, with 79% of the tumours being defined as exophytic and 21% deep. The HAs and glues used included gelatin matrix thrombin (FloSeal), fibrin gel (Tisseel), bovine serum albumin (BioGlue), cyanoacrylate glue (Glubran), oxidized regenerated cellulose (Surgicel), or combinations of these. Sixteen centres performed concomitant suturing/bolstering. The overall postoperative bleeding requiring transfusion and urine leakage rates were 2.7% and 1.9%, respectively., Conclusions: The use of HAs and/or glues is routine in most centres performing LPN. The overall haemorrhage and urine leakage rates are low following LPN. More studies are needed to assess the potential role of HAs and/or glues in LPN., (European Association of Urology.)

Objectives: Because of the shortage of cadaveric kidneys for allograft transplantation, laparoscopic donor nephrectomy is becoming a more feasible option. Several large published series have reported hospital stays as long as 3.3 days. We report the positive effect of preoperative bowel rest and the use of ketorolac for postoperative analgesia on reducing the hospital stay after laparoscopic donor nephrectomy., Methods: From 2000 to 2005, 300 patients underwent laparoscopic donor nephrectomy at our institution by a single surgeon (P.G.S.). All patients underwent a bowel preparation regimen involving a clear liquid diet beginning 2 days before surgery. Furthermore, two bottles of magnesium citrate were taken orally the day before surgery, and all patients fasted after midnight before surgery. Patients self-administered one Fleets enema the evening before surgery. Postoperatively, the patients received ketorolac 30 mg intravenously every 6 hours for a maximum of 48 hours, with additional narcotics if necessary for analgesia., Results: The mean operative time was 180 +/- 55 minutes. Typically, patients were admitted the day of surgery and discharged the next postoperative day. The mean donor hospital stay was 1.1 days (range 1 to 3) with no readmissions. More than 97% of our patients were able to tolerate a clear liquid diet, pass flatus, and ambulate the day after surgery., Conclusions: With implementation of a strict bowel preparation regimen and the use of ketorolac for postoperative analgesia, the donor length of stay was markedly improved from previously published results. We attribute the shorter hospital stay to the quicker return of bowel function and to less postoperative discomfort.

Objectives: Because of the shortage of cadaveric kidneys, laparoscopic living donor nephrectomy (LLDN) has become a more common option for transplant recipients. The complication rate has been reported at 6.4% to 16.5%. We present the initial University of California, Los Angeles experience with the complications and their management during LLDN., Methods: From January 2000 to December 2005, a single surgeon performed 300 consecutive LLDNs at our institution. A committee of urologists, nephrologists, and support staff approved each donor before surgery. After LLDN was completed, the patients received 30 mg of ketorolac intravenously every 6 hours until discharge. We reviewed the intraoperative and postoperative complications and their management at our institution., Results: Three patients required open conversion, for an overall conversion rate of 1%. Two of the three conversions were a result of a major vascular complication (0.6%). The first major vascular complication resulted from an endovascular stapler malfunction during transection of an accessory left renal artery. The second vascular complication was a Veress needle injury to the left common iliac artery. Three postoperative major complications (1%) occurred, including 1 case of rhabdomyolysis and 2 cases of chylous ascites. Also, 7 minor postoperative complications (2.3%) occurred. Our overall complication rate was 4%. No patients died, and the mean hospital stay was 1.1 days., Conclusions: Our results have shown that LLDN is a safe procedure associated with low morbidity and a quick recovery. Appropriate patient selection is essential to ensure the safety of this procedure.

Objectives: To report our results after antegrade endoscopic treatment of ureteral stenosis with balloon dilation with or without holmium laser endoureterotomy. Ureteral stenosis is the most common long-term urologic complication of renal transplantation., Methods: From July 2000 to October 2002, 9 renal transplant patients with ureteral obstruction diagnosed by an increase in serum creatinine and radiologic evidence presented for endoscopic treatment. All patients were treated with nephrostomy tube drainage followed by antegrade flexible nephroureteroscopy and balloon dilation of the stricture. Three patients required holmium laser endoureterotomy during the same procedure because of fluoroscopic and endoscopic evidence of persistent stricture. All patients were treated with ureteral stents and nephrostomy tubes postoperatively. The median follow-up was 24 months (range 6 to 32)., Results: The site of stenosis was at the ureterovesical anastomosis in all patients, and the mean stricture length was 0.28 cm. Two patients had previously undergone ureteroneocystostomy for prior ureteral stenosis. Six patients (66%) required only balloon dilation, and 3 patients (33%) also required holmium laser endoureterotomy. The median ureteral stent and nephrostomy tube duration was 40 and 62 days, respectively. The mean serum creatinine level was 2.3 mg/dL at presentation and 1.7 mg/dL at the last follow-up visit. After a median follow-up of 24 months, the ureteral patency and graft function rates were both 100%. No perioperative complications occurred., Conclusions: Balloon dilation with or without holmium laser endoureterotomy was successful and safe in this group of renal transplant patients with short ureterovesical anastomotic strictures.

Renal angiomyolipomas in patients with tuberous sclerosis can be associated with significant morbidity, mostly related to complications from bleeding. We describe a patient with tuberous sclerosis and massive bilateral renal angiomyolipomas (total tumor burden 5500 g) who presented with acute right renal hemorrhage. She was treated with right renal artery embolization followed immediately by right nephrectomy and left partial nephrectomy. The patient had a creatinine nadir of 1.3 mg/dL postoperatively. We demonstrate that nephron-sparing surgery is feasible, even in the setting of very large angiomyolipomas, such as the one presented here, currently the largest such tumor by weight reported.

Laparoscopic access can be obtained quickly and without complication by placing a radially dilating trocar sleeve into the peritoneum through a 3-mm umbilical incision and dilating to 5 or 10 mm. This provides a tight seal without purse-string sutures. This is our preferred method of open laparoscopic access.

Objectives: Exploratory laparotomy offers the greatest diagnostic accuracy of intra-abdominal pathologic processes, but can be associated with significant morbidity. Laparoscopy provides diagnostic capabilities equivalent to that of open exploration, but with potentially less morbidity. We present 3 cases in which laparoscopy was used to diagnose and manage urologic patients with an acute abdomen in a postoperative period., Methods: Three patients underwent laparoscopy between 1 and 14 days postoperatively for an acute abdomen (fever, elevated white blood cell count, and peritoneal signs). The initial procedures included a pubovaginal sling repair with fascia lata, endoscopic placement of a percutaneous gastrostomy tube, and a laparoscopic ureterolithotomy for a distal stone., Results: In each of the 3 patients laparoscopy revealed misplacement or malfunction of a previously placed tube. In all cases, the patient was managed laparoscopically without the need for laparotomy., Conclusions: These cases demonstrate the feasibility of laparoscopy to provide diagnostic and therapeutic solutions to postoperative urologic patients presenting with an acute abdomen.

Objectives: To determine the feasibility and efficacy of a laparoscopic approach to the radical retropubic prostatectomy (RRP)., Methods: A transperitoneal laparoscopic technique was developed to perform an RRP. Intra-abdominal access was obtained through five 10-mm trocars. After dissection of the prostate, the urethrovesical anastomosis was created via a transvesical approach. The prostate was removed by extending the umbilical incision., Results: Between September 1991 and May 1995, nine laparoscopic RRPs were performed. The operative time averaged 9.4 hours. Only 1 of 9 patients had a positive surgical margin that involved the urethra. Six of 9 patients were completely continent postoperatively. Of the 4 patients who were potent preoperatively, 2 continued to have erections. There were three complications: cholecystitis, thrombophlebitis associated with a pulmonary embolism, and a small bowel hernia into a trocar site., Conclusions: Laparoscopic radical prostatectomy is feasible but currently offers no advantage over open surgery with regard to tumor removal, continence, potency, length of stay, convalescence, and cosmetic result.

Damage to the bladder during inguinal hernia repair is possible especially if the bladder or a bladder diverticulum is involved in the hernia sac. Unrecognized injury to the bladder can lead to late complications. We report a case of pseudotumor in a bladder diverticulum due to long-term retention of a misplaced suture. The literature on bladder injury after inguinal herniorrhaphy and on pseudotumor formation is briefly reviewed. It is important to be aware of a history of inguinal surgery and to obtain definitive histologic evidence of malignancy prior to making the diagnosis of bladder carcinoma. This will avoid unnecessary radical surgery, chemotherapy, or radiation therapy.

Objectives: New instrumentation and techniques have enabled laparoscopic surgeons to perform complicated reconstructive procedures. Few centers have attempted these procedures because of the excessive time involved with laparoscopic suturing. The Endo stitch suture device was developed to facilitate suture placement. We clinically compared conventional intracorporeal suturing and Endo Stitch suturing for laparoscopic suture placement and knot tying., Methods: Intracorporeal suturing was used to complete laparoscopic dismembered pyeloplasties and bladder neck suspensions. Sutures were placed with either needle holders and graspers or the automatic suture device. A total of 85 maneuvers were assessed. Operative videotapes were reviewed to assess accuracy of suture placement, knot tying, and time to place suture and tie knots. All suturing was performed by an experienced laparoscopist., Results: Accuracy of stitch placement and knot tying were equivalent. The average time for stitch placement with the Endo Stitch was 43 +/- 27 seconds (n = 41). This was significantly less than the average stitch placement time for conventional suturing, which was 151 +/- 24 seconds (n = 14). The Endo Stitch knot tying was completed in an average of 74 +/- 50 seconds (n = 17), whereas knot tying with the conventional technique took 197 +/- 70 seconds (n = 13). The needle is automatically loaded in the Endo Stitch after each suture and is immediately ready., Conclusions: The Endo Stitch device reduced the amount of time needed for placement of stitches and knot tying. Reconstructive laparoscopic procedures requiring multiple suture placement may be completed in a shorter time period using this instrument.