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Purpose: Accurately predicting new baseline glomerular filtration rate (NBGFR) after radical nephrectomy (RN) can improve counseling about RN vs partial nephrectomy. Split renal function (SRF)-based models are optimal, and differential parenchymal volume analysis (PVA) is more accurate than nuclear renal scans (NRS) for this purpose. However, there are minimal data regarding the limitations of PVA. Our objective was to identify patient-/tumor-related factors associated with PVA inaccuracy., Materials and Methods: Five hundred and ninety-eight RN patients (2006-2021) with preoperative CT/MRI were retrospectively analyzed, with 235 also having NRS. Our SRF-based model to predict NBGFR was: 1.25 × (Global GFRPre-RN × SRF Contralateral ), where GFR indicates glomerular filtration rate, with SRF determined by PVA or NRS, and with 1.25 representing the median renal functional compensation in adults. Accuracy of predicted NBGFR within 15% of observed was evaluated in various patient/tumor cohorts using multivariable logistic regression analysis., Results: PVA and NRS accuracy were 73%/52% overall, and 71%/52% in patients with both studies (n = 235, P < .001), respectively. PVA inaccuracy independently associated with pyelonephritis, hydronephrosis, renal vein thrombosis, and infiltrative features (all P < .03). Ipsilateral hydronephrosis and renal vein thrombosis associated with PVA underprediction, while contralateral hydronephrosis and increased age associated with PVA overprediction (all P < .01). NRS inaccuracy was more common and did not associate with any of these conditions. Even among cohorts where PVA inaccuracy was observed (22% of our patients), there was no significant difference in the accuracies of NRS- and PVA-based predictions., Conclusions: PVA was more accurate for predicting NBGFR after RN than NRS. Inaccuracy of PVA correlated with factors that distort the parenchymal volume/function relationship or alter renal functional compensation. NRS inaccuracy was more common and unpredictable, likely reflecting the inherent inaccuracy of NRS. Awareness of cohorts where PVA is less accurate can help guide clinical decision-making.

Purpose: While lymph node dissection (LND) at radical cystectomy (RC) for muscle-invasive bladder cancer has been studied extensively, the role of LND for nonmuscle-invasive bladder cancer (NMIBC) remains incompletely defined. Herein, we aim to assess the association between extent of LND during RC for NMIBC and local pelvic recurrence-free survival (LPRS), cancer-specific survival (CSS) and overall survival (OS)., Materials and Methods: A multi-institutional retrospective review was performed of patients with NMIBC undergoing RC at 3 large tertiary referral centers. To identify a threshold for lymph node yield (LNY) to optimize LPRS, CSS and OS, separate Cox regression models were developed for each possible LNY threshold. Model performance including Q-statistics and hazard ratios (HRs) were used to identify optimal LNY thresholds., Results: A total of 1,647 patients underwent RC for NMIBC, with a median LNY of 15 (quartiles 9,23). Model performance curves suggested LNY of 10 and 20 to optimize LPRS and CSS/OS, respectively. On multivariable regression, LNY >10 was associated with lower risk of LPR compared to LNY ≤10 (HR 0.63, 95% CI 0.42-0.93, p=0.02). Similarly, LNY >20 was associated with improved CSS (HR 0.67, 95% CI 0.52-0.87, p=0.002) and OS (HR 0.75, 95% CI 0.64-0.88, p <0.001) compared to LNY ≤20. Similar results were observed in the cT1 and cTis subgroups., Conclusions: Greater extent of LND during RC for NMIBC is associated with improved LPRS, CSS and OS, supporting the inclusion of LND during RC for NMIBC, particularly among patients with cTis or cT1 disease. Future prospective studies are warranted to assess the ideal anatomical template of LND in NMIBC.

Purpose: The incidence and risk factors for metachronous upper tract urothelial carcinoma (UTUC) following radical cystectomy (RC) remain incompletely defined, which has limited the ability to individualize postoperative surveillance., Materials and Methods: A retrospective review of 2 institutional registries was performed to identify patients undergoing RC for urothelial carcinoma. Multivariable Cox proportional hazard models for metachronous post-RC UTUC were developed in one institutional data set and validated in the second institutional data set. A post-RC UTUC risk score was then developed from these models., Results: A total of 3,170 RC patients were included from the training cohort and 959 RC patients from the validation cohort. At a median followup after RC of 4.6 years (IQR 2.1-8.7), 167 patients were diagnosed with UTUC. On multivariable analysis in the training cohort, risk factors for metachronous UTUC were the presence of positive urothelial margin (HR 2.60, p <0.01), history of bacillus Calmette-Guérin treatment prior to RC (HR 2.20, p <0.01), carcinoma in situ at RC (HR 2.01, p <0.01) and pre-RC hydronephrosis (HR 1.48, p=0.04). These factors had similar discriminative capacity in the training and validation cohorts (C-statistic 0.71 and 0.73, respectively). A UTUC risk score was developed with these variables which stratified patients into low (0 points), intermediate (1-3 points), and high risk (4+ points) for post-RC UTUC, with respective 5-year UTUC-free survivals of 99%, 96%, 89% in the training cohort and 98%, 96%, and 91% in the validation cohort., Conclusions: We developed and validated a risk score for post-RC UTUC that may optimize UTUC surveillance protocols after RC.

Purpose: Bladder cancer management options include open radical cystectomy and robot-assisted radical cystectomy with intracorporeal or extracorporeal urinary diversion. The existing literature shows no difference in the major complication rate between open radical cystectomy and extracorporeal urinary diversion. However, the emerging popularity of intracorporeal urinary diversion has exposed the need to compare a completely intracorporeal method to alternative approaches. To our knowledge the robotic intracorporeal advantage regarding major complications has not yet been established in an evaluation of all 3 modalities. We compared outcomes and complications of open, intracorporeal and extracorporeal cystectomy techniques at a high volume institution., Materials and Methods: We queried a prospectively maintained database for patients who underwent radical cystectomy from 2011 to 2018 for an oncologic indication. Perioperative and pathological outcomes, and 30 and 90-day major complications were assessed. Statistical analyses were done using the Pearson chi-square, Kruskal-Wallis and Kaplan-Meier tests, and multivariable regression., Results: A total of 948 patients met the study criteria, including 272, 301 and 375 treated with open radical cystectomy, intracorporeal urinary diversion and extracorporeal urinary diversion, respectively. Median followup was 26 months. Intracorporeal urinary diversion cases had lower estimated blood loss (p <0.001), shorter hospitalization (p <0.001) and a lower ileus rate (p=0.023) than extracorporeal urinary diversion and open radical cystectomy cases. Importantly, intracorporeal urinary diversion was associated with lower 30 and 90-day major complication rates vs extracorporeal urinary diversion and open radical cystectomy (90-day Clavien-Dindo III-V 16.9% vs 24.8% and 26.1%, respectively, p=0.015). There was no significant difference in the readmission rate according to the surgical approach. Multivariable predictors of increased 90-day major complications were patient age, the Charlson Comorbidity Index and operative time. On multivariable analysis intracorporeal urinary diversion was associated with reduced 90-day major complications (OR 0.58, p=0.037)., Conclusions: In a 3-way comparison intracorporeal urinary diversion demonstrated a lower major complication rate and perioperative benefits compared to extracorporeal urinary diversion and open radical cystectomy.

Purpose: Measuring quality is a high priority for health care systems globally. Despite the high perioperative morbidity, mortality, expenditures and performance variation of radical cystectomy there is a paucity of validated bladder cancer quality metrics. We aimed to create a hospital quality scoring system for radical cystectomy which is disease specific and associated with patient centered outcomes., Materials and Methods: We used the National Cancer Database to identify hospitals where radical cystectomy was performed from 2004 to 2014. Mixed effects models were constructed to assess variation in hospital performance across 7 quality indicators. Indirect standardization was used to case mix adjust hospital performance. We assessed associations between quality indicators as well as the novel BC-QS (Bladder Cancer Quality Score) composite hospital quality metric with 30-day, 90-day and overall mortality using logistic and Cox regression, respectively., Results: At 1,200 facilities radical cystectomy was performed in a total of 48,341 patients from 2004 to 2014. Mixed effects models demonstrated significant between hospital variation across all quality indicators after case mix adjustment. The composite BC-QS metric was composed of the hospital positive margin rate, the lymph node dissection rate and the neoadjuvant chemotherapy rate. Better BC-QS performance was associated with lower 30-day and 90-day mortality (adjusted OR 0.78, 95% CI 0.64-0.96, and OR 0.84, 95% CI 0.72-0.97, respectively) and overall mortality (HR 0.86, 95% CI 0.81-0.92). Hospitals with a higher BC-QS had higher volume and more were affiliated with an academic institution than hospitals with a lower BC-QS (p <0.0001)., Conclusions: The BC-QS captures variations in the hospital performance of radical cystectomy and it shows an association of higher quality with lower patient mortality. Our validation of this quality metric provides support for its potential use by policy makers and payers in efforts to measure hospital quality for high cost surgeries.

Purpose: Currently no data exist to guide renal surgeons on the perioperative use of renin-angiotensin blockers despite potential cardiorenal benefits. We aimed to assess the impact of resuming renin-angiotensin blockers on postoperative renal function and adverse cardiac events following partial nephrectomy., Materials and Methods: This is an observational analysis of patients who underwent robot-assisted laparoscopic partial nephrectomy from 2006 to 2014 at a single institution. The Wilcoxon rank sum and chi-square tests, and logistic regression were used to assess the risk of adverse renal and cardiac events stratified by history and pattern of renin-angiotensin blockade perioperatively., Results: We identified 900 patients with a median followup of 16.3 months (IQR 1.4-39.1). There were no significant differences in severe renal dysfunction at last followup on univariate analysis or adverse cardiac events at 30 days on multivariate analysis in patients stratified by a history of renin-angiotensin blockade. Of the 338 patients 137 (41.9%) resumed renin-angiotensin blockade immediately after surgery, which did not result in any significant difference in the postoperative glomerular filtration rate (p >0.05). Resuming renin-angiotensin blockade at discharge home was associated with a decreased risk of heart failure within 30 days of surgery (0.3% vs 11.8% of cases) and stage IV/V chronic kidney disease at last followup (2.6% vs 25.5%, each p <0.001)., Conclusions: Renin-angiotensin blockers appear safe to continue immediately after renal surgery. Discharge home with angiotensin converting enzyme inhibitors/angiotensin receptor blockers was associated with a decreased risk of heart failure and severe renal dysfunction. However, this risk may be overstated as a result of the small number of patients discharged without resuming the home medication., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: After CMS introduced the concept of the Hospital Readmissions Reduction Program, hospitals and health care centers became financially penalized for exceeding specific readmission rates., Materials and Methods: We retrospectively reviewed our institutional review board approved database of patients undergoing robotic partial nephrectomy at our institution and included in our analysis patients who were readmitted to any hospital as an inpatient stay within 30 days from discharge home after robotic partial nephrectomy., Results: From March 2006 to March 2013 a total of 627 patients underwent robotic partial nephrectomy at our center and 28 (4.46%) were readmitted within 30 days of surgery. Postoperative bleeding was responsible for 8 (28.5%) readmissions. Pulmonary embolism was reported in 3 cases and retroperitoneal abscess was diagnosed in 2. Urinary leak requiring surgical intervention developed in 2 patients, pneumonia was diagnosed in 2 and 2 patients were readmitted for chest pain. Overall 9 (32.1%) patients presented with major complications requiring intervention. On multivariable analysis Charlson comorbidity index score was the only factor significantly associated with a higher 30-day readmission rate (p = 0.03). If the Charlson score was 5 or greater the chance of hospital readmission would be 2.7 times higher., Conclusions: Increased comorbidity, specifically a Charlson score of 5 or greater, was the only significant predictor of a higher incidence of 30-day readmission. This information can be useful in counseling patients regarding robotic partial nephrectomy and in determining baseline rates if CMS expands the number of conditions they evaluate for excess 30-day readmissions., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We evaluated the change in renal function after renal cryoablation and partial nephrectomy based on tumor complexity according to the R.E.N.A.L. nephrometry score., Materials and Methods: We retrospectively reviewed the data of patients who had a renal tumor in a solitary kidney, and underwent renal cryoablation and partial nephrectomy between December 2000 and January 2012. Renal tumor complexity was categorized into 3 groups by R.E.N.A.L. nephrometry score as low (4 to 6), intermediate (7 to 9) and high (10 to 12). All baseline demographic data, perioperative parameters and followup data including renal function were collected. Comparisons were made among similar tumor complexities., Results: In the renal cryoablation and partial nephrectomy groups 29 patients (43 tumors) and 33 patients were identified, respectively. In all renal tumor complexities, renal cryoablation provided a better perioperative outcome in terms of median operative time, estimated blood loss, transfusion, hospital stay and complications. The median change in serum creatinine and estimated glomerular filtration rate was slightly greater in the partial nephrectomy group. However, the differences were not statistically significant for any of the tumor complexities. Three patients (10%) in the renal cryoablation group and 2 (6%) in the partial nephrectomy group required long-term dialysis., Conclusions: In patients with solitary kidneys, renal cryoablation is associated with superior perioperative outcomes compared to partial nephrectomy. Specifically, partial nephrectomy is not associated with greater loss of renal function than renal cryoablation regardless of the extent of tumor complexity., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We analyzed the incidence of and risk factors for complications and conversions in a large contemporary series of patients treated with urological laparoendoscopic single site surgery., Materials and Methods: The study cohort consisted of consecutive patients treated with laparoendoscopic single site surgery between August 2007 and December 2010 at a total of 21 institutions. A logistic regression model was used to analyze the risks of conversion, and of any grade and only high grade postoperative complications., Results: Included in analysis were 1,163 cases. Intraoperatively complications occurred in 3.3% of cases. The overall conversion rate was 19.6% with 14.6%, 4% and 1.1% of procedures converted to reduced port laparoscopy, conventional laparoscopic/robotic surgery and open surgery, respectively. On multivariable analysis the factors significantly associated with the risk of conversion were oncological surgical indication (p=0.02), pelvic surgery (p<0.001), robotic approach (p<0.001), high difficulty score (p=0.004), extended operative time (p=0.03) and an intraoperative complication (p=0.001). A total of 120 postoperative complications occurred in 109 patients (9.4%) with major complications in only 2.4% of the entire cohort. Reconstructive procedure (p=0.03), high difficulty score (p=0.002) and extended operative time (p=0.02) predicted high grade complications., Conclusions: Urological laparoendoscopic single site surgery can be done with a low complication rate, resembling that in laparoscopic series. The conversion rate suggests that early adopters of the technique have adhered to the principles of careful patient selection and safety. Besides facilitating future comparisons across institutions, this analysis can be useful to counsel patients on the current risks of urological laparoendoscopic single site surgery., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Despite numerous retrospective series of laparoendoscopic single site surgery, cohorts have generally been small and followup largely short-term. Therefore, we report intermediate term outcomes for patients undergoing reconstructive laparoendoscopic single site procedures at a single institution., Materials and Methods: Upon review of our prospectively maintained laparoendoscopic single site urological database of 185 cases, 32 reconstructive procedures were identified including pyeloplasty (25), ileal interposition (3), ureteroneocystostomy (3) and retrocaval ureter repair (1). Perioperative data were reviewed, and clinical and radiographic success was noted., Results: Median followup was 24.4 months for pyeloplasty, 35 months for ileal interposition, 29.4 months for ureteroneocystostomy and 20 months for retrocaval ureter repair. At last followup 24 of 25 patients treated with pyeloplasty, 2 of 3 with ileal ureter, 3 of 3 with ureteroneocystostomy and 1 of 1 with retrocaval ureter reported being asymptomatic or improved after the procedure. Delayed incisional hernia repair was required in 1 patient. One death occurred during the followup period, remote from the date of surgery. No other complications were noted., Conclusions: Intermediate term results after laparoendoscopic single site reconstructive procedures remain promising. Further followup of this patient population is required to ensure the durability of results. Prospective evaluation is also needed to assess if advantages exist for laparoendoscopic single site reconstructive procedures compared to standard minimally invasive approaches., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We evaluated the incidence of perioperative complications after robotic partial nephrectomy., Materials and Methods: We retrospectively reviewed the records of patients treated with robotic assisted partial nephrectomy across the 4 participating institutions. Demographic, blood loss, warm ischemia time, and intraoperative and postoperative complication data were collected. All complications were graded according to the Clavien classification system., Results: A total of 450 consecutive robotic assisted partial nephrectomies were done between June 2006 and May 2009. Overall 71 patients (15.8%) had a complication, including intraoperative and postoperative complications in 8 (1.8%) and 65 (14.4%), respectively. Hemorrhage developed in 2 patients (0.2%) intraoperatively and in 22 (4.9%) postoperatively. Seven patients (1.6%) had urine leakage. As classified by the Clavien system, complications were grade I-II in 76.1% of cases and grade III-IV in 23.9%. Robotic assisted partial nephrectomy was converted to open or conventional laparoscopic surgery in 3 patients (0.7%) and to radical nephrectomy in 7 (1.6%). There were no deaths., Conclusions: Current data indicate that robotic assisted partial nephrectomy is safe. Most postoperative complications are Clavien grade I or II, or can be managed conservatively., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We evaluated the oncological and functional outcomes of computerized tomography guided percutaneous cryotherapy or radio frequency ablation of kidney tumors in patients with a solitary kidney., Materials and Methods: We reviewed the medical charts of patients with a solitary kidney who underwent percutaneous probe ablation for renal masses at our institution from April 2002 through March 2010. Followup consisted of computerized tomography or magnetic resonance imaging 1 day postoperatively, at 3, 6 and 12 months, and annually thereafter. Serum creatinine and estimated glomerular filtration rate were used to measure renal function. The cryotherapy and radio frequency ablation groups were compared for demographics, the 2-year actuarial survival rate and renal function., Results: Overall 65 patients were included in this retrospective analysis, of whom 29 (44.6%) underwent cryotherapy and 36 (55.4%) underwent radio frequency ablation. Median followup was 15.1 (IQR 4.4 to 32.9) and 38.8 months (13.8 to 50.7), respectively. The 2 groups were comparable in median age, body mass index, American Society of Anesthesiologists score, tumor size and preoperative estimated glomerular filtration rate. The 3 primary treatment failures, including 1 after cryotherapy and 2 after radio frequency ablation, were successfully re-treated with thermal ablation. There were 14 recurrences after radio frequency ablation and 3 after cryotherapy. Two-year actuarial overall, cancer specific, recurrence-free and metastasis-free survival rates for cryotherapy vs radio frequency ablation were 89% vs 93%, 100% vs 96%, 69% vs 58% and 86% vs 91%, respectively. For each group no significant decrease in renal functional parameters was found at the latest followup visit., Conclusions: Computerized tomography guided percutaneous probe ablation represents a safe treatment option in surgical patients at high risk with a solitary kidney. It provides low morbidity, acceptable short-term cancer control and minimal clinical impact on postoperative renal function., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: alpha-Melanocyte stimulating hormone protects kidneys against ischemia and sepsis induced acute kidney injury in rodents. We examined the efficacy of alpha-melanocyte stimulating hormone analogue AP214 to protect against acute kidney injury in higher vertebrates., Materials and Methods: We performed a prospective, blinded, randomized, placebo controlled study in 26 pigs. Laparoscopic technique was used for left nephrectomy and to induce complete warm ischemia in the right kidney for 120 minutes. AP214 (200 microg/kg intravenously) was administered daily on the day of surgery and for 5 days thereafter. Kidney function was measured for 9 days. We measured changes in serum creatinine, estimated glomerular filtration rate, serum C-reactive protein and urine interleukin-18., Results: In the placebo control and AP214 groups mean peak serum creatinine was 10.2 vs 3.92 mg/dl and the estimated glomerular filtration rate nadir was 22.9 vs 62.6 ml per minute per kg (each p = 0.001). Functional nadir occurred at 72 vs 24 hours in the control vs AP214 groups. Estimated glomerular filtration rate outcome on postoperative day 9 was 118 vs 156 ml per minute per kg in the control vs AP214 groups (p = 0.04)., Conclusions: We noted a robust renoprotective effect of AP214. A similar AP214 effect may be observed in humans. Future research includes mechanistic studies in pigs and a phase II human clinical trial of AP214 in kidney transplant and partial nephrectomy populations., (Copyright (c) 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Percutaneous imaging guided tumor ablation has an increasingly prominent role as minimally invasive treatment for renal tumors. Precise cryoprobe placement is essential for successful ablation. CT-Nav is a novel stereotactic surgical navigation system with the potential to achieve precise percutaneous cryoprobe placement while decreasing radiation exposure compared to conventional computerized tomography guided procedures., Materials and Methods: We performed a prospective pilot study to evaluate the technical feasibility, safety and accuracy of the system during renal cryoablation. Patients with enhancing renal masses amenable to renal cryoablation underwent preoperative computerized tomography with a preplaced tracking sensor taped to the body. Using a stereroscopic infrared camera the tracking sensor was located 3-dimensionally and a tracking handle was used to guide the cryoprobe percutaneously based on preoperative preloaded computerized tomography. Demographic and perioperative data were added prospectively to an institutional review board approved database. Immediately after cryoprobe placement computerized tomography was repeated to confirm placement accuracy., Results: A total of 13 tumors in 10 patients were successfully cryoablated with the novel navigational system. Mean tumor size was 2.2 cm. Preoperative biopsy revealed renal cell carcinoma in 9 cases. Mean operative time was 155 minutes. No intraoperative or postoperative complications were noted. Mean length of stay was 9.5 hours. Mean targeting registration error was 4.2 mm., Conclusions: Stereotactic percutaneous cryoablation for renal tumors offers the potential for safe, precise needle placement., (2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We present oncological outcomes at a followup of 10 years or greater after laparoscopic radical nephrectomy for cancer., Materials and Methods: Between February 1994 and March 1999 a total of 73 laparoscopic radical nephrectomies were performed by 2 surgeons for pathologically confirmed renal cell carcinoma. Data were obtained from patient charts, radiographic reports, telephone followup and a check of the Social Security Death Index., Results: Mean followup was 11.2 years (range 10 to 15). Each patient completed a minimum 10-year followup. Mean patient age at surgery was 60 years. Mean tumor size on computerized tomography was 5 cm (range 1.7 to 13). Pathological stage was pT1a in 41% of cases, pT1b in 30%, pT2 in 15%, pT3a in 10%, pT3b in 3% and pT4 in 1%. High grade tumors (Fuhrman 3 or greater) were present in 18 cases (28%). A positive surgical margin occurred in 1 case. Actual 10-year overall, cancer specific and recurrence-free survival rates were 65%, 92% and 86%, respectively. Overall, cancer specific and recurrence-free survival rates at 12 years were 35%, 78% and 77%, respectively. At a mean of 67 months 10 patients (14%) had metastatic disease, of whom 8 (11%) died., Conclusions: Long-term oncological outcomes after laparoscopic radical nephrectomy for renal cell carcinoma are excellent and appear comparable to those of open surgery.

Purpose: Energy sources used during nerve sparing radical prostatectomy are known to compromise cavernous nerve function. Lasers offer the potential for accurate dissection while minimizing collateral injury to delicate neural structures. We evaluated cavernous nerve function following KTP laser dissection and compared outcomes to those of ultrasonic shears and cold scissor dissection., Materials and Methods: Laparoscopic unilateral neurovascular bundle mobilization was performed in 36 survival dogs using a KTP laser, ultrasonic shears and an athermal technique with cold scissors and clips in 12 each. Peak intracavernous pressure upon cavernous nerve stimulation, expressed as a percent of mean arterial pressure, was measured acutely and at 1 month. Thermal spread from the KTP laser and ultrasonic shears was assessed histologically ex vivo in harvested peritoneum., Results: Median peak intracavernous pressure as a percent of mean arterial pressure was similar immediately and 1 month after laser and athermal dissection, and significantly decreased after dissection with ultrasonic shears. Acute peak intracavernous pressure as a percent of mean arterial pressure was 53%, 96% and 98% for ultrasonic shears, laser and the athermal technique, respectively (laser vs athermal p = 0.51, ultrasonic shears vs laser p <0.001 and ultrasonic shears vs athermal p <0.001). Chronic peak intracavernous pressure as a percent of mean arterial pressure was 56%, 98% and 100% for ultrasonic shears, laser and the athermal technique, respectively (laser vs athermal p = 0.38, ultrasonic shears vs laser p = 0.016 and ultrasonic shears vs athermal p = 0.013). The median depth of acute laser injury was 600 microm compared to 1.2 mm for ultrasonic shear dissection and 450 microm crush injury due to the athermal technique. Thermography revealed less collateral thermal spread from the laser than from the ultrasonic shears (median greater than 60C thermal spread 1.07 vs 6.42 mm, p <0.01)., Conclusions: The KTP laser was comparable to the athermal technique and superior to the ultrasonic shears for preserving cavernous nerve function.

Purpose: We assessed the impact of percutaneous renal surgery on renal function based on the modification of diet in renal disease estimated glomerular filtration rate in solitary renal units. We also determined the variables predictive of functional improvement or impairment following percutaneous surgery in solitary kidneys., Materials and Methods: A prospective database was augmented by retrospective chart review. Between 1984 and 2007, 81 patients with a solitary kidney, which was anatomical in 61.7%, functional in 18.5%, a transplant allograft in 11.1% and unknown in 8.6%, underwent a total of 92 percutaneous procedures. Serum creatinine was measured preoperatively, postoperatively, at 1 month and at 1 year. The 4-variable modification of diet in renal disease equation was used to calculate estimated creatinine clearance. The study population was divided into 3 groups, including group 1-a change in the estimated glomerular filtration rate of 5% or less at 1 year, group 2-an increase of greater than 5% at 1 year and group 3-a decrease of greater than 5% at 1 year. Univariate and multivariate regression analysis was performed using the ordinal logistic fit model to assess the effects of variables on postoperative renal function at 1 year., Results: Percutaneous intervention was performed for stone disease in 64 patients (69.6%), of whom 25 had staghorn calculi. Two patients required concomitant antegrade endopyelotomy for ureteropelvic junction obstruction. Percutaneous resection of transitional cell carcinoma was performed in 28 patients (30.4%). Of the patients 46% had baseline stage 3 chronic kidney disease. Complications developed in 8 patients (8.6%). In the entire cohort the modification of diet in renal disease estimated glomerular filtration rate was 44.7, 42.5, 55.4 and 49.9 ml per minute per 1.73 m(2) at baseline, immediately postoperatively, at 1 month and at 1 year, respectively. Female gender (OR 3.11, p = 0.0038) and an initial postoperative improvement in modification of diet in renal disease estimated glomerular filtration rate of greater than 5% (OR 6.84, p = 0.0026) were predictive of renal function improvement at 1 year on multivariate analysis., Conclusions: Percutaneous renal surgery in the solitary kidney is safe and it results in renal function preservation for up to 1 year of followup. Female gender and an immediate postoperative improvement in the modification of diet in renal disease estimated glomerular filtration rate are predictive of a sustained increase in that rate at 1 year.

Purpose: We present long-term oncological outcomes following laparoscopic nephroureterectomy for upper tract transitional cell carcinoma., Materials and Methods: Between December 1997 and August 2005, 100 patients underwent laparoscopic nephroureterectomy for upper tract transitional cell carcinoma at our institution. Data were obtained from a prospectively maintained database, patient charts, telephone followup and a review of the Social Security Death Index., Results: Median patient age at surgery was 73 years. Final pathological stage was pTis/pTa in 28% of patients, pT1 in 31%, pT2 in 13%, pT3 in 24% and pT4 in 4%. High grade lesions were present in 58% of patients, multifocal disease was present in 23% and lymphovascular invasion was present in 9%. Positive surgical margins occurred in 7 patients (7%). Median followup was 7 years (range 2 to 10). At 2, 5 and 7 years overall survival was 81%, 59% and 50%, cancer specific survival was 91%, 77% and 72%, and recurrence-free survival was 66%, 50% and 36%, respectively. Five-year cancer specific survival by stage was 80% for pTis/Ta, 70% for pT1, 68% for pT2, 60% for pT3 and 0% for pT4. On univariate analysis nonorgan confined disease and lymphovascular invasion affected cancer specific survival (p = 0.01 and 0.04, respectively). On multivariate analysis only nonorgan confined disease was a significant factor (p = 0.04). Concomitant bladder tumor at diagnosis was associated with poor recurrence-free survival on univariate and multivariate analysis (p = 0.02 and 0.01, respectively)., Conclusions: To our knowledge the largest long-term followup after laparoscopic nephroureterectomy for upper tract transitional cell carcinoma is presented. Long-term oncological outcomes appear comparable to those of open surgery.

Purpose: We present the initial 4 patients undergoing single port transumbilical live donor nephrectomy. Scar-free abdominal surgery via natural body orifices is called NOTES (natural orifice translumenal endoscopic surgery). In a similar manner the umbilicus, an embryonic (E) natural orifice, permits abdominal access with hidden scar of entry. We propose the term E-NOTES for embryonic natural orifice transumbilical endoscopic surgery., Materials and Methods: Through an intra-umbilical incision a novel single access tri-lumen R-port was inserted into the abdomen. No extra-umbilical skin incisions were made whatsoever. A 2 mm Veress needle port, inserted via skin needle puncture to establish pneumoperitoneum, was used to selectively insert a needlescopic grasper for tissue retraction. Donor kidney was pre-entrapped and extracted transumbilically., Results: E-NOTES donor nephrectomy was successful in all 4 patients. Median operating time was 3.3 hours, blood loss was 50 cc, warm ischemia time was 6.2 minutes and hospital stay was 3 days. Median length of harvested renal artery was 3.3 cm, renal vein 4 cm and ureter 15 cm. No intraoperative complications occurred. Donor visual analog scores were 0/10 at 2 weeks. Each allograft functioned immediately on transplantation., Conclusions: The initial experience with E-NOTES donor nephrectomy is encouraging. Excellent donor vascular and tissue dissection could be performed, and a quality donor kidney was retrieved transumbilically without any extra-umbilical skin incision. E-NOTES donor nephrectomy appears to have relevance and promise, especially for this typically younger, altruistic population. Natural orifices present an unprecedented opportunity for scar-free surgery.

Purpose: Although the dog is often used as a radical prostatectomy model, precise descriptions of canine prostate and neurovascular bundle anatomy are lacking. We describe canine prostate and neurovascular bundle anatomical and electrophysiological characteristics., Materials and Methods: The canine prostate and pelvic neurovascular structures were dissected in 6 canine cadavers and 12 anesthetized dogs. Pelvic plexus branches were stimulated using a CaverMap probe and peak intracavernous pressure responses were recorded as a percent of mean arterial pressure., Results: The canine pelvic plexus lies 5 to 10 mm lateral to the prostate. It is supplied by the hypogastric nerve cranially and the pelvic nerve laterally. The neurovascular bundles course distal from the pelvic plexus along the posterolateral aspect of the prostate, including a dominant cavernous nerve along its lateral aspect. CaverMap stimulation of the efferent branches of the pelvic plexus confirmed their roles in tumescence. Histology revealed extensive neurovascular tissue along the posterolateral aspect of the prostate beneath the periprostatic fascia. Notable differences to human anatomy were the absence of seminal vesicles, the lateral positions of the pelvic plexus, the dominant cavernous nerve and the circumferential urethral distribution of the cavernous nerves., Conclusions: Canine neurovascular anatomy resembles that of humans and it is a suitable model in which to assess prostatectomy related erectile dysfunction. However, there are key differences in neurovascular relationships that must be considered when the canine prostate is used as a radical prostatectomy model.

Purpose: To our knowledge the outcomes of laparoscopic renal oncological surgery in patients with major aortic and/or inferior vena caval pathology are unknown. We present our experience spanning an 8-year period., Materials and Methods: From March 1998 to October 2006, 1,826 laparoscopic renal procedures were performed for tumor. Of these patients 66 (3.6%) had major abdominal aortic or vena caval pathology concomitantly. Demographics, specific entities of the vascular disease, and intraoperative and postoperative data were reviewed., Results: A total of 66 patients had a history of abdominal aortic disease (54), vena caval disease (9) or both (3). Of the patients 85% had 3 or greater comorbidities, 88% had an American Society of Anesthesiologists score of 3 or greater and 88% were on chronic anticoagulation therapy. A total of 27 patients (41%) had undergone prior surgical treatment for vascular pathology. Laparoscopic renal surgery, which was transperitoneal in 25 cases and retroperitoneal in 41, included radical nephrectomy in 20, partial nephrectomy in 17 and cryoablation in 29. Open conversion was performed in 3 patients (5%). There were 3 intraoperative (5%) and 9 postoperative (14%) complications. One patient died of pulmonary sepsis. There was no statistically significant difference in perioperative outcomes between the aortic and vena caval disease groups. The retroperitoneal approach was associated with less blood loss and shorter operative time (p = 0.0003 and 0.004, respectively)., Conclusions: Laparoscopic surgery for renal tumor in the presence of aortic or vena caval disease is safe and feasible. Considerable prior laparoscopic experience is necessary when treating these patients at high risk.

Purpose: We present our experience with and the technique of laparoscopic mesh reconstruction or suture repair of intentional resection or intraoperative injury of the diaphragm., Materials and Methods: In a 10-year (1997 to 2006) review of 1,850 upper abdominal renal and/or adrenal laparoscopic procedures at our institution 13 patients (0.7%) sustained diaphragmatic entry, including iatrogenic injury in 7 (0.4%), deliberate laparoscopic excision of a portion of the diaphragm in 2 and diaphragmatic incision during transthoracic adrenalectomy in 4. Laparoscopic repair techniques involved primary suture repair in 11 cases and primary reconstruction with a synthetic graft in 2. A rubber catheter and water seal system were used to primarily evacuate the pneumothorax., Results: Inadvertent diaphragmatic injury in 7 cases occurred during transperitoneal (6) and retroperitoneal (1) laparoscopy, including partial nephrectomy in 4, radical nephrectomy in 2 and adrenalectomy in 1. A diaphragmatic breach occurred due to hook electrocautery in 5 cases, trocar insertion in 1 and liver retraction in 1. Deliberate diaphragmatic excision and mesh reconstruction in 2 cases were performed after en bloc excision of the diaphragm during radical nephrectomy in 1 and during excision of a metastatic diaphragmatic nodule in 1. Four transthoracic transdiaphragmatic adrenalectomies were completed successfully without any intraoperative complications. All cases were completed laparoscopically without open conversion. A chest tube was placed prophylactically in the initial 2 patients undergoing transthoracic transdiaphragmatic adrenalectomy., Conclusions: Laparoscopic and transthoracic repair/reconstruction of the diaphragm is safe and effective.

Purpose: We determined the incidence of and risk factors for perioperative complications associated with laparoscopic oncological surgery for urological malignancy., Materials and Methods: All records of patients undergoing laparoscopic surgery for urological malignancy at a tertiary care institution from April 1997 through January 2006 were reviewed. Relevant demographic and perioperative data during and within 6 weeks of surgery were evaluated retrospectively. Various factors were analyzed to estimate risk of a perioperative complication such as the Charlson Comorbidity Index, American Society of Anesthesiologists score, European Scoring System for laparoscopic urological operations and surgeon experience. Logistic regression was used to identify independent risk factors for perioperative complications., Results: A total of 1,867 laparoscopic oncological surgeries were performed, including radical or partial nephrectomy, nephroureterectomy, radical prostatectomy and radical cystectomy. Perioperative complications occurred in 12.4% of patients, including 3.5% intraoperatively and 8.9% postoperatively. Intraoperative (2.3%) and postoperative hemorrhage (2.7%) accounted for 40% of all perioperative complications. All cause perioperative mortality occurred in 8 patients (0.4%). On multivariate analysis radical cystectomy (adjusted OR 4.9, p <0.001), partial nephrectomy (adjusted OR 2.4, p <0.001), length of surgery greater than 4 hours (adjusted OR 2.5, p <0.001) and preoperative serum creatinine greater than 1.5 mg/dl (adjusted OR 2.1, p = 0.04) were independent risk factors for perioperative complications. Comparing the periods of 1997 to 2000 vs 2001 to 2005, despite a significant increase in technical complexity of procedures (European Scoring System 9.8 vs 60.6, p <0.001), the incidence of complications tended to decrease (17.3% vs 12.5%, p = 0.3)., Conclusions: In appropriately selected patients laparoscopic urological oncological surgery is safe. These data on perioperative complications could possibly serve as a reference benchmark for practicing urologists.

Purpose: We externally validated a previously designed neural network model to predict outcome and duration of passage for ureteral/renal calculi. The model was also evaluated using a 6 mm largest stone dimension cutoff in predicting stone outcome., Materials and Methods: The model was previously designed on 301 patients at Albany Medical Center (free shareware from www.uroengineering.com). The model had a prediction accuracy of 86% for passage outcome and 87% for passage duration. In this study we tested the model on a separate 384 patients from 6 different external institutions to assess the prediction accuracy. All patients had a single renal/ureteral calculus by evaluation in an emergency room setting or by primary physicians and were then referred for further treatment. Model accuracy was also compared to using a 6 mm largest stone dimension cutoff in predicting the need for intervention., Results: Testing on the 384 patients from all 6 external institutions revealed an outcome prediction accuracy of 88%. The area under the ROC curve was 0.9. Using a 6 mm stone size cutoff provided 79% (ROC 0.8) accuracy. The model duration of passage prediction accuracy was 80% (133 patients passed the stone, area under ROC of 0.8)., Conclusions: The model provided high stone outcome prediction accuracy (ROC of 0.9 and 0.8) at the 6 external institutions, comparable to that of the design institution. The model provided higher accuracy than using only the largest stone dimension as a cutoff. Increasing experience will further assess the model's accuracy.