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Standard treatment modalities of caliceal diverticular calculi range from extracorporal shockwave lithotripsy (SWL) over retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PNL) and laparoscopic stone removal. A 55-year-old woman presented with a history of pyelonephritis based on a caliceal diverticular calculus. Due to the narrow infundibulum and anterior location, a robot-assisted laparoscopic calicotomy with extraction of the calculi and fulguration of the diverticulum was performed, with no specific perioperative problems and good stone-free results. This article shows technical feasibility with minimal morbidity of robot-assisted laparoscopic stone removal and obliteration of a caliceal diverticulum.

A systematic revision of the lace bug genusNethersiaHorváth 1925 is given including a redescription of the genus. Previously described speciesN.absimilisDrake 1944,N.haplotesDrake and Ruhoff 1962,N.maculosaHorváth 1925 andN.setosa(Hacker 1927) are redescribed. The New Caledonian speciesTingis chazeauiGuilbert (1997) is transferred toNethersia. Eighteen new species are described:N.acaciaphilasp.n.,N.apphasp.n.,N.bipannanotasp.n.,N.boorabbinensissp.n.,N.costatasp.n.,N.finlayaesp.n.,N.kimberleyensissp.n.,N.magnasp.n.,N.mareebasp.n.,N.mcquillanisp.n.,N.nigrasp.n.,N.pilbarasp.n.,N.silveiraesp.n.,N.stipulasp.n.,N.tatarnicisp.n.,N.tanamisp.n.,N.tomentosasp.n. andN.westralensissp.n.Nethersia pugnaDrake 1944 is removed from synonymy withN.maculosaHorváth and treated as a valid species. An identification key species is given which relies on colour patterning, vestiture and texture of the dorsum.Nethersia nigritarsis(Horváth, 1925) is transferred fromNethersiatoTingisand designated asincertae sedis. Phylogenetic analysis ofNethersiawas undertaken resulting in fully resolved topologies for a range of concavity constant settings (K= 2–6) under implied weights. The plant associations ofNethersiaare documented, with most species recorded from phyllodinousAcaciaspecies, with twenty designated as host plants.

Background Management of multiple ipsilateral renal tumors is a dilemma in clinical practice. The effects of minimally invasive nephron-sparing procedures in this group of patients have not been assessed. Objective To evaluate the technical feasibility and outcomes of laparoscopic partial nephrectomy (LPN) and laparoscopic cryoablation (LCA) for multiple ipsilateral renal tumors. Design, Setting, and Participants Between September 1999 and December 2006, 27 patients were treated with minimally invasive nephron sparing surgery (LPN or LCA) for synchronous multiple ipsilateral renal tumors in a single operating session at our institution. Fourteen patients with 28 tumors underwent LPN, and 13 patients with 31 tumors underwent LCA as the sole treatment modality. Intervention Medical records were retrospectively reviewed and data were collected. Measurements Demographic, intraoperative, postoperative, and intermediate-term follow-up data were compared between the two groups. Results and Limitations Patients in the LPN group had fewer tumors (2 vs. 2.4, p =0.04) and larger dominant tumor size (3.6 vs. 2.5cm, p =0.005) in the affected kidney and lower preoperative serum creatinine levels (1 vs. 1.4mg/dl, p =0.02). Compared to the LCA group, patients in the LPN group had greater estimated blood loss (200 vs. 125ml, p =0.02) and longer hospital stays (90 vs. 52.3h , p =0.02). There were no open conversions, and no kidneys were lost. Complication rate, renal functional outcomes, and intermediate-term cancer-specific survival rates were similar between the two groups. Conclusions Both LPN and LCA are viable options for patients with multiple ipsilateral renal tumors in select patients. Renal functional outcomes, complication rates, and intermediate-term survival rates are comparable between the two groups in this small series.

La laparoscopia e la tecnica di riferimento nella presa in carico chirurgica delle malattie surrenaliche benigne. Negli ultimi 5 anni vi sono stati parallelamente miglioramenti nel campo della chirurgia robotica. La quasi totalita degli interventi urologici, inizialmente eseguiti in laparoscopia, sono stati oggetto di miglioramento grazie all’impiego del robot. Dopo un cenno degli elementi di anatomia, questo articolo tratta delle indicazioni all’intervento di surrenalectomia laparoscopica robot-assistito; riassume poi gli inizi della sperimentazione robotica in questo campo e descrive infine dettagliatamente la tecnica della surrenalectomia laparoscopica robot-assistita. La surrenalectomia laparoscopica robotizzata e ad oggi poco diffusa. I suoi vantaggi rispetto a quella laparoscopica convenzionale non sono ancora stabiliti. Sono attesi miglioramenti nel campo della robotica, segnatamente l’aggiunta di capacita sensoriali tattili (da ritorno della spinta), miniaturizzazione dei diversi componenti, riduzione dei costi e nuove acquisizioni nel campo della telemanipolazione. Essi permetteranno di definire meglio il ruolo della robotica nella presa in carico delle patologie surrenaliche

Objectives To investigate whether systematic postoperative VAC therapy could improve vulvectomy healing. Study design We reviewed medical data from 54 women who underwent in the period of March 2006 to December 2009 radical vulvectomy or wide local vulvectomy with defect volume >40cm 3 . Patients were divided into two groups according to immediate postoperative care. Patients treated with systematic vacuum-assisted closure (VAC) therapy immediately after surgery were included in the "VAC group" while patients receiving conventional care (CC) were included in the "CC group". Results The characteristics of the VAC group ( n =30) and CC group ( n =24) were similar and there were no significant differences in operative data, histological results or oncologic follow-up. The median length of use of VAC was 11 days after surgery (6–38). The length of hospital stay for patients in the VAC group and CC group was 17.8 (±8.7) and 18.4 days (±9.9) ( p =0.8) respectively. The lengths of complete healing were 44.4 (±18.4) vs. 60.2 (±28.7) days ( p =0.0175) respectively. Conclusions In our study we proved that using VAC dressing immediately after vulvectomy (at least 6cm×7cm) for 11 days reduces the total length of cicatrization by approximately 16 days.

We evaluated the efficacy of α-blockers to improve ureteral stent related morbidity and quality of life.We performed a search of MEDLINE®, Embase™ and The Cochrane Library plus a hand search of conference proceedings from January 2000 to October 2010 to identify randomized, controlled trials comparing treatment for ureteral stent symptoms with α-blockers. Two reviewers independently screened studies and extracted data. Trial methodological quality was assessed by The Cochrane Collaboration quality assessment tool. Placebo randomized, controlled trials with the ureteral stent symptom questionnaire as the outcome were eligible for meta-analysis. Meta-analysis was done using the mean difference to determine the aggregate effect size.A total of 12 randomized, controlled trials including 2 α-blockers in a total of 946 patients were eligible, including 4 (33%) presented only as an abstract at a urological meeting and 4 (33%) eligible for meta-analysis. Meta-analysis using a random effects model showed that α-blockers were associated with a significant decrease in urinary symptoms (MD -6.76, 95% CI -11.52 to -2.00, p=0.005), a significant decrease in pain (MD -3.55, 95% CI -5.51 to -1.60, p=0.0004) and significant improvement in general health (MD -1.90, 95% CI -3.05 to -0.75, p=0.001). However, they were not associated with a benefit in work (MD 2.41, 95% CI -1.62 to 6.44, p=0.24) or sexual matters (MD 0.20, 95% CI -1.06 to 1.45, p=0.33). Eight studies were not included in the meta-analysis, of which 7 showed a significant clinical decrease in urinary symptoms and pain.Existing evidence from randomized, controlled trials shows that α-blockers are associated with improvement in ureteral stent symptoms and supports their use in routine clinical practice.

Purpose: It is not yet possible to estimate the number of cases required for a beginner to become expert in laparoscopic radical prostatectomy. We estimated the learning curve of laparoscopic radical prostatectomy for positive surgical margins compared to a published learning curve for open radical prostatectomy. Materials and Methods: We reviewed records from 8,544 consecutive patients with prostate cancer treated laparoscopically by 51 surgeons at 14 academic institutions in Europe and the United States. The probability of a positive surgical margin was calculated as a function of surgeon experience with adjustment for pathological stage, Gleason score and prostate specific antigen. A second model incorporated prior experience with open radical prostatectomy and surgeon generation. Results: Positive surgical margins occurred in 1,862 patients (22%). There was an apparent improvement in surgical margin rates up to a plateau at 200 to 250 surgeries. Changes in margin rates once this plateau was reached were relatively minimal relative to the CIs. The absolute risk difference for 10 vs 250 prior surgeries was 4.8% (95% CI 1.5, 8.5). Neither surgeon generation nor prior open radical prostatectomy experience was statistically significant when added to the model. The rate of decrease in positive surgical margins was more rapid in the open vs laparoscopic learning curve. Conclusions: The learning curve for surgical margins after laparoscopic radical prostatectomy plateaus at approximately 200 to 250 cases. Prior open experience and surgeon generation do not improve the margin rate, suggesting that the rate is primarily a function of specifically laparoscopic training and experience.

Primary cancers of the ureter and renal pelvis are rare tumours,90% of which are transitional cell carcinomas. Only approximately 5% of urothelial tumours arise in the upper urinary tract (UUT). Many environmental factors contribute to the development of these cancers. Some are similar to bladder cancer-associated factors (tobacco, occupational exposure), while others are more specific to carcinogenesis of the UUT (phenacetine, Balkan endemic nephropathy [BEN], Chinese herb nephropathy or association with Blackfoot disease [BFD]). This review discusses the environmental factors involved in UUT carcinoma. Tobacco and occupational exposure remain the principal exogenous risk factors for developing these tumours. Conversely, carcinogenesis of UUT tumours resulting from phenacetine consumption has almost disappeared. Although the incidence of BEN is also on the decline, roles for aristolochic acid and the consumption of Chinese herbs in the physiopathology and induction of this nephropathy, respectively, have proposed. In Taiwan, the association of this tumour type with BFD and arsenic exposure remains unclear to date. As some genetic polymorphisms are associated with an increased risk of cancer or faster disease progression, there is variability in interindividual susceptibility to the development of UUT carcinoma when exposed to the aforementioned risk factors Cytosolic sulfotransferases (SULTs) catalyse the detoxification of many environmental chemicals but also in the bioactivation of dietary and other mutagens. Polymorphism of the SULT gene, is thought to confer susceptibility to upper tract tumours.

We previously reported the learning curve for open radical prostatectomy, reporting large decreases in recurrence rates with increasing surgeon experience. Here we aim to characterise the learning curve for laparoscopic radical prostatectomy.We did a retrospective cohort study of 4702 patients with prostate cancer treated laparoscopically by one of 29 surgeons from seven institutions in Europe and North America between January, 1998, and June, 2007. Multivariable models were used to assess the association between surgeon experience at the time of each patient's operation and prostate-cancer recurrence, with adjustment for established predictors.After adjusting for case mix, greater surgeon experience was associated with a lower risk of recurrence (p=0.0053). The 5-year risk of recurrence decreased from 17% to 16% to 9% for a patient treated by a surgeon with 10, 250, and 750 prior laparoscopic procedures, respectively (risk difference between 10 and 750 procedures 8.0%, 95% CI 4.4-12.0). The learning curve for laparoscopic radical prostatectomy was slower than the previously reported learning curve for open surgery (p0.001). Surgeons with previous experience of open radical prostatectomy had significantly poorer results than those whose first operation was laparoscopic (risk difference 12.3%, 95% CI 8.8-15.7).Increasing surgical experience is associated with substantial reductions in cancer recurrence after laparoscopic radical prostatectomy, but improvements in outcome seem to accrue more slowly than for open surgery. Laparoscopic radical prostatectomy seems to involve skills that do not translate well from open radical prostatectomy.National Cancer Institute, the Allbritton Fund, and the David J Koch Foundation.

Resume La cœlioscopie est la technique de reference dans la prise en charge chirurgicale des maladies surrenaliennes benignes. Les cinq dernieres annees ont vu des ameliorations concomitantes dans le domaine de la chirurgie robotique. La presque totalite des interventions urologiques, initialement realisee en cœlioscopique, l'a ainsi ete a l'aide d'une assistance robotique. Apres un rappel de considerations anatomiques, cet article traite des indications de surrenalectomie cœlioscopique robotisee, resume les debuts de l'experimentation robotique menee dans le domaine et detaille la technique de surrenalectomie cœlioscopique robotisee. La surrenalectomie cœlioscopique robotisee reste peu repandue a ce jour. Ses avantages par rapport a la cœlioscopie conventionnelle ne sont pas encore reconnus. Des ameliorations dans le domaine de la robotique, notamment l'addition d'une sensation tactile par retour de force, une miniaturisation des differents materiels, une reduction des couts et des avancees dans le domaine de la telemanipulation sont attendues. Cela permettra de mieux definir la place de la robotique dans la prise en charge des pathologies surrenaliennes.

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.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.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).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.

laparoscopic transducer (Aloka Inc, Japan) was used to image renal tumors for the purpose of nephron sparing surgery. Transperitoneal robotic partial nephrectomies were performed in a non-survival pig model using the da Vinci S Surgical System (Intuitive Surgical, Sunnyvale). TilePro was used in all cases to overlay real-time ultrasound images on to the console (Figure 2). The robotic partial nephrectomy specimens

V1056 VIDEO DEMONSTRATION OF ROBOTIC TESTICULAR SPERM EXTRACTION: CRITICAL EVALUATION COMPARED TO OPEN TESE AND PERCUTANEOUS NEEDLE LAVAGE TECHNIQUES IN CANINE MODEL AND THE FIRST HUMAN CASES Scott A Polackwich*, Patrick Villicana, Carl Bischoff, Bayo Tojuola, Benjamin K Canales, Marc S Cohen, Philipp Dahm, Johannes Vieweg, Sijo J Parekattil. Gainesville, FL. INTRODUCTION AND OBJECTIVE: Testicular sperm