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Background The LAP-01 trial was designed to address the lack of high-quality literature comparing robotic-assisted (RARP) and laparoscopic (LRP) radical prostatectomy. Objective To compare the functional and oncological outcomes between RARP and LRP at 3 mo of follow-up. Design, setting, and participants In this multicentre, randomised, patient-blinded controlled trial, patients referred for radical prostatectomy to four hospitals in Germany were randomly assigned (3:1) to undergo either RARP or LRP. Outcome measurements and statistical analysis The primary outcome was time to continence recovery at 3 mo based on the patient’s pad diary. Secondary outcomes included continence and potency as well as quality of life in addition to oncological outcomes for up to 3 yr of follow-up. Time to continence was analysed by log-rank test and depicted by the Kaplan-Meier method. Continuous measurements were analysed by means of linear mixed models. Results and limitations A total of 782 patients were randomised. The primary endpoint was evaluable in 718 patients (547 RARPs; full analysis set). At 3 mo, the difference in continence rates was 8.7% in favour of RARP (54% vs 46%, p = 0.027). RARP remained superior to LRP even after adjustment for the randomisation stratum nerve sparing and age >65 yr (hazard ratio = 1.40 [1.09–1.81], p = 0.008). A significant benefit in early potency recovery was also identified, while similar oncological and morbidity outcomes were documented. It is a limitation that the influence of different anastomotic techniques was not investigated in this study. Conclusions RARP resulted in significantly better continence recovery at 3 mo. Patient summary In this randomised trial, we looked at the outcomes following radical prostate surgery in a large German population. We conclude that patients undergoing robotic prostatectomy had better continence than those undergoing laparoscopic surgery when assessed at 3 mo following surgery. Age and the nerve-sparing technique further affected continence restoration.

Background: This study assessed the quality of life (QoL) and the implication of time effort of everolimus treatment in patients with metastatic renal cell carcinoma (mRCC). Methods: Adult patients with mRCC were eligible for everolimus treatment after first-line vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitors or bevacizumab therapy. The primary end-point, QoL, was assessed by means of the NCCN-FACT FKSI-19 questionnaire. Results: In total, 202 patients (24% of female patients; median age, 71 years) were evaluable for QoL analyses. The median treatment duration was 4.4 months (95% CI, 3.8-5.3) and the median time to progression was 6 months (95% CI, 5.4-7.5). The median FKSI-19 total score remained stable during treatment (52.0 at therapy start, 55.0 at observation end). The median time effort spent on total therapy was 20 hours per patient. Most of the patients stated to have “no limitations,” “a little” or “moderate” limitations in their daily, social, and professional lives. Two months after the start of treatment, 65 patients reported none or a little time burden due to therapy. Conclusions: QoL was maintained during the everolimus therapy and limitations as well as time effort were acceptable for most of the patients. The study supports previous findings on switching mode of action after anti-VEGFR-targeted therapy to a mammalian target of rapamycin inhibitor.

Objectives: To systematically review studies comparing extraperitoneal (E-RP) and transperitoneal minimally invasive radical prostatectomy (T-RP). Methods: The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in September 2015. Several databases were searched including Medline and Scopus. Only studies comparing E-RP and T-RP (either laparoscopic or robot-assisted approach) were evaluated. The follow-up of the included patients had to be â¥6 months. Results: In all, 1256 records were identified after the initial database search. Of these 20 studies (2580 patients) met the inclusion criteria. The hospital stay was significantly lower in the E-RP cohort, with a mean difference of â0.30 days (95% confidence interval [CI] â0.35, â0.24) for the laparoscopic group and 1.09 days (95% CI â1.47, â0.70) for the robotic group (PÂ

Paragangliomas are neuroendocrine tumours of extra adrenal origin. Although it occurs rarely in the genitourinary system, urinary bladder is the most common site. Its diagnosis warrants complete surgical excision with lymphadenectomy in case of metastatic disease. The functional status of this tumour makes intraoperative handling challenging. Surgical resection necessitates minimal manipulation of tumour thereby mitigating intraoperative physiological jeopardy. We report the possibility of minimally invasive partial cystectomy with bilateral vesico-ureteric junction resection and re-implantation for non-malignant paraganglioma involving the bladder trigone. Intraoperative frozen section is deemed necessary to achieve tumour free margin status.

Objective Emotional distress in cancer patients often goes unnoticed in daily routine; therefore, distress screening is now recommended in many national guidelines. However, screening alone does not necessarily translate into better well-being. We examined whether stepped psychooncological care improves referral to consultation-liaison (CL) services and improves well-being. Methods In a cluster-randomized trial, wards were randomly allocated to stepped versus standard care. Stepped care comprised screening for distress, consultation between doctor and patient about the patient's need for CL services, and provision of CL service. Primary outcomes were referral to psychosocial services and emotional well-being half a year after baseline, measured with the Hospital Anxiety and Depression Scale. A secondary endpoint was uptake of outpatient health care. Analysis employed mixed-effects multivariate regression modeling. Results Thirteen wards were randomized; 1012 patients participated. With stepped care (N = 570; 7 wards), 22% of the patients were referred to CL services and 3% with standard care (N = 442; 6 wards; odds ratio [OR] 10.0; P

We explored the relationship between socio-economic characteristics and cancer stage at presentation. Patients admitted to a university hospital for diagnosis and treatment of cancer provided data on their education, vocational training, income, employment, job, health insurance and postcode. Tumor stage was classified according to the Union International Contre le Cancer (UICC). To analyze disparities in the likelihood of late-stage (UICC III/IV vs. I/II) diagnoses, logistic regression models adjusting for age and gender were used. Out of 1,012 patients, 572 (59%) had late-stage cancer. Separately tested, increased odds of advanced disease were associated with post-compulsory education compared to college degrees, with apprenticeship and no vocational training, with unemployment, disability pension, jobs with a low hierarchy level, blue collar jobs and with low income. Health insurance and community size were not related with late-stage cancer. Jointly modelled, there was evidence for an independent effect of unemployment (odds ratio (OR) 1.7, CI 1.0-2.8), disability pension (OR 1.8, CI 1.0-3.2) and very low income (OR 2.6, CI 1.1-6.1) on the likelihood of advanced disease stage. It is of great concern that these socio-economic gradients occur even in systems with equal access to health care.

INTRODUCTION: To describe the technique of total extraperitoneal inguinal hernia repair performed during Robot-assisted Endoscopic Extraperitoneal Radical Prostatectomy (R-EERPE) and to present the initial outcomes. MATERIAL AND METHODS: 12 patients underwent inguinal hernia repair during 120 R-EERPEs performed between July 2011 and March 2012. All patients had a clinically palpable inguinal hernia preoperatively. The hernia was repaired using a Total Extraperitoneal Patch (TEP) at the end of the procedure. RESULTS: Sac dissection and mesh placement was simpler compared to conventional laparoscopy due to improved, magnified, 3-D vision along with 7° of movement, and better control of mesh placement. The median operating time was 185 minutes, with on average, an additional 12 minutes incurred per hernia repair. The median blood loss for the procedures was 250 ml, and the mean pathological prostate weight was 55 gm. No additional blood loss was noted and there were no postoperative complications. None of the patients had a recurrence at 12 months. We await long-term follow-up data. CONCLUSIONS: Robot-assisted TEP is feasible and should be considered in patients with hernia at the time of R-EERPE.

Background Symptomatic lymphocele following radical prostatectomy (RP) and concomitant bilateral extended pelvic lymph node dissection (ePLND) has a significant impact on postoperative recovery and may sometimes require surgical intervention. Objective To report on the use of four-point peritoneal flap fixation (4PPFF) during RP to reduce lymphocele occurrence following PLND. Design, setting, and participants Between April 2010 and May 2017, 1358 patients underwent RP with concomitant bilateral ePLND. From this cohort, 193 patients who had undergone PNLD with 4PPFF were matched in a 1:1 ratio with respect to age, body mass index, initial PSA, and number of lymph nodes removed to patients who had undergone PLND without 4PPFF. Intervention 4PPFF was performed by suturing the cut end of the ventral parietal peritoneum at four points (to the anterior and lateral pelvic side wall on both sides) following PLND so that the peritoneal surface was exposed to the iliac vessels and obturator fossa. Outcome measurements and statistical analysis All patients underwent ultrasound on postoperative days 6, 28, and 90 to test for the presence of lymphocele. For univariate analysis, a χ2 test and analysis of variance were applied, as appropriate. Statistical significance was set at p Results and limitations There were no significant differences between the two groups with respect to intraoperative blood loss, positive surgical margin rate, Gleason score, clinical stage, and number of positive cores. Asymptomatic lymphocele was observed in four patients (2.07%) in the 4PPFF group compared to 16 patients (8.3%) without 4PPFF (p=0.0058). Similarly, a significant difference in the incidence of symptomatic lymphocele was observed: two patients (1.03%) in the 4PPFF group versus nine patients (4.6%) without 4PPFF (p=0.0322). There were no differences in other complication rates between the two groups. The limitations of the study are its retrospective and nonrandomised nature, with postoperative follow-up based on ultrasound imaging rather than computed tomography because of ethical considerations, which could have caused observer bias. Conclusions 4PPFF is a safe and effective procedure in preventing lymphocele occurrence in patients undergoing RP with PLND. The increase in exposure of the PLND raw area to the peritoneal surface following this procedure may aid in increased absorption of accumulating lymph fluid. Further prospective randomised multicentre studies are warranted to confirm our observations. Patient summary We report on the use of a surgical technique to decrease the collection of lymphatic fluid in the abdominal cavity following lymph node removal during radical removal of the prostate gland in patients with prostate cancer. Patients undergoing this procedure had significantly better outcomes when compared to patients operated on in the conventional approach.

Hintergrund Die laparoskopische radikale Prostatektomie (LRP) hat sich seit der Erstbeschreibung vor uber 20 Jahren als Standardverfahren zur Therapie des lokal begrenzten Prostatakarzinoms etabliert. Aktuell wird die LRP trotz der hohen Zusatzkosten zunehmend durch die roboterassistierte Methode (RALP) verdrangt.

Background and aims The adipokine adipocyte fatty acid binding protein (AFABP) is positively associated with the development of the metabolic syndrome, diabetes mellitus, and cardiovascular disease. We hypothesized that AFABP also increases with deteriorating renal function. Methods and results Serum AFABP levels were quantified by enzyme linked immunosorbent assay in 532 patients with chronic kidney disease (CKD) covering the whole spectrum of estimated glomerular filtration rate (eGFR) categories from G1 to G5 (study population 1). Furthermore, AFABP was measured in 32 patients before and within 30 h after elective unilateral nephrectomy, a model of acute kidney dysfunction (AKD) (study population 2). Moreover, circulating AFABP was investigated in rats undergoing bilateral nephrectomy (BNE) as compared to sham-operated animals. Median serum AFABP levels adjusted for age, gender, and body mass index significantly increased with increasing eGFR category (G1: 22.0 μg/l; G2: 34.6 μg/l; G3: 56.7 μg/l; G4: 95.2 μg/l; and G5: 173.9 μg/l). Furthermore, renal dysfunction remained positively associated with AFABP in multivariate analysis in this cohort. In patients undergoing unilateral nephrectomy, AFABP increased significantly after surgery (42.1 μg/l) as compared to pre-surgical values (29.3 μg/l). Furthermore, relative changes of post-to-pre-surgical AFABP levels were independently associated with relative changes of post-to-pre-surgical creatinine concentrations. After BNE in rats, AFABP increased significantly as compared to sham-operated animals. Conclusions We show that AFABP is significantly elevated in CKD and AKD patients. Furthermore, measures of renal function are associated with circulating AFABP. Moreover, animal experiments indicate that AFABP levels strongly depend on renal function.

Hintergrund Das Harnblasenkarzinom ist der dritthaufigste Tumor in Deutschland. Die Resektionstherapie beim oberflachlichen Harnblasenkarzinom (Ta, CIS) sieht derzeit schon die photodynamische Diagnostik (PDD) mit HEXVIX® zur besseren Beurteilung der Tumorausbreitung vor. Versuche, diese Photosensibilisatoren auch zur photodynamischen Therapie (PDT) zu nutzen, haben nur begrenzte Erfolge gezeigt. Insbesondere die zu geringe Gewebepenetration aufgrund der Anregung mit kurzwelligem Licht ist eine wesentliche Einschrankung.

Background Follistatin-like 3 (FSTL3) is a novel cytokine that regulates insulin sensitivity and counteracts activin/myostatin signalling. In the present study, regulation of FSTL3 in renal dysfunction was investigated in both human chronic kidney disease (CKD) and acute kidney dysfunction (AKD). Furthermore, mFSTL3 expression was analysed in insulin-sensitive tissues in a mouse model of CKD. Methods Circulating FSTL3 was quantified by enzyme-linked immunosorbent assay in 581 patients with CKD covering the whole spectrum of estimated glomerular filtration rate (eGFR) categories from G1 to G5. Furthermore, FSTL3 was measured in 61 patients before and within 30 h after elective unilateral nephrectomy, an established model of AKD. Moreover, mFSTL3 mRNA expression was investigated in an animal CKD model, that is, eNOS-/-db/db mice, and compared with littermate controls. Results Median circulating FSTL3 levels significantly and continuously increased with deteriorating renal function (eGFR category G1: 6.1; G2: 8.2; G3: 12.7; G4: 18.5; G5: 32.1 µg/L; P

OBJECTIVE To describe our robot-assisted Boari flap ureteric reimplantation (RA-BFUR) technique, Please see Video S1. METHODS The RA-BFUR technique is based on the open surgical technique of Ubelhor, and the experience includes 11 cases. RESULTS Excellent results were achieved after a mean follow-up period of >12 months. CONCLUSION The RA-BFUR technique could be considered a safe and effective method of ureteric reimplantation for long distal ureteric strictures.

Radical prostatectomy remains the gold-standard surgical treatment for clinically localized prostate cancer. Contrast imaging of the upper urinary tract is not part of the routine work-up of the patient before radical prostatectomy. This may lead to rare, albeit serious complications when anatomical anomalies are present. This article reports a case of delayed anastomotic leakage following radical prostatectomy due to an unrecognized duplex system on the left side and inclusion of the ureteric orifice draining the upper moiety in the anastomosis, which caused failure of healing and persistent leakage.

Die zunehmende Anzahl von Ultraschall- und Schnittbilduntersuchungen bei nichturologischen Fragestellungen fuhrt in der letzten Zeit zu einer gestiegenen Anzahl diagnostizierter kleiner, inzidenteller, asymptomatischer Nierentumoren. Zu den Optionen bei Patienten mit einem kleinen Nierentumor gehoren die aktive Uberwachung, die chirurgische Exstirpation sowie ablative Techniken. Auch bei kleinen Nierentumoren besteht ein Metastasierungsrisiko, sodass die chirurgische Tumorentfernung bei allgemeiner Operabilitat die Therapie der Wahl bleibt. Die Nierenteilresektion (offen-chirurgisch oder minimal-invasiv) ist aufgrund der hervorragenden onkologischen Langzeitergebnisse und der Protektion der Nierenfunktion der Goldstandard in der Therapie des kleinen Nierentumors. Ablative Verfahren wie Kryoablation und Radiofrequenzablation sind angemessen bei multimorbiden Patienten, die eine aktive Behandlung des kleinen Nierentumors wunschen. „Active surveillance“ ist bei Hochrisikopatienten eine mogliche Alternative. Eine sorgfaltige Patientenselektion durch den Urologen und die Patientenpraferenz werden die Wahl der Therapie in Zukunft bestimmen.

Objectives: Urologists are cautious to offer minimally invasive radical prostatectomy in prostate cancer patients with high prostate-specific antigen (and therefore anticipated to have locally advanced or metastatic disease) because of concerns regarding lack of complete cure after minimally invasive radical prostatectomy and of worsening of continence if adjuvant radiotherapy is used. Methods: A retrospective review of our institutional database was carried out to identify patients with PSA ≥20 ng/mL who underwent minimally invasive radical prostatectomy between January 2002 and October 2010. Intraoperative, pathological, functional and short-term oncological outcomes were assessed. Results: Overall, 233 patients met study criteria and were included in the analysis. The median prostate-specific antigen and prostate size were 28.5 ng/mL and 47 mL, respectively. Intraoperative complications were the following: rectal injury (0.86%) and blood transfusion (1.7%). Early postoperative complications included prolonged (>6 days) catheterization (9.4%), hematoma (4.7%), deep venous thrombosis (0.86%) and lymphocele (5.1%). Late postoperative complications included cerebrovascular accident (0.4%) and anastomotic stricture (0.8%). Pathology revealed poorly differentiated cancer in 48.9%, pT3/pT4 disease in 55.8%, positive margins in 28.3% and lymph node disease in 20.2% of the cases. Adverse pathological findings were more frequent in patients with prostate-specific antigen >40 ng/mL and (or) in those with locally advanced disease (pT3/pT4). In 62.2% of the cases, adjuvant radiotherapy was used. At 1-year follow up, 80% of patients did not show evidence of biochemical recurrence and 98.8% of them had good recovery of continence. Conclusion: Minimally invasive radical prostatectomy might represent a reasonable option in prostate cancer patients with high prostate-specific antigen as a part of a multimodality treatment approach.

Zwischen laparoskopischer radikaler Prostatektomie (LRPE) und roboterassistierte laparoskopische radikale Prostatektomie (R-LRPE) konnten bisher keine signifikanten Unterschiede bezuglich der perioperativen, onkologischen und funktionellen Ergebnisse nachgewiesen werden. Vereinzelt wurde uber bessere funktionelle Ergebnisse, insbesondere bessere Potenzraten bei der R-LRPE berichtet. Jedoch existieren keine prospektiven, randomisierten, multizentrischen Studien zum Vergleich der beiden Methoden. Bei einem erfahrenen Operateur sind mit beiden Methoden sehr gute, vergleichbare Ergebnisse zu erwarten. Durch die Monopolstellung von Intuitiv bleiben nach wie vor die extrem hohen Anschaffungs- und Unterhaltungskosten der entscheidende Nachteil der R-LRPE.

Several techniques have been introduced to improve early postoperative continence. In this study, we evaluated the impact of bladder neck (vesicourethral anastomosis) suspension on the outcome of extraperitoneal endoscopic radical prostatectomy (EERPE). In this research, a total of 180 patients underwent EERPE. Group 1 included patients who underwent nerve-sparing EERPE (nsEERPE) (n=45), and Group 2 included patients who underwent nsEERPE with bladder neck suspension (BNS, n=45). Groups 3 (n=45) and 4 (n=45) included patients who received EERPE and EERPE with BNS, respectively. Patients were randomly assigned to receive BNS with their nsEERPE or EERPE procedure. Perioperative parameters were recorded, and continence was evaluated by determining the number and weight of absorbent pads (pad weighing test) on the second day after catheter removal and by a questionnaire 3 months postoperatively. Two days after catheter removal, 11.1% of Group 1, 11.1% of Group 2, 4.4% of Group 3 and 8.9% of Group 4 were continent. The average urine loss was 80.4, 70.1, 325.0 and 291.3 g for the each of these groups, respectively. At 3 months, 76.5% of Group 1 and 81.3% of Group 2 were continent. The continence figures for Group 3 and 4 were 48.5% and 43.8%, respectively. Similar overall rates were observed in all groups. In conclusion, although there are controversial reports in the literature, early continence was never observed to be significantly higher in the BNS groups when compared with the non-BNS groups, regardless of the EERPE technique performed.

Objective To investigate whether previous laparoscopic inguinal hernia repair (LIHR) affected adversely key outcome measures in radical prostatectomy, including perioperative data, pathologic data, complications, potency, continence, and prostate-specific antigen (PSA). We have shown previously that LIHR does not preclude safe endoscopic extraperitoneal radical prostatectomy (EERPE). Methods EERPE is the standard approach to radical prostatectomy in our unit. Between 2001 and June 2009 we encountered 92 patients who had previously undergone LIHR who underwent our standard technique of EERPE other than modification of port placement and development of the extraperitoneal space. We recorded our standard perioperative/postoperative dataset. Twelve-month follow-up data were available from 75 of 92 patients with 6-month follow-up of the remaining 17. Results Fifty-nine patients had undergone previous unilateral total extraperitoneal hernioplasty (TEP): 16 bilateral TEP, 15 unilateral transabdominal extraperitoneal hernioplasty (TAPP), and 2 bilateral TAPP. Although we needed to modify our technique, there was no increase in our operative time (153 minutes). Where indicated, we were able to perform bilateral nerve sparing and pelvic lymphadenectomy on the contralateral side to the LIHR. There were no major complications and no blood transfusions. Our positive margin rate, continence, and potency rates did not differ from our series of 2000 consecutive EERPEs. Ninety-four-point-seven percent of men had an undetectable PSA at 12 months. Conclusions LIHR does not adversely affect perioperative and key outcome measures in EERPE.

Objective • To assess, in a prospective randomized study, the efficiency of the FreeHand® (Prosurgics Ltd, Bracknell, UK) compared to manual camera control during the performance of endoscopic extraperitoneal radical prostatectomy (EERPE). Patients and methods • Three surgeons performed 50 EERPE for localized prostate cancer. In group A (n= 25), procedures were performed with manual control of the camera by the assistant, whereas group B (n= 25) patients were treated with the assistance of the FreeHand® robotic device. • The EERPE procedure was divided into several steps. • Total operation duration, time for each surgical step, number of camera movements, number of movement errors, number of times the lens was cleaned, blood loss and margin status were compared. Results • No statistically significant difference was observed in terms of patient age, preoperative prostate-specific antigen level, Gleason score, positive cores and prostate volume. • The average operation duration required for the performance of each step did not differ significantly between the two groups. • Significant differences in favour of the FreeHand® camera holder were observed in case of horizontal and zooming camera movement, camera cleaning and camera errors. • Vertical camera movements were performed significantly faster by the human assistant compared to the robotic camera holder. • The average total operation duration was similar for both groups. • Positive surgical margins were detected in one patient in each group (4% of the patients). Conclusions • A comparison of the FreeHand® robotic camera holder with human camera control during EERPE showed a similar time requirement for the performance of each step of the procedure. • The robotic system provided accurate and fast movements of the camera without compromising the outcome of the procedure.

631 The EVERPRO study: Final results of a non-interventional study evaluating QoL in second-line treatment of mRCC with everolimus Background: Although the prognosis of mRCC patients remains poor, median overall survival has improved since 2006, probably due to the introduction of TKIs. Everolimus treatment following first-line VEGFR-TKI was demonstrated to be efficacious and safe and is recommended by current guidelines. Assuring an adequate QoL has become a major therapy goal, especially in the 2nd line. Hence, QoL and the implication of time effort of everolimus treatment were the major objectives assessed in this study. Methods: Adult patients scheduled for in-label everolimus treatment after 1st line VEGFR-TKI or bevacizumab were eligible. QoL was assessed by means of the NCCN-FACT FKSI-19 questionnaire. Additionally, time needed for therapy and limitations thereof were evaluated based on a particularly developed questionnaire (including total treatment duration and treatment type). Results: 202 patients were evaluable for analyses. Median treatment duration was 19.1 weeks [95% CI: 16.4 – 23.0] and median time to progression was 26.0 weeks [95% CI: 23.3 – 32.6]. The FKSI-19 median total score remained stable during treatment. The median time effort spent on total therapy was 20 hours per patient. Most of the patients stated to have ‘no’, ‘a little’ or ‘moderate’ limitations in their daily, social and professional life. Two months after treatment start, 65 patients reported none or a little time burden due to therapy. 167 patients experienced 804 adverse events (AEs) in total. The most commonly reported AEs related to everolimus were dyspnoea, fatigue and anaemia (all grade). Conclusions: QoL was maintained during everolimus therapy and limitations as well as time effort were acceptable for most patients. The observed safety profile is consistent with previous data and does not implicate changes on the benefit-risk balance of everolimus. This study supports previously published data demonstrating that everolimus is an effective and safe treatment option following a VEGF(R)-targeted drug. Clinical trial information: 2284.

Objectives: Prostate biopsy grade is a key factor when deciding whether to perform pelvic lymph node dissection (PLND) at laparoscopic radical prostatectomy. In common with many laparoscopic radical prostatectomy centers, we perform PLND in patients found to have intermediate and high-risk prostate cancer based upon preoperative PSA, prostate biopsy and imaging. We assessed the feasibility of performing a secondary laparoscopic PLND 6 weeks postoperatively in the presence of postoperative upgrading in patients who did not have PLND. Methods: A prospective study recording the pathological results and operative outcomes prospectively over a 10-month period during which 24 patients underwent a secondary PLND. All patients had a preoperative PSA level Results: During the 10-month period, 377 prostatectomies were carried out in our department in which 54 (18.3%) had an upgrading in the prostatectomy specimen. 24 patients (mean age 60 and mean PSA 6.7 ng/ml) agreed to a secondary PLND. No lymph nodes metastases were observed. One patient who was sexually potent following a nerve-sparing prostatectomy was impotent after the secondary PLND. Conclusions: Upgrading of prostate Gleason score is seen in up to a third of cases in many large published series that is reflected in our experience. A laparoscopic secondary lymphadenectomy is feasible with low morbidity and yields valuable pathological clinical staging for subsequent surveillance and therapy for these high-risk patients.

We report the outcome of 2400 endoscopic extraperitoneal radical prostatectomy (EERPE) cases performed in three institutions, with emphasis on the evolution of the EERPE technique.In total, 2400 EERPE procedures were performed in three institutions. Several surgeons performed the operations. The presented cases also include the learning curve of the surgeons. EERPE was performed in all cases of localized prostate cancer with the same indications to open and transperitoneal laparoscopic radical prostatectomy.Average patient age was 63.3 years (range 41-81 years), and mean preoperative prostate specific antigen (PSA) level was 9.8 ng/mL (range 0.08-93 ng/mL); 857 (38%) patients had previously undergone abdominal or pelvic surgery, while 143 (5.8%) patients had prior prostatic treatment. Pelvic lymph node dissection took place in 1219 (50.8%) patients. Bilateral nerve sparing was performed in 672 patients and unilateral in 284 patients; 100 patients underwent intraoperative hernia repair with mesh placement (82 unilateral and 18 bilateral). Mean operative time was 150.7 minutes (range 50-340 minutes). Conversion to open surgery was never deemed necessary. Fifteen patients received transfusion (0.7%). The mean catheterization time was 6.19 days (range 3-40 days). Overall, 71.7% and 94.7% of the patients were continent at 3 and 12 months, respectively. Totally, 956 patients were treated with nerve-sparing procedure either interfascial or intrafascial; 672 patients underwent bilateral neurovascular bundle preservation, and 284, unilateral. Younger patients tend to have better postoperative potency. Bilateral nerve-sparing EERPE in patients younger than 55 years results in potency rate of 32.4%, 75.3%, and 84.9% at 3, 6, and 12 months postoperatively.The functional and oncological outcome of EERPE is comparable to other approaches for radical prostatectomy. Continuous refinements contribute to the improving outcome of the procedure. Long-term results especially in terms of oncological efficacy are expected.

Acute focal bacterial nephritis (AFBN) is a rarely diagnosed interstitial bacterial infection of the kidney. Due to the non-specific clinical presentation of this entity, correct diagnosis can be challenging. In this work, we present three cases of AFBN aiming to stress the diversity of clinical presentation associated with the disease and the fact that patients with AFBN are at risk of undergoing unnecessary invasive procedures. The employment of invasive diagnostic and therapeutic procedures on the management of AFBN should be limited, as the majority of patients respond well to conservative therapy.

We retrospectively reviewed our experience in performing endoscopic extraperitoneal radical prostatectomy (EERPE) and totally extraperitoneal (TEP) hernia repair in one procedure to evaluate its feasibility and safety. Based on our experience of 70 laparoscopic radical prostatectomies, a total of 60 patients underwent EERPE. Eight of these had 10 hernias repaired with Prolene mesh. The median total operating time for EERPE was 165 minutes. Mesh placement required an additional 15 minutes for a unilateral hernia and 25 minutes for bilateral hernias. The conversion rate and the reoperation rate were 0%. The median duration of vesical catheterization was 8.3 days. One patient required a blood transfusion. The most common minor complications, occurring in eight patients, were edema and hematoma of the penis. No wound infection occurred. The only major complication was a deep venous thrombosis in one patient. No additional complications developed in the hernioplasty group. We conclude that the extraperitoneal approach for radical prostatectomy allows concomitant inguinal hernia repair with a low morbidity rate and within an acceptable operating time.

Laparoscopic radical prostatectomy (LRP) is the standard of care for the management of localized and locally advanced prostatic cancer in numerous institutions worldwide. The extraperitoneal approach for LRP (Endoscopic Extraperitoneal Radical Prostatectomy- EERPE) has been also well established in everyday clinical practice. Both approaches have been refined in the course of time and have achieved oncological and functional results directly comparable to open radical prostatectomy (ORP) and Robot-assisted laparoscopic radical prostatectomy (RALP). The complication rates remain similar among the approaches with LRP and RALP having a favorable outcome in terms of blood loss and postoperative hospitalization. Long-term outcomes of LRP have been published in the recent years and reveal oncological efficacy comparable to the alternative approaches. LRP seems to have stood the test of time and currently provides a cost-effective approach to minimally invasive radical prostatectomy in institutions that do not have access to a robotic surgical system.

Objective To present the experience with the extraperitoneal approach for robotic-assisted simple prostatectomy (RASP) in a technique replicating the vesicocapsular incision technique of open surgery. Patients and Methods RASP was performed on patients with a prostate volume of >80 cm 3 with an indication for open enucleation of the prostate. Preoperatively, all patients were evaluated by uroflowmetry, prostate-specific antigen level, and postvoid residual measurement, as well as by the International Prostate Symptom Score questionnaire. All perioperative data were recorded in a prospective database. Follow-up appointments included the aforementioned measurements and were scheduled at 1 and 6 months postoperatively. Results Ten RASP procedures were successfully performed by the extraperitoneal approach. Mean patient age and prostate volume were 63.1 years (range, 55-74 years) and 129.4 cm 3 (range, 90-170 cm 3 ), respectively. Mean operative time was 122.5 minutes (range, 85-140 minutes) and represented the time from the first incision to the closure of the all incisions. The estimated blood loss was minimal (mean value, 230 mL). Transfusions were not necessary. Mean catheterization period was 7.4 days (range, 6-8 days). The symptomatology, as reported by the International Prostate Symptom Score, was improved at the follow-up appointments in comparison with the baseline values. One case of prolonged fever was noted postoperatively and managed by antibiotics. Conclusion The extraperitoneal approach for RASP proved to be efficient in the management of large prostates. The results are directly comparable with the current available experience with transperitoneal RASP. The extraperitoneal RASP seems to favorably compare with the open simple prostatectomy, while the results are at least comparable with those of conventional laparoscopic approach.

Ureteral reconstructive surgery necessitates adequate exposure of the ureteral lesion and results in large abdominal incisions. Robot assistance allows the performance of complex ureteral reconstructive surgery through small incisions. The current series includes only cases of Boari flaps performed by robot assistance and attempts to describe in detail the technique, review the literature, as well as to expand the experience in the current literature.Eight patients underwent ureteral reimplantation by Boari flap technique. The indications for the performance of the procedure included ureteral stricture from iatrogenic injury in three patients, recurrent ureteral stricture after multiple endoscopic stone management procedures in one patient, ureteral stricture from previous malignant disease in the pelvis or abdomen in three patients, and ureteral stricture due to trauma in one patient. Five cases were located in the left side and three cases in the right side. A variety of parameters were recorded in a prospective database including the time for robot docking and total operative time as well as catheterization and drainage time. The follow-up of the patients included the performance of renal ultrasonography 4 weeks, 3, 6, and 12 months after the procedure.Mean age of the patients was 50.8 (range 39-62) years and mean body mass index was 26.2 (range 23.22-29.29) kg/m(2). Operative time ranged 115 and 240 (mean 171.9) minutes. Mean blood loss was 161.3 (50-250) mL. Conversion to open surgery did not take place in the current series. No intraoperative complications were observed. Postoperative complications included one case of prolonged anastomotic leakage.The robot-assisted approach is efficient in the performance of ureteral reimplantation with Boari flap. Low blood loss, short catheterization time, low complication rate, and excellent reconstructive outcome are associated with the approach. Robot assistance seems to be beneficial for ureteral reconstructive surgery.

SummaryObjective Fibroblast growth factor (FGF)-21 has recently been introduced as a circulating adipokine which reverses insulin resistance and obesity in rodents. In this study, regulation of FGF-21 in renal dysfunction was elucidated in both chronic kidney disease (CKD) and acute kidney dysfunction (AKD). Study design and methods Serum concentrations of total FGF-21 were quantified by enzyme-linked immunosorbent assay in 499 patients with CKD stages 1–5 (study population 1). Furthermore, total FGF-21 was determined before and within 30 h after unilateral nephrectomy, a model of AKD, in 32 patients (study population 2). FGF-21 levels were correlated to anthropometric and biochemical parameters of renal function, glucose and lipid metabolism, as well as inflammation, in both studies. Results In study population 1, median [interquartile range] circulating FGF-21 adjusted for age, gender and body mass index was significantly different between CKD stages with highest values detectable in stage 5 (stage 1: 86·4 [132·9]; 2: 206·4 [223·1]; 3: 289·8 [409·3]; 4: 591·3 [789·0]; 5: 1918·1 [4157·0] ng/l). Furthermore, estimated glomerular filtration rate remained a strong independent and negative predictor of FGF-21. In study population 2, FGF-21 increased significantly postsurgically (325·0 [984·0] ng/l) as compared to presurgical values (255·5 [243·0] ng/l). Furthermore, relative changes of FGF-21 were independently and positively predicted by relative changes of creatinine. Conclusions We demonstrate that circulating FGF-21 is increased in both CKD and AKD. Our results suggest renal excretion as a major route for FGF-21 elimination. The pathophysiological significance of these findings needs to be elucidated in more detail.

Radical prostatectomy is the gold standard surgical treatment for organ-confined prostate cancer. There is no consensus on the impact of previous laparoscopic experience on the learning curve of robot-assisted laparoscopic prostatectomy (RALP). We compared the perioperative complications and early patient outcomes from our initial 100 cases of RALP with laparoscopic prostatectomy (LRP) cases performed well beyond the learning curve.Between July 2011 and January 2012, 110 RALP were performed by one of two surgeons, each with previous experience of more than 1000 LRP. The cases were pair matched from among the last 208 patients who had undergone LRP by the same surgeons at the same time. The clinical parameters, operative details, postoperative complications, and short-term outcomes from these patients, collected prospectively, were compared between the two groups.The prostate-specific antigen (PSA) level and age of the two groups was similar. The operative time (128.4 vs 153.9 min; P=0.01) and blood loss (200 vs 254 mL; P=0.01) was significantly less for the LRP group, but the duration of catheterization was similar (5.89 vs 6.2 days). The complication rate was low. No procedures needed conversions, and no patient had a visceral injury or blood transfusion. Twenty-three patients in the LRP group and 33 patients in the RALP group had extraprostatic disease, and the positive margin rate was 14% and 19% for these respective groups. At 3 months, PSA level was undetectable in 94% of LRP and 92% RALP patients, while 56% and 65% (P=0.062) patients in these groups were using 0 to 2 pads per day.The initial results of the outcome of RALP are at least at par with those of LRP and with those of previously published RALP series. This suggests the lack of a steep learning curve for experienced laparoscopic surgeons in performing RALP.

Laparoendoscopic single-site surgery (LESS) has emerged in the recent years as an alternative approach to conventional laparoscopic surgery which is accompanied by additional advantages over laparoscopy. In this work we attempt to review the current literature and to investigate the possible combination of LESS to other currently available approaches such as natural orifice transluminal endoscopic surgery (NOTES), needlescopic and robotic laparoscopic surgery. Extensive literature search on the topics of LESS, hybrid and pure NOTES, Needlescopic-assisted LESS and “Robot-assisted LESS” took place. Additionally, the accumulated experience from 118 LESSs performed in our departments is presented in an attempt to provide evidence regarding the mix of technique in LESS in urology. The challenging nature of LESS limits the broader application and acceptance. Expanding experience in single-site surgery has currently provided tools such as transvaginal access, needlescopic instruments and robot assistance that can aid LESS and enhance its efficiency without compromising any of its advantages. A mix of these techniques with LESS could ease the stiff learning curve of the second and benefit not only its performance but also the adaptation of LESS as a standard practice. Pure LESS although feasible, remains a technical challenge for the surgeon, preventing the widespread application of the technique. The goal of urologists on LESS surgery should not be the purity of LESS approach, but the superiority against already established techniques. A mix of techniques could be a key for the documentation of the advantages of LESS over conventional laparoscopy.

The conventional laparoscopic surgery is now paving way to the new technologies including robotic and laparoscopic single-site surgery (LESS). We present our updated experience on LESS radical nephrectomy (LESS-RN).The data from patients undergoing LESS-RN in our two institutions were reviewed along with various clinical and pathological parameters.Between 2008 and 2011, 42 LESS-RN were performed (right = 22, left = 20) with mean (range) age and BMI of 63.7 (33-86) years and 25.1 (18-38.6) kg/m(2), respectively. In addition to the instruments in the single port, one extra 3-mm needlescopic instrument was required in 19 patients (right = 17, left = 2). In three patients, two additional 5-mm trocars and instruments were required. None required open conversion. The recorded adverse events include one bowel injury (intraoperative closure without the need for stoma), one postoperative bleeding requiring blood transfusion, one prolonged ileus, and one deep venous thrombosis. The resected specimens revealed pT1a (n = 3), pT1b (n = 33), pT2a (n = 4), and pT3b (n = 2) tumors. The finding of pT3b was incidental rather than planned procedure. None of the patients had positive margins.LESS-RN has proven to be feasible and safe. Beyond cosmesis, further advantages of this approach need to be addressed by randomized trials.

To investigate the outcome of preperitoneal inguinal hernia mesh repairs performed during endoscopic extraperitoneal radical prostatectomy (EERPE).Ninety-three patients underwent inguinal hernia repair during 2125 EERPEs performed between 2002 and 2008. Seventy-seven patients had a unilateral hernia and 16 bilateral inguinal hernias. Patients were treated with EERPE or nerve-sparing EERPE and pelvic lymphadenectomy (if indicated) for localized prostate cancer.The mean age of the patients was 63 years (range 49-75 years). Operative time was 150 minutes (range 85-285 minutes) and estimated mean blood loss was 240 mL (range 30-600 mL). Blood transfusion was never deemed necessary. No conversions to open surgery took place. The mean duration of catheterization was 6.5 days (range 4-25 days). One patient developed a pelvic haematoma, three patients had symptomatic pelvic lymphoceles, and one developed an anastomotic stricture. One patient suffered a rectal injury during the procedure and another developed deep venous thrombosis. The only complication of hernia repair was mild penile bruising and edema. During the follow-up period, we have never observed mesh infection or hernia recurrence.EERPE combined with either a unilateral or bilateral laparoscopic hernia repair appears to be a safe and effective procedure. The incidence of complications related to either EERPE or the hernia repair was not increased. Oncological and functional outcome of EERPE seems not to be influenced by the performance of inguinal hernia repair.

The indications, instrumentation, surgical technique, and complications of laparoendoscopic single-site radical nephrectomy (LESS-RN) are being described in detail in an attempt to familiarize urologists with this novel laparoscopic technique. Our initial experience of 30 consecutive cases of LESS-RN is reported. The results indicate that, in experienced hands, LESS-RN is feasible and safe, with results comparable to those of conventional laparoscopic radical nephrectomy. Nevertheless, larger series of patients are needed to prove if the increased technical difficulty of LESS-RN justifies its use in routine urologic practice.

To present our initial experience with the laparoendoscopic single-site surgery (LESS) approach to bladder diverticulectomy.Four patients underwent LESS bladder diverticulectomy for the management of diverticula that were associated with persistent symptoms. The median diameter of the diverticula was 8.5 cm (range 4-9 cm). Immediately before, a double-pigtail ureteral catheter was inserted in the ureter on the side of the diverticulum. An 18F urethral catheter was placed via guidewire, and its balloon was inflated into the diverticulum under fluoroscopic control. A TriPort inserted in the umbilicus and a combination of prebent and conventional laparoscopic instruments were used. The balloon inside the diverticulum was inflated and the diverticulum were incised. The diverticulum was dissected circumferentially and removed. Suturing of the bladder lesion followed. The specimen was extracted through the umbilical incision. Perioperative parameters were recorded. Postoperative follow-up included cystography, uroflowmetry, and ultrasonography measurement of postvoid residual urine.Average patient age was 51 years (range 42-66 y) and the average body mass index was 26 kg/m(2) (range 23.7-28.7 kg/m(2)). Average operative time was 130 minutes (range 101-154 min). Blood loss was minimal, with 150 mL the higher loss. Complications were not observed during the follow-up period. The catheter was removed on postoperative day (POD) 8 (n=3) and on POD 9 (n=1). Histologic examination did not reveal malignancy. Postoperative pain and analgesic medication requirement were minimal.LESS bladder diverticulectomy proved to be feasible with comparable postoperative outcome to that of the laparoscopic procedure. Further clinical evaluation is deemed necessary.

Laparoscopic extraperitoneal radical prostatectomy (LERP) is considered the standard care treatment option for the management of localized and locally advanced prostatic cancer (PCa) in many institutes worldwide. In this work, the main advantages and disadvantages of LERP approach are reviewed with regard to its outcomes, the complication management, the learning curve, and the extend of pelvic lymph node dissection (PLND). It is concluded that LERP demonstrates comparable cancer control, urinary continence, and potency outcomes with the open and the robot-assisted radical prostatectomy, while offering advantages in complication management in comparison to the transperitoneal approach. Learning curve of LERP is considered long and stiff and significantly affects perioperative outcomes and morbidity, cancer control, and functional results. Thus, close mentoring especially in the beginning of the learning curve is advised. Finally, LERP still has a role in the limited or modified PLND offered in intermediate risk PCa patients.

New operating procedures that spare the important neural structures of the urogenital tract have led to improved functional results in terms of bladder function, urinary continence and erectile potency. Well-described examples are nerve-sparing radical prostatectomy [1–3] and cystectomy (continence, potency) [3, 4], ureteric antireflux surgery (bladder function) [5], extended radical hysterectomy with total mesometrial resection (bladder function) [6] and rectal resection (continence, bladder function, potency) [7].

Whilst the patient is supine, following induction of anaesthesia, a urinary catheter is inserted. The patient is now rotated to the lateral position and the urinary bag is placed either at the top or bottom end of the bed for access by the anaesthetist. The legs are separated and protected with either pillows or a specially designed foam or rubber device between them as seen in the inset, in order to relieve any weight on pressure points, while the legs are slightly flexed at the knees. All other bony points, including shoulders and hips, are protected by the rubber or foam mat that is positioned on the operating table. The head and neck are supported with either pillows or a rubber head ring in order to maintain them in a neutral position. Depending on the softness of the table mattress, an axillary rubber roll may be required (not illustrated in these images) to prevent brachial plexus injury.

The laparoscopic approach has been established as a treatment modality for the performance of radical nephrectomy during the recent years, while laparoscopic partial nephrectomy represents an alternative under investigation in several centers of laparoscopic excellence around the world. Significant advantages of laparoscopic surgery when compared to the classical open approach have extensively documented for over 2 decades. Nevertheless, laparoscopy is an evolving surgical field, which is characterized by the rapid adaptation of technical innovations. Laparoscopic renal surgery includes approaches for radical and partial nephrectomy with oncological outcome similar to open surgery and decreased postoperative morbidity and therefore can be considered for the same indications as open surgery. Several issues regarding the technical feasibility and refinement as well as the oncological efficacy of these procedures are presented.

Laparoendoscopic single-site surgery (LESS) represents the latest innovation in laparoscopic surgery. We compare in dry and animal laboratory the efficacy of recently introduced pre-bent instruments with conventional laparoscopic and flexible instruments in terms of time requirement, maneuverability, and ease of handling.Participants of varying laparoscopic experience were included in the study and divided in groups according to their experience. The participants performed predetermined tasks in dry laboratory using all sets of instruments. An experienced laparoscopic surgeon performed 24 nephrectomies in 12 pigs using all sets of instruments. Single port was used for all instrument sets except for the conventional instruments, which were inserted through three ports. The time required for the performance of dry laboratory tasks and the porcine nephrectomies was recorded. Errors in the performance of dry laboratory tasks of each instrument type were also recorded.Pre-bent instruments had a significant advantage over flexible instruments in terms of time requirement to accomplish tasks and procedures as well as maneuverability. Flexible instruments were more time consuming in comparison to the conventional laparoscopic instruments during the performance of the tasks. There were no significant differences in the time required for the accomplishment of dry laboratory tasks or steps of nephrectomy using conventional instruments through appropriate number of ports in comparison to pre-bent instruments through single port.Pre-bent instruments were less time consuming and with better maneuverability in comparison to flexible instruments in experimental single-port access surgery. Further clinical investigations would elucidate the efficacy of pre-bent instruments.

Objective: The current study investigates the effect of bladder neck (BN) preservation on postoperative continence and positive surgical margins (+SMs). Patients and Methods: 150 patients (group 1) who underwent BN-sparing endoscopic extraperitoneal radical prostatectomy (EERPE) and 90 patients treated with EERPE and BN resection (group 2) were retrospectively evaluated. Results: Both groups were similar for age, prostate-specific antigen and prostate size. There was no significant difference in operative time, mean blood loss or transfusion rate. Mean catheterization time was similar. The overall +SM rates were very similar at 10.7% for group 1 and 10.0% for group 2 (group 1, pT2 = 5.1% and pT3 = 30.3%; group 2, pT2 = 2.9% and pT3 = 33.3%). One of 16 patients in group 1 and 1 of 9 in group 2 had a +SM at BN. Statistically significant differences in continence were observed 24 h after catheter removal and 3 months postoperatively between both groups. Conclusion: BN preservation proved to have an impact on postoperative early continence of patients undergoing EERPE. Continence of patients who underwent BN preservation was improved after catheter removal and at the 3-month follow-up in comparison to those without BN preservation, but +SMs were not affected by the BN-sparing surgery.

To compare the outcome of intrafascial nerve-sparing endoscopic extraperitoneal radical prostatectomy (nsEERPE) with interfascial (standard) nsEERPE.Four-hundred patients underwent nsEERPE; 200 patients underwent bilateral intrafascial nsEERPE (group A) and 200 bilateral standard nsEERPE (group B). Tumor stages of T1 and T2a, prostate-specific antigen level10 ng/mL, maximal Gleason score 3+4 (not 4+3) and preoperative potency were considered as candidates for nsEERPE. Patients were randomized to the aforementioned groups. Perioperative data, and functional and oncological outcome were reviewed. Patients not requiring any pads or requiring 1 pad for safety were defined as continent. Patients responding positively to sexual encounter profile diary question numbers 2, 3, and 5 were considered as potent.Perioperative data were similar between groups. At 3 months, 74% of group A and and 63% of group B were continent. At 6 months, the respective figures were 87.9% and 76.2%, respectively (A, B). At 12 months, 93.2% of group A and 90.7% of group B were continent. Potency rates of group A were 93.5% (55 years), 83.3% (55-65 years), and 60% (65 years) at 12 months. The respective figures for Group B were 77.1%, 50%, and 40%. Positive surgical margins were detected in 9% and 9.5% of groups A and B, respectively.Intrafascial nsEERPE provides significantly better potency in patients55 years of age at 12 months and in patients 55-65 years of age at 6 and 12 months, with probably limited effect on the oncological outcome. Significantly improved continence was observed at 3 and 6 months in favor of intrafascial nsEEPRE.

Objectives To study radical prostatectomy that has been reported to be more challenging and associated with complications in patients with history of transurethral resection of prostate (TURP). Methods In our series, 100 of 2300 patients had undergone endoscopic extraperitoneal radical prostatectomy (EERPE) after previous TURP. All patients included in the study had at least 1-year follow-up. Patient demographics, mean blood loss, mean catheterization time, complications, functional and oncologic outcome were reviewed. Results In all, 100 patients underwent EERPE and 26 of these patients were treated by nerve-sparing EERPE. Lymphadenectomy was performed in 45 patients. Operative time and mean blood loss were similar to previous EERPE series. The transfusion rate and mean time of catheterization were slightly higher than general EERPE population. Positive surgical margin rates were 7% for pT2 and 36% for pT3/4. At 12-month follow-up, 94% of the patients did not experience prostate-specific antigen level ≥ 0.1 ng/mL. The overall complication rate was 14%. At 12 months, 93% of patients were continent, 4% used 1-2 pads/day and 3% needed >2 pads/day. The potency rates for the 26 patients who underwent nerve-sparing EERPE were 52.6% and 66.7% at 6 and 12 months, respectively. Conclusions Patients who had previously undergone TURP should be considered for radical treatment with EERPE. The procedure is safe even though technically more demanding. Perioperative, functional, and short-term oncologic outcome is promising and directly comparable to existing EERPE experience. Potency results were lower in comparison with existing EERPE series.

Background Laparoscopic-endoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery. Objective To assess the feasibility of LESS radical nephrectomy (LESS-RN). Design, setting, and participants Ten patients with body mass index (BMI) ≤30 underwent LESS-RN for renal tumour by two experienced laparoscopists. Surgical procedure TriPort (Olympus Winter & Ibe, Hamburg, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and flexible grasper and scissors was used. A 5-mm 30° camera was also used. The standard laparoscopic transperitoneal nephrectomy technique was performed. Measurements Patient demographics, operative details, and final pathology were prospectively recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. Results and limitations Ten cases were successfully accomplished (two right-sided tumours and eight left-sided tumours; tumour diameter ranges: 4–8cm). The mean patient age was 63.5 yr (22–77 yr), and median BMI was 23.56 (18.2–26.6). The mean operative time was 146.4min (120–180min), and the mean blood loss was 202ml (50–900ml). Pathological examination observed organ-confined T1 renal cell carcinoma in nine cases and pT3b tumour in one case. One bleeding complication occurred. Limitations regarding the intraoperative instrument ergonomics and the requirement for ambidexterity of the surgeon were noted. Conclusions LESS-RN proved to be safe and feasible. Further clinical investigation in comparison to the established techniques should take place to evaluate the outcome of LESS-RN.

This study investigated aberrations in baroreflex function and cardiovascular reactivity related to the condition of chronic low blood pressure. In 40 hypotensive and 40 normotensive control subjects, blood pressures were continuously recorded at rest and during mental stress. Baroreflex sensitivity was determined in the time domain using sequence analysis. Beat-to-beat hemodynamic indices were estimated from the blood pressure waveforms by means of Modelflow analysis. In the hypotensive sample, a higher baroreflex sensitivity was observed under both conditions. Furthermore, this group experienced a less pronounced increase of blood pressure and stroke volume under stress. The findings underline the involvement of the baroreflex in the long-term setting of tonic blood pressure and suggest its relevance in the etiology of chronic hypotension. In addition, this study documents reduced cardiovascular reactivity and thus deficient hemodynamic adjustment to situational requirements in chronic low blood pressure.

Laparoscopic transperitoneal radical prostatectomy (LRP) and endoscopic extraperitoneal radical prostatectomy (EERPE) are established techniques for the management of localized prostate cancer in numerous specialized urologic centers worldwide. The complication rates of LRP and EERPE are ranging between 2 and 17%. Rare but possible complications are vascular injuries, bowel injury, lymphocele formation, port-site hernia, anastomotic leakage, gas embolism and catheter obstruction and other rare events. Prevention and management of complications requires high surgical expertise and adequate standardization of the technique. We herein review our experience with the endoscopic extraperitoneal radical prostatectomy in a series of 1,800 consecutive patients regarding the appearance of complications and their management.