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Background: Partial nephrectomy for small renal masses (SRM) may be useful for preserving renal function, but is technically more difficult than radical nephrectomy. Cryoablation may be performed under local anesthesia. The objective of the present study is to assess the safety and therapeutic efficacy of cryoablation with lipiodol marking for SRM., Methods: Cryoablation therapy was performed on 42 patients under local anesthesia. Their median age was 74 years (31-91). The median tumor diameter was 21 mm (10-42). Responses to the treatment were evaluated using modified Response Evaluation Criteria in Solid Tumors (mRECIST) by contrast-enhanced CT. In six patients (14.3%) for whom it was not possible to use contrast medium, plain CT findings were assessed according to Response Evaluation Criteria in Solid Tumors (RECIST)., Results: Twenty-nine (69%) and five (12%) patients achieved complete responses (CR) and partial responses (PR), respectively, while four (10%) and four (10%) patients each had stable disease (SD) and progressive disease (PD) after the first course of therapy. A second course of cryoablation therapy with lipiodol marking was performed on three out of four patients with PD after the first course of therapy, and resulted in a total of 32 patients achieving CR (76%). Four (36.4%) out of 11 patients for whom lipiodol marking was not conducted had PD, whereas none of the 31 patients for whom lipiodol marking was conducted had PD. All grade complications were reported in 11 (24.4%) patients while grade 3 in two (4.4%) patients. 11 (24.4%) A significant difference was observed in postoperative hemorrhagic events in all grades (18% in patients undergoing cryoablation without lipiodol marking vs. 0% in patients undergoing cryoablation without lipiodol marking)., Conclusions: Although further studies involving more patients are needed in order to evaluate long-term results, cryoablation therapy appears to be a useful treatment option for SRM. Preoperative marking with lipiodol was helpful for improving complication and survival rates with cryoablation.

Objectives: To assess the effectiveness of soft coagulation in off-clamp laparoscopic partial nephrectomy., Methods: A total of 32 patients with renal tumors underwent laparoscopic partial nephrectomy with off-clamp using soft coagulation between May 2012 and September 2013. Tumor resection was carried out using a combination of bipolar forceps and a ball electrode using the soft coagulation system without hilar clamping. The outcomes of these patients were compared with those of 30 patients treated with hilar clamping., Results: This off-clamp procedure was successfully completed in 31 cases. No significant differences were observed in the mean age (60 vs 61 years), sex (male/female; 25/7 vs 20/10), mean RENAL nephrometry score (5.7 vs 5.8), mean body mass index (24.4 vs 23) or tumor size (15 mm vs 16 mm) between the two groups. No significant differences were noted in positive surgical margins (0 vs 0) or blood loss (104 vs 115 cc) as well. In contrast, a significant difference was noted in the total operative time (278 vs 238 min). Serum creatinine percentage changes at 3 months were 6.4 versus 7.3% in the off-clamp and hilum-clamp groups, respectively, which were not significantly different., Conclusions: Off-clamp laparoscopic partial nephrectomy can be safely carried out by using a soft coagulation technique., (© 2015 The Japanese Urological Association.)

Introduction: The aim of this study was to evaluate our institution's experience in performing laparoscopic radical nephrectomy (LRN) and partial nephrectomy (PN) in patients with small renal masses., Methods: 142 patients with cT1aN0M0 lesions were identified. 68 of these subjects were treated with LRN and 74 were treated with laparoscopic PN (LPN). The clinicopathological characteristics of the two groups of patients, including diameter-axial-polar (DAP) nephrometry and RENAL nephrometry score (RENAL-NS), operative results, and outcomes, were retrospectively analyzed., Results: A multivariate logistic regression analysis for the selection of PN as the treatment showed that tumor size, DAP nephrometry, RENAL-NS and imperative condition were all independent factors. The area under the curve receiver operating characteristics (ROC-AUC) of DAP and RENAL-NS for performing LPN were 0.897 and 0.825, respectively., Conclusions: Although LRN was performed in patients with a high nephrometry score in this study, open partial nephrectomy (OPN) should be considered for patients with a high nephrometry score in T1a renal cell carcinoma (RCC) because of better functional and similar oncological outcomes. Based on ROC analysis, when DAP is 6 or less, LPN should be considered and when DAP is 7 or more, OPN should be considered.

Objective: To evaluate the feasibility of regional cramp in laparoscopic partial nephrectomy, we performed partial nephrectomy using a kidney grasper that enabled the application of ischemia to a limited region of the kidney., Materials and Methods: The subjects were 5 renal cell carcinoma patients. The mean tumor diameter was 15 mm. There were 2 male and 3 female patients. A transperitoneal approach was used in all cases. Following the standard procedure of laparoscopic partial resection, the hilum of the kidney was confirmed and treated to prepare for rapidly applying clamping with forceps. Tumor resection and suture were then performed under partial warm ischemia using a kidney grasper., Results: Surgery could be completed in 4 patients using this method. In the remaining patient, control of bleeding was considered difficult during tumor resection after applying partial ischemia, and so the procedure was switched to renal artery clamping using bulldog forceps. In the 4 patients in whom a kidney grasper was used, the mean partial warm ischemia time was 23.6 minutes (range, 23-25 minutes), and the mean blood loss was 110 mL (range, 20-260 mL)., Conclusions: This procedure may be a useful option in ischemia for partial nephrectomy.

Objectives: To investigate the long-term outcomes of hand-assisted laparoscopic radical nephrectomy compared with those of open nephrectomy., Methods: Hand-assisted laparoscopic radical nephrectomy was carried out in 132 patients with T1 renal cell carcinoma (between November 1999 and November 2008). Their outcomes were compared with those of 61 patients treated with open nephrectomy. The durations of follow up were 6-121 months (median 65 months) and 7-146 months (median 84 months) in the hand-assisted laparoscopic radical nephrectomy and open nephrectomy groups, respectively., Results: The 7-year recurrence-free rates were 88.5 and 85.6% in the hand-assisted laparoscopic radical nephrectomy and open nephrectomy groups, respectively, showing no significant difference between the two groups. The 7-year cancer-specific survival rates were 92.3 and 91.4% in the hand-assisted laparoscopic radical nephrectomy and open nephrectomy groups, respectively, showing no significant difference between the two groups. Also, the 10-year recurrence-free rates were 85.4 and 78.1% in the hand-assisted laparoscopic radical nephrectomy and open nephrectomy groups, respectively. When changes in the recurrence-free rate were analyzed using the Kaplan-Meier method, no significant difference was observed between the two groups. The 10-year cancer-specific survival rates were 91.8 and 87.9% for hand-assisted laparoscopic radical nephrectomy and open nephrectomy, respectively, showing no significant difference between the groups., Conclusions: Hand-assisted laparoscopic radical nephrectomy might be comparable with open nephrectomy with regard to long-term cancer control., (© 2014 The Japanese Urological Association.)

Purpose: To determine the occurrence of flank symptoms, flank muscle atrophy, bulge, and hernia formation after open and laparoscopic partial nephrectomy (LPN)., Patients and Methods: Our prospective Institutional Review Board-approved database was queried to identify 50 consecutive patients who were treated with open partial nephrectomy (OPN) and 50 consecutive patients who were treated with LPN between September 2006 and May 2008. Study patients had: Solitary clinical T1 renal tumor, preoperative and ≥6 month postoperative CT scan performed at our institution, and a confirmed renal-cell carcinoma on the final pathology report. Patients with previous abdominal surgery and neuromuscular disorders were excluded. Oncocare software was used to measure abdominal wall musculature on preoperative and postoperative CT scan. Bilateral flanks were compared for muscle volume, bulge, and hernia. Patients were administered a phone questionnaire to assess postoperative flank symptoms., Results: No statistical significant difference was found in the demographics between the two groups. Median age (range) was 59.9 years (20.6-80.7) in the OPN group and 57.5 years (25-78) in the LPN group (P=0.89). Median (range) body mass index and American Society of Anesthesiologists scores were similar between the two groups. On CT scans, median percent variation (range) in abdominal wall muscle volume was significantly greater in the OPN group: -1.03% (-31.4-1.5) vs-0.39% (-5.2-1.8) (P=0.006). The median extent of flank bulge on CT scans (range) was also greater in the OPN group: 0.75 cm (-1.9-7.6) vs 0 cm (-2.7-2.8) (P=0.0004). The OPN group was also more symptomatic, including paresthesia 48% vs 8% (P=0.0053); numbness 44% vs 0% (P=0.002); and flank bulge 57% vs 12% (P=0.007)., Conclusions: Minimally invasive partial nephrectomy has lesser deleterious impact on flank muscle volume compared with OPN with fewer symptoms of flank bulge, paresthesia, and numbness.

Objective: To evaluate the hemostatic effect of newly developed medical adhesive in animal partial nephrectomy models., Materials and Methods: A total of 30 experimental rabbits were used in the first study. After clamping the renal vessels, partial nephrectomy was performed up to the opening of the calices. Bioglue was applied to the resection stumps using the new glue (group 1, n = 10) or fibrin glue (group 2, n = 10) for 2 minutes, and the blood loss was measured after unclamping the vessels. Simple unclamping without glue (group 3, n = 10) was also evaluated. For the second study, we used 9 dogs with blood pressure monitoring. After preparation similar to that for the first study, the new glue was applied in 3 dogs (group 4), fibrin glue in 3 dogs (group 5) and no glue in 3 dogs (group 6). Histologic evaluation was performed at 7 days and 1 month after surgery., Results: The mean blood loss was significantly less in group 1 (1.45 g) than in groups 2 (6.59 g) and 3 (19.77 g; P <.001 for both). It was also significantly less in group 4 (12.5 g) than in group 5 (182.5 g; P <.001). Group 4 maintained their initial blood pressure throughout the study, but a significant decrease was observed in group 5. No hematoma was observed at day 7., Conclusion: The new glue showed acceptable hemostasis when applied to the resection stumps after partial nephrectomy in both the rabbit and the dog models. These findings indicate that it could be useful for hemostasis after partial nephrectomy., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: We compare perioperative, functional and intermediate-term oncological outcomes of laparoscopic partial nephrectomy (LPN) vs laparoscopic cryoablation (LCA) for small renal tumour in patients with a solitary kidney. A treatment algorithm is also proposed., Patient and Methods: Over a 10-year period (02/1998-09/2008), 78 patients with a small tumour in a functionally solitary kidney underwent LPN (n = 48) or LCA (n = 30). Baseline, perioperative, and follow-up data were collected prospectively and analyzed retrospectively., Results: Demographic data were similar between the LPN and LCA groups. Tumours were somewhat larger (3.2 vs 2.6 cm) in the LPN group. LPN was associated with greater blood loss (391 vs 162 mL; P = 0.003), and trended towards more post-operative complications (22.9% vs 6.7%; P = 0.07). By 3 months post-operative, eGFR decreased by 14.5% and 7.3% after LPN and LCA, respectively (P = 0.02). Post-operative temporary dialysis was required after 3 LPN (6.2% vs 0%, P = 0.16). Median follow-up time for LPN and LCA was 42.7 and 60.2 months, respectively. Local recurrence was detected in 4 (13.3%) LCA patients only (P = 0.02). Overall survival was comparable between LPN and LCA at 3 and 5 years, respectively (P = 0.74). The LPN group had superior cancer-specific and recurrence-free survival at 3 and 5 years compared to the LCA group (P < 0.05, for all comparisons)., Conclusions: Given adequate technical expertise, both LPN and LCA are viable nephron-sparing options for patients with tumour in a solitary kidney. Although LCA is technically easier and has superior functional outcomes, oncologic outcomes are superior after LPN., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Purpose: Management for intraparenchymal renal tumors represents a technical challenge during laparoscopic partial nephrectomy since, unlike exophytic tumors, there are no external visual cues on the renal surface to guide tumor localization or excision. Also, hemostatic renorrhaphy and pelvicalyceal suture repair in these completely intrarenal tumors create additional challenges. We examined the safety and technical feasibility of this procedure in this cohort., Materials and Methods: Of 800 patients who underwent laparoscopic partial nephrectomy 55 (6.9%) had completely intraparenchymal tumors. Technical steps included intraoperative ultrasound guidance of tumor resection, en bloc hilar clamping, cold excision of tumor and sutured renal reconstruction., Results: Mean tumor size was 2.3 cm (range 1.0 to 4.5), mean blood loss was 236 cc (range 25 to 1,000) and mean warm ischemia time was 29.9 minutes (range 7 to 57). There were no positive margins. When we compared laparoscopic partial nephrectomy for intraparenchymal tumors to the same procedure in another 3 tumor groups, including completely exophytic tumors, tumors infiltrating up to sinus fat and tumors infiltrating but not up to sinus fat, there were no statistically significant differences among the groups in complications, positive margin rate, blood loss, or tumor excision or warm ischemia time., Conclusions: Laparoscopic partial nephrectomy for completely intrarenal tumors is a technically advanced but effective, safe procedure. Facility and experience with the technique, effective use of intracorporeal laparoscopic ultrasound and adherence to sound surgical principles are the keys to success. Most recently we have performed laparoscopic and robotic partial nephrectomy for such completely intrarenal tumors using a zero ischemia technique., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: To present our initial operative experience in which single-port-light endoscopic robot-assisted reconstructive and extirpative urological surgery was performed by one surgeon, using a pig model., Materials and Methods: This pilot study was conducted in male farm pigs to determine the feasibility and safety of single-port, single-surgeon urological surgery. All pigs had a general anaesthetic and were placed in the flank position. A 2-cm umbilical incision was made, through which a single port was placed and pneumoperitoneum obtained. An operative laparoscope was introduced and securely held using a novel low-profile robot under foot and/or voice control. Using articulating instruments, each pig had bilateral reconstructive and extirpative renal surgery. Salient intraoperative and postmortem data were recorded. Results were analysed statistically to determine if outcomes improved with surgeon experience., Results: Five male farm pigs underwent bilateral partial nephrectomy and bilateral pyeloplasty before a completion bilateral radical nephrectomy. There were no intraoperative complications and there was no need for additional ports to be placed. The mean (range) operative duration for partial nephrectomy, pyeloplasty, and nephrectomy were 120 (100-150), 110 (95-130) and 20 (15-30) min, respectively. The mean (range) estimated blood loss for all procedures was 240 (200-280) mL. The preparation time decreased with increasing number of cases (P = 0.002)., Conclusions: The combination of a single-port, a robotic endoscope holder and articulated instruments operated by one surgeon is feasible. With a single-port access, the robot allows more room to the surgeon than an assistant.

Purpose: We hypothesized that from 1999 to 2008 patient and tumor selection criteria, perioperative outcomes, complications and renal function outcomes may have evolved significantly in 800 laparoscopic partial nephrectomies., Materials and Methods: We retrospectively divided 800 patients who underwent laparoscopic partial nephrectomy for tumor, as done by 1 surgeon, into 3 chronologic eras, including era 1-276 from September 1999 to December 2003, era 2-289 from January 2004 to December 2006 and era 3-235 from January 2007 through November 2008. We evaluated prospectively collected data on tumor characteristics, perioperative outcomes and renal function outcomes., Results: When comparing eras 1 to 3, tumors in the most recent era were larger, more commonly 4 cm or greater, and central, and less often peripheral and less than 4 cm (each p value significant). Despite increasing tumor complexity warm ischemia time was shorter (31.9, 31.6 and 14.4 minutes, respectively, p <0.0001), and the overall rates of postoperative and urological complications were significantly lower in the most recent era. The rate of parenchymal margins positive for cancer was 1%, 1% and 0.6%, respectively. Renal function outcomes were superior in era 3, as reflected by a lesser decrease in the estimated glomerular filtration rate (18%, 20% and 11%, respectively). In the 744 patients with pathologically confirmed malignancy 5-year overall, cancer specific and recurrence-free survival was 90%, 99% and 97%, respectively., Conclusions: During our 9-year experience with 800 consecutive laparoscopic partial nephrectomies tumor characteristics and surgical outcomes evolved. Despite increasing tumor complexity in contemporary practice 3 key outcomes of laparoscopic partial nephrectomy improved significantly, including ischemia time, complications and renal function. We now routinely offer laparoscopic partial nephrectomy for most tumors hitherto reserved for open nephron sparing surgery.

Purpose: We present a large series of minimally invasive nephron sparing surgery outcomes in solitary kidneys with a focus on treatment selection criteria, and oncological and functional outcomes., Materials and Methods: Of 1,019 patients who underwent minimally invasive nephron sparing surgery since September 1997 at our institution 36, 36 and 29 underwent laparoscopic partial nephrectomy, cryoablation and radio frequency ablation, respectively, for tumors in a solitary kidney. Data, including patient and tumor characteristics, surgery details, complications, and postoperative renal function and intermediate term oncological outcomes in each patient, were obtained by telephone contact or from charts. The 3 groups were compared for perioperative, functional and oncological outcomes., Results: On multivariate analysis tumor size, aspect and remnant kidney status were independent predictors of treatment selection. Cancer specific and overall survival at 2 years was 100% and 91.2% for laparoscopic partial nephrectomy, 88.5% and 88.5% for cryoablation, and 83.9% and 83.9% for radio frequency ablation, respectively. Disease-free survival was significantly better for laparoscopic partial nephrectomy than for cryoablation and radio frequency ablation (100% vs 69.6% and 33.2%, respectively, p <0.0001). The mean estimated glomerular filtration rate change for laparoscopic partial nephrectomy, cryoablation and radio frequency ablation of 17, 3 and 7 ml per minute per 1.73 m(2) reflected a 26%, 6% and 13% decrease from baseline, respectively, which was statistically significant (p = 0.0016)., Conclusions: Laparoscopic partial nephrectomy and probe ablative procedures can be safely and efficiently done for renal tumor in patients with a solitary kidney. Intermediate term oncological outcomes are superior for laparoscopic partial nephrectomy despite somewhat poorer renal function outcomes than those of cryoablation and radio frequency ablation.

Objectives: To determine the technical feasibility and reproducibility of pure natural orifice transluminal endoscopic surgery (NOTES) transvaginal nephrectomy using NOTES-specific instrumentation, with no transabdominal assistance., Materials and Methods: Five female farm pigs (mean weight 45 kg) had a right NOTES nephrectomy, using a single-channel gastroscope in the first three pigs and a dual-channel gastroscope in the remaining two. The peritoneal cavity was accessed through the posterior fornix of the vagina. Dissection was started at the lower pole of the kidney, and the ureter was retracted laterally and followed towards the hilum. An XL articulated 60 cm endo-GIA stapler (US Surgical, Norwalk, CO, USA), inserted transvaginally via a separate vaginal incision, was used for tissue retraction and renal hilar transection. The kidney was freed, entrapped in an impermeable sac, and extracted intact transvaginally., Results: All five procedures were successful with no addition of a transabdominal laparoscopic port or open conversion. The total operative duration decreased from 200 min in the first pig to 60 min in the last (mean 113 min); the mean blood loss was <50 mL, the mean kidney length was 13.9 cm and the weight was 142 g. There were no intraoperative complications; at autopsy, there was no pelvic or bowel injury., Conclusions: Pure NOTES transvaginal nephrectomy is feasible in the porcine model. It has the potential of a less morbid approach, providing truly scar-less surgery. Further development of instrumentation is necessary.

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.

OBJECTIVE To determine whether a novel port (QuadPort, Advanced Surgical Concepts, Wicklow, Ireland) can facilitate transvaginal nephrectomy (TN), a natural orifice transluminal surgery (NOTES) procedure, using standard and articulating laparoscopic instruments. MATERIALS AND METHODS Four fresh female cadavers were used in this feasibility study with a plan to perform two right-sided and two left-sided TN. Exclusion criteria were a history of nephrectomy and a height of >1.82 m. The cadaver was placed in the lithotomy position with the target side up 30-45 degrees . A three-channel R-port (Advanced Surgical Concepts) was placed in the umbilicus to monitor the transvaginal procedure. The four-channel QuadPort was placed through the posterior fornix into the peritoneal cavity. Regular laparoscopic instruments were used transvaginally to mobilize the colon, dissect the ureter, identify and divide the renal artery between clips, and divide the renal vein with a laparoscopic stapler. Remaining attachments of the kidney were divided and the specimen entrapped in a plastic bag before transvaginal extraction. RESULTS Three (two right- and one left-sided) TNs were performed successfully; one left-sided TN was aborted in the last cadaver due to dense pelvic adhesions from previous pelvic surgery. In the first two cadavers we required assistance from the umbilical port only to divide the attachments between the upper pole of the kidney and the diaphragm supero-posteriorly. In the third case we were able to perform this dissection completely transvaginally using a flexible gastroscope. CONCLUSIONS A completely NOTES-based TN in humans is challenging. Robust laparoscopic instruments have the requisite tensile strength when deployed through a large calibre, secure, multichannel transvaginal port. Extra-long laparoscopic instruments are helpful. The cephalad aspect of the hilum and the upper pole attachments are difficult areas. Novel and robust flexible instruments still need to be developed.

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.

Objective: To present our laboratory experience with natural orifice translumenal endoscopic surgery (NOTES) renal cryoablation., Materials and Methods: In two female farm pigs, we performed four procedures of NOTES renal cryoablation. In each pig, NOTES was performed through a transgastric approach and a transvaginal approach for each kidney, respectively. The pig was placed in the flank position and pneumoperitoneum obtained using a transabdominal Veress needle. In the first pig, we started with the left kidney with a transgastric approach: a dual-channel video gastroscope (Olympus, Tokyo, Japan) was used, the stomach wall was punctured using a needle-knife, a guidewire was passed into the abdominal cavity and the access dilated using a controlled radial expansion balloon. The bowel was mobilized medially and the Gerota's fascia overlying the upper pole was dissected. Under direct endoscopic vision, a cryoablation probe was introduced percutaneously into the anterior upper pole of the kidney. The pig was then flipped to the right flank position and a transvaginal approach was used: the gastroscope was introduced through the posterior fornix of the vagina. For the second pig, we performed initially a transgastric right-side cryoablation then a transvaginal left-side cryoablation as described for the first pig., Results: All four procedures were performed successfully, with no intraoperative complications. No additional laparoscopic ports or open conversions were necessary. The vision of the kidney and the ice-ball was adequate for all cases. The mean operative duration was 83 min. Stomach closure was tested watertight, and there were no abdominal or pelvic injuries found at autopsy., Conclusions: NOTES can provide adequate minimal surgical dissection for safe and effective percutaneous renal cryoablation under direct videoscopic monitoring at kidney locations otherwise not accessible percutaneously. Both transgastric and transvaginal approaches can be used effectively for renal cryoablation providing a minimally invasive scar-less surgery.

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. 2.5 cm, p=0.005) in the affected kidney and lower preoperative serum creatinine levels (1 vs. 1.4 mg/dl, p=0.02). Compared to the LCA group, patients in the LPN group had greater estimated blood loss (200 vs. 125 ml, 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.

Objectives: To present an initial experience with robotic natural orifice translumenal surgery (R-NOTES) in reconstructive urology using the da Vinci surgical system., Methods: In 10 female farm pigs (mean weight, 34.5 kg), 10 pyeloplasties (right 5, left 5), 10 partial nephrectomies (right 5, left 5), and 10 radical nephrectomies (right 5, left 5) were performed. The robot telescope and the first robotic arm were placed through a single 2-cm umbilical incision, and the second robotic arm was placed through the vagina., Results: All 30 R-NOTES procedures were performed successfully without any addition of laparoscopic port or open conversion. Mean length of the umbilical incision was 2.6 cm. Mean operative time was 154 minutes, and mean estimated total blood loss was 72 mL. Mean warm ischemia time in the partial nephrectomy group was 25.4 minutes. There were no intraoperative complications. There were no robotic system failures during the entire experiment. We did not find any significant difference when comparing right-side and left-side procedures. When analyzing the learning curve, only robot preparation time reached a statistically significant inverse correlation with increasing number of cases (r = -0.72, P = .018)., Conclusions: Robotic NOTES pyeloplasty, partial nephrectomy, and radical nephrectomy are feasible and safe in the porcine model. This approach has the potential for a less morbid and scarless outcome. Intracorporeal suturing is significantly enhanced using the robot, especially through the challenging translumenal natural orifice approach. Further development of robots adaptive to NOTES would boost efforts toward clinical NOTES applications.

Purpose: We evaluate our experience with laparoscopic partial nephrectomy to determine risk factors for postoperative complications., Materials and Methods: A prospectively maintained database of 507 laparoscopic partial nephrectomy procedures since September 1999 was retrospectively analyzed with emphasis on postoperative complications. Severity of complications was graded using a 5-tiered scale based on National Cancer Institute Common Toxicity Criteria Version 2.0 reporting criteria. Complication rates were compared between 1999 to 2002 and 2003 to 2006. Multivariate analysis of baseline and perioperative variables was performed to identify risk factors associated with postoperative complications for the 2 eras., Results: After 507 laparoscopic partial nephrectomy procedures 93 patients (19.7%) had 107 complications, including 49 urological (9.7%) and 58 nonurological (11.4%). Of the complications, 20.6% were grade I, 45% were grade II, 30% were grade III, 4.7% were grade IV and none were grade V. On multivariate analysis, presence of a solitary kidney (1999 to 2002 p = 0.0115, 2003 to 2006 p = 0.0045), increased warm ischemia time (1999 to 2002 p = 0.0399, 2003 to 2006 p = 0.0066) and increased estimated blood loss (1999 to 2002 p = 0.0224, 2003 to 2006 p = 0.0293) were significant predictors of overall postoperative complications for the 2 eras. Compared to the 1999 to 2002 era, the 2003 to 2006 era witnessed a dramatic increase in number of total laparoscopic partial nephrectomy procedures (100% increase) and complex tumors (132% increase), yet overall (p = 0.001), urological (p = 0.03) and nonurological (p = 0.02) complications decreased significantly., Conclusions: Prolonged warm ischemia, increased intraoperative blood loss and solitary kidney status increase the likelihood of postoperative complications after laparoscopic partial nephrectomy. With experience the incidence of complications has decreased significantly despite a significant increase in tumor and procedural complexity.

Bilateral nephrectomy in the rats deprived of water for 46 h markedly reduced plasma angiotensin II concentrations (P less than 0.001), but it was without effect on extremely low levels of the hormone in the hypothalamic tissue. These results may suggest that the activity of a possible intrinsic brain renin-angiotensin system is not influenced by that of the kidney-plasma renin-angiotensin system.