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INTRODUCTION AND OBJECTIVE:Discrimination against women in surgical training has been subjectively described for decades. Despite significant growth over the years, Urology continues to have one of...

INTRODUCTION AND OBJECTIVE:Previous studies of surgical residents have shown that males and females acquire surgical skill at different rates. To date, it remains unclear if this difference exists ...

Objective To provide real-time assessment and feedback on the competency of urology residents’ surgical skill via mobile applications and examine their feasibility and utility. Materials and methods Two mobile application-based systems (SIMPL and myTIPreport) were sequentially implemented for the case-by-case assessment of residents’ performance of surgical skills at a single institution. Data was collected regarding residents’ perception of their feedback pre- and post-implementation of the applications. Faculty were surveyed after their implementation to determine their feasibility and utility. Results 297 individual evaluations were completed with SIMPL and 822 with myTIPreport over four and eleven months respectively. Post-implementation, residents showed significantly improved perceptions regarding the quantity and personalization of surgical skill feedback (P = .043 and .005 respectively). A majority (75%) of the faculty found the mobile applications feasible to use, an improvement compared to prior methods of resident evaluation, and would recommend continued use. Conclusion This study represents the first documented use of real-time surgical competency assessment in urology. The use of mobile applications to evaluate urology residents’ surgical competency in clinical practice is both feasible and useful. Their use may allow for more individualized surgical skill teaching during training and for the verification of the surgical skills necessary to practice autonomously.

This is a hands-on introductory practical data analytics teaching case that can be used in an auditing or related course. Students will learn about data attributes, data creation, structured query language (SQL), basic statistics, and performing basic audit procedures using analytics by utilizing the open source software R. Instructors can use this case for an in-class discussion or an independent out-of-class assignment. A solutions guide is available in the Teaching Notes. Multimedia files are available for download, see Appendix B.

Researchers have found that the volume of exceptions generated by a continuous auditing system can be overwhelming for an internal audit department to handle. In this paper, we propose and validate a framework that systematically prioritizes exceptions based on the likelihood of an exception being erroneous or fraudulent and evaluate the framework using an experiment. The framework consists of six stages: (1) generation of exceptions using defined rules, (2) assignment of suspicion scores to exceptions using belief functions, (3) exception prioritization, (4) exception investigation, (5) rule confidence level update utilizing back propagation, and (6) rule(s) addition utilizing a rule learner algorithm. We also simulate the proposed framework using an experiment. The experiment results provide evidence that the framework can be effective in prioritizing exceptions and thus maximizing audit efficiency.

Benign prostatic hyperplasia (BPH) is common in aging males and is the most common cause of bladder outlet obstruction (BOO) in these patients. Over 80 % of men in their eighth decade have been diagnosed with BPH, and many will require one or more treatments for outflow obstruction throughout their lives. Additional causes of BOO include urethral strictures, lower urinary tract malignancy, and obstructing bladder stones. Diagnosing the cause of lower urinary tract symptoms (LUTS) in male patients may, at times, prove difficult. In patients for whom a diagnosis of BOO is suspected, urodynamic testing may aid in confirming this diagnosis, as well as determining the degree of obstruction. The American Urological Association recommends that urodynamic testing should be considered optional in the evaluation of patients presenting with LUTS suggestive of BOO.

Although more than a decade of experience with laparoscopic radical nephrectomy indicates it is an alternative to open surgery for localized renal-cell carcinoma (RCC), the long-term oncologic effectiveness of this procedure remains to be established.A thorough MEDLINE and PubMed literature research on long-term outcomes of laparoscopic radical nephrectomy was performed, and all pertinent articles were reviewed in detail. This review was formulated on the current cancer indication, the oncologic basis, the oncologic efficacy, and the longterm oncologic effectiveness of the procedure, including laparoscopic cytoreductive nephrectomy, with regard to metastasis, port-site tumor recurrence, and the relation to laparoscopic partial nephrectomy. Furthermore, the authors' previous report on the intermediate-term efficacy of laparoscopic radical nephrectomy was updated.With increasing experience, the indications for laparoscopic radical nephrectomy continue to expand. There were many reports of intermediate-term, two reports of long-term, and our up-to-date outcomes analyzing the management of localized RCC that showed effective cancer control with no statistically significant difference between laparoscopic and open radical nephrectomy in the true 5- and 10-year survival analysis.Long-term data, critical in the evaluation of any treatment for cancer, are currently available with respect to laparoscopic radical nephrectomy for localized RCC.

Our goal was to correlate the size of renal cell carcinoma with tumor stage, nuclear grade, and histologic subtype in patients treated using partial or radical nephrectomy.We retrospectively reviewed 213 consecutive renal cell carcinomas resected at our institution from 1995 through 1999. Three groups of lesions stratified by size (or = 3 cm,3-5 cm,5 cm) were compared with regard to pathologic findings. Statistical significance was assessed using Fisher's exact test.Of 50 lesions 3 cm or smaller, 19 (38%) had extension outside the renal capsule (T3 or T4) and 14 (28%) were a high nuclear grade (Fuhrman grade 3 or 4). Lesions 3 cm or smaller and those greater than 3 cm to 5 cm did not differ statistically with regard to T stage or nuclear grade. Lesions larger than 5 cm showed a statistically higher T stage (p0.001) and nuclear grade (p = 0.001) than the other smaller lesions. More non-clear cell tumors were found in the two groups of smaller lesions (p = 0.105) but without statistical significance. The majority (58%) of the tumors were asymptomatic and had been detected incidentally on cross-sectional imaging. Lesions larger than 5 cm were significantly more likely to be symptomatic (p0.001). Seventy-nine percent of the tumors 3 cm or smaller were incidental, and these lesions did not differ significantly from the symptomatic lesions with regard to stage, grade, or histology.In our study population, renal cell carcinomas up to 3 cm, including asymptomatic lesions, showed a significant incidence of high nuclear grade and tumor extension beyond the renal capsule; these findings support aggressive management of small lesions. Symptomatic status was not an adequate discriminator to guide management. A longitudinal study is necessary to further evaluate the efficacy of current patterns of therapy.

Most minimally invasive ablative techniques utilize thermal energies for tissue destruction. However, the heat-sink phenomenon may limit the efficacy of radiofrequency ablation and cryotherapy of tissue near blood vessels. One alternative non-temperature-dependent ablative technique is photon radiation. This radiation is dependent on energy and intensity, and its effects are influenced only by the density of the surrounding tissue. Photon radiation therapy may offer a unique alternative for ablating tissue surrounding vascular structures.

Purpose: High intensity focused ultrasound is an ablative technology capable of producing thermal coagulative necrosis of sub-surface structures without injuring intervening tissues. We assessed the feasibility of using high intensity focused ultrasound to produce occlusion of the canine vas deferens.Materials and Methods: A high intensity focused ultrasound transducer was incorporated into a hand held clip specially designed to grasp the vas deferens transcutaneously. Slots within the jaws of the clip ensured that the vas deferens and high intensity focused ultrasound target zone were properly co-located. We ablated 10 vasa using a range of power and time parameters. At 2 weeks after ablation each vas, epididymis and testis was surgically harvested en bloc. Retrograde vasography was performed to assess vasal occlusion, followed by pathological analysis.Results: High intensity focused ultrasound occlusion of the vas deferens was confirmed in 4 specimens ablated with parameters at the upper end of the para...

Purpose: Several studies have documented that increased biopsy sampling, that is 6 versus 12 biopsy cores, can detect more prostate cancer. It is unknown whether increased sampling of the prostate will detect a higher number of potentially insignificant tumors.Materials and Methods: We searched the surgical pathology files at The Johns Hopkins Hospital for patients in whom prostate needle biopsy was performed by a single urologist between April 1993 and April 2000, and subsequently underwent radical prostatectomy. Patients who underwent radical prostatectomy and had 8 core biopsies or less between March 1994 and August 1999 were also studied. Clinically significant tumors were defined as those with volume greater than 0.5 cc, Gleason score 7 or greater or nonorgan confined disease.Results: A total of 297 patients with a mean age of 60 years (range 36 to 75) were evaluated. Group 1 consisted of 107 men with 8 core biopsies or less, including 51 with 6, and group 2 comprised 190 men with 9 cores or greater,...

We evaluated the clinical efficacy of laparoscopic versus open radical nephrectomy in patients with clinically localized renal cell carcinoma.Between 1991 and 1999, 67 laparoscopic radical nephrectomies were performed for clinically localized, stages cT1/2 NXMX, pathologically confirmed renal cell carcinoma. During this period 54 patients who underwent open radical nephrectomy with pathologically confirmed stages pT1/2 NXMX disease were also identified. Medical and operative records were retrospectively reviewed and telephone followup was done to assess patient status.In the laparoscopic and open groups average tumor size was 5.1 (range 1 to 13) and 5.4 cm. (range 0.2 to 18), respectively, which was not statistically significant. No patient had laparoscopic port site, wound or renal fossa tumor recurrence in either group. All patients were followed at least 12 months. In the laparoscopic group 2 cancer specific deaths occurred at a mean followup of 35.6 months. In the open group there were 2 cancer specific deaths and 3 cases of disease progression at a mean followup of 44 months. Kaplan-Meier disease-free survival and actuarial survival analysis revealed no significant differences in the laparoscopic and open radical nephrectomy groups. Also, no differences were noted in the complication rate.Laparoscopic radical nephrectomy is an effective alternative for localized renal cell carcinoma when the principles of surgical oncology are maintained. Initial data show shorter patient hospitalization and effective cancer control with no significant difference in survival compared with open radical nephrectomy.

Objectives. To evaluate the influence of isolated, histologically identified capsular incision (CI) (exposure of benign or malignant glands to the inked surgical margin in the setting of organ-confined disease) on disease progression after anatomic radical retropubic prostatectomy (RRP) for clinically localized prostate cancer. Methods. Between March 1993 and September 1999, 4747 men underwent RRP at the Johns Hopkins Hospital; 107 men (2.3%) were diagnosed with CI in otherwise organ-confined disease; 92 (86%) had at least 6 months (mean 30) of follow-up. We matched these CI cases (based on surgeon, age, clinical stage, final pathologic Gleason grade, and preoperative serum prostate-specific antigen level) one-for-one with controls in three additional pathologically defined groups and compared the freedom from disease progression (prostate-specific antigen level greater than 0.2 ng/mL and/or local palpable recurrence) after RRP. Results. The actuarial 3-year likelihood of freedom from disease progression was 87.8% for the CI group, 96.4% for men with organ-confined disease (P = 0.10), 91.3% for men with extraprostatic extension and negative surgical margins (P = 0.99), and 73.9% for men with positive surgical margins resulting from extraprostatic extension (P

Objectives. The techniques for hemostasis after renal tumor excision have limited the widespread application of laparoscopic partial nephrectomy (LPN). To improve hemostasis and aid visualization, we report our experience with a novel radiofrequency coagulation (RFC) technique for LPN. Methods. Ten patients underwent RFC-assisted LPN. The demographic and perioperative data were tabulated. Patients were positioned as for laparoscopic nephrectomy, and laparoscopic ports were placed. The kidney within Gerota’s fascia was mobilized, and the fat overlying the tumor was carefully removed for pathologic evaluation. Under laparoscopic guidance, a radiofrequency probe was percutaneously inserted into the lesion and deployed to coagulate the lesion and a margin of normal parenchyma. Laparoscopic scissors were used to excise the lesion; additional hemostatic maneuvers were used selectively. Results. The mean renal tumor size was 2.1 cm (range 1.0 to 3.2). The median operative time was 170 minutes and the median blood loss was 125 mL. The RFC technique resulted in complete tissue coagulation within the treated volume, thereby facilitating intraoperative visualization, minimizing blood loss, and permitting rapid and controlled tumor resection. The renal architecture was preserved, allowing accurate diagnosis of renal cell carcinoma and angiomyolipoma in 9 and 1 cases, respectively. No perioperative complications occurred. Conclusions. The use of RFC is an effective method to facilitate LPN of both exophytic and endophytic masses. By coagulating a margin of normal parenchyma, the technique minimizes blood loss and improves visualization during LPN. We anticipate this technique will broaden the clinical application for LPN.

Objectives. To establish the safety and efficacy of laparoscopic and laparoscopic-assisted nephroureterectomy. Methods. Since 1993, 25 patients with a minimum of 12 months of follow-up underwent nephroureterectomy using a total laparoscopic or laparoscopic-assisted technique. Four patients had specimen morcellation for tissue removal. All patients had regular follow-up with physical examinations, interval cystoscopy, and radiographs, depending on the metastatic potential of the tumor. Retrospective chart review was performed and assessed for operative time, blood loss, tumor pathologic stage, complications, and outcome. One patient was excluded because of an open conversion due to multiple previous abdominal surgeries and failure to progress. Results. The mean operating time was 329 minutes but decreased with experience. The median hospital stay was 4 days. Tumor stage was directly related to tumor grade. Associated bladder tumors (prior history or recurrent tumors) occurred in 50% of the patients. Ipsilateral ureteral stump site recurrence occurred in 1 patient. Although no port site seeding occurred, 1 patient, whose tumor was discovered histologically after laparoscopic pyeloplasty for presumed benign disease, developed recurrence in the renal fossa and metastatic disease. Two patients developed liver metastasis. Conclusions. Total laparoscopic and laparoscopic-assisted nephroureterectomy are acceptable alternatives to open surgery in the treatment of transitional cell carcinoma of the upper urinary tract. Tumor morcellation did not appear to adversely affect patient outcome. As with open nephroureterectomy, tumor grade is the most important prognostic indicator of local, bladder, and metastatic recurrence. No port site seeding was observed in either the total laparoscopic or laparoscopic-assisted groups.

Technological breakthroughs have advanced the fields of urology, radiology, and minimally invasive surgery. Today, the various imaging modalities are increasingly applied to guiding therapy. Among the procedures now in use or under development are percutaneous cyst drainage or sclerotherapy; tissue ablation with high-intensity focused ultrasound, cold, heat, or photon radiation; and conformal radiation and brachytherapy. As current limitations are overcome, image-guided therapy will expand.

Purpose The purpose of this work was to define the temporal CT characteristics of hepatic and renal ablation following point-source radioablation utilizing a low energy, photon X-ray source emitted from a miniature probe. Method Twelve mongrel dogs underwent each of three hepatic and two renal point-source radiation ablations. Animals underwent serial, dual phase, spiral CT scans and were killed at 1, 3, and 6 months after treatment. Results Ablative lesions were clearly visible at 1 month following therapy and consistently diminished in size over the 6 months of follow-up. Lesion size tended to be proportional to dose delivered. Both hepatic and renal lesions were low in attenuation with frequent rim enhancement that diminished over time. Hepatic lesions frequently showed transient hepatic attenuation differences (THADs). Lesion size appeared independent of proximity to vessels. Conclusion Following hepatic or renal interstitial radiotherapy, lesions are generated that are similar in CT appearance to those produced by other ablative techniques. The presence of rim or THAD enhancement can be seen early on as part of the normal tissue-healing response.

A miniature photon radiosurgery system (PRS) has been described as an alternative to surgical resection and external-beam radiation for tumors and may now offer an alternative for ablation of renal lesions. We evaluated the feasibility of ablation by PRS in a normal parenchyma canine model.Twelve mongrel dogs were used in this survival study. In the left and right kidneys of each animal, a peripheral lesion and central-hilar lesion, respectively, were induced with PRS. The probes were placed in the renal parenchyma, and local radiation of 15 Gy at a radius of 1.3 cm was delivered over 10 minutes. Serum electrolytes were measured serially. Computed tomography scans were obtained, and the animals were sacrificed for pathologic correlation. In a separate study, the liver received three additional treatments of 10 to 20 minutes of radiation.Eleven dogs survived this 6-month study and were sacrificed as scheduled. One animal expired after 2 weeks from radiation-induced fulminant hepatic failure with normal renal function. No other complications were observed. The average lesion size was 2.5 cm in diameter. Histologic analysis confirmed coagulative necrosis with sharp demarcation from the surrounding parenchyma.Preliminary studies demonstrate the feasibility of PRS ablation of the renal parenchyma. Further tumor model testing will be important to determine the ultimate efficacy of local photon radiation energy.

Telementoring allows a less experienced surgeon to benefit from an expert surgical consultation, reducing cost, travel, and the learning curve associated with new procedures. However, there are several technical limitations that affect practical applications. One potentially serious problem is the time delay that occurs any time data are transferred across long distances. To date, the effect of time delay on surgical performance has not been studied.A two-phase trial was designed to examine the effect of time delay on surgical performance. In the first phase, a series of tasks was performed, and the numbers of robotic movements required for completion was counted. Programmed incremental time delays were made in audiovisual acquisition and robotic controls. The number of errors made while performing each task at various time delay intervals was noted. In the second phase, a remote surgeon in Baltimore performed the tasks 9000 miles away in Singapore. The number of errors made was recorded.As the time delay increased, the number of operator errors increased. The accuracy needed to perform remote robotic procedures was diminished as the time delay increased. A learning curve did exist for each task, but as the time delay interval increased, it took longer to complete the task.Time delay does affect surgical performance. There is an acceptable delay of700 msec in which surgeons can compensate for this phenomenon. Clinical studies will be needed to evaluate the true impact of time delay.

Objectives. To present the preliminary results of renal ablative cryosurgery in selected patients. Methods. Seven patients were treated, all of whom had small peripheral tumors and chose not to undergo partial or radical nephrectomy. Four patients underwent a rib-sparing flank incision; the remaining three underwent laparoscopy. All tumors were biopsied before cryoablation. Intraoperative ultrasound was used to monitor the cryolesion. Results. There were no intraoperative complications. The estimated blood loss averaged 111 mL. To date, 6 of the 7 patients have undergone at least one follow-up computed tomography scan (14.2 months average follow-up); all these scans demonstrated partial resolution of the lesion. Clinically, the patients tolerated the procedure without any renal complications or significant changes in creatinine. Conclusions. This limited clinical trial has demonstrated the feasibility of treating small peripherally located renal tumors with cryosurgery with minimal morbidity and a favorable outcome. Further studies are necessary to determine the long-term efficacy of this treatment modality.

Adhesions from prior extensive open abdominal surgery can make initial transperitoneal access for laparoscopy hazardous. An alternative to open port placement is a retroperitoneal approach to the peritoneal cavity. We describe our retroperitoneal access for transperitoneal laparoscopy and evaluate the success of the subsequent laparoscopic procedure.Eight patients with a history of abdominal surgery have undergone retroperitoneal access to the peritoneum prior to a laparoscopic urologic procedure. With the patient in a lateral decubitus position, the retroperitoneum is entered with a 10-mm Visiport device (US Surgical Corp., Norwalk, CT) along the posterior axillary line. A working space is bluntly created, the peritoneum identified anterior to the colon, and the endoscope passed through a peritoneotomy. The abdomen is then inspected, transperitoneal ports are strategically placed under direct vision, and the intended procedure is commenced.In all cases, retroperitoneal access to the peritoneum and subsequent trocar placement was successful. In five cases, the intended procedure was completed laparoscopically. In a case of bilateral ureterolysis, one side was completed laparoscopically; however, the other required open conversion. In two nephrectomies for xanthogranulomatous pyelonephritis (XGP), open conversion was necessary because of fibrosis.Retroperitoneal access to the peritoneal cavity permits safe and effective port placement when previous abdominal surgery makes initial transabdominal access difficult. However, despite successful access, in patients at risk for extensive perinephric fibrosis (e.g., XGP), a high incidence of open conversion may be expected.

Laparoscopic donor nephrectomy was developed to remove disincentives to live donation. It has been demonstrated to decrease the length of hospitalization, postoperative pain, time to convalescence and activity, while providing an optimal cosmetic result. Initial reports suggest that laparoscopic donor nephrectomy is feasible and equivalent to open donor nephrectomy.

The disadvantages of standard percutaneous nephrolithotomy (PCNL) as compared with ureteroscopy or extracorporeal shock-wave lithotripsy include increased blood loss, greater pain, and longer hospital stay. A 13-Fr "mini-perc" technique using a ureteroscopy sheath for PCNL was developed in an attempt to address these drawbacks. Nine "mini-percs" have been performed in patients aged 40-73 years with stone burdens of < or = 2 cm2. On average, patients had 1.4 stones with a cross-sectional area of 1.5 cm2. The mean total procedure time, estimated blood loss, and hematocrit decrease were 176 min, 83 ml, and 6.6%, respectively. On average, patients used 14 mg of parenteral morphine and stayed 1.7 days in the hospital. There was no procedure-related complication or transfusion. Eight of nine kidneys (89%) were stone-free on early follow-up at a mean of 3.8 weeks. As compared with standard PCNL, the "mini-perc" technique has similar early success rates in selected patients and may offer advantages with respect to hemorrhage, postoperative pain, and shortened hospital stays.

A small incision (minilaparotomy) radical retropubic prostatectomy is described and evaluated. A newly designed self-retaining retractor was used as a robot and functioned as a second operative assistant.A total of 522 consecutive patients underwent minilaparotomy radical prostatectomy by a single surgeon (F. F. M.) between 1991 and 1997. The technique of minilaparotomy radical retropubic prostatectomy (a 7 to 8 cm. midline incision) is described in detail.A questionnaire was mailed to all 522 patients and there were 265 responses. Satisfactory continence was achieved in the short term in 85% of patients (0 to 1 pad). Of the patients 83% had a prostate specific antigen of less than 0.2 ng./ml. at average followup of 2.6 years. There was no operative mortality and the overall complication rates were similar to other patients treated by the same department staff with a larger incision. The typical patient was discharged home 3 days postoperatively.Minilaparotomy radical retropubic prostatectomy compares favorably with standard radical retropubic prostatectomy.

Researchers have found that the volume of exceptions generated by a continuous auditing system can be overwhelming for an internal audit department to investigate. In this paper, we propose a framework that systematically prioritizes exceptions based on the likelihood of an exception being erroneous or fraudulent. The framework consists of six stages: 1) generation of exceptions using defined rules, 2) assignment of suspicious scores to exceptions using belief functions, 3) exception prioritization, 4) exception investigation by auditors, 5) rule confidence refinement by back propagation, and 6) rule additions by a rule learner algorithm. We also simulated the proposed framework using an experiment. The results from the experiment show that the framework has the potential to effectively prioritize exceptions in practice.

The objective of this paper is to examine the relationship between an independent audit and financial reporting conservatism in the small private commercial bank setting. We use the timely recognition of probable losses and the minimal use of discretionary accruals as proxies for conservatism. Intuition and prior literature leads us to hypothesize that banks that are audited should exhibit greater conservatism in financial reporting than those banks that are not audited. However, we find evidence that persistently audited banks are on average less conservative. In contrast, we find evidence that banks are on average more conservative in the period in which they switched from not being audited to audited. Collectively, the evidence suggests there is an initial positive relationship between an independent audit and financial reporting conservatism. However, there is a negative relationship between an independent audit and financial reporting conservatism when an independent audit is a persistent occurrence.

Purpose: We present our experience with laparoscopic pyeloplasty plus pyelolithotomy in patients in whom stones were not the cause of ureteropelvic junction obstruction.Materials and Methods: A transperitoneal approach was used for laparoscopic pyeloplasty and pyelolithotomy in 19 patients (20 renal units). Before ureteropelvic junction repair stones were extracted through a small pyelotomy that was eventually incorporated into the final pyeloplasty incision. Stones in the renal pelvis were removed with rigid graspers under direct laparoscopic vision. A flexible cystoscope introduced through a port was used to extract stones in the calices. The renal pelvis was reconstructed based on the anatomy of the ureteropelvic junction.Results: A median of 1 stone (range 1 to 28) was recovered. In 11, 8 and 1 patients the Anderson-Hynes dismembered pyeloplasty, Y-V plasty and the Heinecke Mickulicz procedure were performed, respectively. At 3 months 2 patients had residual calculi for a procedural stone-free rate of...

Absent regulatory requirements, 64% of small private commercial banks voluntarily procured an independent audit in our dataset. Hence, it can be argued that an independent audit may have a perceived value. In our study, we examine whether the decision to procure an audit is systematic. First, we model and predict the decision to procure a voluntary audit using classification learning algorithms. We find, in particular, that the IBK and Random Forest learning algorithms have the highest cross-validated prediction accuracy of 81% and 80% respectively, thus supporting the claim that the decision to procure an audit is not made arbitrarily, but rather systematically, and therefore is amenable to analysis. Second, we use logistic regression to identify those characteristics that may systematically influence the decision to procure an independent audit. Generally, we find that bank size, profitability, growth, leverage, complexity of operations, and type of ownership may systematically influence the decision to procure an independent audit. In contrast, banks that are less capitalized are less likely to procure an audit.

We describe our surgical technique for rapid ligation of the renal hilum during transperitoneal laparoscopic nephrectomy. This technique is reliable and provides an efficient method of hilar ligation.

Purpose: Controlled ligation and division of the renal hilum are critical steps during any nephrectomy procedure. The use of the endovascular gastrointestinal anastomosis (GIA) stapling device for control of the renal vessels during laparoscopic nephrectomy has become standard practice. However, malfunction can lead to serious consequences which require emergency conversion to an open procedure. We report our experience with GIA malfunction during laparoscopic nephrectomy.Materials and Methods: From July 1993 to September 1999, 565 patients underwent laparoscopic nephrectomy at 2 institutions for benign and malignant diseases, and for live renal donation. Retrospective chart reviews and primary surgeon interviews were conducted to determine etiology of failure, intraoperative management and possible future prevention.Results: Malfunction occurred in 10 cases (1.7%). In 8 cases the renal vein was involved and malfunctions affected the renal artery in 2. The estimated blood loss ranged from 200 to 1,200 cc....

The recently recognized Xp11 translocation renal cell carcinomas (RCCs), all of which bear gene fusions involving the TFE3 transcription factor gene, comprise at least one-third of pediatric RCC. Only rare adult cases have been reported, without detailed pathologic analysis. We identified and analyzed 28 Xp11 translocation RCC in patients over the age of 20 years. All cases were confirmed by TFE3 immunohistochemistry, a sensitive and specific marker of neoplasms with TFE3 gene fusions, which can be applied to archival material. Three cases were also confirmed genetically. Patients ranged from ages 22 to 78 years, with a strong female predominance (F:M=22:6). These cancers tended to present at advanced stage; 14 of 28 presented at stage 4, whereas lymph nodes were involved by metastatic carcinoma in 11 of 13 cases in which they were resected. Previously not described and distinctive clinical presentations included dense tumor calcifications such that the tumor mimicked renal lithiasis, and obstruction of the renal pelvis promoting extensive obscuring xanthogranulomatous pyelonephritis. Previously unreported morphologic variants included tumor giant cells, fascicles of spindle cells, and a biphasic appearance that simulated the RCC characterized by a t(6;11)(p21;q12) chromosome translocation. One case harbored a novel variant translocation, t(X;3)(p11;q23). Five of 6 patients with 1 or more years of follow-up developed hematogenous metastases, with 2 dying within 1 year of diagnosis. Xp11 translocation RCC can occur in adults, and may be aggressive cancers that require morphologic distinction from clear cell and papillary RCC. Although they may be uncommon on a percentage basis, given the vast predominance of RCC in adults compared with children, adult Xp11 translocation RCC may well outnumber their pediatric counterparts.

Curative surgery in more advanced renal cell carcinoma is limited to solitary metastases or regional disease. Response to systemic immunotherapy continues to be reported; however, most responses are limited and not durable. Only randomized, prospective clinical trials will prove the efficacy of systemic therapy.

We evaluated the concordance between post-digital rectal examination and post-prostate biopsy urine samples using conventional methylation specific polymerase chain reaction analysis of 3 gene promoters in patients with suspected or confirmed prostate cancer.Voided urine specimens were collected from 17 men after 15-second digital rectal examination and again after transrectal ultrasound guided biopsy of the prostate for suspected malignancy or for followup biopsy as part of an expectant management protocol. Urine sediment DNA was isolated and subjected to bisulfite modification. Methylation of GSTP1, EDNRB and APC promoters was determined by conventional methylation specific polymerase chain reaction analysis in post-digital rectal examination and post-biopsy samples, and correlated with clinical information.Prostate cancer was detected on prostate biopsy in 12 of 17 patients (71%). Promoter methylation was detected in post-digital rectal examination urine specimens for GSTP1 (24%), APC (12%) and EDNRB (66%). Promoter methylation was detected in post-biopsy urine specimens for GSTP1 (18%), APC (18%) and EDNRB (77%). The concordance between post-digital rectal examination and post-biopsy urine samples was 94% for GSTP1 and APC, and 82% for EDNRB. Overall 100% of patients with biopsy proven prostate cancer had at least 1 gene methylated in urine vs 60% of those without evidence of prostate cancer on biopsy.Gene analysis using conventional methylation specific polymerase chain reaction is a reliable method for detecting abnormal DNA methylation in voided urine samples obtained following digital rectal examination or prostate needle biopsy. The concordance between post-digital rectal examination and post-biopsy urinary samples for promoter methylation is high (82% to 94%), suggesting that urine collected after digital rectal examination may be used for genetic analysis with results similar to those in post-biopsy urine samples.

This report assesses the long-term oncological efficacy of laparoscopic radical nephrectomy compared with open radical nephrectomy in patients with clinically localized renal cell carcinoma.We analyzed the data from 121 patients who underwent radical nephrectomy between 1991 and 1999 for clinical tumor stage T1/2 N0M0. The medical records of all patients were retrospectively reviewed with emphasis on tumor recurrence and survival. Statistical comparison was performed using Kaplan-Meier analysis.The median followup was 73 months for the laparoscopic group and 80 months for the open group. Of the 67 patients who underwent laparoscopic surgery, 53 survived without any recurrence of disease, 2 are currently alive with metastasis, 2 died of metastatic disease in months 12 and 17, and 10 patients died without any disease recurrence. Laparoscopic port site metastasis did not develop in any patients. Of the 54 who underwent open surgery, 34 survived without any recurrence of disease, 1 currently has metastasis, 6 died of metastasis within 17 to 74 months, and 13 died without any disease recurrence. A comparison of the 5 and 10-year disease-free survival rates of the laparoscopic and open groups revealed no significant differences. In addition, the 5 and 10-year cancer specific and actuarial survival rates were not significantly different.Based on long-term followup, our evaluation confirmed for clinical tumor stage T1/2 N0M0 that laparoscopic radical nephrectomy is oncologically equivalent to open radical nephrectomy.

Various sources contribute to mask haze formation including: chemical residuals from mask cleaning, out-gassing from pellicle glue/materials, and contaminants from the scanner ambient. This joint work examines cleaning techniques for haze minimization and whether or not there is haze formation after continuous laser irradiation. Masks with various designs and different cleaning techniques were tested in an ideal environment, isolated from out-gassing or other possible contaminants from the fab environment. Masks with and without patterns were subjected to 40kJ, accumulated dose, of laser radiation to simulate a wafer fab environment. Ion Chromatography (IC) and other surface analytical techniques were used to check the surface condition of masks before and after laser exposure. No haze was found on masks through transmission and IC measurements, when the test chamber was N2 purged. This may suggest that new cleaning techniques have helped reduce chemical residuals on masks. It is less likely for haze to grow when masks are clean to an ionic level and when laser exposure occurs in an uncontaminated, purged environment.© (2005) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

Positive surgical margins adversely affect biochemical recurrence-free survival after radical retropubic prostatectomy (RRP) for prostate cancer. We retrospectively reviewed a large series of men who underwent RRP at a single academic university urology program to define the change in the incidence of organ confined (OC) disease and positive surgical margin (SM+) during the last 2 decades.Between 1982 and 2001, 9,035 men underwent RRP for clinically localized prostate cancer (T1 to T3a) at a single institution. We compared the incidences of OC disease and SM+ in this population.An increasing proportion of men presented with OC disease over time. The incidence of SM+ in the overall RRP population decreased dramatically over time. However, in men with nonorgan confined disease (pT3), the proportion with SM+ was stable and consistently elevated (22.7% to 27.8%), after the initial decrease from the early 1980s (53%).Widespread early detection programs for prostate cancer resulted in a downward stage migration in men presenting with clinically localized prostate cancer at our institution during the last 2 decades. The decrease in the percentage of men with SM+ was due to the increasing number of men with organ confined disease. These results imply that the decrease in surgical margin rates in the overall RRP population is most likely due to stage migration and improved patient selection, rather than major improvements in surgical technique. The stable percentage of SM+ among men with pT3 disease dictates the need for continued evaluation of surgical technique and the need for effective adjuvant therapy.

The presence of a foreign body in the genitourinary tract represents a urologic challenge that often requires prompt intervention. We describe an endoscopic approach that was used for removal of a foreign body located in the prostatic urethra of a schizophrenic man. A nitinol stone basket was used as an effective means for extraction of a large metal screw from the urethra of this patient.