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Introduction: Radical prostatectomy (RP) with pelvic lymph node dissection (PLND) is the standard treatment of high-risk prostate cancer. High-risk patients and those with lymph node metastasis (LNM) require further treatment. We review outcomes of RP+PLND in Kaiser Permanente Southern California (KPSC)., Methods: Patients who underwent RP+PLND in KPSC from January 1, 2001, to July 1, 2015 were included. Patient charts were retrospectively reviewed for demographic information and clinicopathologic data which were used to calculate positive surgical margin rate, LNM, adjuvant treatment, 5-year biochemical recurrence, and overall survival. Univariate and multivariate logistic regression analyses were used to identify factors associated with margin positivity., Results: Patients (N = 1829) underwent RP+PLND (241 high-risk, 943 intermediate-risk, 645 low-risk). Positive margin rates were 17.8%, 14.8%, and 11.9% in the high, intermediate- and low-risk groups. Biochemical recurrence rates were 22% in high-risk and 12.1% in the low-risk category. Androgen deprivation use was 4.1% in the high-risk group and 0.9% in the low-risk group. Five-year overall survival was 92.5% in lymph node-positive patients and 94.9% in lymph node-negative patients (p = 0.8). On multivariate analysis, age (odds ratio [OR] = 1.02, p = 0.02), prebiopsy prostate-specific antigen (OR = 1.02, p < 0.001), and clinical T stage (OR = 1.49, p = 0.01) were associated with margin positivity., Conclusion: In KPSC, RP+PLND was performed in patients with low-, intermediate-, and high-risk prostate cancer. Age, prebiopsy prostate-specific antigen, and clinical stage were associated with positive surgical margins in patients with LNM. Recipients of RP+PLND with LNM and positive surgical margins required adjuvant treatment.

Context: Local recurrence after radiotherapy for prostate cancer remains challenging to treat effectively. Although oncologic control is highest with salvage prostatectomy, the procedure is associated with substantial morbidity., Objective: To identify factors associated with successful salvage cryoablation for radiorecurrent prostate cancer., Design: We retrospectively reviewed the medical records of patients who underwent salvage cryoablation at our institution between 2005 and 2015. All patients had biopsy-proven local recurrence after radiotherapy. Patients with seminal vesicle invasion or metastases were excluded. Complete follow-up was obtained for all patients., Main Outcome Measures: Primary study endpoint was biochemical progression-free survival based on the Phoenix criteria., Results: Seventy-five patients underwent salvage cryotherapy. Mean patient age was 69.3 years. The overall biochemical salvage rate was 50.7% at a median follow-up of 3.9 years. The following factors were independently associated with successful cryotherapy: Precryotherapy Gleason score of 3 + 3 or 3 + 4, low precryotherapy prostate-specific antigen (PSA), low precryotherapy PSA density, longer time to PSA nadir after radiotherapy, and low postcryotherapy PSA nadir. A postcryotherapy PSA nadir of 0.5 ng/mL or less was associated with a biochemical progression-free survival of 79.7% at 3 years and 64.7% at 5 years, whereas a postcryotherapy PSA nadir above 0.5 was associated with a biochemical progression-free survival of 5.6% at 3 years and 0% at 5 years (p < 0.0001)., Conclusion: Approximately 50% of the patients achieved biochemical salvage with cryoablation at 5 years. Nadir PSA after salvage was the strongest predictor of biochemical progression-free survival in our cohort.

Tumors of the anterior prostate (ie, the portion of the prostate anterior to the urethra) account for approximately 20% of all prostate cancers. Although anterior prostate cancers frequently occur, they have historically been underdetected because of infrequent sampling. Recent advances in multiparametric magnetic resonance imaging and improved biopsy schemes have significantly increased our diagnostic accuracy for detecting anterior tumors. Herein, we review these developments and highlight key aspects of the diagnosis and management of anterior prostate cancers., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction and Objectives: Caliceal leak after partial nephrectomy (PN) typically resolves with conservative management. However, persistent fistulae pose a formidable challenge that may require additional therapeutic actions., Methods: We describe a case of a patient with a solitary kidney who suffered a persistent urine leak following PN. A novel retrograde ureteroscopic approach was taken that utilized the combined techniques of caliceal fulguration and fibrin glue injection., Results: Imaging demonstrated resolution of the caliceal fistula at 13 months postoperatively., Conclusions: Persistent urine leak after PN remains a burdensome complication that often requires creative steps to resolve. Our case presents a solution using a novel ureteroscopic technique.

Objectives: Since its introduction, there have been many refinements in the technique and implementation of robotic-assisted radical prostatectomy (RARP). However, it is unclear whether operative outcomes are influenced by surgical case order. We evaluated the effect of case order on perioperative outcomes for RARP within a large health maintenance organization., Materials and Methods: We conducted a retrospective review of RARP cases performed at our institution from September 2008 to December 2010 using a single robotic platform. Case order was determined from surgical schedules each day and surgeries were grouped into 1(st), 2(nd) and 3(rd) round cases. Fourth round cases (n = 1) were excluded from analysis. We compared clinicopathological variables including operative time, estimated blood loss (EBL), surgical margin rates and complication rates between groups., Results: Of the 1018 RARP cases in this cohort, 476 (47%) were performed as 1(st) round cases, 398 (39%) 2(nd) round cases and 144 (14%) 3(rd) round cases by a total of 18 surgeons. Mean operative time was shorter as cases were performed later in the day (213 min vs. 209 min vs. 180 min, P < 0.0001) and similarly, EBL also decreased with surgical order (136 mL vs. 134 mL vs. 103 mL, P = 0.01). Transfusion rates, surgical margin rates and complication rates did not significantly differ between groups. Patients undergoing RARP later in the day were much more likely to have a hospital stay of 2 or more days than earlier cases (10% vs. 11% vs. 32%, P = 0.01)., Conclusions: Surgical case order may influence perioperative outcomes for RARP with decreased operative times and increased length of hospital stay associated with later cases. These findings indicate that select perioperative factors may improve with ascending case order as the surgical team "warms up" during the day. In addition, 3(rd) round cases can increase hospital costs associated with increased lengths of hospital stay. Knowledge of these differences may assist in surgical planning to improve outcomes and limit costs.

Objective: To determine whether multiparametric magnetic resonance imaging might improve the identification of patients with higher risk disease at diagnosis and thereby reduce the incidence of undergrading or understaging., Methods: We retrospectively reviewed the clinical records of 115 patients who underwent multiparametric magnetic resonance imaging before radical prostatectomy. We used Epstein's criteria of insignificant disease with and without a magnetic resonance imaging (MRI) parameter (apparent diffusion coefficient) to calculate sensitivity, specificity, as well as negative and positive predictive values [NPV and PPV] across varying definitions of clinically significant cancer based on Gleason grade and tumor volume (0.2 mL, 0.5 mL, and 1.3 mL) on whole-mount prostate specimens. Logistic regression analysis was performed to determine the incremental benefit of MRI in delineating significant cancer., Results: The majority had a prostate-specific antigen from 4.1-10.0 (67%), normal rectal examinations (90%), biopsy Gleason score ≤ 6 (68%), and ≤ 2 cores positive (55%). Of the 58 patients pathologically staged with Gleason 7 or pT3 disease at prostatectomy, Epstein's criteria alone missed 12 patients (sensitivity of 79% and NPV of 68%). Addition of apparent diffusion coefficient improved the sensitivity and NPV for predicting significant disease at prostatectomy to 93% and 84%, respectively. MRI improved detection of large Gleason 6 (≥ 1.3 mL, P = .006) or Gleason ≥ 7 lesions of any size (P <.001)., Conclusion: Integration of MRI with existing clinical staging criteria helps identify patients with significant cancer. Clinicians should consider utilizing MRI in the decision-making process., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Robotic-assisted surgery has been rapidly adopted within urology practice. As a result, academic centers are challenged with the burden of how to effectively train residents and fellows to perform robotic-assisted surgery without compromising outcomes. We evaluated the perioperative outcomes of trainee involvement with robotic-assisted radical prostatectomy (RARP) within our healthcare organization. We retrospectively reviewed RARP cases performed at our institution between September 2008 and December 2010 using a single da Vinci robotic platform. Trainees consisted of urology residents and fellows who operated with staff surgeons on select operating days, whereas two staff surgeon teams performed RARP on alternate days. We compared clinicopathologic variables including operating time, estimated blood loss, surgical margin rates, and complication rates between the trainee and staff-only surgeon groups. Overall, 1,019 RARP surgeries were performed within the study period and trainees participated in 162 cases (16 %). Clinical characteristics were similar between men undergoing surgery with a trainee and those without. Positive surgical margin rates were lower for patients with pT2 disease for cases with trainee involvement (11 vs. 19 %, p = 0.02), although overall margin rates and margin rates for patients with pT3 disease were similar between the groups (p = 0.34). Surgical cases involving trainees were longer (241 vs. 200 min, p < 0.001) and resulted in higher estimated blood loss (190 vs. 120 mL, p < 0.001) than the two staff surgeon cases. However, transfusion rates as well as intraoperative and postoperative complication rates did not differ significantly between groups. In conclusion, surgical margin rates were lower in teaching cases for patients with pT2 disease. Importantly, trainee involvement in RARP is safe, with similar perioperative outcomes to staff-only surgical cases. This information may be useful for training and surgical planning.

Objectives: Robot-assisted radical prostatectomy (RARP) has now become the most common surgical treatment option for prostate cancer (CaP). Clinicopathologic data (i.e., biopsy, digital rectal exam, prostate specific antigen level) and patient-specific factors (e.g., age, erectile function, co-morbidities) are the primary sources of information that urologists use for counseling and treatment decision making. Magnetic resonance imaging (MRI) has evolved along a similar temporal arc to RARP, with increased utilization and precision over the past decade. MRI prior to RARP provides multifaceted adjunctive information, including enhancement of locoregional staging, delineation of spatial anatomic information, and identification of aberrant anatomy, all of which aid in patient treatment counseling and operative planning. This article is designed for urologic surgeons who perform RARP, with the aim of providing a review of prostate MRI imaging and highlighting findings which may specifically alter the operation., Methods and Materials: A review of the literature was performed, focusing on the most recent publications., Results: MRI imaging of the prostate has become increasing accurate for the identification, localization, and characterization of CaP lesions. In addition to tumor-specific information, a number of intra- and extra-prostatic findings are consistently identified on MRI which may impact RARP., Conclusions: MRI provides important information which may alter RARP., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The introduction of serum prostate-specific antigen to the prostate cancer screening algorithm has led to an increase in prostate cancer diagnosis as well as a migration toward lower-stage cancer at the time of diagnosis. This stage migration has coincided with changes in treatment options; these include active surveillance, new therapies, and advances in surgical techniques. Use of robot-assisted radical prostatectomy (RARP) as a surgical technique has seen a significant increase over the past several years: the number of patients undergoing RARP has risen from 1% to 40% of all prostatectomies from 2001-2006 to as many as 80% in 2010. The robotic interface provides a 3D magnified view of the surgical field, intuitive instrument manipulation, motion scaling, tremor filtration, and excellent dexterity and range of motion. However, in some cases, the lack of tactile (haptic) feedback may limit the surgeon's decision making ability in assessing malignant involvement of the neurovascular bundles. Pre-operative planning relies on nomograms based on limited clinical and prostate biopsy information. The surgical decision to spare or resect the neurovascular bundles is based on clinical information which is not spatially or anatomically based. Advances in magnetic resonance imaging (MRI) may provide spatially localized information to fill this void and aid surgical planning, particularly for robotic surgeons. In this review, we discuss the potential role of pre-operative MRI in surgical planning for radical prostatectomy.

Purpose: To compare en bloc and artery-only clamping techniques on renal function and perioperative outcomes after laparoscopic partial nephrectomy (LPN)., Patients and Methods: From March 2003 to December 2008, 205 patients underwent LPN by one surgeon in a single institution. The first 103 LPNs were achieved with artery-only clamping (AO), and the last 102 LPNs were realized under control of the renal hilum (artery and vein [AV] clamping). Renal function was evaluated by creatinine changes, estimation of the glomerular filtration rate (eGFR), and assessment of split renal function using renal mercaptoacetyl triglycine-Lasix scintigraphy. Sixty-two of 205 patients had renal scintigraphy before and after surgery., Results: There was no significant difference between the two groups regarding demographic data and renal mass characteristics. Warm ischemia time (WIT) was higher in the AO group: 30.4 ± 8.2 vs 23.3 minutes ± 10.0 (P<0.0001). The eGFR change was significantly lower in the AV group during the postoperative period: 10.2 mL/min vs 13.7 mL/min (P=0.0472). Operative blood loss, operative time, and complication rate were not statistically different between groups. Average loss of differential function of the operated kidney was 13.6 ± 9.2% for the AO group and 14.3 ± 12.3% for the AV group (P=0.8016). On multivariate analysis, clamping technique was not a predictive factor of renal function reduction., Conclusion: AV and AO techniques are associated with similar renal function outcomes in patients who were undergoing LPN. In our series, the AV technique was associated with a lower WIT, an important predictor of decrease in renal function.

Purpose: The prognostic usefulness of the Fuhrman nuclear grading system has been questioned for chromophobe renal cell carcinoma due to its frequent nuclear and nucleolar pleomorphism. Chromophobe tumor grade, a novel 3-tier tumor grading system based on geographic nuclear crowding and anaplasia, was recently reported to be superior to the Fuhrman system. We compared the 2 scoring systems in a large sporadic chromophobe renal cell carcinoma cohort to determine which grading scheme provides the most predictive assessment of clinical risk., Materials and Methods: We identified a total of 84 cases of sporadic chromophobe renal cell carcinoma in 82 patients from a total of 2,634 cases (3.2%) spanning 1989 to 2010. A subset of 11 tumors had secondary areas of sarcomatoid transformation. All cases were reviewed for Fuhrman nuclear grade and chromophobe tumor grade according to published parameters by an expert genitourinary pathologist blinded to clinicopathological information., Results: The distribution of Fuhrman nuclear grades 1 to 4 was 0%, 52.4%, 32.9% and 14.7% of cases, and the distribution of chromophobe tumor grades 1 to 3 was 48.8%, 36.5% and 14.7%, respectively. Metastasis developed in 20 patients (24.4%). Survival analysis revealed statistically significant differences in recurrence-free survival when adjusted for chromophobe tumor grade and Fuhrman nuclear grade. Chromophobe tumor grade showed a slightly higher AUC for recurrence-free survival and overall survival than the Fuhrman nuclear grading system. Neither chromophobe tumor grade nor Fuhrman nuclear grade was retained as an independent predictor of outcome in multivariate modeling when patients with sarcomatoid lesions were excluded., Conclusions: Chromophobe tumor grade effectively stratifies patients with chromophobe renal cell carcinoma across all grading levels. Since it does not rely on nuclear features, it avoids the hazard of overestimating the malignant potential of chromophobe renal cell carcinoma. Overall chromophobe tumor grade has higher predictive accuracy than the Fuhrman nuclear grading system., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: • To evaluate associations between baseline characteristics, nerve-sparing (NS) status and return of continence, as a relationship may exist between return to continence and preservation of the neurovascular bundles for potency during radical prostatectomy (RP)., Patients and Methods: • The study included 592 consecutive robotic RPs completed between 2002 and 2007. • All data were entered prospectively into an electronic database. • Continence data (defined as zero pads) was collected using self-administered validated questionnaires. • Baseline characteristics (age, International Index of Erectile Function [IIEF-5] score, American Urological Association symptom score, body mass index [BMI], clinical T-stage, Gleason score, and prostate-specific antigen level), NS status and learning curve were retrospectively evaluated for association with overall continence at 1, 3 and 12 months after RP using univariate and multivariable methods. • Any patient taking preoperative phosphodiesterase inhibitors was excluded from the postoperative analysis., Results: • Complete data were available for 537 of 592 patients (91%). • Continence rates at 12 months after RP were 89.2%, 88.9% and 84.8% for bilateral NS, unilateral NS and non-NS respectively (P= 0.56). • In multivariable analysis age, IIEF-5 score and BMI were significant independent predictors of continence. • CavernosalNS status did not significantly affect continence after adjusting for other co-variables., Conclusion: • After careful multivariable analysis of baseline characteristics age, IIEF-5 score and BMI affected continence in a statistically significant fashion. This suggests that baseline factors and not the physical preservation of the cavernosal nerves predict overall return to continence., (© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL.)

Purpose: Urinary retention is a common complication after orthotopic neobladder urinary diversion. We reviewed a case series of women who underwent neobladder creation and discuss anatomical findings, and urinary retention etiology and prevention., Materials and Methods: We retrospectively reviewed the records of all orthotopic neobladder urinary diversions in female patients performed at our institution from 1999 through 2010. We abstracted baseline clinical and demographic characteristics, operative information, and postoperative clinical, urodynamic, imaging and secondary procedure followup. We defined urinary retention as the need for intermittent catheterization., Results: We identified 21 female patients who underwent neobladder diversion. Median age at cystectomy was 62 years (range 43 to 77). Median followup was 3 years (range 3 to 138 months). Of the patients 14 underwent ileocolic diversion, 6 underwent Studer ileal diversion and 1 underwent preservation of a right colon augmentation. All patients underwent prior or concurrent hysterectomy. In 2 patients with a history of genitourinary tuberculosis neobladder-vaginal fistulas developed postoperatively and they were excluded from analysis. Of the 19 female patients with a neobladder included in analysis 7 (36.8%) experienced urinary retention requiring clean intermittent catheterization. Associated abnormalities included neocystocele formation in 6 cases, anastomotic stricture in 1 and progressive neurological disease in 1. Upon straining the average neobladder descent was approximately 2 cm and the average change in the neocystourethral angle in patients with neocystoceles was 18 degrees. Of the patients 11 (57.9%) had a nonobstructive voiding pattern., Conclusions: Urinary retention in female patients with a neobladder can be functional, anatomical or multifactorial. In our series common anatomical findings associated with urinary retention were neocystocele formation and urethral kinking., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Context: Advances in basic research will enhance prognosis, diagnosis, and treatment of renal cancer patients., Objective: To discuss advances in our understanding of the molecular basis of renal cancer, targeted therapies, renal cancer and immunity, and genetic factors and renal cell carcinoma (RCC)., Evidence Acquisition: Data on recently published (2005-2011) basic science papers were reviewed., Evidence Synthesis: Advances in basic research have shown that renal cancers can be subdivided based on specific genetic profiles. Now that this molecular basis has been established, it is becoming clear that additional events play a major role in the development of renal cancer. For example, aberrant chromatin remodelling appears to be a main driving force behind tumour progression in clear cell RCC. A large number of potential biomarkers have emerged using various high-throughput platforms, but adequate biomarkers for RCC are still lacking. To bring the potential biomarkers and biomarker profiles to the clinical arena is a major challenge for the field. The introduction of tyrosine kinase inhibitors (TKIs) for therapy has shifted the interest away from immunologic approaches. Nevertheless, a wealth of evidence supports immunotherapy for RCC. Interestingly, studies are now appearing that suggest a combination of TKI and immunotherapy may be beneficial. Thus far, little attention has been paid to patient-specific differences. With high-throughput methods becoming cheaper and with the advances in sequencing possibilities, this situation is expected to change rapidly., Conclusions: Great strides have been made in the understanding of molecular mechanisms of RCC. This has led this field to the enviable position of having a range of molecularly targeted therapies. Large sequencing efforts are now revealing more and more genes responsible for tumour development and progression, offering new targets for therapy. It is foreseen that through integration of high-throughput platforms, personalised cancer treatment for RCC patients will become possible., (Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: • To evaluate whether current nephrectomy pathology reports are sufficient to allow clinicians to use prognostic nomograms, tailor surveillance, enroll patients into adjuvant trials and select systemic therapy for renal cell carcinoma (RCC)., Patients and Methods: • Nephrectomy pathology reports were obtained from the LA County Tumor Registry. Key reporting elements identified by the College of American Pathology (CAP) and utilized in RCC prognostic models were abstracted. Hospital type was coded as community, teaching or cancer centre. • Reporting quality was assessed across hospital type and year., Results: • A total of 317 of 344 sampled reports (92.2%) met the inclusion criteria. Tumour size and margin status were commonly reported. Some 90.2% and 84.2% of reports provided data on histology and Fuhrman grade. Tumour classification was omitted in 27.8%. • Microvascular invasion and necrosis were infrequently reported (44.5% and 25.6%, respectively). Only 59.9% of reports met CAP guidelines for tumour classification, margin, size, histology and grade. • Two prognostic nomograms (Stage, Size, Grade and Necrosis system and Kattan) could rarely be utilized (15.8% and 12.3%, respectively), whereas the UCLA Integrated Staging System could be used frequently (65.6%). There were discrepancies satisfying CAP guidelines between community, teaching and cancer centre hospitals, with 54.7%, 70.5% and 75% of reports meeting CAP criteria (P= 0.0102)., Conclusions: • Current RCC pathology reporting fails to satisfy CAP guidelines, does not permit the use of prognostic systems, and may hinder enrollment into adjuvant trials and the selection of systemic therapy. Important reporting discrepancies exist between hospital types, with cancer centres performing best. • Quality improvement initiatives to encourage consistent, comprehensive and clinically relevant pathology reports would improve the quality of RCC patient care., (© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL.)

Potentially curative salvage options for radio-recurrent prostate cancer include prostatectomy, brachytherapy, high-intensity focused ultrasound, and cryotherapy. Salvage cryoablation technology, surgical technique, oncologic outcomes, and complication rates have improved dramatically over the past few decades, shifting this treatment modality from investigational status to an established therapeutic option. In this review, we focus on the most up-to-date oncologic and functional outcomes, as well as complications of salvage cryotherapy for radiation-recurrent prostate cancer.

Controlled tissue cooling, or hypothermia, has been used therapeutically for decades to mitigate the negative effects of traumatic, ischemic, and surgical insults. When applied systemically, moderate hypothermia can attenuate or prevent the extent of neurologic sequelae. Localized hypothermia, on the other hand, has the capacity to reduce tissue edema, suppress inflammation, and minimize the severity of peripheral nerve injury. Therapeutic hypothermia has been used in critical care, neurosurgery, ophthalmology, otolaryngology, cardiothoracic surgery and most recently in urology. Nerve injury during radical pelvic surgery can result in urinary incontinence or retention, impotence and bowel dysfunction. Localized hypothermia during radical prostatectomy has demonstrated improved recovery of urinary continence and erectile function, and similar benefits might be observed in other types of radical pelvic surgery.

Epithelial cell transformation has been demonstrated in numerous animal models for the study of solid tumor biology. However, little evidence exists for human epithelial cell transformation without previous immortalization via genetic influences such as SV40 T-antigen, thus limiting our knowledge of the events that can transform naive human epithelium. Here we describe a system developed in our laboratory to directly transform freshly isolated primary human prostate epithelial cells without previous culture or immortalization. Prostate tissue is obtained from patients and benign tissue is separated from malignant tissue. Benign and malignant tissues are mechanically and enzymatically dissociated to single cells overnight, and immune cells and epithelial subsets are isolated on the basis of differential expression of surface antigens. Epithelial progenitor cells are transduced with lentiviruses expressing oncogenes and combined with inductive stroma for in vivo studies. At 8-16 weeks after transplantation into immune-deficient mice, the development of lesions, histologically classified as benign prostate, prostatic intraepithelial neoplasia and adenocarcinoma, can be evaluated.

Background: Partial nephrectomy (PN) is now the gold standard for the surgical treatment of small renal masses. We evaluated the effect of WIT and other factors on RDF assessed by preoperative and postoperative renal scintigraphy., Methods: Between 2003 and 2008, 182 consecutive laparoscopic PN (LPN) were performed in an academic centre. Among those, 56 had mercaptoacetyl triglycine (MAG3) lasix renal scintigraphy preoperatively and postoperatively., Results: Medians for age, preoperative estimated glomerular filtration rate and computed tomography scan tumour size were 62 years, 82 mL/min/1.73m(2) and 26 mm, respectively. Median WIT and preoperative RDF were 30 minutes and 50%, respectively. Median loss of RDF after surgery was 14%. Linear regression curves showed that loss in RDF rate was 0.2% per minute when WIT was <30 minutes and 0.7% per minute when WIT was ≥30 minutes. In multivariate analysis, length of WIT and endophytic tumour location were associated with a statistically significant loss of RDF (p < 0.05), but only in the group who experienced >30 minutes of WIT., Interpretation: Our results suggest that the factors associated with loss of RDF are not the same before and after 30 minutes of WIT and that the rate of loss in RDF increases after 30 minutes. Since, the effect of WIT is small up to 30 minutes, we believe that surgery should focus on limiting the resection of normal parenchyma and to ensure negative margins and hemostasis, rather than on premature unclamping.

At present, immunotherapy in urological malignancy is experiencing a renaissance, particularly with the emergence of a host of innovative cancer vaccines. Herein, we will review promising immunotherapeutic approaches and evaluate the data supporting their inclusion in novel combination strategies., (© 2010 The Japanese Urological Association.)

Objectives: To evaluate the immunohistochemical profile of a carcinoid (low grade neuroendocrine tumor of the kidney) from a patient with lymph node positive disease who remains disease free for 31 months after radical nephrectomy, lymph node dissection, and adjuvant therapy with sunitinib malate., Methods: Immunohistochemical staining was performed for chromogranin, synaptophysin, CD31, VEGF, HIF-1α, HIF-2, and Glut-1. Staining was evaluated in 3 high-power fields and samples scored as strongly positive (3+), moderately positive (2+), weakly positive (1+), or negative (0). A clear cell renal cell carcinoma was used as positive control., Results: Immunohistochemical staining was strongly positive VEGF, weak to moderately positive for HIF-2, and negative for HIF-1α and Glut-1., Conclusions: Our case of primary renal carcinoid stained intensely for VEGF and HIF-2, consistent with a VHL-HIF1-HIF2-Glut1 independent pathway for VEGF activation. These data suggest that like other neuroendocrine tumors, primary renal carcinoid is a potential target for anti-angiogenic therapy with sunitinib., (Copyright © 2011 Elsevier Inc. All rights reserved.)

In the past 15 years, there has been an increased understanding of the tumor biology of renal cell carcinoma (RCC). The identification of vascular endothelial growth factor (VEGF), its related receptor (VEGFR), and the mammalian target of rapamycin as dysregulated signaling pathways in the development and progression of RCC has resulted in the rational development of pharmaceutical agents capable of specifically targeting key steps in these pathways. Clinical trials have demonstrated survival benefit with these agents, particularly in clear cell RCC patients. However, metastatic RCC will progress in all patients, resulting in a critical need to determine patient risk and optimize treatment. The goal of this article is to highlight the significant breakthroughs made in understanding the critical genetic alterations and signaling pathways underlying the pathogenesis of RCC. The discovery of prognostic factors and development of comprehensive nomograms to stratify patient risk and predictive biomarkers to facilitate individualized treatment selection and predict patient response to therapy also are reviewed.

Immune-sensitive urologic malignancies include prostate, kidney and bladder cancers. To date, most immunotherapeutic treatments have been applied to advanced metastatic disease. Limited efficacy in this setting is likely due to an excessive disease burden, which overwhelms the capacity of the immune system. Immunotherapy has not been widely utilized in a low-disease-burden state - a setting in which the immune system may be best suited to effectively mount a clinically meaningful response. The emergence of high-intensity focused ultrasound, and more recently, low-intensity focused ultrasound technologies, have demonstrated not only immune-stimulatory effects but also an interesting capacity to alter tissue architecture and cell membrane properties, which may be exploited to increase tumoral uptake of drugs and vaccines. In this article, we review the literature supporting the novel use of ultrasound combination therapy with adjunctive agents in the treatment of urologic malignancy.

Robotic pelvic lymphadenectomy is a well established procedure in the urologic and gynecologic literature. To our knowledge robotic pelvic lymphadectomy for metastatic melanoma has yet to be described. Herein we present the first report of robot-assisted pelvic lymphadenectomy in malignant melanoma. After placement of six laparoscopic ports (12 mm camera, three 8-mm robotic ports, 12-mm and 5-mm assistant ports) the DaVinci S robot (Intuitive Surgical, CA, USA) was docked in standard fashion with the patient in low lithotomy. In both cases the patients had enlarged pelvic lymph nodes on computed tomography and complete excision of these masses was accomplished along with complete lymphadenectomy extending from Cooper's ligament to just below the hypogastric artery in case 1 and to level of the bifurcation of aorta in case 2. A PK Maryland Dissector and monopolar scissors were used for dissection. Both patients were discharged on postoperative day #1. Robotic pelvic lymphadenectomy can be safely used for management of patients with metastatic melanoma involving the pelvic lymph nodes. Compared with the standard open procedure, pelvic lymphadenectomy with robotic assistance is associated with excellent vision and minimum morbidity.

Background and Purpose: This is the third publication that updates clinical outcomes using a novel technique to apply locoregional hypothermia to the pelvis during robot-assisted radical prostatectomy (RARP) to reduce inflammatory injury. This report updates urinary and sexual clinical outcomes with a minimum of 1 year follow-up., Patients and Methods: Regional pelvic cooling (<30 degrees C) [corrected] was achieved with a prototype endorectal cooling balloon (ECB) during the course ofRARP. All clinical data were entered prospectively into an electronic database for historic (cases 1-666) and hypothermic groups (115 pts). Urinary and sexual outcomes were obtained using self-administered validated questionnaires. Continence was defined as no pads, and potency was defined as two affirmative answers to "erections adequate for penetration" and "were the erections satisfactory.", Results: Six patients were excluded: three ECB malfunction, three previous radiation/surgery. Median time to zero pad use was 39 days vs 62 days (hypothermic vs controls, P = 0.0003). At 1 year, overall pad-free continence was 96.3% (105/109) vs controls of 86.6%, P < 0.001. Potency was evaluated in all men (40-78 years) with preoperative International Index of Erectile Function-5 scores of 22 to 25. At 3 months, potency results were unchanged between groups: 24% vs 23%. At 15 months, the potency rates were significantly better for the hypothermic group, 83% vs controls 66%, P = 0.045. No difference in oncologic outcome was noted with cooling., Conclusions: Using a prototype cooling balloon, hypothermic RARP significantly improved time to continence and overall continence. Hypothermia also resulted in a modest but statistically significant improvement in potency at 15 months. Once cooling parameters have been optimized, a randomized multicenter clinical trial will be needed for validation.

Purpose: After radical prostatectomy continence is commonly defined as no pads except a security pad or 0 to 1 pad. We evaluated the association of pad status and urinary quality of life to determine whether security and 1 pad status differ from pad-free status to better define 0 pads as the post-prostatectomy standard., Materials and Methods: A total of 500 consecutive men underwent robot assisted radical prostatectomy from October 2003 to July 2007. Data were collected prospectively and entered into an electronic database. Postoperatively men completed self-administered validated questionnaires including questions on 1) daily pad use (0, security, 1, or 2 or more), 2) urine leakage (daily, about once weekly, less than once weekly or not at all), 3) urinary control (none, frequent dribbling, occasional dribbling or total control), 4) American Urological Association symptom score and 5) urinary quality of life., Results: Postoperatively men who indicated 0 pad use had a mean +/- SE symptom score of 5.8 +/- 0.3 and pleased quality of life (1.16 +/- 0.08). In contrast, men with a security pad and 1 pad had a symptom score of 7.6 +/- 0.7 and 9.2 +/- 0.6 but mixed quality of life (2.78 +/- 0.18 and 3.41 +/- 0.15, respectively, p <0.0005)., Conclusions: Results show a significant decrease in quality of life between no pads (1.16 or pleased), a security pad and 0 or 1 pad (2.78 and 3.41 or mixed, respectively). Findings do not support defining continence with a security pad or 0 to 1 pad. Continence should be strictly defined as 0 pads., (Copyright (c) 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Cryotherapy is a technique to ablate tissue by local induction of extremely cold temperatures. Recently, the American Urological Association Best Practice Statement recognized cryoablation of the prostate as an established treatment option for men with newly diagnosed or radiorecurrent organ-confined prostate cancer. Emerging data suggest that, in select cases, cryoablation may have a role in focal ablation of prostate. The current state of the art of cryoablation in these applications is reviewed., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Aim: Whether or not sacrificing accessory pudendal arteries (APAs) during radical prostatectomy affects potency has been an ongoing source of concern. Herein, we present our potency results relative to sacrificing APAs in normally pre-potent men following robot-assisted radical prostatectomy (RARP)., Methods: The distribution of APAs and clinical characteristics were prospectively recorded in 200 consecutive patients undergoing RARP with a cautery-free technique. Sexual function was assessed using the International Index of Erectile Function 5-item questionnaire (IIEF-5). All APAs were sacrificed due to stapling the dorsal vein complex., Main Outcome Measures: Postoperatively, potency was defined by an affirmative answer to the following two questions: "Were erections adequate for penetration?" and "were the erections satisfactory?" Postoperative IIEF-5 scores and quality of erections (% of preoperative firmness: 0%, 25%, 50%, 75%, 100%) were also obtained. Subgroup analysis of patients age < or =65 years with IIEF-5 score of 22-25 was performed., Results: Eighty patients (40%) had APAs. Preoperatively, there was no association with having an APA and normal/abnormal sexual function. Preoperatively, 58/200 were < or =65 years with self-administered IIEF-5 scores of 22-25. Postoperatively, 53/58 (91%) were potent at 24 months follow-up. Nineteen of 58 patients had a sacrificed APA; 39 patients had no APA. Eighteen of 19 (95%) patients with sacrificed APAs were potent vs. 35/39 (90%) with no APA present (P = 0.53). Multivariate analysis showed no significant correlation between sacrificing an APA and time of potency recovery, quality of postoperative erections (94% vs. 90% P = 0.80) or mean IIEF-5 score (22.4 vs. 20.8, P = 0.13)., Conclusion: We found no correlation between the presence or absence of APAs and preoperative sexual function. Furthermore, after sacrificing all APAs, we found no correlation with potency return, time to return of potency, quality of erections, or mean IIEF-5 scores at 24 months.

Objectives: To analyse the impact of a approximately 50% reduction of cavernous nervous tissue on the qualitative and quantitative recovery of sexual function after unilateral (UNS) and bilateral (BNS) nerve-sparing robotic radical prostatectomy (RALP), by evaluating these differences in two groups treated with cautery and a cautery-free technique (CFT)., Patients and Methods: UNS was defined as wide-excision of one neurovascular bundle (NVB). Only men aged < or =65 years with preoperative International Index of Erectile Function (IIEF-5) scores of > or =22 were included. The cautery group comprised 42 men (of case numbers 1-125) undergoing RALP with cautery, and the CFT group (62 men of cases 151-350) had a cautery-free technique along the NVB. Data were collected prospectively using validated self-administered questionnaires. Potency was defined as two affirmative answers to: do you have erections 'adequate for vaginal penetration?' and 'Are they satisfactory?'. Patient-reported IIEF-5 scores and quality of erections (i.e. an estimate of erection as 0%, 25%, 50%, 75% or 100% of preoperative fullness) were obtained after surgery., Results: In the cautery group, doubling the nerve volume increased potency by 1.36 times (UNS 50% vs BNS 68%). The results were similar in the CFT group as doubling nerve tissue increased potency by 1.15 times (UNS 80% and BNS 93%). At 24 months, comparing IIEF-5 scores, there was no difference between UNS and BNS for the cautery group, at 19.6 (95% confidence interval 15.7-23.5) vs 18.9 (16.6-21.0), or the CFT group, at 22.0 (20.2-23.8) vs 21.0 (19.8-22.1)., Conclusions: Doubling the nerve volume only increased potency by 1.15-1.36 times for both the CFT and cautery groups. Furthermore, the quality of erections and IIEF-5 scores did not vary appreciably with doubling of nerve tissue.

Post-prostatectomy urinary incontinence is a major cause of morbidity from radical prostatectomy. Efforts have been made to develop techniques to hasten return of urinary control. Several authors have demonstrated improved early continence with anterior, posterior, or combined reconstruction of the urethral-pelvic attachments. In this study, we compare three-month urinary function and continence data for patients who underwent RALP with posterior reconstruction and anterior suspension with single anastomotic suture (PRASS). A prospective cohort of 50 patients underwent RALP with PRASS reconstruction and were compared to 50 control patients who underwent standard RALP. Continence was defined as use of 0-1 urinary pads and was evaluated at each follow-up visit using the EPIC-26 questionnaire. A weighted summary score was created and group differences were compared using a repeated measures analysis of variance model. After adjusting for age, baseline AUA symptom score, and SHIM scores, which were found to correlate with continence, patients who underwent the PRASS reconstruction had significantly improved urinary control at three months compared with the control group; 90.9% of the patients in the PRASS group wore 0-1 pads per day versus 48.2% in the control group (P = 0.014). Of the patients undergoing the standard prostatectomy 20.6% were totally pad-free compared with 42% of the patients undergoing the PRASS procedure (P = 0.042). In conclusion, the PRASS technique resulted in statistically significant improvement in urinary control three months post-operation. The PRASS reconstruction is technically straightforward, requires no additional sutures, and is a simple technique that is easily learned and adaptable to other robotic surgery.

Purpose: Adipose tissue has been suggested to contribute to the pathogenesis of various disease states, including prostate cancer. We investigated the association of cytokines and growth factors secreted by periprostatic adipose tissue with pathological features of aggressive prostate cancer., Materials and Methods: Periprostatic adipose tissue was harvested from patients undergoing radical prostatectomy and cultured for 24 hours to generate conditioned medium or snap frozen immediately for functional signaling profiling. Multiplex analysis of the periprostatic adipose tissue conditioned medium was used to detect cytokine levels and compared to patient matched serum from 7 patients. Interleukin-6 in serum and periprostatic adipose tissue conditioned medium was further analyzed by enzyme-linked immunosorbent assay and correlated with clinical variables, such as age, body mass index and Gleason score, in 45 patients. Interleukin-6 expression in periprostatic adipose tissue was determined by immunohistochemistry. Reverse phase protein microarray technology was used to analyze cell signaling networks in periprostatic adipose tissue., Results: Interleukin-6 in periprostatic adipose tissue conditioned medium was approximately 375 times greater than that in patient matched serum and levels correlated with pathological grade. This finding was further extended by cell signaling analysis of periprostatic adipose tissue, which showed greater phosphorylation on Stat3 with high grade tumors (any component of Gleason score 4 or 5)., Conclusions: Higher Gleason score correlated with high levels of conditioned medium derived interleukin-6. Moreover, cell signaling analysis of periprostatic adipose tissue identified activated signaling molecules, including STAT3, that correlated with Gleason score. Since STAT3 is interleukin-6 regulated, these findings suggest that periprostatic adipose tissue may have a role in modulating prostate cancer aggressiveness by serving as a source of interleukin-6. Also, we found low numbers of inflammatory cells in the fat, suggesting that adipocytes are the major secretors of interleukin-6.

Introduction: Radical prostatectomy undoubtedly causes inflammatory damage to surrounding neuromuscular tissues (i.e., bladder, urethra, and nerves) that may contribute to urinary incontinence. We report the use of local hypothermia during robot-assisted laparoscopic prostatectomy to attenuate this injury., Methods: Regional pelvic cooling was achieved using cold intracorporeal irrigation and an endorectal cooling balloon (ECB). In all, 115 men undergoing hypothermic robot-assisted laparoscopic radical prostatectomy (hRLP) (case #667-782) were prospectively compared with a historical cohort (case #1-666). Intracorporeal rectal and neurovascular bundle temperatures (T) and intrarectal temperatures were measured. Continence was defined as zero urinary pads. Kaplan-Meier analysis of time to zero pads and multivariate Cox proportional hazards regression was used., Results: Hypothermia was achieved in 112/115 patients; 6 were excluded (3 ECB malfunction, 2 prior radiation, and 1 completion prostatectomy). Median endorectal T = 18.7 degrees C (range 9.1-29.5 degrees C). Mean intracorporeal T = 25.58 degrees C (ECB + irrigation, range 19.4-34.0 degrees C). Three and 12-month hRLP zero pad rates were 81% to 89% and 100% for initial and extended cooling groups versus 65% and 89% for controls. Return to continence was significantly faster for hRLP versus controls: median time to zero pad use was 39 days for hRLP versus 62 days for controls. Multivariate analysis adjusting for American Urological Association (AUA) symptom score, nerve-sparing surgery, learning curve, international index of erectile function-5, age, and prostate weight demonstrated a significantly faster return to continence (hazard ratio = 1.526; 95% CI 1.11, 2.09). Trends toward improved continence were observed with colder temperatures and older patients., Conclusions: Local hypothermia during prostatectomy resulted in a significant improvement in early postoperative zero pad continence rates. Longer and deeper cooling appears to be associated with improved continence, particularly among older patients.

Objectives: To report the first application of preemptive local hypothermia during robotic-assisted laparoscopic prostatectomy (hRLP) to attenuate inflammation. Surgical excision of the prostate during radical prostatectomy causes inflammatory damage to the surrounding neuromuscular tissues that could affect urinary continence., Methods: Of 50 consecutive patients undergoing nerve-sparing hRLP (case numbers 668-717; 3 were excluded--2 underwent radiotherapy and 1 was withdrawn because of balloon failure), 47 were prospectively compared with a standard RLP cohort (case numbers 1-667). Pelvic cooling was achieved using cold irrigation and an endorectal cooling balloon cycled with 4 degrees C saline. The intracorporeal temperatures were measured. Continence was defined as 0 urinary pads. The Kaplan-Meier analysis of the time to 0 pads and multivariate Cox proportional hazards regression analysis was used to examine the group differences in continence after adjusting for the baseline characteristics., Results: The median temperature was 29.0 degrees C (endorectal cooling balloon only, range 24.4 degrees-35.9 degrees C) and 25.5 degrees C (endorectal cooling balloon plus irrigation, range 19.4 degrees-34.0 degrees C). The time to 0-pad status was determined in 590 of 667 controls (88%). The 3-month hRLP 0-pad rate was 86.8% +/- 5.8% and was 68.6% +/- 2.0% for the controls. The return to continence was faster for hRLP vs controls: median 39 days (range 0-110) vs 59 days (range 1-720), respectively (P = .002, log-rank test). A multivariate analysis adjusting for factors, including age, American Urological Association symptom score, abbreviated International Index of Erectile Function-5, body mass index, prostate weight, stage, nerve-sparing, and learning curve demonstrated a faster return to continence for the hRLP group relative to the control group (hazard ratio 1.66, 95% confidence interval 1.11-2.49, P = .014)., Conclusions: This study represents the initial application of local hypothermia to reduce the traumatic inflammatory sequela of RLP. Hypothermia was easily induced and safe and resulted in a statistically significant improvement in early postoperative continence.

Purpose: To identify surgeon specific factors for preserving sexual function (and minimize patient related factors) we report 2-year potency outcomes in men 65 years or younger with normal preoperative sexual function undergoing nerve sparing robot assisted laparoscopic radical prostatectomy., Materials and Methods: Between July 2004 and February 2006, 200 consecutive patients underwent robot assisted laparoscopic radical prostatectomy by 1 surgeon. Inclusion criteria were age 65 years or younger with normal baseline 5-item International Index of Erectile Function score of 22 to 25 and complete 2-year followup. Postoperatively potency was defined by a yes to "erections adequate for vaginal penetration" and "satisfactory erections" on prospective self-administered validated questionnaires with or without phosphodiesterase type 5 medications. Men also reported 5-item International Index of Erectile Function scores and erectile fullness of 0% to 10%, 25%, 50%, 75% or 100% compared to before surgery., Results: A total of 62 patients met the inclusion criteria, and of these 3 were lost to followup and 1 was excluded from study due to receiving hormonal therapy. At 3 months 32.1% reported potency. At 24 months potency was 89.7% (52 of 58) overall, 93.0% (40 of 43) for bilateral and 80.0% (12 of 15) for unilateral nerve sparing. For potent men the mean 5-item International Index of Erectile Function score was 20.4 at 3 months vs 21.3 at 24 months. Mean erectile firmness at 24 months was 91% compared to preoperative baseline, with 34 of 52 (65%) reporting 100% of preoperative fullness. The 5-item International Index of Erectile Function score and fullness at 24 months were equivalent for unilateral nerve sparing and bilateral nerve sparing., Conclusions: Overall 90% of men reported return of potency at 24 months, and 46% returned to baseline with normal 5-item International Index of Erectile Function scores and 100% firmness. Remarkably there was no difference in 5-item International Index of Erectile Function scores or fullness between unilateral nerve sparing and bilateral nerve sparing.

Purpose: To describe our Seldinger technique of percutaneous renal cryoablation that was devised to facilitate renal biopsy, cryoprobe placement, and instillation of adjunctive hemostatics while protecting surrounding tissues from cryoinjury., Patients and Methods: This approach was used to manage 13 renal masses in 12 adult patients. Under CT-fluoroscopic guidance, an access needle was inserted to abut the surface of the tumor, followed by an Amplatz super-stiff guidewire and a customized coaxial catheter system, which was used as a conduit for needle biopsy, cryoprobe insertion, and FloSeal instillation. In addition, a porcine model was used to compare the temperature readings adjacent to the sheathed and the unsheathed cryoprobe during percutaneous renal cryoablation., Results: In all patients, the use of this access approach was accomplished without incident. Two patients needed blood transfusions. No patient had significant skin, muscle, or nerve debility. At a mean follow-up of 11 months, none had evidence of persistent disease on CT or MRI contrast imaging. In the porcine model, the customized sheath protected the surrounding tissues from reaching temperatures below 5 degrees C while temperatures down to -15 degrees C were obtained when no insulating sheath was used., Conclusions: A modified Seldinger technique enabled us to perform percutaneous renal cryotherapy through a single access channel, which facilitated access for biopsy, cryoprobe placement, and instillation of hemostatic agents. This approach may provide a protective barrier against cryogenic damage to neighboring tissues and could theoretically help minimize the chance of tract seeding.

Aim: Stuttering priapism is an uncommon form of recurrent priapism whose etiology if often unknown. To date, there has been one report of a patient with stuttering priapism and glucose-6-phosphate dehydrogenase (G6PD) deficiency. Herein we describe the second-known case of recurrent priapism in a patient with G6PD deficiency. The pathophysiology of G6PD deficiency and its potential to cause priapism is reviewed., Methods: A case report is described of a 29-year-old African-American man with G6PD deficiency who presented with numerous episodes of recurrent ischemic priapism. Clinical data was reviewed., Results: Despite medical management with gonadotropin-releasing hormone (GnRH) agonist, an antiandrogen, and baclofen, he required several surgical procedures which also ultimately failed. A continuous phosphodiesterase type-5 inhibitor (PDE5) was started and the patient had no recurrences at 3-month follow-up., Conclusion: Idiopathic recurrent priapism may be explained by underlying hemolytic anemia associated with G6PD deficiency. Several possible mechanisms exist to explain this association, including hyperviscosity, direct endothelial dysfunction secondary to bare hemoglobin vasculotoxicity, and relative nitric oxide deficiency causing vasoconstriction and vascular smooth muscle proliferation.

Background and Objectives: Ureteral injuries, while rare, do occur during gynecologic procedures. The expansion of laparoscopic and robotic pelvic surgical procedures increases the risk of ureteral injury from these procedures and suggests a role for minimally invasive approaches to the delayed repair of ureteral injuries. We present, to our knowledge, the first case of delayed robotic-assisted ureteral deligation and ureterolysis following iatrogenic ureteral injury occurring during a robotic abdominal hysterectomy., Methods: We present a case report and review of the literature., Results: A 57-year-old female underwent a seemingly uncomplicated robotic-assisted laparoscopic total abdominal hysterectomy and bilateral oophorectomy for symptomatic fibroids. On postoperative day 8, she presented with persistent right flank pain. Imaging studies revealed high-grade ureteral obstruction consistent with suture ligation of the right ureter. She underwent successful robotic-assisted ureteral deligation and ureterolysis. Her postoperative course was unremarkable, and she was discharged home on postoperative day 1 from the deligation., Conclusion: Robotic-assisted management of complications from urologic or gynecologic surgery is technically feasible. This can potentially preserve the advantages to the patient that are being seen from the initial less-invasive surgery.

Objectives: Fungal sepsis after ureteroscopy (URS) is rarely reported. We report on 2 cases of acute fungemia that developed after routine ureteroscopic stone manipulation in patients with advanced liver cirrhosis. This represents a unique and high-risk population, and, to our knowledge, these are the first such cases reported., Methods: We performed a retrospective review of the medical records of 2 patients with Child-Pugh class B and C liver cirrhosis who had undergone ureteroscopy (URS) and holmium laser lithotripsy for obstructing ureteral calculi., Results: The treated stones measured 10 mm and 12 mm and were at the right ureteropelvic junction and left ureterovesical junction, respectively. Both patients had had indwelling ureteral stents in place for 1 and 2 months before URS plus holmium laser lithotripsy, with negative preoperative urine cultures. Each procedure was uncomplicated, and a ureteral stent was left in situ in each case. Within 12 hours of URS, each patient became tachycardic, hypotensive, and febrile. Blood, urine (proximal to the stone), and stone cultures were positive for Candida albicans in both patients. They were both successfully treated with intravenous fluconazole and subsequently discharged from the hospital on postoperative day 12 and 13, respectively., Conclusions: Patients with advanced liver disease appear to be at greater risk of fungal sepsis after otherwise uncomplicated URS and stone manipulation. Consideration should be given to prophylactic antifungal therapy, in addition to the standard antibacterial prophylaxis for such procedures.

Purpose: We reviewed our 4-year experience with percutaneous cryoablation and laparoscopy for treating small renal masses., Materials and Methods: After institutional review board approval we retrospectively analyzed renal cryoablation procedures performed between March 2003 and October 2007. An in-depth analysis was performed concerning demographics, hospital course and short-term outcome with respect to percutaneous vs laparoscopic cryoablation., Results: A total of 37 patients underwent treatment for 43 renal masses. Of the 37 patients 19 underwent laparoscopic cryoablation (24 tumors) and 18 underwent percutaneous cryoablation (19 tumors) using computerized tomography fluoroscopy. For percutaneous cryoablation a saline instillation was used in 58% of cases to move nonrenal vital structures away from the targeted renal mass. There were 5 cases of hemorrhage requiring transfusion, all of which were associated with the use of multiple cryoprobes. The transfusion rate in the percutaneous and laparoscopic cryoablation groups was 11.1% and 27.8%, respectively. Operative time was significantly longer in the laparoscopic cryoablation group compared to the percutaneous cryoablation group at 147 (range 89 to 209) vs 250.2 (range 151 to 360) minutes, respectively. The overall complication rate (including transfusion) was lower in the percutaneous cryoablation group compared to the laparoscopic cryoablation group (4 of 18 [22.2%] vs 8 of 20 [40%], respectively). Hospital stay was significantly shorter in the percutaneous vs laparoscopic cryoablation group at 1.3 vs 3.1 days, p <0.0001, respectively. Narcotic use in the percutaneous cryoablation group was more than half that used by the laparoscopic cryoablation group (5.1 vs 17.8 mg, p = 0.03, respectively). Among patients with biopsy proven renal cell carcinoma during a median followup of 11.4 and 13.4 months in the percutaneous and laparoscopic cryoablation groups, cancer specific survival was 100% and 100%, respectively, and the treatment failure rate was 5.3% and 4.2%, respectively., Conclusions: Percutaneous cryoablation is an efficient, minimally morbid method for the treatment of small renal masses and it appears to be superior to the laparoscopic approach. Short-term followup has shown no difference in tumor recurrence or need for re-treatment. Of note, hemorrhage was solely associated with the use of multiple probes.

Purpose: Computed tomography (CT)-guided percutaneous procedures are often made more difficult due to the movement of the kidney during respiration. Here we examine the use of high-frequency oscillatory ventilation (HFOV), which eliminates the movement of the kidney, potentially making cryoprobe access to the kidney simpler and possibly more efficient., Methods: We compared seven CT-guided percutaneous procedures using a single cryoprobe and either standard mechanical ventilation (MV) (n=4) or HFOV (n=3). The variables studied included: total time of patient intubation, operative time, overall duration of interventional radiology (IR) suite time, change in hematocrit, narcotic use, and complications. The ease of the procedure was rated on a subjective scale from 1 to 3., Results: The total intubation time remained nearly identical at 210 minutes for HFOV and 208 minutes for MV, but surgeon procedural time decreased by 31 minutes in the HFOV group (HFOV=99 minutes and MV=130 minutes) (P=0.40). Total IR time was 225 minutes for HFOV compared to 212 minutes for the MV group (P=0.63). There were no significant differences in the postoperative hematocrit, creatinine, or narcotic use between the two groups. There were no complications related to the procedure or anesthesia in either group. Both urology attending physicians and the interventional radiologist noted that the procedure seemed easier with HFOV., Conclusion: HFOV may shorten the actual procedural time required to perform cryoablation, likely due to the elimination of renal movement during the procedure, thereby facilitating targeting and access to the renal mass. In this initial experience, patients tolerated HFOV without incident, and the operating surgeons found it easier to perform the procedures.