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Lymph node dissection is part of the standard treatment protocol for various cancers, but its role in prostate cancer has been debatable for some time. Pelvic lymphadenectomy has been shown to better help stage prostate cancer patients, but has yet to be definitively proven to be of any benefit for survival. Various templates for lymph node dissections exist, and though some national guidelines have endorsed an extended pelvic node dissection, the choice of template is still controversial. Pelvic lymphadenectomy may lead to a slightly higher rate complications and operative time, and their use must be judiciously applied to patients with a high enough risk of lymph node involvement. We present a comprehensive review of the literature regarding the benefits and harms of lymph node dissection in prostate cancer.

Minimal literature informs the use of robotic partial nephrectomy (RPN) in patients with chronic kidney disease (CKD). Therefore, we evaluated the renal functional outcomes in CKD patients undergoing RPN.We reviewed a prospective database of patients undergoing RPN 2010 to 2015 and identified 182 patients who had preoperative and postoperative nuclear renal scintigraphy (at 2 and 12 months postop). Preoperative and 12-month postoperative eGFR (mL/min/1.73 mOf 182 patients, 30 (16.5%) had baseline CKD. Preoperative eGFR was 48.5 and 99.0 in CKD and non-CKD patients, respectively (p 0.001). From preoperation to 12 months postoperation, eGFR decreased by 2.8 and 1.1 mL/min/1.73 mRPN is a reasonable treatment option in patients with CKD, as it did not lead to a greater decline in renal function contributed by the surgical kidney. The patterns of kidney function recovery after surgery are similar between patients with and without CKD.

Objective To assess the relationship between individual nephrometry score (NS) constituents (RENAL) on perioperative outcomes and renal function of the surgical kidney in patients undergoing laparoscopic partial nephrectomy or robotic-assisted partial nephrectomy. Materials and Methods Two hundred forty-five patients who underwent laparoscopic partial nephrectomy or robotic-assisted partial nephrectomy between 2005 and 2014 were retrospectively reviewed. Each renal mass' NS was calculated from preoperative computed tomography imaging. Multivariate regression analysis was used to evaluate the effect of NS variables on perioperative outcomes and change in overall renal function (as estimated by glomerular filtration rate) from preoperative to 1-year postoperative. A cohort analysis assessed the effect of NS variables on change in split renal function of the surgical kidney from pre- to postoperative based on nuclear medicine renal scintigraphy. Results Tumor radius (R), endophytic nature (E), and nearness to collecting system (N) variables significantly and incrementally predicted a longer operative time and warm ischemia time. Overall renal function based on glomerular filtration rate was not affected by any NS variable. However, percent function of the surgical kidney by renal scintigraphy significantly decreased postoperatively as R and E values increased. Conclusion R, E, and N were associated with significant changes in warm ischemia time and operative time. R and E were associated with a significant decrease in split renal function of the surgical kidney at 1 year after surgery but not with overall renal function. R, E, and N are the NS constituents most relevant to perioperative outcomes and postoperative differential renal function after partial nephrectomy.

High vesicovaginal fistulas (VVF) in the setting of good apical support are best repaired via a transabdominal approach. Laparoscopic VVF repair was first reported in 1998. Several series of robot-assisted VVF repairs have since been published. The robot-assisted approach allows repair of high apical vaginal fistulas while avoiding the morbidity of laparotomy, shortening convalescence, and facilitating the use of omental interposition flaps. This video presents the technique for robot-assisted extravesical VVF repair utilizing a laparoscopically mobilized omental flap.A 43-year-old woman developed a VVF after a total abdominal hysterectomy for fibroids. Pre-operative CT urogram and office cystoscopy confirmed the diagnosis and ruled out ureteral involvement. She underwent a robot-assisted extravesical VVF repair utilizing a laparoscopically mobilized omental flap.The surgery was uncomplicated, and the patient was discharged on post-operative day 1. A cystogram 2 weeks post-operatively revealed no evidence of a fistula. At 3 months follow-up, the patient denied any urinary incontinence.Robot-assisted extravesical VVF repair avoids the morbidity of a laparotomy, provides excellent exposure, and avoids a large cystotomy. It maintains vaginal length and allows for significantly better visualization compared with the transvaginal approach. This repair offers improved outcomes for certain patients depending on their history, anatomy, and the surgeon's experience.

Background The uptake of robotic surgery has led to changes in potential operative complications, as many surgeons learn minimally invasive surgery, and has allowed the documentation of such complications through the routine collection of intraoperative video. Objective We documented intraoperative complications from robot-assisted radical prostatectomy (RARP) with the aim of reporting the mechanisms, etiology, and necessary steps to avoid them. Our goal was to facilitate learning from these complications to improve patient care. Design, setting, and participants Contributors delivered videos of complications that occurred during laparoscopic and robotic prostatectomy between 2010 and 2015. Surgical procedure Surgical footage was available for a variety of complications during RARP. Outcome measurements and statistical analysis Based on these videos, a literature search was performed using relevant terms ( prostatectomy, robotic, complications ), and the intraoperative steps of the procedures and methods of preventing complications were outlined. Results and limitations As a major surgical procedure, RARP has much potential for intra- and postoperative complications related to patient positioning, access, and the procedure itself. However, with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, we suggest that the majority of such complications are preventable. Conclusions Considering the complexity of the procedure, RARP is safe and reproducible for the surgical management of prostate cancer. Insight from experienced surgeons may allow surgeons to avoid complications during the learning curve. Patient summary Robot-assisted radical prostatectomy has potential for intra- and postoperative complications, but with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, most complications are preventable.

Robotic-assisted laparoscopic prostatectomy requires patients to be secured in a steep Trendelenburg position for several hours. Added to the CO2 pneumoperitoneum that is created, this positioning invariably restricts diaphragmatic and chest wall excursion, which can adversely affect respiratory gas exchange. This study sought to measure the extent of respiratory gas change during this procedure.Retrospective, institutional review board approved.Operating room.N = 186 males, American Society of Anesthesiologists 2-3, with prostatic carcinoma undergoing robotic-assisted laparoscopic radical prostatectomy.Arterial blood gases and noninvasive respiratory measurements were recorded for those patients (n = 32) in whom a radial arterial catheter had been inserted intraoperatively, specifically timed to different phases of the procedure: supine lithotomy, steep Trendelenburg, and return to supine. Ventilatory parameters were standardized.Systemic blood pressure, heart rate, respiratory rate, Pao2, Paco2, oxygen saturation as measured by pulse oximetry, and end-tidal carbon dioxide pressure.Although no patients developed perioperative respiratory complications, the Pao2 invariably fell (395 vs 316 mm Hg; P = .001) while the patients were in steep Trendelenburg, and the Paco2-end-tidal carbon dioxide pressure rose (10.0 vs 13.4 mm Hg; P.0001). Upon return to supine, patients' respiratory measurements promptly returned to within 15% of baseline. Subgroup analysis for high-BMI vs low-BMI patients as well as for patients with pulmonary disease and/or a smoking history showed similar individual effects and only small, although significant, respiratory gas exchange aberrations.Positioning patients with a CO2 pneumoperitoneum in steep Trendelenburg for several hours imposes restriction of diaphragmatic and chest wall movement sufficient for respiratory gas exchange to be adversely affected. Return of function to within 15% of baseline occurred within minutes after return to supine and release of the CO2 pneumoperitoneum. No patients during the study period developed pulmonary complications that required alteration in their level of care.

Open radical nephroureterectomy (ONU) and excision of the ipsilateral ureteral orifice with a periureteral cuff of the bladder is the gold standard for the treatment of upper tract urothelial cancer (UTUC). Laparoscopic techniques were introduced as a less invasive alternative in 1991 by Clayman et al. The use of minimally invasive nephroureterectomy (MINU) has increased for the management of UTUC with majority of nephroureterectomies being performed robotically. Patients with UTUC are often elderly and comorbid secondary to associated risk factors for developing this malignancy. Significant perioperative complications may occur in this surgical population with rates as high as 40%. Preoperative considerations include medical optimization, patient positioning, antibiotic prophylaxis, and deep venous thrombosis prophylaxis. Intraoperative vascular, bowel, and adjacent organ injuries are potential serious complications that can be life-threatening. The incidence and effects of many complications can be minimized with meticulous attention to the anatomical details and proper surgical techniques.

Purpose To assess accuracy of prostate measurements with and without endorectal coil (ERC). Materials and methods Anteroposterior (AP), transverse (TX) and craniocaudal (CC) measurements were recorded from 49 prostate magnetic resonance images (MRIs) done both with and without ERC. Prostate weight was calculated as follows: AP*TX*CC* π /6. Prostate dimensions and weight were obtained from radical prostatectomy pathology report. Results After ERC placement, AP decreased by 0.71cm [95% confidence interval (CI) 0.80–0.61], TX and CC increased by 0.26cm (95% CI 0.18–0.33) and 0.25cm (95% CI 0.16–0.35), respectively. Agreement between weight on pathology and MR was excellent: intraclass correlation coefficient (ICC) without ERC=0.96, ICC with ERC=0.90. Conclusion Although ERC distorts measurements and despite a tendency to underestimate the prostate weight, absolute agreement between prostate weight on pathology and MRI is excellent, both with and without ERC.

Objective To characterise the surgical feasibility and outcomes of robot-assisted radical cystectomy (RARC) for pathological T4 bladder cancer. Patients and Methods Retrospective evaluation of a prospectively maintained International Radical Cystectomy Consortium database was conducted for 1118 patients who underwent RARC between 2003 and 2012. We dichotomised patients based on pathological stage (≤pT3 vs pT4) and evaluated demographic, operative and pathological variables in relation to morbidity and mortality. Results In all, 1000 ≤pT3 and 118 pT4 patients were evaluated. The pT4 patients were older than the ≤pT3 patients (P = 0.001). The median operating time and blood loss were 386 min and 350 mL vs 396 min and 350 mL for p T4 and ≤pT3, respectively. The complication rate was similar (54% vs 58%; P = 0.64) among ≤pT3 and pT4 patients, respectively. The overall 30- and 90-day mortality rate was 0.4% and 1.8% vs 4.2% and 8.5% for ≤pT3 vs pT4 patients (P < 0.001), respectively. The body mass index (BMI), American Society of Anesthesiology score, length of hospital stay (LOS) >10 days, and 90-day readmission were significantly associated with complications in pT4 patients. Meanwhile, BMI, LOS >10 days, grade 3–5 complications, 90-day readmission, smoking, previous abdominal surgery and neoadjuvant chemotherapy were significantly associated with mortality in pT4 patients. On multivariate analysis, BMI was an independent predictor of complications in pT4 patients, but not for mortality. Conclusions RARC for pT4 bladder cancer is surgically feasible but entails significant morbidity and mortality. BMI was independent predictor of complications in pT4 patients.

Renal preservation in selected patients with upper-tract urothelial cancer (UTUC) has been well described, offering an alternative to radical nephroureterectomy. We present our experiences in performing percutaneous treatments after neoadjuvant chemotherapy in one such patient with a large, complex, high-grade UTUC in a solitary kidney.A 55-year-old woman with a solitary kidney presented with a 5.2 cm enhancing mass with calcifications involving the left renal pelvis and lower pole. Cystoscopy and retrograde pyelography demonstrated normal bladder mucosa. Ureteroscopy revealed a large, papillary tumor occupying the renal pelvis. Ureteroscopic treatment was deemed impossible because of the lesion's volume. We proceeded with percutaneous resection after downsizing the tumor after a course of neoadjuvant chemotherapy. Using a 25F resectoscope via a percutaneous tract, resection was performed to fully excise the tumor, and the patient received two postoperative chemotherapy courses. A recurrence developed within an isolated calix 8 months postoperatively, which was also managed percutaneously.A multimodal approach in a highly motivated patient could represent a reasonable strategy for patients in whom such a therapy is desired.

Background: Positive surgical margins (PSMs) are a known risk factor for biochemical recurrence in patients with prostate cancer (PCa) and are potentially affected by surgical technique and volume. Objective: To investigate whether radical prostatectomy (RP) modality and volume affect PSM rates. Design, setting, and participants: Fourteen institutions in Europe, the United States, and Australia were invited to participate in this study, all of which retrospectively provided margins data on 9778 open RP, 4918 laparoscopic RP, and 7697 robotic RP patients operated on between January 2000 and October 2011. Outcome measurements and statistical analyses: The outcome measure was PSM rate. Multivariable logistic regression analyses and propensity score methods identified odds ratios for risk of a PSM for one modality compared with another, after adjustment for age, preoperative prostate-specific antigen, postoperative Gleason score, pathologic stage, and year of surgery. Classic adjustment using standard covariates was also implemented to compare PSM rates based on center volume for each minimally invasive surgical cohort. Results and limitations: Open RP patients had higher-risk PCa at time of surgery on average and were operated on earlier in the study time period on average, compared with minimally invasive cohorts. Crude margin rates were lowest for robotic RP (13.8%), intermediate for laparoscopic RP (16.3%), and highest for open RP (22.8%); significant differences persisted, although were ameliorated, after statistical adjustments. Lower-volume centers had increased risks of PSM compared with the highest-volume center for both laparoscopic RP and robotic RP. The study is limited by its nonrandomized nature; missing data across covariates, especially year of surgery in many of the open cohort cases; lack of standardized histologic processing and central pathology review; and lack of information regarding potential confounders such as patient comorbidity, nerve-sparing status, lymph node status, tumor volume, and individual surgeon caseload. Conclusions: This multinational, multi-institutional study of 22 393 patients after RP suggests that PSM rates might be lower after minimally invasive techniques than after open RP and that PSM rates are affected by center volume in laparoscopic and robotic cases. Patient summary: In this study, we compared the effectiveness of different types of surgery for prostate cancer by looking at the rates of cancer cells left at the margins of what was removed in the operations. We compared open, keyhole, and robotic surgery from many centers across the globe and found that robotic and keyhole operations appeared to have lower margin rates than open surgeries. How many cases a center and surgeon do seems to affect this rate for both robotic and keyhole procedures. (C) 2013 European Association of Urology. Published by Elsevier B. V. All rights reserved.

INTRODUCTION AND OBJECTIVES: There is an ongoing debate on removing the label of cancer from Gleason 6 tumors. The aim of the study was to analyze long-term oncological outcomes in patients with pathologic Gleason 3+3 score after radical prostatectomy and to add further knowledge to the discussion. METHODS: We retrospectively analyzed the data of 2942 patients who underwent RP between January 1998 and 2010 and showed a Gleason score 3þ3 in final pathology. Biochemical recurrence (BCR)-free survival, metastasis-free survival (MFS) and cancer-specific survival (CSS) was reported. In multivariate regression analyses further prognosticators of oncological outcome in these patients were analyzed. RESULTS: Median follow-up was 80.7 months. 795 (27.1%) patients underwent lymph node dissection, whereas only one of these patients had positive lymph nodes. Mean preoperative PSA was 6.6 ng/ml, 9.1% of patients had a positive surgical margin and 94.4% had an organ-confined tumor. 198 patients (7.2%) recurred during the follow-up period, 15 (0.5%) patients developed metastasis and 7 (0.2%) patients died of their disease. Patients developing metastases had a significantly higher preoperative PSA (p1⁄40.03) and were more likely to harbor a non-organ-confined tumor (p

An increasing number of small renal masses (SRMs) are being detected with modern cross-sectional imaging. The natural history of SRMs is mostly unknown. Initial active surveillance (AS) is a reasonable treatment option for small renal masses (SRMs) < 4 cm in the infirm patient with major comorbidities. Partial nephrectomy (PN) is the established treatment for T1a tumors, provided that the operation is technically feasible and the tumor can be completely removed. Laparoscopic and, most recently, robotic PN have functional and oncologic outcomes comparable to open PN, but are technically demanding procedures. Radical nephrectomy (RN) should be limited to those cases where the tumor is not amenable to PN. Percutaneous needle biopsy of SRMs can be safely performed and has the potential to characterize SRMs histologically. It is best utilized in conjunction with ablative technologies. However, ablative therapies should be reserved for carefully selected patients who are poor surgical candidates.

Laparoscopic partial nephrectomy (LPN) has become a well-established treatment for patients with selected renal malignancies. As the skills of urologic laparoscopic surgeons have increased, more complex and larger tumors are now being approached in this manner. Laparoscopic heminephrectomy (LHN), defined as the resection of30% of a kidney, is described in this article. Standardized nephrometry scoring is used to grade tumor complexity; complications, renal function, and perioperative outcomes are discussed.One hundred forty-five patients underwent minimally invasive partial nephrectomy. Parameters studied included patient demographics, tumor characteristics, operative time, estimated blood loss (EBL), length of stay (LOS), clamp time, change in renal function over time, and complication rate using the Clavien system.Twenty-four patients underwent LHN. Patients who had LHN performed had significantly larger tumors (4.7 vs 2.6 cm, P=0.05) with higher nephrometry scoring (6.6 vs 5.0, P=0.007). On univariate analysis, both operative (176.0 vs 151.6 min, P=0.036) and clamp time (29.3 vs 21.9 min, P=0.003) were significantly increased. There was no difference in LOS, EBL, change of renal function over time, or complications.LHN is efficacious and feasible. Although both operative and clamp times were significantly increased, there was no significant impact on LOS, EBL, change in renal function over time, or complication rate.

Robotic-assisted radical cystectomy continues to evolve as a surgical option in the management of muscle-invasive bladder cancer. Current oncologic outcomes appear comparable in the short-term with open radical cystectomy. Long-term follow-up, however, remains lacking for this emerging technique. Modern robotic technology allows a comparable extent of pelvic lymph node dissection as open surgery, a previous criticism of the procedure. Complications compare very favorably to open surgery in comparative series, and blood loss and transfusion rates are routinely lower. Length of stay has been shortened in some series, though not uniformly. Finally, robotic assistance can increase the cost of radical cystectomy.

Objectives To describe the incidence, identification and management of common intraoperative complications, including vascular, urological, bowel and visceral complications, of laparoscopic urological surgery. Methods We searched the databases of PubMed and Medline for relevant English language reports, using the keywords ‘laparoscopy’, ‘urologic’ and ‘complication’. Results The search yielded 967 papers in all, and a review of these yielded a total of 42 relevant papers. Conclusion Despite its advantages, laparoscopic urological surgery is associated with complications having rates as high as 22%. As surgical volumes increase, the incidence and magnitude of complications have increased progressively. Meticulous surgical technique, surgeon experience, and a high degree of suspicion are necessary throughout the surgical endeavour. The intraoperative recognition and management of complications is mandatory.

With the rapid and widespread adoption of minimally invasive procedures (laparoscopic and robotic) for the treatment of prostate and bladder cancers in the last decade, concerns have been raised regarding whether the technique can emulate the time-tested gold standard open procedures. This article briefly reviews the indications for lymph node dissection for bladder and prostate cancer, and reviews the role of extended lymphadenectomy in each procedure. Much of the focus of this review is on minimally invasive approaches and the technical aspects of the procedures, the feasibility of the robotic technique, and early oncologic outcomes.

What's known on the subject? and What does the study add? Minimally invasive approaches to radical prostatectomy have been touted to lead to superior surgical and functional outcomes with less potential complications despite scant and often conflicting reports in the peer reviewed literature. This review provides evidence that the minimally invasive prostatectomy literature still fails to meet the standards and critical benchmarks necessary for adequate complications reporting. Given our current release on observational studies. Increased effects should be made to standardize all complications and functional outcomes reporting for minimally invasive prostate cancer surgery. To query the minimally invasive urological literature from 2006 to the middle of 2010, focusing on complications and functional outcome reporting in laparoscopic radical prostatectomy (LRP) and robot-assisted LRP (RALP), to see if there has been an improvement in the overall reporting of complications. We performed a Medline search using the Medical Subject Heading terms ‘prostatectomy’, ‘laparoscopy’, ‘robotics’, and ‘minimally invasive’. We then applied the Martin criteria for complications reporting to the selected articles. We identified 51 studies for a total of 32 680 patients. When excluding functional outcomes the outpatient complications reporting was 20/51 (39.2%). In all, 35% and 43% of papers did not list any method for recording continence and potency, respectively. A complication grading system was only used in 30 studies (58.8%). Of the 16 papers using a grading scale in 2006–2007, only 31.3% used the Clavien system, compared with 69% from 2008 to the first half of 2010. In all, 27% of papers used some form of risk-factor analysis for complications. Multivariate analysis was used in 43% of papers, 29% looked at body mass index, while one looked at prostate weight, and another age. There has been an overall improvement in complications reporting in the minimally invasive RP literature since 2005. However, most studies still do not fulfil many of the criteria necessary for standardised complication reporting. Functional outcome reporting remains poor and unstandardised. Given our current reliance on observational studies, increased efforts should be made to standardise all complication outcomes reporting.

Conventional wisdom and small animal studies suggest repeated hilar clamping during partial nephrectomy is deleterious to renal function. We describe the impact of repeated renal hilar clamping during laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RPN) on the overall function of the operated kidney.A retrospective analysis of all patients undergoing RPN or LPN with repeated hilar clamping was performed. Patient and tumor characteristics were recorded. All patients had preoperative and postoperative mercaptoacetyltriglycine (MAG)3 renal scans, and the change in function was calculated. Change in glomerular filtration rate (GFR) was calculated with the modified Modification of Diet in Renal Disease equation as well.Seven patients were studied with an average age of 60 and a body mass index of 32. Tumors averaged 3.6 cm, and there were four and three right- and left-sided tumors, respectively. The reasons for repeated clamping were bleeding in three patients and either gross or microscopic positive margins in four patients, all of whom had repeated resection. The average initial clamp time was 20 minutes, and the average reclamp time was 12 minutes. The average operative time was 185 minutes. and average blood loss was 171 mL. All renal units were functioning postoperatively. The average change in absolute renal function on the operated kidney was -4.9%, and the relative loss of function was -10%, both measured on MAG3 scan. The average GFR before surgery was 61.4 (mL/min/1.73m(2)); after surgery, the average GFR was 57.1 (mL/min/1.73m(2)), for an average loss of -7%. The range of change in GFR was from 0% to -23%.Although not optimal, repeated clamping of the renal hilum during partial nephrectomy to control bleeding or to obtain a clear surgical margin is associated with minimal loss of renal function.

Lymph node dissection in bladder cancer is an integral part of radical cystectomy. It allows for accurate staging of the patient and will, therefore, serve to dictate additional treatment and add prognostic information. The issue of what is an adequate lymphadenectomy as to the extent and boundaries of the operation, specifically the cephalad extent, has been the focus of recent debate. Some have suggested that lymph node yield, in terms of number, could serve as a surrogate for the adequacy of the node dissection and, thus, the oncologic efficacy of the operation. It has also been suggested that it is a marker for the experience of the operating surgeon. What is meant by a limited, standard and extended lymph node dissection varies among different publications. Recent evidence suggests that an 'extended' node dissection infers oncologic efficacy. With the advent of minimally invasive and, specifically, robotic-assisted surgery, more cystectomies are approached robotically. As such, there has been recent debate as to whether a robotic-assisted procedure can emulate the open approach, satisfying the accepted boundaries and extent of dissection and ultimately leading to equivalent oncologic outcomes without increasing morbidity. In this review, we focus on the extent of lymphadenectomy in bladder cancer by reviewing the lymphatic drainage and arguments in favor of a more extended dissection. We will then address the minimally invasive techniques, focusing on robotic-assisted surgery, and review the evidence suggesting that this is a promising new technique that results in acceptable nodal yield and potentially equivalent oncologic outcomes with no added morbidity.

Objectives To present our experience with the management of renal artery pseudoaneurysms following laparoscopic partial nephrectomy (LPN). Methods Our bi-institutional LPN database of 259 patients from July 2001 to April 2008 was queried for patients diagnosed with a postoperative renal artery pseudoaneurysm. Demographic data, perioperative course, complications, and follow-up studies in identified subjects were analyzed. Postembolization success was defined as symptomatic relief, resolution of hematuria, and a stable hematocrit and serum creatinine. Results We identified 6 patients (2.3%) who were diagnosed with a renal artery pseudoaneurysm after LPN. The mean age of our cohort was 61.2 years (49-76), mean operative time was 208 minutes (140-265), and mean estimated blood loss was 408 mL (50-800). Patients presented at a mean of 12.6 days (5-23) after the initial surgery. Five patients had gross hematuria and a decreased hematocrit, with 1 patient presenting with clinical symptoms of hypovolemia. The sixth patient was incidentally diagnosed. The diagnosis of a renal artery pseudoaneurysm was confirmed in all cases by angiography. Selective angioembolization was successfully performed in all patients. At a median follow-up of 8.3 months all patients (100%) remained without any evidence of recurrence. Conclusions Although pseudoaneuryms are a rare postoperative complication of LPN, they are potentially life-threatening. Early identification and proper management can help reduce the potential morbidity associated with pseudoaneurysms. Our experience demonstrates the feasibility and supports the use of selective angioembolization as an excellent first-line option for patients who present with this form of delayed bleeding.

To compare the perioperative and functional outcomes of laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic prostatectomy (RALP) in a single-surgeon series. Robotic assistance aids the laparoscopically naive surgeon in performing minimally invasive prostate surgery by offering superior visualization and dexterity.The initial 75 patients with/=12 months of functional data who had undergone RALP by a single surgeon were selected. These were compared with 75 patients who had undergone LRP from a confidential database of the same surgeon experienced in LRP toward the end of his experience with this modality (300 cases).The patients in both groups were similar with respect to age, preoperative prostate-specific antigen level, biopsy Gleason score, pathologic stage, and positive margin rate. Statistically significant differences were noted in favor of RALP vs LRP with regard to operative time (199 vs 232 minutes, P.001), intraoperative blood loss (230 vs 311 mL, P = .004), and length of stay (1.95 vs 3.4 days, P.0001). The 12-month continence rate was 89% after LRP and 93.3% after RALP (P = .56). The potency rate was 71.1% and 76.5% at 12 months after LRP and RALP (P = .64) for a bilateral nerve-sparing procedure, respectively.Our initial experience has revealed that RALP is an equivalent, if not a superior, minimally invasive surgical option for localized prostate cancer with less blood loss and a shorter operative time and length of stay. Although the potency and continence rates were comparable, a trend was noted toward a faster return of functional outcomes in our early RALP experience.

Objectives Renal medullary carcinoma (RMC) is a devastating and extremely rare malignancy primarily afflicting young men with sickle cell trait. We present our clinical experience with 9 cases of RMC during a 10-year period and briefly review the published data. Methods A retrospective chart review of 9 cases of RMC during a 10-year period at our institutions was performed. The clinical patient characteristics, presentations, treatments, and outcomes were recorded. The radiographic images and pathologic specimens were reviewed. Applicable studies were selected from a Medline search. Results All 9 patients had sickle cell trait, the male/female ratio was 6:3, and the age range was 13 to 31 years. All the patients presented with flank pain, two thirds had hematuria, and 3 of the 9 patients presented with a palpable mass. Eight of the nine tumors were right sided, ranging from 4 to 12 cm in the greatest diameter. Of the 9 patients, 7 underwent radical nephrectomy. One patient was deemed to have unresectable disease by the operating surgeon, and one was given initial chemotherapy after biopsy of a metastatic lesion. The neoadjuvant therapies varied. Overall survival ranged from 4 to 16 months, with 2 patients still living at the last follow-up visit. Conclusions Our urban setting likely explains our relatively large experience with this rare and extremely aggressive tumor. An early diagnosis is critical, and a high index of suspicion should be given to any individual with sickle cell trait and new-onset hematuria, especially in the setting of a right-sided mass. Prospective trials are needed for chemotherapy/immunotherapy, because surgical intervention alone is inadequate.

Introduction: While radical retropubic prostatectomy has been the gold standard surgical approach, the explosion of minimally invasive methods has led to the search for less invasive treatment options. We offer an overview of the evolution of laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic prostatectomy (RALP) in terms of the landmark publications and recent head-to-head comparisons, and we review our own experience. Materials and Methods: A Medline search was performed using the keywords prostate cancer, prostatectomy, laparoscopic, and robotic. All pertinent articles concerning localized prostate cancer were reviewed. The Montefiore experience consisted of a retrospective review of a prospectively maintained confidential database. Results: Several laparoscopic and robotic series were identified including review articles of each modality as well as studies directly comparing the two. Both LRP and RALP compare very favorably with conventional open surgery in terms of safety and oncologic efficacy. Both minimally invasive approaches offer decreased blood loss, transfusion rate, and length of hospital stay when contrasted with open surgery. When compared directly, LRP and RALP offer similar surgical, oncologic, and functional outcomes. However, RALP likely requires a shorter learning curve. Conclusion: The use of minimally invasive techniques has revolutionized the surgical treatment of prostate cancer. Pure LRP has been shown to be feasible and reproducible. However, it has a steep learning curve and is difficult to learn. In contrast, RALP is easier to learn and is now the surgical treatment of choice in most centers of excellence in the United States. The superior optics with respect to visualization and magnification translates into a procedure that is equivalent, if not superior, with respect to perioperative parameters, oncologic outcomes, and functional outcomes to its open counterpart.

with cold scissors, the tumor pseudocapsule is identified (white asterisk) and separated from normal renal parenchyma (black plus sign). C) As the tumor pseudocapsule (white asterisk) is freed from renal parenchyma, the tumor can be rolled out of the tumor bed (black plus sign). d) Once the tumor is removed, hemostatic agents are applied to the tumor bed and manual pressure is held with the robot for five minutes. Renorraphy may be performed, but not necessary if bleeding is controlled. RESULTS: All 42 RALER procedures were completed robotically. The mean patient age was 60 years (standard deviation (SD) 12), with a mean BMI of 34.3 (SD 6.7). Radiographic mass size was 0.05). Limitations include small sample size and short follow up. CONCLUSIONS: RALER is a safe and oncologically sound approach to small renal mass excision. This technique is maximally renal sparing as there is no resection of normal renal parenchyma and can be performed off clamp.

To evaluate the influence of intensive laparoscopic skills training and self-critical video review on the learning curve for laparoscopic radical prostatectomy (LRP).The initial 40 patients who underwent a transperitoneal LRP (groups 1-4) and the subsequent 20 who underwent LRP by the extraperitoneal approach (group 5) were studied. Eight weeks prior to initiating the LRP program, intensive laparoscopic skills training at a minimally invasive surgery center was undertaken for an average of 4 hours per week. This self-training was continued for 12 weeks into the program, with self-critical review of videotapes of each procedure. The groups were compared with respect to total operative time (ORT), anastomosis time, and blood loss.There were significant differences in the ORT and anastomosis times between each of the first two groups and the last two groups (P0.001). The learning curve for ORT was overcome after approximately 35 cases, as there were no significant differences in ORT between group 3 and the subsequent groups. The anastomosis took longer to master, as significant time decreases were observed up to group 4, after which, the mean reached a plateau (group 4 v 5 P = NS). The differences in blood loss were not significant. Overall, there were 7 intraoperative (12.7%) and 8 postoperative (14.5%) complications.The use of similar facilities and training tools can help overcome the steep learning curve of LRP. Longer follow-up is needed to assess these means of attaining better functional results after LRP.

Renal cell carcinoma is increasingly being diagnosed at an earlier stage owing to medical advances. Since the pathologic stage is the most crucial predictor of patient outcome, an accurate and universal tumor staging system is of outmost importance. The TNM staging system, after multiple revisions, has evolved into a more precise system that correlates with cancer specific survival. Renal cell carcinoma staging systems have important clinical implications pertaining to nephron sparing surgery and the need for adrenalectomy or lymphadenectomy.

To analyze the perioperative outcomes and management considerations in patients with dialysis-dependent end-stage renal disease (ESRD) undergoing laparoscopic radical nephrectomy for renal-cell carcinoma (RCC).There were 224 consecutive laparoscopic radical nephrectomies reviewed. Of those, 37 patients with ESRD were identified and compared with 187 patients with sporadic RCC. Evaluable parameters included age, sex, race, side of surgery, medical comorbidities, body mass index, American Society of Anesthesiologist (ASA) scoring, and age adjusted Charlson Comorbidity Index. All complications occurring intraoperatively and within the first 30 days were classified as per the Clavien classification system. Presurgical workup and transplant considerations were evaluated. Demographic and clinical characteristics were compared using Student t tests and chi-square tests for categoric variables.Compared with non-ESRD patients, those with ESRD were younger and had smaller tumors. ASA was significantly higher in the ESRD group (P0.001). Mean blood loss was similar between ESRD patients and non-ESRD patients. Overall complication rates were higher in patients with ESRD. Pathologic characteristics of ESRD renal masses included a higher proportion of papillary RCC.Patients with RCC associated with ESRD tend to have a higher ASA class and lower grade tumors. In addition, this population is at increased risk of surgical complications and more likely to need transfusions. Careful preoperative preparation and intraoperative anesthetic management are crucial to minimize patient morbidity and improve outcomes.

It is well known that adipose tissue plays a key role in the metabolic syndrome. We investigated whether visceral fat (VFA) and or subcutaneous fat (SQF) levels are associated with the tumor phenotype of small renal masses. Additionally, we sought to investigate the relationship between VFA and baseline renal function as measured by glomerular filtration rate.From 2002 through 2011, 144 patients undergoing minimally invasive partial nephrectomy were retrospectively reviewed by a radiologist for VFA and SQF fat measurements, using standard software. A third parameter, visceral adipose tissue percent (VAT%), was also calculated using the formula: (VAT%=[VFA/VFA+SQF]×100%). We used tertiles of VFA and SQF content to compare demographic and clinical characteristics. We also looked at VFA as a continuous variable. Associations between covariables were analyzed using multivariate logistic regression analysis and odds ratios with 95% confidence intervals.Eighty-one patients had renal-cell carcinoma (RCC) and 30 patients had non-RCC pathology. On multivariate analysis, increasing BMI (p=0.023), VFA (p=0.048), VAT% (p=0.028), and Charlson comorbidity score (p=0.047) were significantly associated with worse preoperative Modification of Diet in Renal Disease (MDRD). In a subset multivariate analysis of the 81 patients with RCC, increasing VFA was statistically associated with worsening Fuhrman grade (p=0.017).VFA may be linked to the pathophysiology of renal function in patients evaluated for renal masses. Additionally, VFA may be associated with worsening tumor grades in patients with small-volume RCC. Interestingly, SQF did not play such a role. This small study proposes an interesting physiologic link between VFA and the biology of both kidney function and tumor histology. Larger studies are needed to corroborate our findings.