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Decreased glomerular filtration rate has been reported in patients with primary aldosteronism after unilateral adrenalectomy. Glomerular hyperfiltration has been assumed to mask the preoperative subtle renal impairment. In this study, we investigated predictors for decreased estimated glomerular filtration rate after adrenalectomy in patients with primary aldosteronism.From January 2006 through September 2018, 328 patients with confirmatory diagnoses of primary aldosteronism received unilateral laparoscopic adrenalectomy and subsequent follow-up for 12 months. We prospectively collected related parameters of the clinical outcomes and renal function to identify predictors of renal function impairment at 12 months after surgery.Patients were stratified into three groups by preoperative estimated glomerular filtration rate level: 144 (43.9%) with estimated glomerular filtration rate ≥90, 130 (39.6%) with estimated glomerular filtration rate within 60-89.9, and 54 (16.5%) with estimated glomerular filtration rate60 mL/min/1.73 mEstimated glomerular filtration rate declined significantly after adrenalectomy in patients with estimated glomerular filtration rate ≥90. The study provided important information to identify primary aldosteronism patients with higher risk of estimated glomerular filtration rate decline after adrenalectomy and might help to adopt early interventions to improve the outcomes.

The aim of this study was to update the information on internationally acceptable standards and clinical practice recommendations for the management of patients with primary aldosteronism (PA). The Taiwan Society of Aldosteronism (TSA) Task Force acknowledged the novel issues of PA and reached a group consensus on PA in Taiwan by collecting the best available evidence and conducting one group meeting, several conference calls, and multiple e-mail communications. Unilateral adrenalectomy is the preferred treatment for patients with aldosterone-producing adenoma (APA). For medical treatment with mineralocorticoid receptor antagonists (MRAs), spironolactone is the first-line treatment, and eplerenone is a reasonable alternative in PA patients intolerant or contraindicated to spironolactone. The dose of MRAs can be titrated according to plasma renin activity (PRA). For screening PA-related comorbidities, we suggest albuminuria to predict a post-treatment decline in renal function, echocardiography as cardiac evaluation, bone mineral density scan for osteoporosis, and obstructive sleep apnea. In tissue and genetic surveys, we suggest immunohistochemical staining and somatic mutation screening for post-operative adrenal specimens in APA patients. With this consensus, we hope to update the information on PA for clinical physicians to facilitate better identification, management and treatment of patients with PA.

Background: In primary aldosteronism (PA), kidney function impairment could be concealed by relative hyperfiltration and emerge after adrenalectomy. We hypothesized transtubular gradient potassium gradient (TTKG), a kidney aldosterone bioactivity indicator, could correlate to end organ damage and forecast kidney function impairment after adrenalectomy. Methods: In the present prospective study, we enrolled lateralized PA patients who underwent adrenalectomy and were followed up 12 months after operation in the Taiwan Primary Aldosteronism Investigation (TAIPAI) registry from 2010 to 2018. The clinical outcome was kidney function impairment, defined as estimated glomerular filtration rate (eGFR) 2 at 12 months after adrenalectomy. End organ damage is determined by microalbuminuria and left ventricular mass. Results: In total, 323 patients [mean, 50.8 ± 10.9 years old; female 178 (55.1%)] were enrolled. Comparing pre-operation and post-operation data, systolic blood pressure, serum aldosterone, urinary albumin to creatinine ratio and eGFR decreased. TTKG ⩾ 4.9 correlated with pre-operative urinary albumin to creatinine ratio >50 mg/g [odds ratio (OR) = 2.42; p = 0.034] and left ventricular mass (B = 20.10; p = 0.018). Multivariate logistic regression analysis demonstrated that TTKG ⩾ 4.9 could predict concealed chronic kidney disease (OR = 5.42; p = 0.011) and clinical success (OR = 2.90, p = 0.017) at 12 months after adrenalectomy. Conclusions: TTKG could predict concealed kidney function impairment and cure of hypertension in PA patients after adrenalectomy. TTKG more than 4.9 as an adverse surrogate of aldosterone and hypokalaemia correlated with pre-operative end organ damage in terms of high proteinuria and cardiac hypertrophy.

IntroductionPrimary aldosteronism (PA) is a common form of secondary hypertension that has significant cardiovascular events and increased prevalence of metabolic syndrome and diabetics. Although plasma aldosterone concentration is positively correlated with visceral fat area (VFA) in non-PA individuals, the role of visceral adiposity associated with clinical success after surgery is not known.Research design and methodsWe analyzed patients who underwent adrenalectomy for aldosterone-producing adenoma (APA) at the Taiwan PA Investigator group. VFA was calculated from the abdominal CT scan at APA diagnosis, and all patients received adrenalectomy.ResultsThe study involved 100 consecutive patients with APA (42 males; mean age 49.3 years) matched with 41 essential hypertension (EH) patients. Patients with APA had smaller VFA (p=0.010) than their EH counterparts. Multiple linear regression analysis revealed that the duration of hypertension (p=0.007), but not plasma aldosterone, was negatively correlated with VFA in patients with APA. Logistic regression analysis showed that log VFA (OR=0.065, p<0.001) and duration of hypertension before PA diagnosis (OR=0.919, p=0.011) can predict complete clinical success after adrenalectomy. Multifactor-adjusted generalized additive model demonstrated that log VFA ConclusionsPatients with APA had smaller VFA than their EH counterparts, and VFA increased after adrenalectomy. Clinical complete cure of hypertension after surgery was associated with smaller VFA and shorter duration of hypertension at PA diagnosis, suggesting a potential interplay of visceral adiposity and aldosterone of the patients with APA.

Background Acute kidney injury (AKI) after cardiovascular surgery is a serious complication. Little is known about the ability of novel biomarkers in combination with clinical risk scores for prediction of advanced AKI. Methods In this prospectively conducted multicenter study, urine samples were collected from 149 adults at 0, 3, 6, 12 and 24 h after cardiovascular surgery. We measured urinary hemojuvelin (uHJV), kidney injury molecule-1 (uKIM-1), neutrophil gelatinase-associated lipocalin (uNGAL), α-glutathione S-transferase (uα-GST) and π-glutathione S-transferase (uπ-GST). The primary outcome was advanced AKI, under the definition of Kidney Disease: Improving Global Outcomes (KDIGO) stage 2, 3 and composite outcomes were KDIGO stage 2, 3 or 90-day mortality after hospital discharge. Results Patients with advanced AKI had significantly higher levels of uHJV and uKIM-1 at 3, 6 and 12 h after surgery. When normalized by urinary creatinine level, uKIM-1 in combination with uHJV at 3 h post-surgery had a high predictive ability for advanced AKI and composite outcome (AUC = 0.898 and 0.905, respectively). The combination of this biomarker panel (normalized uKIM-1, uHJV at 3 h post-operation) and Liano’s score was superior in predicting advanced AKI (AUC = 0.931, category-free net reclassification improvement of 1.149, and p

Primary aldosteronism (PA) is associated with increased urinary calcium excretion and osteoporosis prevalence. We studied the long-term effect of hyperaldosterone on fracture risk and possible risk mitigation via treatments, by comparing PA patients and their essential hypertension (EH) counterparts extracted by propensity score match. We used a longitudinal population database from the Taiwan National Health Insurance, and used a validated algorithm to identify PA patients diagnosed in 1997-2010. Our sample included 2533 PA patients, including 921 patients with aldosterone-producing adenoma (APA). Our methods for assessing excessive fracture risk included multivariable Cox regression and the competing risk regression. The incidence rate of fracture at any site was 14.4 per 1000 person-years for PA, and 11.2 per 1000 person-years for APA. In contrast, the incidence rate of fracture at any site was 8.3 per 1000 person-years in EH controls for PA, and 6.5 per 1000 person-years in EH controls for APA. Mineralocorticoid receptor antagonist (MRA) treatment might be associated with higher risk of osteoporotic fracture in the whole female PA cohort (subdistribution hazard ratio [SHR] = 2.12, p = 0.008) as well as female APA patients (SHR = 1.15, p = 0.049). As to fracture at any site, MRA treatment was also associated with higher risk; the SHR was 1.88 (p < 0.001) in the whole female PA cohort, and 2.17 (p = 0.019) in female APA patients. PA is tightly associated with higher risk of bone fracture, even in the case where the competing risk of death was controlled. Particularly, female PA patients treated with MRA were confronted with significantly higher risk in bone fracture than their EH controls. © 2017 American Society for Bone and Mineral Research.

Background Superior performance of surgical treatment over medical treatment for primary aldosteronism (PA) has been reported in small-scale clinical studies with diverse clinical outcomes, but no solid conclusion has been drawn as results of large randomized trials are lacking. Methods: We performed a search of PubMed, MEDLINE, Embase and Cochrane Library for randomized or observational studies that investigated cardiovascular outcomes in patients with primary aldosteronism undergoing medical versus surgical treatment. - Composite outcomes including persistence of hypertension (HT) and incidence of significant clinical events (e.g. major adverse cardiovascular events [MACE] and all-cause mortality) after treatment was considered. Meta-analyses of both composite and individual outcomes were conducted. Risks of bias of the included studies were assessed with Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) checklist. Findings: A total of 368 related citations were reviewed and 11 studies that fulfilled the inclusion criteria, with altogether 5,994 PA patients, were included in the meta-analysis. Evaluation showed that there were low-moderate risks of bias in (63.64%) 7 of the included studies. The results of meta-analyses demonstrated lower incidence of composite outcomes among PA patients who underwent surgical treatment over medical treatment (Odds Ratio (OR): 0.49, 95% CI: 0.29-0.83 in random effects model). Surgical treatment also led to less incidence of persistence of HT (OR of non-cure of HT: 0.31, 95% CI: 0.11-0.85 in random effects model). Fewer major cardiovascular events and mortality events after surgical treatment were observed in the fixed effect model (OR: 0.47, 95% CI: 0.39-0.56), but failed to reach significant statistical levels in random effects model (OR: 0.71, 95% CI: 0.33-1.52) when compared to medical treatment. Interpretation: Superior performance of surgical treatment over medical treatment for PA patients is confirmed with meta-analyses in terms of lower incidences of composite outcomes and non-cure of HT. Hence, adrenalectomy could now be concluded as the treatment of choice for lateralized PA. Funding Statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of Interests: All authors declare no competing interests Ethics Approval Statement: The pre-defined review protocol was registered at the PROSPERO international prospective register of systematic reviews (PROSPERO registration number CRD42019119175). The protocol for this trial and supporting CONSORT checklist are available as supporting information.

Background: Bladder urinary calculi occur in 3%–8% of men with bladder outlet obstruction, and although most of them are composed of calcium, in a few cases uric acid bladder stones are diagnosed. Case Presentation: We present clinical images and therapeutic management of a 65-year-old diabetic man with significant prostate enlargement and >30 bladder stones, the largest being 17 mm. Despite the large stone burden, the patient was managed by cystolithotripsy. Remarkably, stone composition analysis revealed 100% uric acid stone. Intraoperative and postoperative course were uneventfully. Conclusion: Uric acid bladder stone pathogenesis seems to be multifactorial with local and systemic factors contributing in different manners and even large stone burdens may be cystoscopically managed.

The use of statin therapy on the prevention of atherosclerotic cardiovascular disease (ASCVD) is recommended by the American College of Cardiology (ACC) and the American Heart Association (AHA), nevertheless, its validation on primary aldosteronism (PA) patients has not been reported. We investigated the risk of incident ASCVD in middle-aged patients with PA compared with essential hypertension (EH) based on ACC/AHA recommendations. We enrolled 461 PA patients and 553 EH patients. Even though the ratio of metabolic syndrome in each group was similar, the PA group had higher systolic blood pressures, higher low-density lipoprotein levels, higher plasma aldosterone concentration (PAC), lower high-density lipoprotein levels, and higher 10-year ASCVD compared to the EH group. The discriminative power for predicting ASCVD by the recommended statin use from the ACC/AHA guidelines was proper in the PA group (i.e., under the receiver operating characteristic curve (95% confidence interval, 0.94 (0.91–0.96)). The generalized additive model showed patients with PAC higher than 60 ng/dL accompanying the standard timing of the statin use suggested by the ACC/AHA. The ACC/AHA guidelines have good discriminative power in the prediction of middle-aged high-risk hypertensive patients, while PAC identifies those high-risk individuals who may benefit from early statin therapy.

Although statin treatment is recommended for patients with chronic kidney disease (CKD) stages I–IV, its potential benefits have not been reported in advanced CKD patients. Non-diabetic patients with advanced CKD (pre-dialysis patients, estimated glomerular filtration rate &lt, 15 mL/min/1.73 m2) were enrolled from a National Health Insurance Research Database with a population of 23 million. Statin users and non-users were matched using propensity scoring and analyzed using Cox proportional hazards models, taking mortality as a competing risk with subsequent end-stage renal disease (ESRD) and statin doses as time-dependent variables. A total of 2551 statin users and 7653 matched statin non-users were identified from a total 14,452 patients with advanced CKD. Taking mortality as a competing risk, statin use did not increase the risk of new-onset diabetes mellitus (NODM) or decrease the risk of de novo major adverse cardiovascular events (MACE), but reduced all-cause mortality (hazard ratio (HR) = 0.59 [95% CI 0.42–0.84], p = 0.004) and sepsis-related mortality (HR = 0.53 [95% CI 0.32–0.87], p = 0.012). For advanced CKD patients, statin was neither associated with increased risks of developing NODM, nor with decreased risk of de novo MACE occurrence, but with a reduced risk of all-cause mortality, mainly septic deaths.

Context The aberrant expression or alternation of miRNA in the pathogenesis of aldosterone-producing adenomas (APAs) is still largely unknown. Objective We investigated the role of miRNA-203 (screened from miRNA microarrays) and elucidated its effects on the Wnt/β-catenin pathway regarding aldosterone production and cell proliferation in APAs. Methods miR-203 expression was upregulated or downregulated by transfecting miR-203 mimics or inhibitors into primary APA cells, the human adrenocortical cell line HAC15, and C57BL/6 mice. In vitro and biochemical data were correlated with the respective clinical parameters of APAs to evaluate their clinical importance. Results The expression of miR-203 in human APA samples was significantly lower than that of peritumor adrenal samples. Tumoral miR-203 abundance correlated negatively with both plasma aldosterone level and tumor size in patients with APAs. miR-203 inhibitors increased aldosterone production and cell proliferation in HAC15 cells, and restoration of expression via miR-203 mimics showed decreased cell proliferation and aldosterone hypersecretion in APA cell cultures. In vivo selective inhibition of miR-203 via intra-adrenal injection of miR-203 inhibitors in mice led to a substantial increase in systolic blood pressure and plasma aldosterone levels. Additionally, the dual-luciferase reporter assay demonstrated that WNT5A is a direct target of miR-203. Furthermore, plasma Wnt5a levels in adrenal vein sampling were helpful in differentiating tumor localization, and preoperative plasma Wnt5a levels predicted the cure of hypertension after adrenalectomy. Conclusion We have demonstrated that attenuated miR-203 expression in APAs increases aldosterone production and the tumorigenesis of adrenal cells by activating the Wnt5a/β-catenin pathway.

Acute kidney injury (AKI) is detrimental after cardiac surgery. In this multicenter study, the novel biomarker hemojuvelin (HJV) was evaluated for AKI prediction following cardiac surgery. Urinary HJV, neutrophil gelatinase-associated lipocalin (NGAL), and urinary creatinine were measured in 151 patients after surgery. The outcomes of advanced AKI (KDIGO stages 2 and 3) and all causes of in-hospital mortality as the composite outcome were recorded. Areas under the receiver operator characteristic curves (AUC) and a multivariate generalized additive model (GAM) were applied to predict these outcomes of interest. Urinary HJV differentiated patients with/without AKI, advanced AKI or composite outcome after surgery (p p p ponding AUC values of 0.768 and 0.828, respectively. The performance of creatinine-adjusted HJV was also superior to NGAL in predicting advanced AKI (AUC = 0.784 and 0.694; p = 0.037) and composite outcome (AUC = 0.842 and 0.676; p = 0.002). The integration of HJV into the Cleveland Clinic score for advanced AKI led to a significant increase in risk stratification (net reclassification improvement [NRI] = 0.598; p

Scientific Reports 6: Article number: 32103; published online: 02 September 2016; updated: 24 March 2017 The original version of this Article contained an error in the Abstract. “While need for receptor antagonist (MRA) MRA after diagnosis suggests that a defined daily dose (DDD) of MRA between 12.5and 50 mg may alleviate risk of death in a U-shape pattern”.

Constitutive activation of the Wnt pathway/β-catenin signaling may be important in aldosterone-producing adenoma (APA). However, significant gaps remain in our understanding of the prevalence and clinical outcomes after adrenalectomy in APA patients harboring CTNNB1 mutations. The molecular expression of CYP11B2 and gonadal receptors in adenomas were also explored. Adenomas from 219 APA patients (95 men; 44.2%; aged 50.5 ± 11.9 years) showed a high rate of somatic mutations (n = 128, 58.4%). The majority of them harbored KCNJ5 mutations (n = 116, 52.9%); 8 patients (3.7%, 6 women) had CTNNB1 mutations. Patients with APAs harboring CTNNB1 mutations were older and had shorter duration of hypertension. After adrenalectomy, CTNNB1 mutation carriers had a higher possibility (87.5%) of residual hypertension than other APA patients. APAs harboring CTNNB1 mutations have heterogeneous staining of β-catenin and variable expression of gonadal receptors and both CYP11B1 and CYP11B2. This suggests that CTNNB1 mutations may be more related to tumorigenesis rather than excessive aldosterone production.

To present oncologic results of laparoscopic radical prostatectomy (LRP) monotherapy for men with high-risk, localized prostate cancer, and to find factors associated with a good prognosis via surgery alone.Between 2002 and 2009, 241 men underwent LRP at an Asian tertiary referral center. Among them, we retrospectively identified 85 (35.3%) men who met the D'Amico's high-risk criteria: Prostate-specific antigen level20 ng/mL, Gleason score of 8 to 10, or clinical stage ≥T2c. Perioperative parameters were analyzed against biochemical recurrence (BCR)-free survival.At a median follow-up of 54 months, BCR developed in 28 (34.1%), with an actuarial BCR-free survival rate of 63.3% at 5 years. Pathologically, 37.6% of the men had organ-confined (OC) disease. Positive surgical margins (PSM) were identified in 49.4% of the patients. A favorable pathologic outcome, defined as OC(+)PSM(-), was observed in 24 patients and associated with a 5-year BCR-free survival rate of 87.0%, compared with 100%, 54.0%, and 46.4% in men with OC(+)PSM(+), OC(-)PSM(-) and OC(-)PSM(+) disease (log-rank, P=0.008). The overall positive lymph node rate was 14.1%. Men (65.9%) with only one D'Amico risk factor had a 5-year BCR-free survival rate of 76.9%, compared with 34.6% in men (34.1%) with ≥2 risk factors (log-rank, P0.001).Radical prostatectomy monotherapy performed laparoscopically or robotically appears to be an option for high-risk prostate cancer, especially in men with a single D'Amico risk factor. Men with ≥2 risk factors are more prone for BCR to develop after surgery and may need second-line therapy.

What's known on the subject? and What does the study add? LESS-NU may be an alternative minimally-invasive treatment option for patients eligible to undergo laparoscopic surgery for upper urinary tract urothelial carcinoma. The true benefits of LESS-NU remain to be determined and require randomized control trials in the future. Despite encouraging early findings, clinical trials still are warranted before this procedure is adopted widely, and longer follow-up is needed to determine its oncological durability. Objective To report a large multi-institutional series of laparoendoscopic single-site (LESS) nephroureterectomy (NU). Materials and Methods Data on all cases of LESS-NU performed between 2008 and 2012 at 15 institutions were retrospectively gathered. The main demographic data and perioperative outcomes were analysed. Results The study included 101 patients whose mean (sd) age was 66.4 (9.9) years and mean (sd) body mass index was 24.8 (4) kg/m2, and of whom 29.7% had undergone previous abdominal/pelvic surgery. The mean (sd) operating time was 221.4 (73.7) min, estimated blood loss 231.7 (348.0) mL. A robot-assisted LESS technique was applied in 25.7% of cases. An extra trocar was inserted in 28.7% of cases to complete the procedure. Conversion to open surgery was necessary in three cases (3.0%). There was no bladder cuff excision in 20.8% of cases, and excision was carried out using a variety of techniques in the remaining cases. Six intra-operative complications occurred (5.9%). The mean (sd) length of hospital stay was 6.3 (3.5) days. The overall postoperative complication rate was 10.0%, and most of the complications were low grade (Clavien grades 1 and 2). The mean tumour size was 3.1 (1.9) cm. Pathological staging was pTis in two patients, pTa in 12 patients, pT1 in 42 patients, pT2 in 20 patients, pT3 in 23 patients and pT4 in two patients. Pathological grade was high in 71 and low in 30 patients. At a mean follow-up of 14 months, six patients (5.9%) had died. Disease recurrence (including distant and bladder recurrence) was detected in 22.8% of patients, with a mean time to recurrence of 11.5 months. Conclusions This study reports the largest multi-institutional experience of LESS-NU to date. Peri-operative outcomes mirror those of published standard laparoscopy series. Despite encouraging early findings, longer follow-up is needed to determine the oncological efficacy of the procedure.

There exists a great knowledge gap in terms of long-term effects of various surgical and pharmacological treatments on outcomes among primary aldosteronism (PA) patients. Using a validated algorithm, we extracted longitudinal data for all PA patients diagnosed in 1997–2010 and treated in the Taiwan National Health Insurance. We identified 3362 PA patients for whom the mean length of follow-up was 5.75 years. PA has higher major cardiovascular events (MACE) than essential hypertension (23.3% vs 19.3%, p = 0.015). Results from the Cox model suggest a strong effect of adrenalectomy on lowering mortality (HR = 0.23 with residual hypertension and 0.21 with resolved hypertension). While the need for mineralocorticoid receptor antagonist (MRA) after diagnosis suggests that a defined daily dose (DDD) of MRA between 12.5 and 50 mg may alleviate risk of death in a U-shape pattern. A specificity test identified patients who has aldosterone producing adenoma (HR = 0.50, p = 0.005) also confirmed adrenalectomy attenuated all-cause mortality. Adrenalectomy decreases long-term all-cause mortality independently from PA cure from hypertension. Prescription corresponding to a DDD between 12.5 and 50 mg may decrease mortality for patients needing MRA. It calls for more attention on early diagnosis, early treatment and prescription of appropriate dosage of MRA for PA patients.

Primary aldosteronism (PA) is associated with increased urinary calcium excretion and osteoporosis prevalence. We studied the long-term effect of hyperaldosterone on fracture risk and possible risk mitigation via treatments, by comparing PA patients and their essential hypertension (EH) counterparts extracted by propensity score match. We used a longitudinal population database from the Taiwan National Health Insurance, and used a validated algorithm to identify PA patients diagnosed in 1997-2010. Our sample included 2533 PA patients, including 921 patients with aldosterone-producing adenoma (APA). Our methods for assessing excessive fracture risk included multivariable Cox regression and the competing risk regression. The incidence rate of fracture at any site was 14.4 per 1000 person-years for PA, and 11.2 per 1000 person-years for APA. In contrast, the incidence rate of fracture at any site was 8.3 per 1000 person-years in EH controls for PA, and 6.5 per 1000 person-years in EH controls for APA. Mineralocorticoid receptor antagonist (MRA) treatment might be associated with higher risk of osteoporotic fracture in the whole female PA cohort (subdistribution hazard ratio [SHR] = 2.12, p = 0.008) as well as female APA patients (SHR = 1.15, p = 0.049). As to fracture at any site, MRA treatment was also associated with higher risk; the SHR was 1.88 (p0.001) in the whole female PA cohort, and 2.17 (p = 0.019) in female APA patients. PA is tightly associated with higher risk of bone fracture, even in the case where the competing risk of death was controlled. Particularly, female PA patients treated with MRA were confronted with significantly higher risk in bone fracture than their EH controls. © 2017 American Society for Bone and Mineral Research.

What’s known on the subject? and What does the study add? Laparoendoscopic single-site (LESS) nephrectomy is feasible to remove diseased kidneys. Most of such procedures previously reported were performed through a transperitoneal (trans-abdominal) approach. We report the feasibility, safety, and techniques of performing such operations without disturbing the bowels (a retroperitoneal LESS approach). This approach provides acceptable operative outcomes, and is especially valuable for patients who need to have an intact peritoneal envelope, or those with potentially abnormal or obliterated peritoneal space. Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVES • To retrospectively review our experience with respect to evaluating the feasibility and safety of retroperitoneoscopic laparoendoscopic single-site surgery (LESS) nephrectomy. • To present the technical details of such a procedure. PATIENTS AND METHODS • In total, eight retroperitoneoscopic LESS nephrectomies (in seven patients) were completed for a variety of indications in a single centre. • The GelPOINT apparatus (Applied Medical, Rancho Santa Margarita, CA, USA) was used as an access platform through a flank incision (3–5 cm). • Except for a bendable grasper and flexible vascular staplers, all instruments used were conventional straight laparoscopic instruments. • Perioperative data were retrospectively obtained for all patients, including demographic data, operative indications, operative records, length of stay, complications, and pathological analysis. RESULTS • All retroperitoneoscopic LESS nephrectomy procedures attempted were completed successfully without complications. No extra working port was required for any case. • Median (range) operating time was 164 (87–198) min and median (range) estimated blood loss was 50 (10–200) cm3. Median (range) length of hospital stay was 2 (1–3) days. • The median narcotic used was 34 mg of parental morphine sulphate equivalent. The median (range) visual analogue pain scale score at discharge was 2 (0–3) out of 10. • The present single arm observation study is limited by the small patient number and the absence of a control cohort. CONCLUSIONS • Retroperitoneoscopic LESS nephrectomy using the GelPOINT apparatus as an access platform is feasible and safe. • It provides adequate flexibility and spacing of port placements as well as acceptable operative outcomes. • It is especially valuable for those patients who need to maintain peritoneal integrity or those with an abnormal or obliterated peritoneal space.

Treating organ recipients who have metastatic renal cell carcinoma (mRCC) is challenging because of the dilemma between transplant-required immunosuppression and cancer control via boosting immunity with immunotherapy. We report such a patient whose case was successfully maintained only with temsirolimus and low-dose steroids, while achieving good allograft function and oncological outcomes. After removal of his primary renal cancer, a kidney recipient was found to have multiple metastases. Since recovery from surgery he has been administered 25 mg/wk temsirolimus for 2 more years. His mRCC is in partial remission, the serum creatinine level has been stable (∼ 1.6 mg/dL), and the performance score has been good. Adverse effects encountered include transient transaminitis, dyslipidemia, and poorly controlled hyperglycemia. The pharmacokinetics of sirolimus (the major first metabolite of temsirolimus) is depicted to speculate the underlying mechanism. To our knowledge, this is the first sustainable success using temsirolimus-based immunotherapy (both immunosuppression and cancer therapy) in a transplant recipient who has mRCC.

Benefits of pulsatile machine perfusion (pumping) of standard criteria donor (SCD) kidneys are unclear. Our center is located 4½ hours from our Organ Procurement Organization. We evaluated outcomes of pumping SCD kidneys under such circumstances by conducting a retrospective examination of all SCD kidneys transplanted between January 2007 and March 2012, comparing kidneys pumped (28 [group 1]) versus standard cold storage (77 [group 2]). Group 1 had fewer delayed graft function (DGF, 3.57% vs. 23.38%, p = 0.02) and slow graft function (SGF, 7.14% vs. 24.68%; p = 0.047) and faster serum creatinine recovery curve (p0.001) than group 2. Having a kidney pumped decreases the incidence (odds ratio [OR], 0.059) of DGF, SGF, or primary nonfunction. Group 1 were quicker to reach an estimated glomerular filtration rate (eGFR)30 ml/min (OR, 4.186; confidence interval [CI], [2.448-7.157]) or an eGFR60 ml/min (OR, 2.669; CI [1.255-5.679]). Pumping the SCD kidneys in a geographically remote transplant center tended to be better than those preserved in cold storage. However, except recovery curve of serum creatinine during the first postoperative month, other parameters failed to reach statistical significance in the post hoc examination of the contemporary groups. Prospective paired kidney study is required to scrutinize this finding.

Objective To describe keys to successful programmatic implementation of laparoendoscopic single-site (LESS)-living donor nephrectomy (LDN) in a small-volume center. Laparoscopic LDN has become the standard of care. Technically challenging LESS-LDN has been limited to high-volume centers. However, approximately half of all U.S. transplant centers perform ≤15 LDNs/year, including our center. Methods A hand-assisted laparoscopy (HAL) device was used as the LESS platform at a periumbilical midline incision. We used an adhesive drape to cover the platform to prevent gas leakage. A 30° telescope and 3-4 instruments were inserted through its gel-cap. After careful dissection, the kidney was bagged into a recovery device with an external handle before its vessels were ligated with staples and was then removed immediately through the LESS wound. Results LESS-LDN was successful in all of 10 living donors without any multisite laparoscopic or open conversion and without any instruments inserted through extra wounds. No patient had perioperative complications or received transfusions. Median operative time was 271 minutes with a warm ischemia time (WIT) of 3.5 minutes. Hospital stay averaged 2 days with visual analog pain score 4 of 10 at discharge and 2 of 10 at 2 weeks. All recipients recuperated well with immediate graft function. Conclusion Our LESS-LDN technique offers improved cosmesis, favorable perioperative outcomes, and versatile options for conversion, if necessary, making it a viable approach for small-volume centers.

The surgical procedures of implanting a kidney graft into the extraperitoneal iliac fossa has not changed much since its inception in 1950s; whereas the other renal transplant-related surgical approaches have been dramatically updated recently, especially with the commencement of urological laparoscopic surgery. The mile-stone advancement is the laparoscopic live donor nephrectomy (LDN). Conventional open LDN technique has been alleged as a hurdle for expanding live donor programs. Minimally invasive surgery approaches, like laparoscopic LDN, have been advocated to overcome this obstacle (Boulware et al., 2002). A variety of laproscopic LDN approaches will be detailed.

Objective To report a technique of minimally invasive radical nephrectomy for a native renal cell carcinoma (RCC) and nonischemic open partial nephrectomy for a transplant kidney RCC with only a laparoendoscopic single-site (LESS) incision. Concomitant RCCs in a native and transplant kidneys are very rare. Conventional surgical approach requires a long incision. Methods A 50-year-old man 14 years after renal transplant was found incidentally to have concomitant RCCs in his native right kidney and transplant kidney. A right lower abdomen Gibson incision, along his transplant wound, was used initially for LESS right radical nephrectomy and lymphadenectomy, and that same wound was used for a nonischemic open partial nephrectomy in the transplant kidney. Results The LESS right radical nephrectomy took 3.25 hours with estimated blood loss (EBL) of 80 mL and the partial nephrectomy for the transplant kidney took 3 hours with EBL of 220 mL. No transfusion was required. Pathologic examination revealed both tumors to be RCC, clear cell type, and 6.5 cm in the right native kidney and 2.8 cm in the transplant kidney. The final wound measured 9 cm. Postoperative recovery was uneventful with inpatient narcotic requirement of 37 mg morphine sulfate equivalent, and oral intake of food resumed in 2.5 days. His allograft function was well preserved with a serum creatinine unchanged (1.4 mg/dL) at discharge. Conclusion In a patient with concomitant tumors in a native kidney and a transplant kidney, this unique approach provides exceptional benefits of minimally invasive tumor excision for both tumors, and good preservation of renal function.

Purpose. To evaluate the midterm oncologic results of extraperitoneal laparoscopic radical prostatectomy (EPLRP) for Asian men with localized prostate cancer.Methods. Between 2004 and 2009, 218 men underwent EPLRP at an Asian tertiary hospital. The mean preoperative prostate-specific antigen (PSA) was 15.5 ng/ml and mean Gleason score was 6.6. Stage distributions were cT1a-b in 21 cases, cT1c in 139, cT2 in 48 and cT3 in 10. Disease recurrence was defined as PSA ≥ 0.2 ng/mL in 2 consecutive measurements or initiation of secondary therapy.Results. Postoperative pathological stage was pT2a-b in 33 patients, pT2cN0 in 10, pT3a in 27, pT3b in 36, pT4 in 9 and pN1 in 10. Positive surgical margins occurred in 14.6% and 48.6% for pT2 and pT3 diseases, respectively (). The overall PSA recurrence-free survival at 3 and 5 years was 82.1% and 74.5%. By the pathological stages, 3-year recurrence-free survival was 92.4% (pT2), 81.1% (pT3a), 62.6% (pT3b-4) and 55.6% (pN1), respectively ().Conclusions. EPLRP is curative even for some locally advanced prostate cancers in a midterm follow-up. Even at an Asian center of low volume of radical prostatectomy EPLRP still provides oncologic outcomes similar to that of high volume centers.

Laparoscopic inguinal hernia repair has been around since the 1990s. A novel surgical approach known as laparoendoscopic single-site surgery (LESS) has been developed to reduce the port-related morbidities and improve the cosmetic outcomes of laparoscopic surgery, including totally extraperitoneal (TEP) inguinal hernia repair. The aim of the present study was to evaluate the safety and feasibility of the LESS TEP technique for inguinal hernia repair and compare the outcomes with the standard TEP approach. Between January and May 2009, 54 consecutive healthy patients (48 men and 6 women) underwent LESS TEP inguinal hernia repair at our institute. All procedures were performed using our homemade single port for simultaneous passage of the laparoscope and instruments. The perioperative data, including patient age, sex, body mass index (BMI), hernia characteristics, operative time, complications, length of hospital stay, return to normal activity, pain score, and cosmetic result, were prospectively collected. All LESS TEP procedures were completed successfully without conversion to standard laparoscopic or open surgery. A total of 98 LESS TEP hernia repairs were performed in 54 patients and compared with 152 standard TEP operations. The mean operative time was significantly shorter in the standard TEP series (61.8 ± 26.0 vs. 70.9 ± 23.8 min, p = 0.04). Other perioperative parameters, including the length of hospital stay, time until return to full activity, complication rate, pain score, and cosmetic result, were all comparable between the two techniques. Our short-term experience with LESS TEP inguinal hernia repair has shown that in experienced hands, inguinal hernia repair via the LESS TEP technique is as safe as the standard TEP technique. However, based on our evidence, we currently believe that the LESS TEP technique is not an efficacious surgical alternative to the standard TEP technique for inguinal hernias.

Bladder diverticulum is rarely associated to hydroureteronephrosis. We present clinical images of an adult patient with a bladder diverticulum near the ureterovesical junction (UVJ) with secondary obstruction. An 84-year-old man presented with left hydroureteronephrosis and a presumed 25-mm left ureteral stone at UVJ on computed tomography. Cystoscopy revealed a stone located in a bladder diverticulum just cephalad and medial to left ureteral orifice; the patient successfully underwent endoscopic laser cystolithotripsy with resolution of his hydronephrosis. Juxta-UVJ bladder diverticula may cause obstruction of the ipsilateral upper urinary tract.

The Hem-o-Lok clips are widely used in various laparoscopic operations because of its easy application and secure clamping. The Hem-o-Lok clips were adopted to ligate bladder cuff during bladder cuff excision because of its advantages. We report 2 cases of bladder migration of Hem-o-Lok clips after laparoscopic nephroureterectomy and bladder cuff excision. The clips were found during routine follow-up cystoscopy and were removed by cystoscopic procedure. We described the case presentation, treatment, and the alternative method to avoid such shortcomings.