Analysis of repeated 24-core saturation prostate biopsy: Inverse association between asymptomatic histological inflammation and prostate cancer detection.

Saturation prostate biopsy protocols have been developed to improve the prostate cancer (PCa) detection rate, particularly in the setting of repeat biopsies. The present study attempted to clarify the association between PCa detection and various risk factors in repeat saturation biopsies. A retrospective analysis was conducted on 78 Japanese patients for whom findings had caused suspicion of PCa despite previous negative prostate biopsies, and who consecutively underwent a 24-core transperineal repeat biopsy at Toyama University Hospital (Toyama, Japan). PCa was confirmed histologically in 16 of the 78 patients (20.5%). A univariate analysis revealed that the prostate-specific antigen (PSA) level at repeat biopsy was higher (P<0.01), the fPSA/tPSA ratio was lower (P=0.04), the total prostate volume was smaller (P=0.01) and the PSA density was higher (P<0.01) in PCa patients than in patients with benign prostatic disease (BPD). Histological inflammation was more frequently observed in BPD patients than in PCa patients (P<0.01). A multivariate analysis revealed that histological inflammation was the only independent predictor of the presence of a malignant lesion on repeat biopsy (odds ratio, 0.027; P=0.01). It must be considered that inflammation may cause a PSA increase in some patients with a negative initial biopsy, leading to unnecessary repeat biopsy.

Wild-type ATTR amyloidosis of the ureter in a 56-year-old woman with rheumatoid arthritis and Sjögren's syndrome.

We present a case of acute pyelonephritis with right hydronephrosis in a middle-aged woman, who had suffered from rheumatoid arthritis and Sjögren's syndrome. She had successfully treated with antibiotics, however, ureteral stenosis sustained. She underwent ureteroscopy and stenting of right ureter. Biopsy specimen revealed submucosal amyloid deposition in the interstitium overlying a benign urothelium. Amyloid protein was positive for transthyretin (TTR) by immunohistochemistry and amyloid deposition was not demonstrated in other organs. The patient's TTR genes were wild type and she was diagnosed with wild-type ATTR (ATTR wt) amyloidosis. This is the first report about symptomatic ATTR wt amyloidosis, which was also called 'systemic senile amyloidosis (SSA)' in the ureter. We should aware that SSA can occur at younger age and cause symptomatic ureteral stenosis. Further investigation is needed to clarify the association of autoimmune diseases to develop ATTR wt amyloidosis.

[A CASE OF RIGHT PYONEPHROSIS DUE TO URETERAL STONES IN A HEMODIALYSIS PATIENT].

We report a case of a 64-year-old male with right pyonephrosis due to ureteral stones in association with chronic renal failure. The patient had been treated with hemodialysis for fourteen years. He was admitted to the Department of Internal Medicine of Kurobe City Hospital with chief complaints of fever and lumbago in January 2013. CT demonstrated a right pyonephrosis accompanied by right ureteral stones positioned in the middle and lower ureter. The stones could not be detected by KUB. He was consequently referred to the Department of Urology. Firstly, percutaneous nephrostomy for the right kidney was performed, and 200 ml of pyuria was discharged at that time. Urine culture demonstrated Escherichia coli. Secondly, rigid transurethral ureterolithotripsy (TUL) for the right ureteral stones was performed using Lithoclast, and a ureteral stent was indwelled on day 15 after nephrostomy construction. The nephrostomy catheter and ureteral stent were removed 10 and 21 days after the operation, respectively. The constituents of the stone were CaOx (26%) and CaP (74%). Right hydronephrosis improved and the patient showed no pyelonephritis for 1 year postoperatively.

Add-on anticholinergic therapy for residual nocturia in patients with lower urinary tract symptoms receiving α1-blocker treatment: a multi-centre, prospective, randomised study.

PURPOSE: To evaluate the efficacy and safety of imidafenacin (IM), a novel short half-life anticholinergic, as add-on therapy for male LUTS with nocturia and nocturnal polyuria. MATERIALS AND METHODS: This multicenter, prospective, randomized, open-labelled study was conducted and involved men who had frequency, urgency, and nocturia despite receiving a stable dose of α1-blocker for ≥1 month. Subjects were randomised to control (α1-blocker alone), IM twice/day (α1-blocker +0.1 mg imidafenacin twice daily), or IM nightly (α1-blocker plus 0.1 mg imidafenacin nightly) group; the treatment period was 8 weeks. Primary endpoints included improvements in night-time frequency and Nocturia Quality of Life Questionnaire (N-QOL) scores. Secondary endpoints included changes from the baseline in frequency volume chart variables, and post-void residual volume. RESULTS AND LIMITATIONS: Compared with the controls, IM twice/day and IM nightly patients had a significantly lower night-time frequency (changes from baseline: 0.1 ± 0.8 in control, -0.6 ± 0.9 in IM twice/day, and -0.4 ± 1.0 in IM nightly, p = 0.5227, 0.0006 and 0.0143, respectively). The hours of undisturbed sleep and N-QOL score were significantly improved in IM twice/day group, though not IM nightly group. Nocturnal urine volume was significantly reduced in IM nightly group, although total urine volume remained unchanged. CONCLUSIONS: A short half-life anticholinergic is suggested to be safe and effective as an add-on therapy for residual nocturia in patients with male LUTS receiving α1-blocker treatment. Anticholinergic administration nightly could reduce the nocturnal urine volume.

Clinical factors associated with sperm DNA fragmentation in male patients with infertility.

OBJECTIVE: The clinical factors associated with sperm DNA fragmentation (SDF) were investigated in male patients with infertility. MATERIALS AND METHODS: Fifty-four ejaculates from infertile Japanese males were used. Thirty-three and twenty-one were from the patients with varicoceles and idiopathic causes of infertility, respectively. We performed blood tests, including the serum sex hormone levels, and conventional and computer-assisted semen analyses. The sperm nuclear vacuolization (SNV) was evaluated using a high-magnification microscope. The SDF was evaluated using the sperm chromatin dispersion test (SCDt) to determine the SDF index (SDFI). The SDFI was compared with semen parameters and other clinical variables, including lifestyle factors. RESULTS: The SDFI was 41.3 ± 22.2% (mean ± standard deviation) and did not depend on the cause of infertility. Chronic alcohol use increased the SDFI to 49.6 ± 23.3% compared with 33.9 ± 18.0% in nondrinkers. The SDFI was related to adverse conventional semen parameters and sperm motion characteristics and correlated with the serum FSH level. The SNV showed a tendency to increase with the SDFI. The multivariate analysis revealed that the sperm progressive motility and chronic alcohol use were significant predictors of the SDF. CONCLUSION: The SCDt should be offered to chronic alcohol users and those with decreased sperm progressive motility.

Sperm nuclear vacuoles in relation to acrosome reactions and sperm motility.

We investigated sperm nuclear vacuolation in relation to acrosome reactions and the maintenance of sperm motility. Thirty male patients who visited our Male Infertility Clinic were enrolled. These patients underwent conventional semen analyses, Acrobeads tests, and high-magnification observation of the sperm head to evaluate the degree of nuclear vacuolation on the Acrobeads test scoring after 24 hours of incubation. The presence of acrosome reactions was evaluated using the Acrobeads test. The spermatozoa were classified into three groups: (I) those bound to MH61-beads, (II) motile spermatozoa that did not bind to MH61-beads, and (III) immotile spermatozoa that did not bind to MH61-beads. The percentage of spermatozoa with large nuclear vacuoles (%LNV) was compared between the three groups. The degree of sperm nuclear vacuolation was evaluated in 17,992 ejaculated spermatozoa. The mean %LNVs were 2.4% in group I, 5.8% in group II, and 9.8% in group III. These values were significantly different from each other (P < 0.001, paired t-test). There were no correlations between the %LNV values and the Acrobeads scores. In conclusion, the degree of sperm nuclear vacuolation was significantly lower in the acrosome-reacted spermatozoa and spermatozoa with maintained motility, and higher in the immotile spermatozoa that did not bind to MH61-beads.

Hand-assisted, conventional and laparoendoscopic single-site surgery for partial nephrectomy without ischemia using a microwave tissue coagulator.

PURPOSE: We report our experience of minimally invasive partial nephrectomy without ischemia using a microwave tissue coagulator (MTC) for hand-assisted laparoscopic partial nephrectomy (HALPN), conventional laparoscopic partial nephrectomy (CLPN), and laparoendoscopic single-site surgery for partial nephrectomy (LESSPN). We retrospectively compared the results of these techniques to better define the individual role and the benefits. MATERIALS AND METHODS: From July 2005 to September 2012, 28 patients with small and exophytic renal tumors underwent HALPN (n = 12), CLPN (n = 10) and LESSPN (n = 6). In these procedures, the surgeon used an MTC for circumferential coagulation around the tumor. After coagulation, the tumor was resected without renal pedicle clamping. RESULTS: The mean operative time was 259, 194 and 174 min for the HALPN, CLPN and LESSPN groups respectively. Two patients (one in HALPN group and one in LESSPN group) converted to laparotomy due to an inability to maintain hemostasis; however, there were no conversions to ischemic partial nephrectomy or radical nephrectomy. No differences between HALPN, CLPN and LESSPN were noted in terms of estimated blood loss, measured analgesic requirements, outcomes, or complications. CONCLUSION: We believe that these techniques are feasible and that they minimize the risk of unexpected collateral thermal damage by appropriate MTC needle puncture. When deciding to use HALPN, CLPN or LESSPN, our findings suggest that the choice of surgical approach should depend on the patient's individual circumstance.

The effect of selective renal parenchymal clamping during laparoscopic partial nephrectomy on early postoperative renal function: a preliminary report.

PURPOSE: A major concern when performing laparoscopic partial nephrectomy (LPN) is potential postoperative renal dysfunction. The objective of this study was to compare the effects of LPN with selective renal parenchymal clamping (SRPC) (LPNSRPC) and LPN using microwave tissue coagulation (MTC) (LPNMTC) on postoperative renal function. MATERIALS AND METHODS: This study included 12 patients (5 men and 7 women) who underwent LPNSRPC (n = 6) or LPNMTC (n = 6) for exophytic tumors. Renal scanning with technetium-99m diethylenetriaminepentaacetic acid (Tc-99m DTPA) was performed preoperatively and postoperatively at 1 month in all patients. RESULTS: The mean tumor size, surgical duration, and intraoperative blood loss were similar in both groups. In the LPNMTC group, although not significant, the mean postoperative glomerular filtration rate (GFR) values in the affected kidneys were decreased compared to the preoperative values. When evaluating the affected renal function by split function (SF), the mean postoperative SF in the affected kidneys was significantly decreased compared to the preoperative value. In the LPNSRPC group, the mean postoperative GFR and SF in the affected kidneys were not significantly changed compared with the preoperative values. CONCLUSION: Our preliminary experience demonstrates that LPNSRPC facilitates maximal nephron-sparing surgery without collateral thermal damage causing renal impairment.

Analysis of inter-examination differences in sperm nuclear vacuoles among male patients with infertility.

We analyzed the inter-examination differences in sperm nuclear vacuoles among male patients with infertility. We enrolled 56 male patients with infertility who underwent multiple semen analyses and high-magnification observation of the sperm head. A total of 162 ejaculates were evaluated. The average patient age was 34.5 years. Following the conventional semen analysis, the nuclear vacuoles in motile spermatozoa were evaluated at 3700-6150 × magnification on an inverted microscope equipped with differential interference contrast optics. A large sperm nuclear vacuole (LNV) was defined as one or more vacuoles with a maximum diameter exhibiting > 50% width of the sperm head. We compared the differences in the proportion of spermatozoa with LNVs between two consecutive semen samples before treatment. Treatment-related differences in the number of LNVs were also analyzed. Student's t-test was used to perform the statistical analyses. No differences were observed in any semen parameters between the first and second ejaculates. On high-magnification microscopy, the proportion of spermatozoa with LNVs was 23.5% and 29.4% (p = 0.0220) in the first and second ejaculates, respectively in 33 patients. Among the 18 patients who underwent varicocele repair using a microsurgical subinguinal approach, the proportion of spermatozoa with LNVs at baseline, three, and six months after surgery was 27.7%, 12.0% (p = 0.0132 versus baseline), and 10.3% (p = 0.0226 versus baseline), respectively. After three months of medical treatment for male infertility in 28 patients, the proportion of spermatozoa with LNVs slightly decreased from 33.3% to 28.6% (p = 0.1276); however, it was not statistically significant. In conclusion, when multiple ejaculates were obtained, in the subset of male patients with infertility, the proportion of spermatozoa with LNVs could be different. The number of LNVs decreased following varicocele repair.

Application of a new technique, spiral tissue microarrays constructed using needle biopsy specimens, to prostate cancer research.

Tissue microarrays were constructed using prostate needle biopsy specimens obtained from 58 patients who underwent radical prostatectomy for localized or locally advanced prostate cancer (PC). We used the spiral array (SA) technique, a novel approach for tissue array construction in a spiral form, which has advantages over small needle biopsy specimens. Roll-shaped tissue pieces produced by slicing a prostate biopsy tissue block and trimming the cancer segment were used to obtain a tissue array block. Cancer segments measuring >3 mm were incorporated into the tissue arrays. Cancer fragments (n=253) were obtained from formalin-fixed, paraffin-embedded needle biopsy specimens. The median number of cancer fragments per patient was four (1-8, min-max). On SA, the median number of confirmed cancer fragments per patient was four (1-7) and 224 cancer fragments (88.5%) were confirmed histologically. Each core of reeled tissue contained at least one cancer fragment. The expressions of multiple prognostic molecular markers for PC (Ki-67, p53 and bcl-2) were immunohistochemically measured using the SA. The Ki-67 and bcl-2 expressions were significantly associated with the Gleason score (GS). A univariate analysis identified Ki-67, bcl-2 and GS as significant predictors of cancer-specific survival, p53 and bcl-2 as significant predictors of overall survival and Ki-67, adjuvant androgen deprivation and GS as significant predictors of biochemical progression. In a multivariate analysis, p53 was independently associated with overall survival, while adjuvant androgen deprivation and GS were associated with biochemical progression. These results indicate that SA has potential as a new tool for translational research on PC.

Factors influencing patient satisfaction with antimuscarinic treatment of overactive bladder syndrome: results of a real-life clinical study.

OBJECTIVES: To investigate patient satisfaction with antimuscarinic treatment of overactive bladder syndrome, and to identify factors having a significant influence on satisfaction. METHODS: A cross-sectional questionnaire survey was carried out to assess treatment satisfaction among male and female patients with overactive bladder (age ≥20 years) in the Hokuriku district of Japan. The overactive bladder symptom scores, treatment efficacies, adverse events (dry mouth and constipation), and patient satisfaction scores were investigated and compared among patients using different antimuscarinic therapeutics. RESULTS: In total, 977 survey respondents (52.6% men; mean age 73.6 years) received antimuscarinic treatment. The mean overactive bladder symptom score of these patients was 6.17; in addition, 32.3% patients were satisfied with their treatment, but 33.1% were dissatisfied. Factors having a significant influence on treatment satisfaction were sex (men were less satisfied), efficacy, adverse events and the overactive bladder symptom score. Constipation negatively influenced patient satisfaction to a greater extent than did dry mouth. Patient satisfaction varied according to the drug used. Constipation was less severe with the immediate-release-type agents (imidafenacin and oxybutynin) than with the extended-release-type (propiverine, solifenacin or tolterodine). CONCLUSIONS: Just one-third of Japanese Hokuriku patients with overactive bladder seem to be satisfied with their antimuscarinic treatment. Patient satisfaction is impaired by poor efficacy and the presence of adverse events; furthermore, constipation should be recognized as an adverse event that negatively influences patient satisfaction to a greater extent than dry mouth. Patient satisfaction differs according to the antimuscarinic agent used, with higher patient satisfaction being associated with less severe constipation.

Retraction-Related Acute Liver Failure after Urological Laparoscopic Surgery.

Liver retraction is necessary for optimal exposure during laparoscopic right renal surgery. We described a patient who developed fulminant liver failure as a result of liver retractor-induced excessive ischemic changes in the right lobe of the liver. A 37-year-old male underwent a right side laparoscopic pyeloplasty for ureteropelvic junction obstruction. At the beginning of the operation, a small snake retractor was placed through a 5-mm port under direct vision. The liver was lifted in the appropriate direction to optimize exposure by using the laparoscope holder. The operation was prolonged. However, we achieved significant improvements in the efficiency of liver retraction using the holder. On the first postoperative day, the patient's serum levels of GOT, GPT and LDH had remarkably increased. A computerized tomogram confirmed the presence of excessive ischemic changes of the right lobe of the liver. Our method which used a laparoscope holder device for liver retraction maintained a better surgical field. However, neglecting to make minor adjustments to the positioning of the retractor can cause significant pressure on the liver parenchyma in a single area. As surgical procedures increase in complexity, the surgeon should keep these potential side effects in mind and shift the retraction point at regular intervals. In this report, we discussed various types of retractor-related liver injuries and their management, and highlighted the importance of intermittent release of retraction during prolonged surgery.

Observation of spermatozoa by a high-magnification microscope.

Semen analyses are the primary tool for evaluating male infertility, as semen parameters are useful for predicting potential fertility. In the field of assisted reproductive technology (ART), the single best motile spermatozoon should be selected, especially when performing intracytoplasmic sperm injection (ICSI). In this context, the motile sperm organelle morphology examination (MSOME) was developed as a method of assessing the detailed morphology of motile spermatozoa in real time at a magnification of up to 6,300× on a video system. The use of ICSI with MSOME-selected sperm is called intracytoplasmic morphologically selected sperm injection (IMSI). IMSI improves the outcomes of ICSI. MSOME can be also applied to evaluate male infertility. Among MSOME parameters, the presence of sperm nuclear vacuoles is the most important finding. Large sperm nuclear vacuoles (LNV) are related not only to poor ART outcomes, but also to poor semen quality and sperm DNA damage, such as DNA fragmentation and chromatin condensation failure. It has been suggested that sperm head vacuoles are produced at earlier stages of sperm maturation. It is possible that the number of LNV can be decreased by surgical or medical treatment for male infertility. Therefore, the level of LNV has the potential to be used as an alternative parameter of semen quality and a new tool for evaluating the therapeutic effects of treatment in male patients with infertility.

Multiple organ retraction during urological laparoscopic surgery.

PURPOSE: During laparoscopic surgery, as in open surgery, exposure is critical. We describe our surgical technique that provides intra-abdominal multiple organ retraction in order to obtain a stable surgical field and adequate exposure. MATERIALS AND METHODS: The Flex Arm™ surgical holder (Mediflex Surgical Products, Islandia, NY) is an adjustable, spring-loaded articulating instrument holder. The device offers the flexibility of the attachment of multiple arms (up to three) on the same rod, which can rotate 360° to aid in positioning. This device permits multiple laparoscopic instruments to be held simultaneously. We used this device for multiple organ retraction during urological laparoscopic surgery (retroperitoneoscopic radical prostatectomy, n=5; laparoscopic radical nephrectomy, n=3; laparoscopic partial nephrectomy, n=2; laparoscopic pyeloplasty, n=2). RESULTS: We achieved significant improvements in the efficiency of retraction of the liver, kidney, colon, and prostate during urological laparoscopic surgery. Our method maintains a constant surgical field through the proper retractor position and the proper amount of isometric force for optimal exposure. CONCLUSIONS: With this device, instrument migration due to muscle fatigue and organ injury as a result of excessive force are all substantially reduced. We believe that this technique may be helpful not only in urological laparoscopic surgery, but also in laparoscopic approaches in other departments.

[A case of urachal abscess accompanied by a stone].

A 64-year-old woman presented to our hospital with the chief complaints of abdominal pain and appetite loss, and she was admitted to the internal medicine department. Kidney, ureter and bladder X-ray revealed intrapelvic calcification near the bladder, and so, the patient consulted our department. Computed tomography and magnetic resonance imaging revealed an urachal abscess accompanied by a stone. Open surgery was performed under general anesthesia. The mass adhered tightly to the intestine and bladder. The urachal abscess ruptured during the operation, and pus leaked into the intraabdominal cavity. Partial cystectomy was performed to remove the mass completely. The stone existed in the urachal abscess, and its constituents were CaOxa (51%) and CaP (49%). The pathological diagnosis was urachal abscess without malignancy.

Utilization of microRNAs with decreased expression levels in response to X-ray irradiation for fine-tuning radiation-controlled gene regulation.

We previously developed a promoter that was responsive to radiation by randomly combining cis-elements of transcription factors that are activated in response to radiation in prostate cancer cells. The promoter enhanced the expression of the luciferase gene linked downstream by more than 10-fold 12 h after X-ray irradiation at 10 Gy. However, without radiation, it still significantly drove its expression. To suppress expression while retaining its enhancement in response to radiation, we focused our attention on microRNAs (miRNAs). miRNAs are a group of non-coding RNAs approximately 22 nucleotides long that control gene expression by binding to a target sequence residing on the 3'-untranslated region (3'UTR) of a target gene. We identified 8 miRNAs that were downregulated in response to X-ray irradiation, and inserted artificial target sequences composed of randomly combined complementary sequences into 3 representative miRNAs into the 3'UTR of the luciferase gene. The target sequences suppressed the expression, and released the expression, after X-ray irradiation, as expected. When we combined an artificial target sequence with the radiation-responsive promoter, it resulted in a clear-cut gene regulation of expression that was greater than that induced by the promoter alone.

Laparoscopic resection of adrenal and extra-adrenal pheochromocytoma.

BACKGROUND AND PURPOSE: Laparoscopic resection of extra-adrenal pheochromocytoma (EAPs) necessitates meticulous surgical procedures because of changes in anatomic disposition and/or proximity to major blood vessels. Complete resection can be traumatic and may cause an increase in catecholamine levels. We present our experiences with laparoscopic resection of EAP (LEAP) and compare the intraoperative hemodynamics with those during laparoscopic resection of adrenal pheochromocytoma (LAP). PATIENTS AND METHODS: We retrospectively reviewed the medical records of five patients who underwent LEAP (retrocaval EAP, n=2; interaortocaval EAP, n=1; periadrenal EAP, n=2) and five who underwent LAP between October 2001 and October 2011. We also evaluated fluctuations in blood pressure (BP) reported during both surgeries. RESULTS: The tumors were successfully resected under laparoscopic guidance in both groups, and conversion to open surgery or blood transfusion was not needed. Intraoperative hypertension (BP>200 mm Hg) was observed in three LEAP and four LAP patients, whereas intraoperative hypotension (BP<80 mm Hg) was observed in five LEAP and three LAP patients. No significant differences were observed between groups, however. CONCLUSIONS: Laparoscopy is the method of choice for surgeons experienced in EAP resection because it is feasible and reproducible with appropriate preoperative planning, similar to LAP.

Expression of Hepatocyte growth factor activator inhibitor type-1 (HAI-1) in prostate cancer.

BACKGROUND: Hepatocyte growth factor activator inhibitor type-1 (HAI-1) inhibits hepatocyte growth factor activator and matriptase. In the present study it was investigated whether the expression of HAI-1 is associated with the progression of prostate cancer. PATIENTS AND METHODS: The expression of HAI-1 was evaluated by immunohistochemistry (IHC) of samples from 51 patients with negative prostate biopsies and 75 patients with untreated prostate cancer. Furthermore, the expression of HAI-1 was evaluated in 24 patients with castration-resistant prostate cancer (CRPC), and the relationship between HAI-1 expression and the prostate-specific antigen (PSA) progression-free rate was investigated. RESULTS: Expression of HAI-1 by IHC in patients with prostate cancer was significantly higher than in those with negative prostate biopsy. CRPC exhibited significantly lower HAI-1 expression than untreated metastatic prostate cancer. The PSA progression-free rate was worse in patients without HAI-1 expression than in those with positive HAI-1 expression. CONCLUSION: It is suggested that HAI-1 may play an important role in the pathogenesis of CRPC.

Laparoendoscopic single-site surgery for partial nephrectomy without ischemia using a microwave tissue coagulator.

BACKGROUND: Herein, we report our initial experience with laparoendoscopic single-site surgery for partial nephrectomy (LESSPN) using a microwave tissue coagulator (MTC). METHODS: Two patients with small and exophytic renal tumors underwent LESSPN. A multichannel port was inserted into the peritoneal or retroperitoneal space through a 3-cm skin incision. After tumor exposure, the surgeon introduced a laparoscopic MTC instrument through a 5-mm port and the tumor margin was coagulated circumferentially. After coagulation, the tumor was resected without renal pedicle clamping. RESULTS: These procedures were successfully performed without any conversions to standard laparoscopy or need for placement of additional trocars. The operative times were 183 and 160 minutes, respectively. The estimated blood loss was <150 mL in both cases. The final length of the LESS wound was 3 cm. Using the transumbilical approach, the operative scar receded into the umbilicus and was hardly visible. CONCLUSIONS: This novel surgical technique is feasible and enables the bloodless resection of a renal tumor without renal pedicle clamping. Further clinical experience and longer follow-up are needed to define the benefits of this new technique.