Propensity Score-Matched Analysis of Perioperative Outcomes of Supine versus Prone Percutaneous Nephrolithotomy.

Objective: To compare the perioperative outcomes of supine and prone percutaneous nephrolithotomy (PCNL). Methods: A retrospective search of a tertiary medical center database yielded 517 patients who underwent supine (n = 91) or prone (n = 426) PCNL between September 2015 and July 2020. Data on demographics, baseline clinical parameters, and stone burden were included as predictors in a logistic regression model, generating a set of propensity scores. Seventy patients after supine PCNL were propensity score-matched 1:1 with patients after prone PCNL and compared for operative time, perioperative complications, system complexity, and stone-free rate. Results: We found that the operative time was significantly shorter in the supine PCNL group than in the prone PCNL group (85.5 ± 25.2 min vs. 96.4 ± 25.8 min, respectively; p = 0.012). The majority of both groups had low-grade (I-II) complexity systems (85.6% and 88.6%, respectively), with no significant difference among all grade groups (p = 0.749). There were no significant differences between the supine and prone PCNL groups in terms of the overall perioperative complication rate (8.6% vs. 4.3%, respectively; p = 0.301) or stone-free rate (74.3 vs. 65.7%, respectively; p = 0.356), while the rate of blood transfusion was significantly higher in the supine group (p = 0.023). Conclusions: In our study, we used propensity score matching to compare patients who underwent PCNL in the supine or prone position, adjusting for selection bias. Supine PCNL was associated with a shorter operative time but a higher blood transfusion rate, with no differences in the overall complication and stone-free rates.

Heat shock proteins 60 and 70 are associated with long-term outcome of T1-stage high-grade urothelial tumors of the bladder treated with intravesical Bacillus Calmette-Guérin immunotherapy.

OBJECTIVES: High-grade nonmuscle-invasive urothelial tumors of the bladder that fail intravesical Bacillus Calmette-Guérin (BCG) immunotherapy are at the highest risk of progression. Initial evidence links heat shock protein expression levels and outcome of bladder cancer after BCG treatment. We aimed to determine the association between HSP60, 70, and 90 expression levels and long-term outcomes of T1 high-grade (T1HG) urothelial bladder tumors treated with BCG immunotherapy. MATERIALS AND METHODS: Data of 54 consecutive patients with primary T1HG bladder tumors who underwent transurethral resection between 2002 and 2008 and received at least an induction course of BCG were reviewed. Immunohistochemical staining for heat shock protein (HSP)60, 70, and 90 were performed on resected specimens. Study outcomes included disease recurrence and progression. The association between HSP expression levels and outcomes were evaluated with univariable and multivariable Cox proportional hazards models. RESULTS: During a median follow-up of 9.6 years, 25 patients had a disease recurrence and 14 patients a disease progression. Estimated 5-year recurrence and progression-free survival were 59% and 81%, respectively. On multivariable analyses, HSP60 staining >65% was associated with a higher risk for progression (hazard ratio [HR] = 3.96, 95% confidence interval [CI] 1.35-11.58, P = 0.012), and HSP70 staining >5% was associated with a decreased risk for progression (HR = 0.33, 95% CI 0.11-0.98, P = 0.045), and recurrence (HR = 0.29, 95% CI 0.13-0.65, P = 0.003). HSP90 expression was not associated with disease recurrence or progression. Five patients had both a HSP60 staining >65% and a HSP70 staining ≤5% all of whom recurred at a median time of 6 months (interquartile range 3, 16) and 80% of whom progressed at a median time of 26 months (interquartile range 5, 60). CONCLUSIONS: HSP60 and 70 cellular expression levels are associated with long-term outcome following BCG treatment of T1HG urothelial bladder tumors. These findings, if further validated, may be used to better stratify the risk of disease recurrence and progression in this group of patients.

How Reliable Is the Intraoperative Assessment of Residual Fragments During Percutaneous Nephrolithotomy? A Prospective Study.

OBJECTIVES: To determine the accuracy of the surgeon's impression as to the stone-free rate at the end of percutaneous nephrolithotomy (PCNL), and to evaluate predictors for inaccurate estimation. MATERIALS AND METHODS: A prospective study conducted between 2010 and 2015. Surgeon's impression, categorized as "insignificant residual fragments (RFs)" (<4 mm) or "significant RF" (>4 mm), was recorded at the end of PCNL, and was compared with postoperative imaging results, using CT or a combination of US and kidney, ureter, and bladder radiograph for radiolucent and radio-opaque stones, respectively. The association between missed significant RF and the patient and operative variables was evaluated with univariable and multivariable logistic regression analysis. RESULTS: The study cohort included 312 patients. Significant RFs were found in 75 (24%) patients, comprising all 22 patients in whom RFs were suspected (100%) and 53 patients who were considered stone free (18.6%). The sensitivity, specificity, and positive and negative predictive value of the surgeon's estimation for the absence of significant RFs were 100%, 39%, 0.83, and 1 for radiopaque stones, and 100%, 12.5%, 0.75, and 1 for radiolucent stones. On multivariate analysis, multiple stones (OR = 4, 95% CI: 1.85-8.7, p < 0.001) and cumulative stone size (OR = 1.04, 95% CI: 1.02-1.1, p = 0.005) were independent predictors for missed RFs. CONCLUSION: In approximately fifth of the patients undergoing PCNL, the surgeon's impression of "insignificant RF" may be inaccurate. Stone size and number were independently associated with higher miss rate. These data should be shared with the patients when the postoperative drainage method and the option for an auxiliary procedure are discussed.

Transplant Kidney Retrograde Ureteral Stent Placement and Exchange: Overcoming the Challenge.

OBJECTIVE: To present a reliable technique for fluoroscopic controlled, large-bore, ureteral stent placement and exchange in transplant kidneys with persistent ureterovesical strictures. MATERIALS AND METHODS: We reviewed the medical charts of all patients who underwent kidney transplant with persistent ureterovesical strictures who underwent ureteral stent placement or exchange at our institution between 2005 and 2015 using the new technique. Clinical characteristics and treatment outcomes of the study cohort were analyzed. RESULTS: Ureteral stent insertion or stent exchange, using this technique, was performed in 32 renal transplant units. Median operating time was 24 minutes (interquartile range, 21-36.75 minutes). The overall success rate of the technique at first attempt was 96.9%. In 1 patient, drainage of the transplanted kidney with a nephrostomy tube was indicated after procedure failure. No other local or systemic complications were encountered, and no stent encrustation was noted in this cohort of patients. Renal function remained stable in all patients during a median follow-up of 59 months (interquartile range, 28-61 months). CONCLUSION: Herein, we present in detail a step-by-step technique for the insertion and exchange of large-bore ureteral stents in transplanted kidneys. The technique was shown to be safe, effective, and highly successful.

Ureteric stent dwelling time: a risk factor for post-ureteroscopy sepsis.

OBJECTIVES: To evaluate the association between stent dwelling time and sepsis after ureteroscopy, and identify risk factors for sepsis in this setting. PATIENTS AND METHODS: The prospectively collected database of a single institution was queried for all patients who underwent ureteroscopy for stone extraction between 2010 and 2016. Demographic, clinical, preoperative and operative data were collected. The primary study endpoint was sepsis within 48 h of ureteroscopy. Logistic regressions were performed to identify predictors of post-ureteroscopy sepsis in the ureteroscopy cohort and specifically in patients with prior stent insertion. RESULTS: Between October 2010 and April 2016, 1 256 patients underwent ureteroscopy for stone extraction. Risk factors for sepsis included prior stent placement, female gender and Charlson comorbidity index. A total of 601 patients had a ureteric stent inserted before the operation and were included in the study cohort, in which the median age was 56 years, 90 patients were women (30%), and 97 patients were treated for positive preoperative urine cultures (16.1%). Postoperative sepsis, <48 h after surgery, occurred in eight (1.2%) non-stented patients and in 28 patients (4.7%) with prior stent insertion. Sepsis rates after stent dwelling times of 1, 2, 3 and >3 months were 1, 4.9, 5.5 and 9.2%, respectively. On multivariate analysis, stent dwelling time, stent insertion because of sepsis, and female gender were significantly associated with post-ureteroscopy sepsis in patients with prior stent placement. CONCLUSIONS: Patients who undergo ureteroscopy after ureteric stent insertion have a higher risk of postoperative sepsis. Prolonged stent dwelling time, sepsis as an indication for stent insertion, and female gender are independent risk factors. Stent placement should be considered cautiously, and if inserted, ureteroscopy should be performed within 1 month.

Clinical Implications of Stent Culture in Patients with Indwelling Ureteral Stents Prior to Ureteroscopy.

PURPOSE: We determined the ability of urine culture to predict stent culture status and associated infectious pathogens, and evaluated the association between stent culture and post-ureteroscopy sepsis. MATERIALS AND METHODS: We queried the prospectively collected database at our institution and identified all patients who underwent ureteroscopy between October 2010 and August 2016 who had a ureteral stent before the operation and from whom urine and stent cultures were obtained. The study end point was post-ureteroscopy sepsis within 48 hours of the procedure. We compared urine and stent culture findings, and performed univariate and multivariate analyses to identify predictors of post-ureteroscopy sepsis. RESULTS: The study group comprised 509 patients with a median age of 56 years, of whom 147 (28.9%) were female. Positive urine cultures were found in 91 patients (17.8%) and positive stent cultures were found in 104 (20.4%). Urine and stent cultures were positive in 48 patients (9.4%), of whom only 24 had identical bacteria in both cultures. The most common pathogens isolated from urine and stent cultures were Escherichia coli in 38.5% and Enterococcus in 18.4%. Sepsis developed in 25 patients (4.9%), including 21 (84%) with a positive stent culture and 14 (59%) with a positive urine culture. On multivariate analysis female gender and positive stent culture were significantly associated with post-ureteroscopy sepsis. CONCLUSIONS: Only half of the patients with ureteral stents prior to ureteroscopy, and positive stent and urine cultures had similar pathogens in both cultures. Female gender and positive stent culture were associated with a higher risk of post-ureteroscopy sepsis in this population. Stent culture may direct the proper antibiotic treatment in patients with sepsis after ureteroscopy.

The impact of retrograde intrarenal surgery for asymptomatic renal stones in patients undergoing ureteroscopy for a symptomatic ureteral stone.

BACKGROUND AND PURPOSE: In the era of rigid ureteroscopy (URS) for ureteral stones, asymptomatic renal stones were often left in place. With the advent of flexible URS, however, the treatment of such renal stones became an attractive option. Data are scarce regarding the impact of retrograde intrarenal surgery (RIRS) performed at the time of URS for a symptomatic ureteral stone in comparison with ureteral stone removal alone. The purpose of the study was to compare the outcomes of URS combined with RIRS with URS alone. PATIENTS AND METHODS: A comparison between patients who underwent URS and RIRS (group A, n=47) and a matched control group of patients undergoing URS alone (group B, n=47) was performed. Matching was based on ureteral stone size and location, and preprocedural Double-J stent placement. RESULTS: The median size of the largest ureteral stone in both groups was 8 mm with a mean total stone burden of 52.9 mm(2) (28.9) and 47 mm(2) (21.1) in groups A and B, respectively. Median renal stone size was 9 mm with a mean total stone burden of 84.1 mm(2) (40.3). Mean surgery time in groups A and B was 68 minutes (19.61) and 39 minutes (15.96), respectively (P<0.001). Median hospital stay was 1 day for both groups. The success rate for ureteral stone removal was 98% and 100% in groups A and B, respectively. Success rate for RIRS was 85% (40/47 cases). Hospitalization length and complications, mainly postoperative fever, did not differ significantly between the groups. CONCLUSIONS: Managing asymptomatic renal stones at the time of URS for symptomatic ureteral stones significantly prolongs surgery duration but does not lengthen hospital stay, increase complications, or lower success rates. This combined approach reduces the need for future procedures and is probably more cost effective.

Retrograde endoureterotomy for persistent ureterovesical anastomotic strictures in renal transplant kidneys after failed antegrade balloon dilation.

OBJECTIVE: To evaluate the long-term outcomes and complications of retrograde endoureterotomy for persistent ureterovesical anastomotic strictures in renal transplant patients after percutaneous balloon dilation failure. METHODS: From January 2000 to May 2010, 26 (2.6%) of 1004 renal transplant patients developed ureterovesical anastomotic stricture after surgery. Seven of these patients and five additional referred patients with similar characteristics were treated with retrograde endoureterotomy after ≥1 previous unsuccessful attempt at percutaneous balloon dilation. All strictures treated were <1 cm in length. The clinical characteristics and outcomes were analyzed. Success was defined as the absence of symptoms and the resolution of obstruction on imaging after the procedure. RESULTS: The median interval from initial treatment to endoureterotomy was 2.9 months (range 1.3-62.1). Before endoscopic treatment, 8 patients (67%) were treated with a single trial of balloon dilation and 4 (33%) with multiple trials. Endoureterotomy was performed using cold knife, holmium:yttrium-aluminum-garnet laser, and Bugbee electrode in 9, 2, and 1 patients, respectively. The median follow-up period was 44.4 months (range 2.4-68.6). Recurrent stricture developed in 2 patients during a mean follow-up of 4.7 months. Thus, the overall success rate was 83%. Postoperative complications appeared in 3 patients (25%) with culture-positive urinary tract infection. One graft failure occurred but was not related to a recurrent stricture. CONCLUSION: After failure of antegrade percutaneous balloon dilation, retrograde endoureterotomy is an effective salvage procedure for well-selected cases of renal transplant patients with a short ureterovesical anastomotic stricture.

Laparoscopic partial nephrectomy versus laparoscopic ablative therapy: a comparison of surgical and functional outcomes in a matched control study.

BACKGROUND AND PURPOSE: Patients who are undergoing laparoscopic ablative therapy (LAT) are often older with more comorbidities in comparison with patients who are undergoing laparoscopic partial nephrectomy (LPN). A matched control study was performed to compare the surgical and functional outcomes of LPN and LAT. PATIENTS AND METHODS: A prospectively maintained database of 250 patients who underwent nephron-sparing surgery was explored. Fifty-one LAT patients (21 and 30 laparoscopic radiofrequency and cryoablation, respectively) were matched with 51 LPN patients. A comparison of preoperative, operative, and postoperative outcomes was performed. RESULTS: The groups were similar in age, sex, body mass index, preoperative estimated glomerular filtration rate (eGFR), number of comorbidities and tumor size. Patients who were undergoing LAT had a lower incidence of endophytic tumor and higher incidence of upper pole and midpolar tumors. Hilar vessels clamping was performed in LPN (47/51 patients). Mean estimated blood loss and operative time were higher in those undergoing LPN (P<0.01). There was no significant difference in transfusion rate and hospital stay, however. Mean follow-up was 27 and 18 months in LAT and LPN, respectively (P<0.01). The mean percent decline of eGFR at the last follow-up was 10 (95% confidence interval [CI]: 4-15) and 7.5 (95% CI: 4-11), respectively (P<0.43). In comparison with baseline, eGFR declined significantly (P<0. 01), but there was no difference between the groups. CONCLUSION: Despite renal ischemia, longer operative time, and higher blood loss associated with LPN, the hospital stay and long-term functional outcomes are similar to those of LAT in a matched control study.

Clinical and histologic predictors of renal function decline after laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: Clinical and surgical factors predict renal function decline after laparoscopic partial nephrectomy (LPN). Additional histopathologic predictors may be found in the specimen's nonneoplastic tissue but were not studied. This study investigated the significance of histologic findings in addition to other known predictors of renal function after LPN. PATIENTS AND METHODS: Data of 150 patients who underwent LPN was analyzed. Renal function changes (median follow-up 15 months) were correlated with perioperative and histopathologic parameters. Three histopathologic features were evaluated and graded in the nonneoplastic parenchyma: Glomerulosclerosis, arteriosclerosis (AS), and interstitial fibrosis/tubular atrophy. Estimated GFR (eGFR) and percent decline on postoperative day 1 (POD1) and at the last follow-up were measured. RESULTS: Median eGFR percent decline at POD1 and last follow-up was -17 and -10, respectively (P<0.001). New-onset ≥stage III chronic kidney disease developed in only 7% of the patients. Three factors independently predicted POD1 eGFR decline: Artery and vein clamping vs artery only clamping (P=0.002), male sex (P=0.015), and larger tumor (P=0.02). Long-term loss of renal function was associated with POD1 eGFR decline (P=0.002) and the percentage of AS (P=0.01). The study limitations include a retrospective analysis leading to variability in the follow-up length and a small size cohort. CONCLUSIONS: LPN is associated with a favorable renal function outcome in most patients. Pathologic findings in the nonneoplastic tissue, in addition to clinical parameters, can be used to predict which patients are more likely to experience renal function impairment.

Laparoscopic radical versus laparoscopic partial nephrectomy for clinical T1bN0M0 renal tumors: comparison of perioperative, pathological, and functional outcomes.

AIM: To compare outcomes in patients treated with laparoscopic partial nephrectomy (LPN) and laparoscopic radical nephrectomy (LRN) for clinical T1bN0M0 renal masses. MATERIALS AND METHODS: Between 2002 and 2008, 33 and 52 consecutive patients who underwent LPN and LRN, respectively, for clinical stage T1bN0M0 tumors were retrospectively identified from a prospectively maintained database of 450 patients undergoing laparoscopic renal surgery. Perioperative, pathological, and postoperative outcomes were compared. RESULTS: The two groups of patients were similar in age, sex, and body-mass index. Mean radiographic tumor size was smaller (4.8 vs. 5.2 cm, p = 0.04) in the LPN group. Mean operative time (228 vs. 175 minutes, p < 0.0001) and mean estimated blood loss (233 vs. 112 mL, p = 0.003) were higher in the LPN group. Intraoperative complication rates of 15.2% versus 5.7% (p = 0.28) and postoperative complication rates of 24.2% versus 13.5% (p = 0.20) were observed in the LPN and LRN groups, respectively. Overall median follow-up was 15 and 21 months for the LPN and LRN cohorts, respectively. A 12.5% and 29.3% decline in estimated glomerular filtration rate was observed (p = 0.002), and 30.3% compared with 55.7% of patients developed an estimated creatinine clearance (eCrCl) < 60 mL/minutes after treatment (p = 0.04) for LPN and LRN, respectively. There were no differences in pathological stage distribution between the two groups. In the LPN group there were no local or systemic recurrences, and one positive surgical margin was observed. One patient developed metastatic disease in the LRN group. CONCLUSIONS: LPN for T1b renal tumors provides superior intermediate-term preservation of renal function compared with LRN. Continued follow-up of these patients is required to evaluate oncological outcomes.

Drilling through impacted ureteral stones: use of the atherectomy rotablator device for urolithiasis.

BACKGROUND AND PURPOSE: The Rotablator is an angioplasty device that is passed over a wire. It uses a high-speed rotational "burr" (2 mm in diameter) that is coated with microscopic diamond particles and cooled by saline. It rotates at high speed (approximately 200,000 rpm) breaking up endovascular blockage into minute (smaller than red blood cells) fragments. We investigated, in vitro and ex vivo, the possible use of the Rotablator for urinary stone disease. MATERIALS AND METHODS: Human stones of different sizes and composition were used for the experiment. Stone impaction in vitro was modeled by wedging the stones into the proximal part of a 16F silicone Foley catheter. Likewise, an ex-vivo study was performed on stones placed into a freshly harvested swine ureter using a nitinol basket. Data regarding the drill time, remaining stone size, and ureteral damage were collected. RESULTS: Overall, 15 stones were treated (10 in vitro and 5 ex vivo). The device successfully drilled through all the stones, along the path of the guidewire, allowing complete passage of the burr. The pretreatment mean stone size for the silicone and ureteral testing was 65 mm(3) and 34 mm(3), respectively (both P < 0.01). The post-treatment size was 54 mm(3) and 24 mm(3), respectively. Average treatment time was 100 seconds. No visual macroscopic ureteral damage or perforation was observed. CONCLUSIONS: In vitro, the Rotablator is capable of drilling through stones with minimal damage. Drilling, however, occurred alongside the stone in which the guidewire was located and, thus, stone fragmentation appears to be minimal. Further studies are necessary to investigate other burr configurations and the use of the Rotablator for the fluoroscopic-guided passage of ureteral impaction in difficult clinical settings.

Microparticulate ice slurry for renal hypothermia: laparoscopic partial nephrectomy in a porcine model.

OBJECTIVES: Previously, we described the feasibility of renal hypothermia using microparticulate ice slurry during laparoscopy. In the present study, we compared surface cooling with the ice slurry versus near-frozen saline or warm ischemia (WI) during laparoscopic partial nephrectomy (LPN) in a porcine model. METHODS: We used a single-kidney porcine model. Animals in 5 equal groups (n = 6 each) underwent right laparoscopic complete nephrectomy. In Phase I, left LPN was performed under 90 minutes of ischemia and 90-minute renal cooling with either slurry (Slurry group 1) or saline (Saline group 1). No cooling was applied in the WI group. In Phase II, to simulate more extreme condition, ischemia time was extended to 120 minutes and cooling shortened to 10 minutes (Slurry group 2 and Saline group 2). The study endpoints were renal and core temperature during the surgery and serum creatinine at baseline and days 1, 3, 7, and 14 after the procedure. RESULTS: The ice slurry was easily produced and delivered. Nadir renal temperature (mean ± SD) was 8 ± 4 °C in Slurry group 1 vs. 22.5 ± 3 °C in Saline group 1 (P < .0001). Renal rewarming to 30 °C occurred after 61 ± 7 minutes in Slurry group 2 vs. 24 ± 6 minutes in Saline group 2 (P < .0001). Core temperature decreased on average to 35 °C in the Saline groups compared with 37 °C in the Slurry groups (P < .0001). Serum creatinine did not differ between the Saline and Slurry groups in Phases I and II at any time point. CONCLUSIONS: Ice slurry provides superior renal cooling compared with near-frozen saline during LPN without associated core hypothermia.

Laparoscopic nephron-sparing surgery in the management of angiomyolipoma: a single center experience.

BACKGROUND AND PURPOSE: Angioembolization is often the first-line treatment for patients with renal angiomyolipoma (AML). Regrowth and repeated hemorrhage after embolization, however, remain a concern. Laparoscopic partial nephrectomy (LPN) is the definitive, minimally invasive treatment alternative. We compared the outcomes of LPN in patients who had a diagnosis of AML with patients with other renal tumors. PATIENTS AND METHODS: From a prospective LPN database, we identified patients with a final pathologic diagnosis of AML (group 1). The ability of preoperative imaging to predict AML final pathology results was studied. Surgical and postoperative outcomes in group 1 were compared with the outcomes of the rest of our LPN cohort (group 2). RESULTS: Of 184 LPNs that were performed between 2002 and 2008, 14 (7.6%) patients and 15 renal units had a diagnosis of AML. Two patients underwent concomitant LPN and radiofrequency ablation (RFA) for multiple AML lesions. In group 1, only 33% of the patients had a preoperative diagnosis of AML. There were no significant differences in tumor size, age, preoperative estimated creatinine clearance, body mass index, and comorbidities between the groups. The mean estimated blood loss in groups 1 and 2 was 214 mL and 178 mL, respectively (P = 0.5). The complication rates were similar between the groups. With a median follow-up of 15 months, no AML recurrences or bleeding was observed in group 1. CONCLUSIONS: The results of LPN or RFA, when appropriate, in AML patients are comparable to the results of LPN for other renal tumors. The preoperative imaging studies were a poor predictor of AML in patients who were undergoing LPN.

Localized T1a renal lesions in the elderly: outcomes of laparoscopic renal surgery.

OBJECTIVE: The objective of this study was to compare the outcomes of patients >or=70 years of age undergoing laparoscopic partial nephrectomy (LPN), laparoscopic radical nephrectomy (LRN), and laparoscopic ablative techniques (LAT) for small renal masses. METHODS: From a prospectively maintained database we identified 19 (LRN), 28 (LPN), and 19 (LAT) patients aged >or=70 who underwent surgery for cT1aN0M0 lesions. Perioperative, surgical, and functional outcomes were compared. RESULTS: The three groups were similar in age, race, body mass index, and estimated creatinine clearance. In the LRN group, mean tumor diameter was larger (3.3 vs. 2.4 cm [LPN] and 2.7 cm [LAT]; p = 0.0005) and there was a higher percentage of central tumors (73.7% vs. 25.0% and 5.3%; p < 0.0005) when compared with the LPN and LAT groups, respectively. Although intraoperative and postoperative complication rates were similar, mean estimated blood loss and operative time were highest in the LPN group (p < 0.05). Moreover, 42.1%, 39.3%, and 42.1% of patients had preoperative stage 3 chronic kidney disease in the LRN, LPN, and LAT groups, respectively. Patients who underwent LRN had a lower follow-up estimated creatinine clearance (43.4 vs. 61.4 mL/min [LPN] and 59.2 [LAT]; p < 0.01) and a higher likelihood of developing stage 3 chronic kidney disease after treatment (100% vs. 25.0% [LPN] vs. 18.2 [LAT]; p < 0.0005). CONCLUSIONS: Impaired renal function is common in elderly patients presenting with renal masses. LPN and LAT provide superior preservation of renal function when compared with LRN in this population. In appropriately selected patients >or=70 years of age presenting with T1a renal lesions, laparoscopic nephron-sparing approaches should be considered.

Laparoscopic partial nephrectomy: a single-center evolving experience.

OBJECTIVES: To review our laparoscopic partial nephrectomy (LPN) experience, examine the evolution of technique, and compare the outcomes between the early and recent experience. The indications and surgical technique of LPN continuously evolve. METHODS: Data for 184 patients who underwent LPN for a tumor between October 2002 and August 2008 was retrieved from a prospective database. Surgical and functional outcomes for the entire cohort were analyzed and the first 50 (group 1) and most recent 50 (group 2) cases were compared. RESULTS: The groups were similar in terms of baseline renal function, body mass index, and comorbidities. The mean tumor size and the proportion of central tumors in groups 1 and 2 were 2.4 vs 3 cm and 12% vs 52%, respectively (P <.003). In group 2 we stopped the use of ureteral catheters and bolster renorrhaphy, and routinely clamped the renal hilum. Mean warm ischemia time in groups 1 and 2 (30 and 27 minute, respectively, P = .3) and the complication rate were similar. Overall, patients with tumors >4 cm had more complications (P = .042). In group 2 the estimated blood loss and hospital stay decreased (243 vs 140 mL, P = .01, 1.4 vs 2.5 days, P <.001). Overall 78% of the tumors were malignant and the positive margin rate was 3%. With a median follow-up of 18 months, no local or distant tumor recurrences were observed. CONCLUSIONS: With growing experience and technical modifications, LPN is now performed for patients with larger and more central tumors. Longer follow-up is necessary to evaluate oncologic outcomes.

Laparoscopic partial nephrectomy for tumors larger than 4 cm: a comparative study.

PURPOSE: To compare the perioperative and functional outcomes of patients with clinical T(1a) and T(1b) renal tumors after laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS: Data of 184 patients who underwent LPN were retrieved from a prospective, Institutional Review Board-approved database. The patients were stratified for analysis into groups: 149 (81%) patients with clinical stage T(1a) (group 1) and 35 (19%) patients with clinical stage T(1b) (group 2). Perioperative and postoperative outcomes were compared. RESULTS: No significant differences between groups 1 and 2 in warm ischemia time, estimated blood loss, operative time, conversion rate, intraoperative complication rate, and hospital stay were observed. The incidence of postoperative complications in group 2, however, was twice that of group 1 (25.7% vs 12%) (P = 0.04). Clinical staging correlated with the pathologic staging in 96% of the patients in group 1 and in only 71% in group 2 (P < 0.001). Upstaging to pT(2) or pT(3) occurred in 29% of the patients in group 2. High-grade tumors were more prevalent in group 2 (36% vs 12%) (P = 0.001). The number of patients with positive margin was higher in group 2, but the difference was not statistically significant. The mean decline in estimated creatinine clearance (median follow-up 18 months) was significantly higher in group 2. CONCLUSIONS: LPN in patients with tumors >4 cm, while safe and feasible in experienced hands, is associated with a higher postoperative complication rate, as well as a higher rate of pathologic upstaging. Such data should be discussed when counseling patients with larger tumors for LPN.

Laparoscopic partial nephrectomy for technically challenging tumours.

STUDY TYPE: Therapy (case series) Level of Evidence 4. OBJECTIVE: To investigate the outcomes of laparoscopic partial nephrectomy (LPN) for endophytic tumours and those located near the hilum or the posterior upper-pole, as these pose a technical challenge. PATIENTS AND METHODS: Technically challenging tumours were defined as endophytic, hilar, or at the posterior upper-pole (group 1), and were compared to tumours in other locations (group 2). We collected data prospectively for all patients undergoing LPN at our institution, including baseline patient and tumour characteristics, surgical and postoperative outcomes. Two-sided t-test or rank-sum test, and chi-square or exact tests were used as appropriate for comparison of continuous and categorical variables, respectively, with P < 0.05 considered to indicate statistical significance. RESULTS: There were 184 patients treated with LPN (42 in group 1 and 142 in group 2) between 2002 and 2008 by one surgeon (A.L.S.). Groups 1 and 2 were similar in terms of baseline variables (age, sex, body mass index, comorbidities, previous surgery, renal function and haematocrit) and in tumour size. LPN for challenging tumours resulted in a higher rate of collecting system repair (78% in group 1, 61% in group 2, P = 0.03). However, operative (surgery time, warm ischaemia time, blood loss, intraoperative complications) and postoperative outcomes (renal function, nadir haematocrit, complication rate, hospital stay and positive margin rate) were similar between the groups. CONCLUSIONS: With developing experience LPN can be safe for technically challenging renal tumours in well selected patients.

Holmium laser endoureterotomy for benign ureteral stricture: a single center experience.

PURPOSE: We assessed the long-term outcome of laser endoureterotomy for benign ureteral stricture. MATERIALS AND METHODS: From a database of 69 patients who underwent retrograde laser endoureterotomy from October 2001 to June 2007 we identified 35 with a benign ureteral stricture. Clinical characteristics, operative results and functional outcomes were investigated. Success was defined as symptomatic improvement and radiographic resolution of obstruction. RESULTS: Median followup was 27 months (range 10 to 72). All except 1 patient were followed at least 16 months. All patients completed clinical followup and 33 completed imaging. Of 35 patients 29 (82%) were symptom-free during followup and 26 of 33 (78.7%) were free of radiographic evidence of obstruction. All except 1 failure occurred within less than 9 months postoperatively. The success rate was higher for nonischemic strictures (100% vs 64.7%, p = 0.027) and tended to be higher for strictures 1 cm or less (89.4% vs 64.2%, p = 0.109). CONCLUSIONS: Holmium laser endoureterotomy is effective for benign ureteral stricture in well selected patients. Most failures occur within less than 9 months after surgery, which may indicate a need for closer followup during postoperative year 1. Factors that might may outcome are ischemia and stricture length.