 Abbreviations: DVT, deep vein thrombosis; L, left; OR, operation; R, right.    These data suggest that the laparoscopic approach  to some malignant neoplasms originating from or  metastasizing to the adrenal gland is reasonable,  but the conversion to an open procedure should  be performed if local invasion is present.    Laparoscopic adrenalectomy has become an  accepted method for removing benign lesions of  the adrenal gland. There is no question that the  advantages of the laparoscopic approach include  shorter hospitalization and convalescence. There  are few contraindications to the laparoscopic  approach, and the transperitoneal and retroperi-  toneal techniques yield excellent results. Virtually  all benign lesions and select malignant lesions can  be removed laparoscopically.   Laparoscopic adrenalectomy has been shown  to be a safe and effective approach to many forms  of adrenal pathologic conditions. It should be  considered the standard of care in the manage-  ment of benign lesions of the adrenal gland that  require surgical removal.    [1] Gagner M, Lacroix A, Bolte E. Laparoscopic  adrenalectomy in Cushing's syndrome and pheo-  chromocytoma. N Engl J Med 1992;327:1033.   [3] Winfield HN, Hamilton BD, Bravo EL, et al. Lapa-  roscopic adrenalectomy: the preferred choice? A  comparison to open adrenalectomy. J Urol 1998;  160:235.   [4] Yoshimura K, Yoshioka T, Miyake O, et al. Com-  parison of clinical outcomes of laparoscopic and  conventional open adrenalectomy. J Endourol  1998;12:555.   [6] Bolli M, Oertli D, Staub J, et al. Laparoscopic adre-   [9] Miccoli P, Raffaelli M, Berti P, et al. Adrenal surgery  before and after the introduction of laparoscopic ad-  renalectomy. Br J Surg 2002;89:779.    [10] Ortega J, Sala C, Garcia S, et al. Cost-effectiveness  of laparoscopic vs open adrenalectomy: small sav-  ings in an expensive process. J Laparoendosc Adv  Surg Tech A 2002;12:1.   [11] Blumenfeld JD, Vaughan ED Jr. Diagnosis and  treatment of primary aldosteronism. World J Urol  1999;17:15.   [12] Goldfarb DA. Contemporary evaluation and man-  agement of Cushing's syndrome. World J Urol  1999;17:22.   [13] Blumenfeld JD, Sealey JE, Schlussel Y, et al. Diag-  nosis and treatment of primary aldosteronism. Ann  Intern Med 1994;121:877.   [14] Walther MM, Keiser HR, Linehan WM. Pheochro-  mocytoma: evaluation, diagnosis, and treatment.  World J Urol 1999;17:35.   [15] Edwin B, Kazaryan AM, Mala T, et al. Laparo-  scopic and open surgery for pheochromocytoma.  BMC Surg 2001;1:2.   [16] Salomon L, Rabii R, Soulie M, et al. Experience  with retroperitoneal laparoscopic adrenalectomy  for pheochromocytoma. J Urol 2001;165:1871.   [17] Gotoh M, Ono Y, Hattori R, et al. Laparoscopic ad-  renalectomy for pheochromocytoma: morbidity  compared with adrenalectomy for tumors of other  pathology. J Endourol 2002;16:245.   [18] Murai M, Baba S, Nakashima J, et al. Management  of incidentally discovered adrenal masses. World J  Urol 1999;17:9.   [19] Belldegrun A, Hussain S, Seltzer S, et al. Incidentally  discovered mass of the adrenal gland. Surg Gynecol  Obstet 1986;163:203.   [20] Cerfolio RJ, Vaughan ED Jr, Brennan TG Jr, et al.  Accuracy of computed tomography in predicting ad-  renal tumor size. Surg Gynecol Obstet 1993;176:307.   [21] Schulick RD, Brenna MF. Adrenocortical carci-  noma. World J Urol 1999;17:26.   [22] Schulick RD, Brennan MF. Long-term survival  after complete resection and repeat resection in pa-  tients with adrenocortical carcinoma. Ann Surg  Oncol 1999:6:719.   [23] Heniford BT, Arca MJ, Walsh RM, et al. Laparo-  scopic adrenalectomy for cancer. Semin Surg Oncol  1999;16:293.   [24] Gill IS, Meraney AM, Thomas JC, et al.  Thoracoscopic transdiaphragmatic adrenalectomy:  the initial experience. J Urol 2001;165:1875.   [25] Lezoche E, Guerrieri M, Feliciotti F, et al. Ante-  rior, lateral, and posterior retroperitoneal ap-  proaches in endoscopic adrenalectomy. Surg  Endosc 2002;16:96.   [26] Suzuki K, Kageyama S, Hirano Y, et al. Comparison  of 3 surgical approaches to laparoscopic adrenalec-  tomy: a nonrandomized, background matched anal-  ysis. J Urol 2001;166:437.   [27] Rubinstein M, Gill IS, Aron M, et al. Prospective,  randomized comparison of transperitoneal versus  retroperitoneal laparoscopic adrenalectomy. J Urol  2005;174(2):442.    Baba S, Ito K, Yanaihara H, et al. Retroperitoneo-  scopic adrenalectomy by a lumbodorsal approach:  clinical experience with solo surgery. World J Urol  1999;17:54.   Nambirajan T, Janetschek G. Laparoscopic partial  adrenalectomy. Minim Invasive Ther Allied Technol  2005;14(2):71.   Wu JC, Wu HS, Lin MS, et al. Comparison of  robot-assisted laparoscopic adrenalectomy with  traditional laparoscopic adrenalectomy—1 year  follow-up. Surg Endosc 2008;22(2):463.   Winter JM, Talamini MA, Stanfield CL, et al. Thirty  robotic adrenalectomies: a single institution’s expe-  rience. Surg Endosc 2006;20(1):119.   Henry JF, Defechereux T, Raffaelli M, et al. Compli-  cations of laparoscopic adrenalectomy: results of  169 consecutive procedures. World J Surg 2000;24:  1342.   Zhang X, Fu B, Lang B, et al. Technique of anatom-  ical retroperitoneoscopic adrenalectomy with report  of 800 cases. J Urol 2007;177(4):1254.   Shen ZJ, Chen SW, Wang S, et al. Predictive factors  for open conversion of laparoscopic adrenalectomy:  a 13-year review of 456 cases. J Endourol 2007;  21(11):1333.   Lezoche E, Guerrieri M, Crosta F, et al. Periopera-  tive results of 214 laparoscopic adrenalectomies by  anterior transperitoneal approach. Surg Endosc  2008;22(2):522.   The Academic Committee of Japanese Society of  Endoscopic Surgeons. Eighth nation wide survey.  J Jpn Soc Endosc Surg 2006;5:527.   MacGillivray DC, Whalen GF, Malchoff CD, et al.  Laparoscopic resection of large adrenal tumors. Ann  Surg Oncol 2002;9:480.   Valeria A, Borrelli A, Presenti L, et al. The influence  of new technologies on laparoscopic adrenalectomy.  Surg Endosc 2002;16:1274.    39] Kebebew E, Siperstein AE, Duh QY. Laparoscopic  adrenalectomy: the optimal surgical approach.  J Laparoendosc Adv Surg Tech A 2001;11:409.   40] Salomon L, Soulie M, Mouly P, et al. Experience  with retroperitoneal laparoscopic adrenalectomy in  115 procedures. J Urol 2001;166:38.   4]] Guazzoni G, Cestari A, Montorsi F, et al. Eight-year  experience with transperitoneal laparoscopic adre-  nal surgery. J Urol 2001;166:820.   43] Soulie M, Mouly P, Caron P, et al. Retroperitoneal  laparoscopic adrenalectomy: clinical experience in  52 procedures. Urology 2000;56:921.   44] Mancini F, Mutter D, Peix JL, et al. Experience with  adrenalectomy in 1997. Apropos of 247 cases: a mul-  ticenter prospective study of the French-speaking  Association of Endocrine Surgery. Chirurgie 1999;  124:368.   45] Shichman SJ, Herndon CD, Sosa RE, et al. Lateral  transperitoneal laparoscopic adrenalectomy. World  J Urol 1999;17:48.   46] Chee C, Ravinthiran T, Cheng C. Laparoscopic ad-  renalectomy: experience with transabdominal and  retroperitoneal approaches. Urology 1998;51:29.   47| Gagner M, Pomp A, Heniford BT, et al.  Laparoscopic adrenalectomy: lessons learned from  100 consecutive procedures. Ann Surg 1997;226:238.   48] Terachi T, Matsuda T, Terai A, et al. Transperito-  neal laparoscopic adrenalectomy: experience in 100  patients. J Endourol 1997;11:361.   49] Rutherford JC, Stowasser M, Tunny TJ, et al.  Laparoscopic adrenalectomy. World J Surg 1996;  20:758.   50] Henry JF, Sebag F, Iacobone M, et al. Results of  laparoscopic adrenalectomy for large and poten-  tially malignant tumors. World J Surg 2002;26:1043.    Minimally Invasive Management  of Upper Tract Malignancies: Renal Cell  and Transitional Cell Carcinoma    Geoffrey N. Box, MD’, Daniel S. Lehman, MD”,  Jaime Landman, MD”, Ralph V. Clayman, MD**    * Department of Urology, University of California Irvine Medical Center,  333 City Boulevard West, Suite 2100, Orange, CA 92868, USA  > Department of Urology, Minimally Invasive Urology/Oncology,  Columbia University Medical Center, 161 Fort Washington Avenue,  Room 1111, New York, NY 10032, USA    The incidence of renal tumors continues to  increase with the more widespread use of abdom-  inal imaging. With this increasing incidence, more  tumors are detected that are potentially amenable  to less invasive treatment. At the same time,  technologic advances have created new minimally  invasive options for the treatment of smaller  lesions [1]. Since the performance of the first  laparoscopic nephrectomy in 1990 [2], there has  been an ever-growing incorporation of laparo-  scopic techniques into clinical practice; in fact,  laparoscopic nephrectomy has become a standard  treatment of renal tumors that are not candidates  for nephron-sparing surgery. Currently, tumors  that are amenable to a nephron-sparing approach  may be treated with one of several options. Lapa-  roscopic partial nephrectomy (LPN) has estab-  lished its intermediate oncologic equivalency to  the open method [3-5], although this technique  has not experienced the same incorporation into  clinical practice as laparoscopic radical nephrec-  tomy (LRN), likely, in large part, because of the  technical complexity of the procedure and the  potentially higher complication rates. When treat-  ing the small renal mass, other alternatives have  become available, specifically needle ablative    techniques. The clinical evidence is building in fa-  vor of cryoablation and radiofrequency ablation  for the treatment of small renal tumors. Other ex-  perimental techniques that could further reduce  the invasiveness of treatment, such as noninvasive  high-intensity focused ultrasound (HIFU) and the  gamma knife, have also been explored; however,  to date, clinical results have been few and disap-  pointing [6,7].   This article focuses primarily on the laparo-  scopic approaches to radical and partial nephrec-  tomy for management of renal cell carcinoma  (RCC). An in-depth discussion of treatment  options for transitional cell carcinoma (TCC) is  also covered.    Most solid renal tumors with a diameter of  4 cm or less are amenable to treatment with  nephron-sparing surgery; the oncologic outcomes  are excellent and equivalent to radical nephrec-  tomy [8-10]. Tumors 3 cm or less are thought to  be best suited for needle ablative treatment. The  natural history and cancer potential of these small  masses is an important consideration, given the  fact they are often found in elderly patients who  have significant comorbidities. One study looked  at tumors 4 cm or less and reviewed the histopath-  ologic results of 287 tumor excisions, attempting  to characterize the aggressiveness of smaller renal    0094-0143/08/$ - see front matter © 2008 Elsevier Inc. All rights reserved.    masses [11]. In this series, 19.5% of the masses  were found to be benign. Among the patients  who had RCC, high grade and high stage seemed  to be correlated with tumor size; to wit, Fuhrman  grade 3/4 or pT3a lesions were found in 4.2% and  4.2% (X2 cm), 5% and 14.9% (2.1-3 cm), and  25.5% and 35.7% (3.1-4.0 cm), respectively.  Distant metastases were seen in 2.4% of tumors  3 cm or less and in 8.4% of tumors 3.1 to  4.0 cm. This underscores the fact that tumor  aggressiveness seems to increase dramatically in  tumors larger than 3 cm, calling into question  the reliability of the current Tla system, which  includes tumors up to 4 cm in size. Indeed, not  only aggressiveness but the likelihood of cancer  seems to be related to the size of the mass.  Regarding the latter, when looking at tumor sizes  from less than 1 cm to greater than 7 cm, with  each l-cm increase in tumor size, the odds of  cancer increase by 17% [12].   An ongoing concern with the treatment of the  small renal mass is that upward of 20% to 25% of  lesions 4 cm or less are benign [12,13]. This high  incidence of benign lesions makes the natural  history of untreated renal masses an area of inter-  est. In a meta-analysis of untreated renal lesions,  the mean growth rate was 2.8 mm/y and only  1% of the patients developed metastasis during  the surveillance period [14]. Important questions,  such as cancer-specific death in untreated lesions  and how to differentiate benign from malignant  growth patterns, remain unanswered. Indeed, sur-  veillance rather than immediate ablative therapy  has been proposed as one treatment strategy. To  this end, the work of Kouba and colleagues [15]  is most enlightening. In this study of 43 patients  who had 46 solid or cystic (Bosniak IV) masses  with a mean size of 2.9 cm who were followed  for an average of 3 years, there was a median  growth rate of 6 mm/y. Only 28% came to surgery  (ie, growth rate of 9 mm/y), among whom 8795  had cancerous lesions. During the same period,  10% of the patients died from unrelated causes,  having had no renal surgery. Over the 3-year  period, no patient developed metastatic disease,  and among those coming to surgery, all still had  a nephron-sparing procedure.    Winfield and colleagues [16] performed the first  LPN in 1991 for benign disease, with McDougall  and colleagues [17] subsequently extending the  application to renal tumors in 1993. The    traditional open approach to nephron-sparing  surgery has established oncologic and functional  outcomes with 10-year follow-up [8,9]. Several  groups have published their results with the lapa-  roscopic technique (Table 1) [3,4,18—25]. Lane and  Gill [4] recently published the results on 58 pa-  tients who had undergone an LPN with at least  5 years of follow-up (median of 5.7 years; range:  5-6.9 years). The mean tumor size was 2.9 cm,  and the 5-year overall and cancer-specific survival  (CSS) rates were 86% and 100%, respectively,  which is comparable to the published open series.  There was one positive surgical margin (1.7%)  and an overall complication rate of 21%. On  average, the creatinine increased from 0.9 mg/dL  before surgery to 1.0 mg/dL after surgery. No pa-  tient with a normal preoperative creatinine level  developed postoperative chronic renal insuffi-  ciency, as defined by a serum creatinine level  greater than 2 mg/dL. Thirty-seven patients  (66%) had RCC on the final histopathologic anal-  ysis, and in this group of patients, there were no  distant recurrences and a single local recurrence  (1.7%). Allaf and colleagues [24] reported the on-  cologic outcomes of 48 patients who had patho-  logically proved RCC with a mean follow-up of  38 months. The mean tumor size was 2.4 cm,  with 42 patients having pT1 tumors and 6 patients  having pT3a tumors. All patients had a negative  intraoperative frozen margin; however, one of  these was determined to be positive on the final  pathologic examination (2.1%). This patient re-  mained disease-free with greater than 3 years of fol-  low-up. Two patients (4.2%) developed a local  recurrence at 18 and 46 months after surgery.  Jeschke and colleagues [3] reported on their series  of 51 patients undergoing LPN with a mean fol-  low-up of 34 months (range: 3-78 months). The  mean tumor size was 2 cm (range: 1-5 cm), with  35 patients having pT1 tumors and 3 having pT3a  tumors; 38 patients (76%) were confirmed to have  pathologic RCC. Surgical margins were negative  in all cases. One patient (2.6%) developed a local re-  currence 12 months after the initial surgery, and no  distant recurrences were seen. The overall compli-  cation rate was 10%.   Three large series comparing laparoscopic with  open partial nephrectomy (OPN) are summarized  in Table 2 [5,26,27]. A direct comparative analysis  of 100 consecutive LPNs to a contemporary  cohort of 100 consecutive OPNs was reported by  Gill and colleagues [28]. The LPN group had  smaller tumors (2.8 versus 3.3 cm), a shorter oper-  ative time (3 versus 3.9 hours), less blood loss    No. Mean MBA wont Positive Length of Recurrence Complications Survival  patients tumor ischemia Mean surgical follow-up/ Cancer-  [tumors) size [cm] time EBL  Malignancy margin months Recurrence- specific Overall  Authors Institution (N) (range) (minutes) (mL) rate (76)  (range) Local Distant Intraoperative Postoperative Overall free   Lane Cleveland 56 2.9 — = 66% 1 (1.7%) 68 I 0 6% 13% 18% 97% 100% 86%  et al [4] Clinic (1.3-7.0) (60-83)  Moinzadeh Cleveland 100 2.9 27 219 6896 2(2%) 43 0 — — = = 100% 100% 86%  et al [18 Clinic (24-62)  Weld Washington 60 25 26.9 226 6095 0(0%) 25 0 0 = = 30% 100% — =  et al [19] University (0.7-5.1) (10-44)  Wille Humboldt 44 2.8 21 — 82% 0 15 0 0 0% = — 100% = =  et al [20 University (1-5) (7-41) (6-37)  Link Johns 217 2.6 27.6 385 66% 7 (3.5%) 24 2 0 = 10.6% = = = =  et al [21 Hopkins (1-10) (5-60) (7-54)  Ramani Cleveland 200 2.9 28.7 247] — 5.5% 27.5% (15.5% 33% — — — —  et al [22] Clinic (1-10) (15-58) delayed)  Abukora Elisabethinen — 78 24 33.8 212 83% 1 (1.2%) 16 0 0 9% 19% 28% 100% — =  et al [23 Austria (0.5-3.5) | (17-56) (3-38)  Allaf Johns 48 24 = = 100% 1 (2.1%) 38 2 0 = = = 96% 100% —  et al [24 Hopkins (1.0-4.0) (22-84)  Seifman University 40 2.3 -= 300 73% 1 (2.5%) 24 0 0 = = 38% 100% — —  et al [25 of Michigan  Jeschke University 51 2.0 — 282 76% 0(0%) 34 0 0 2% 8% 10% 100% 100% —  et al [3] of Innsbruck (3-78)    Data from Canes D. Long-term oncological outcomes of laparoscopic partial nephrectomy. Curr Opin Urol 2008;18:145—9.    Summary of comparative clinical series of laparoscopic versus open partial nephrectomy    Postoperative  mE Recurrence complications Survival  Mean warm Positive Length of  Patients tumor ischemia Mean surgical follow-up Intra Bleeding/ Recurrence- Cancer-  [tumors] size [cm] time EBL ORtime LOS  Malignancy margin [months] operative Urine All post free specific Overall  Authors Institution Surgery (N) (range) (minutes) (mL) (minutes) (days) rate  (range) Local Distant complications leak operative   Gill 3 centers? LPN 771 2.7 30 300 201 33 7295 22 14 1.4%” 0.9%? 1.8% 4.2% 25% = 99%  —  et al [26] (0.5-7.0) — (4-68) (2.9%) | (0-84) 3.196  OPN 1028 3.5 20 376 266 5.8 83% 13 34 1.5%” 2.1%? 1.0% 1.6% 19% -— 99^  —  (0.6—7.0) — (4-52) (1.3%) | (0-91) 2.3%  Permpongkosol Johns LPN 85 24 29.5 437 225 3.3 100% 2 40 2 1 3.5% = 17% 9194* = 94% °  et al [5] Hopkins (0.5—5.3) (24%) | (18-96) (2.3%) (1.2%)  OPN 58 29 48 428 276 5.4 100% 1 49 1 1 3.5% — 22% 979*4* — 969/*  (1-5) (1.7%) | (18-106) (1.7%) (1.7%)  Gill et al [27] Cleveland LPN 100 2.8 28 125 180 2.0 70% 3 = = = 5% 3% 16% = — —  Clinic 3%  OPN 100 3.3 18 250 231 5.0 85% 0 — — — 0% 0% 13% — — —  1%    * Cleveland Clinic, Johns Hopkins, and Mayo Clinic.  > Three-year Kaplan-Meier estimates.  * Five-year Kaplan-Meier estimates.    (125 versus 250 mL), and a longer warm ischemia  time (28 versus 18 minutes) when compared with  the OPN group. The overall complication rate  was similar, with 19% of patients in the LPN  group and 1395 in the OPN group experiencing  complications. Five percent of the LPN group  had intraoperative complications versus none in  the OPN group, however. Additionally, the LPN  group had more renal or urologic complications  (11% versus 2%). This study confirmed that lapa-  roscopic nephron-sparing surgery is an effective  therapeutic approach, albeit a technically de-  manding and more morbid procedure than OPN  even in highly experienced hands. Advantages of  LPN included decreased narcotic use (20- versus  252-mg morphine equivalents), shorter hospital  stay (2 versus 5 days), and a more rapid convales-  cence (4 versus 6 weeks). Permpongkosol and col-  leagues [5] reported the outcomes of 85 LPNs  compared with 58 OPNs with pathologically  proven RCC and mean follow-ups of 40 and  49 months, respectively. The 5-year recurrence-  free and overall survival rates were 9196 versus  97% and 94% versus 96% for LPN and OPN, re-  spectively, demonstrating equivalent intermediate  oncologic outcomes. The largest comparative  study reported the outcomes of 771 LPNs com-  pared with 1028 OPNs from three tertiary care  centers [26]. The OPN group had larger tumors  (3.5 versus 2.7 cm) and represented a higher risk  group based on performance status, impaired re-  nal function, and solitary tumor status. LPN  was associated with a shorter operative time  (201 versus 266 minutes) decreased blood loss  (300 versus 376 mL), and a shorter hospital stay  (3.3 versus 5.7 days) but had a longer warm ische-  mia time (30 versus 20 minutes) and more postop-  erative complications (25% versus 19%). Renal  functional outcomes (98% versus 99%) and  3-year CSS (99% versus 99%) were similar with  both approaches.   With regard to the morbidity of LPN, Ramani  and colleagues [22] looked at the complications  seen in 200 consecutive LPNs. A total of 66 pa-  tients (33%) experienced at least one complica-  tion. Hemorrhage was the most common  complication and was seen in 19 patients (9.5%),  occurring during surgery in 7 (3.5%), after surgery  in 4 (2%), and delayed (after discharge) in 8 (4%)  at a mean of 16 postoperative days. A urine leak  was seen in 9 patients (4.5%) and was typically  managed with a double-J stent. Again, this series  came from the Cleveland Clinic, which has the  largest experience with LPN, stressing that even    in the most experienced hands, the morbidity of  LPN is a significant consideration.   LPNs have been successfully performed by  means of transperitoneal and retroperitoneal ap-  proaches. The choice is typically based on surgeon  preference, tumor location, and patient factors,  although the transperitoneal approach provides  a larger working space with more familiar anat-  omy, which may facilitate tumor excision and  renorrhaphy. In general, for lesions that are  directed posteriorly, a retroperitoneal approach  is chosen, especially if no entry into the collecting  system is anticipated because of the mass being  largely exophytic (ie, less than 10 mm extension  into the kidney).   The use of intraoperative laparoscopic ultra-  sound has become common to define the borders  of the tumor and to assist in planning the plane of  incision for removal. Additionally, the entire  kidney may be surveyed to rule out other lesions.   Vascular clamping provides a bloodless field  for more precise tumor excision. Vascular occlu-  sion can be achieved with internalized bulldog  vascular clamps or with an exteriorized handheld  Satinsky clamp. When using bulldog clamps, one  is typically placed on the artery and another on  the vein, although clamping of the artery alone is  also an option, because the renal venous blood  flow is decreased by upward of 90% with a pneu-  moperitoneum pressure of 15 mm Hg [29].   The bulldog clamps seem to provide the most  reliable occlusive force when placed entirely  across the vessel to the end of the clamp [30]. Ad-  ditionally, over time, some bulldogs fatigue and  no longer provide supraphysiologic occlusion  forces, which could explain some of the variability  noted among bulldog clamps and recommenda-  tions of some surgeons to check for cessation of  arterial inflow to the kidney with a laparoscopic  ultrasound Doppler probe or to place at least  two bulldog clamps on the artery (J. Landman,  personal communication).   The Satinsky clamps are typically placed  across the entire hilum without isolating the artery  and vein individually. In the authors’ experience,  vascular control is not required for all tumors,  and it is their policy to use vascular control only    for tumors that are 10 mm or deeper from the  kidney surface and are likely to entail closure of  the collecting system; with this approach, warm  ischemia time is avoided during the excision of  most exophytic masses [31].   The acceptable duration of warm ischemia that  can be tolerated without causing reversible neph-  ron loss has not been firmly established, although  minimizing warm ischemia time is generally  agreed to be important. Typically, warm ischemia  times 30 minutes or less are desirable, but some  have shown that warm ischemia time up to 40 to  45 minutes may be well tolerated [32]. Of note, in  the porcine model, warm ischemia times of 90 min-  utes are tolerated with complete return of function  in 2 weeks [33]. All this depends more on the pa-  tient than on the absolute warm ischemia time,  because the elderly patient, the hypertensive pa-  tient who has arteriosclerosis, patients with preex-  isting renal insufficiency, or the diabetic patient  seems to be more prone to damage from warm is-  chemia even of short duration. This has led some  surgeons to release the vascular clamps before  completing the renorrhaphy, thereby producing  warm ischemia times of 15 minutes or less [34].   Bleeding is the most common complication  after LPN, and several hemostatic agents exist to  help achieve hemostasis. These include thrombin-  impregnated gelatin matrix, fibrin sealants, and  oxidized cellulose. Looking at risk factors for  complications after LPN, thrombin-impregnated  gelatin matrix has been shown to decrease the risk  for postoperative bleeding complications [35].   Using a transperitoneal approach, the kidney  is mobilized and the renal hilum is isolated en  bloc. The capsule of the kidney is exposed within  Gerota's fascia to the edge of the tumor, leaving  the peritumoral fat in place. Intraoperative ultra-  sound is used to confirm the size and depth of the  tumor, and the argon beam monopolar cautery is  then used to score the renal capsule around the tu-  mor along the planned site of excision. All sutures  (6-inch length of 2-0 Vicryl on SH needle and  10-inch length of 0 Vicryl on CT-1 needle) and  bolsters needed for repair are placed into the ab-  dominal cavity before applying the vascular clamp  to minimize warm ischemia time. The handheld  Satinsky clamp is applied across the renal hilum,  the tumor is excised, and reconstruction is    performed using a specific series of techniques in  an attempt to minimize bleeding [36]. In this re-  gard, at the authors' institution, tumor excision  is performed using an energy-based device; either  a bipolar or ultrasonic based sealing device. The  argon beam monopolar cautery is then applied  to the tumor base, followed by suture repair of  the collecting system and exposed vessels. A ab-  sorbable polydioxanone suture anchor is used to  secure the suture at either end, as previously de-  scribed [37]. A layer of thrombin-impregnated gel-  atin matrix is applied, followed by oxidized  cellulose bolsters; then, a series of simple sutures  is used to close the parenchymal defect, again uti-  lizing absorbable polydioxanone suture anchors.  Finally, fibrin glue or thrombin-impregnated gela-  tin matrix is applied on the surface of the repair.  Using this technique, no early or delayed postop-  erative bleeding complications have occurred over  a 2-year period [36].   In patients who have a 3-cm or smaller tumor  that is nonhilar and does not extend into the renal  parenchyma by more than 10 mm, the lesion can  be excised without any warm ischemia. A spiral  CT angiogram is performed with three-dimen-  sional reconstruction to measure the depth of  the tumor accurately and assess its proximity to  the collecting system. This approach requires the  use of a bipolar or ultrasonic sealing device to  excise the lesion. Although questions have been  raised concerning the integrity of the margin, in  fact, neither the bipolar nor the ultrasonic modal-  ity precludes an accurate assessment of the margin  status according to an extensive study recently  completed at the authors' institution [38]. The ap-  proach to the tumor is based on its location, with  retroperitoneoscopy being performed for posteri-  orly directed tumors and transperitoneal laparos-  copy being performed for anteriorly directed  tumors. The hilum can be dissected at the sur-  geon's discretion; however, this is not routinely  done in the authors’ operating room. Once the  peritumoral fat is removed and the lesion is clearly  seen for a complete 360? circumference, the  planned site of incision is marked with monopolar  electrocautery and the argon beam cautery. The  renal capsule is then incised completely around  the tumor. The pneumoperitoneum pressure is  then elevated to 20 to 25 mm Hg, the anesthesiol-  ogist is notified, and a timer is set for 10 minutes.  Using the bipolar or ultrasonic sealing device, the  activated blade is passed to its full depth at the    inferior point of the tumor; this is done so that  one is always working away from any bleeding  that may occur. Once the jaws of the device are  closed and activated (ie, bipolar based sealing de-  vice) or activated and closed (ie, ultrasonic based  sealing device), the dissection continues to the  right and left side and upward. Throughout the  process, the assistant can use the argon beam to  stop any bleeding that occurs; the surgeon uses  the suction unit in the nondominant hand contin-  ually to expose the next adjacent area to be in-  cised. As the tumor is rolled upward and out of  its parenchymal bed, the argon beam is used to  continue to aid hemostasis on the parenchymal  surface. In this manner, the tumor is mobilized  and excised. As soon as the tumor is free, the pa-  renchymal bed is treated with argon beam cau-  tery, followed by fibrin glue, a layer of oxidized  cellulose, and another layer of fibrin glue; a couple  of minutes are allowed to pass to enable the fibrin  glue to set up. Usually, this entire process should  take less than 10 minutes. The pneumoperitoneum  is then lowered to 5 mm Hg to check for any  bleeding. In none of our cases have we found it  necessary to place a bolster or to suture the edges  of the capsule or parenchyma. A 5-mm round  drain is placed at the end of the procedure.    Since Clayman and colleagues [2] performed  the first laparoscopic nephrectomy (LRN) in  June of 1990 at Washington University, this tech-  nique has become internationally accepted. In  fact, many urologists consider this the standard  of care for those patients who have T1, T2, or  T3a tumors amenable to treatment by means of  the laparoscopic approach but are not candidates  for nephron-sparing surgery. The decreased mor-  bidity of LRN has been well documented with  reductions in postoperative pain, hospital stay,  and convalescence. Several studies with maturing  follow-up data have been published, establishing  the oncologic equivalency to the open procedure  (Table 3) [39-44]. Portis and colleagues [44] re-  ported a multicenter series of 64 patients treated  with LRN compared with a group of 69 patients  treated with open radical nephrectomy (ORN).  With a median follow-up of 54 months (range:  0-94 months), no difference was seen between  the two approaches, with a 5-year recurrence-  free survival, 5-year CSS, and overall survival  rates of 92%, 98%, and 81%, respectively, in  the laparoscopic group. Permpongkosol and    colleagues [42] reported on a series of 67 patients  who had an LRN with a median follow-up of  73 months (range: 12-164 months) that was com-  pared with 54 patients who had renal cancer and  had an ORN. The 10-year disease-free, cancer-  specific, and actuarial survival rates for the lapa-  roscopic group were 94%, 97%, and 76%  compared with 87%, 86%, and 58% in the open  group, respectively. Hemal and colleagues [40]  reported on their series of 132 patients having  a laparoscopic nephrectomy for pT1 to pT2 RCC  with a median follow-up of 56 months (range:  3-80 months). The survival analysis was grouped  by T stage, with 5-year CSS rates and 5-year  recurrence-free survival rates of 97.2% and  97.2%, 86.3% and 84.3%, and 82.2% and  82.2%, respectively, for pTla, pTlb, and pT2  tumors. With a decade of follow-up in some  series, LRN has now demonstrated oncologic  equivalency to open surgery.   Transperitoneal, retroperitoneal, and hand-  assisted approaches to LRN have all been re-  ported. Similar to LPN, the choice often depends  on surgeon experience and patient factors. One  prospective study compared the three approaches  and showed reduced operative time with the hand-  assisted approach, whereas the incision size,  hospital stay, and convalescence were less in the  transperitoneal group [45]. A larger retrospective  study confirmed these findings [46].   One of the benefits of laparoscopic surgery is  the reduced invasiveness of the procedure and the  improved cosmetic result. When a large incision is  made for intact specimen removal, some of these  benefits are lost. Specimen morcellation has been  used to maintain these benefits. A nylon entrap-  ment sack with a polyurethane inner coating is the  only entrapment bag that has been routinely used  for morcellation because it is the only entrapment  device with the appropriate durability and proven  impermeability available. Generally, morcellation  is done with a ring forceps and suction; the  authors routinely enlarge a 12-mm port site to  1 inch and use Sopher ring forceps because they  are stronger with a broader ring than the tradi-  tional ring forceps in the general surgery tray.  Before morcellation, the authors believe it is  of paramount importance that the wound be me-  ticulously triple draped (towel drape, plastic    Length of  Mean follow-up Cancer- Cancer-  Type of Patients Tumor EBL [months] Recurrence- specific Overall Recurrence- specific Overall  Authors Institution surgery (N) size (range) (mL) (range) Complications free  free   Colombo Cleveland LRN 63 5.4 179 65 (19-92) 7% 91% 91% 78% — — —  et al [39] Clinic ORN 53 6.4 501 76 (8-105 — 93% 93% 84% A! - —  Hemal All India LRN 132 6.9(3.6-14) 193 56 (3-80) 17% 87% 88% 86% — = —  et al [40] Institute  Kawauchi 22 centers HALRN 123 4.4 173 4l 9% 92% 92% — — — —  et al [41] ORN 70 4.4 448 | 74 1095 91% 94% — — — —  Permpongkosol Johns LRN 67 T1-46 (69%) — 73 (12-164) — 94% 97% 85% 94% 97% 76%  et al [42] Hopkins T2-21 (31%)  ORN 54 T1-40 (74%) — 80 (8-157) | — 87% 89% 72% 87% 86% 58%  T2-14 (26%)  Saika et al [43] Nagoya LRN 195 3.7 248 40(2-121) 15% 91% = 94% — — —  University ORN 68 4.4 482 65 (11-126) 7% 87% — 94% — —  Portis et al [44] — 3 centers" LRN 64 4.3 (2-10) 219 54 (0-94)  — 92% 98% 81% — = =  ORN 69 6.2(2.5-15) 354 69 (8-114 — 91% 92% 89% — — E    adherent drape, and a nephrostomy drape), and  once the removal of the specimen and entrapment  sack is complete, all those in contact with the  specimen regown and reglove. The wound from  which the entrapment sack has been removed is  then bathed in water or povidone iodine. This is  to prevent seeding of the port site. Since the incep-  tion of laparoscopic nephrectomy by the authors  more than 15 years ago using this approach, to  the best of their knowledge, there has not been  a single instance of wound seeding at Washington  University or at the University of California-  Irvine.    As the proficiency in performing LRN has  improved, the indications for the laparoscopic  management of renal tumors have expanded.  Several groups have reported laparoscopic cytor-  eductive nephrectomy (LCN) before systemic  therapy in patients who had stage IV RCC.  Walther and colleagues [47] were the first to report  a series of LCNs. The group of patients undergo-  ing LCN whose tumor was morcellated had  significantly reduced time to immunotherapy  (interleukin [IL]-2 in this report) compared with  patients undergoing open cytoreductive nephrec-  tomy (OCN). With the introduction of the less  toxic, oral, targeted therapies, patients undergoing  laparoscopic cytoreductive surgery may benefit  from improved recovery and even earlier initiation  of therapy. Rabets and colleagues [48] confirmed  the improved quality-of-life outcomes with LCN  (n = 22) compared with OCN (n = 42) in the met-  astatic setting. The laparoscopic group had  a shorter hospital stay (2.3 versus 6.1 days), de-  creased blood loss (288 versus 1228 mL), and  a shorter time until receiving systemic therapy  (36 versus 61 days). The 1-year survival rate was  61% in the laparoscopic group compared with  65% in the open group. Matin and colleagues  [49] also reported the feasibility and safety of  LCN in 38 patients. These reports support the  role for a laparoscopic approach to nephrectomy  in properly selected patients who have metastatic  disease; however, no survival advantage from  the earlier receipt of the planned immunotherapy  has been demonstrated.    Historically, a lymph node dissection (LND)  was included as part of a radical nephrectomy  [50]. Whether this provides any benefit to the    patient has been debated for many years, and no  clear consensus has been reached. The only pro-  spective randomized trial to assess the need for  an LND detected unsuspected lymph node metas-  tasis in 11 (3.3%) of 336 patients and did not find  a difference in survival at 5-year follow-up [51].  Patients who had microscopic lymph node in-  volvement with renal cancer are hypothetically  most likely to benefit from an LND; however,  given the low incidence of nodal involvement,  demonstrating a survival advantage would re-  quire a large number of study patients. Improved  staging is another argument for LND; however,  without any effective adjuvant therapy to date,  the need for this additional information is again  questionable, plus there are data showing that  the more distant nodes are merely reflective of  the hilar node status [52]. In contrast, LND can  be accomplished when one considers the chance  of nodal involvement to be likely. To wit, Sim-  mons and colleagues [53] reported successful  LND in 14 patients. The LND added an average  of approximately 30 minutes to the operative  time. There was one complication in this group:  postoperative ileus managed conservatively.  These investigators emphasized the importance  of patient selection, using the laparoscopic ap-  proach only if nodal masses were discrete and  the tissue planes around the great vessels were  preserved.    For most renal tumors, LRN, when compared  with the open approach, produces superior mor-  bidity outcomes while maintaining equivalent  long-term oncologic results. When evaluating  any of the options for treating small tumors with  a nephron-sparing approach, it is important to  remember that the outcomes should be measured  against the current “gold standard" open ap-  proach. We are currently at a crossroad in the  treatment of small renal tumors. Although many  of the ablative therapies show tremendous  promise, determining the most effective treatment  that causes the least morbidity in potentially  life-threatening tumors is in need of further clari-  fication. To this end, well-done, meticulous,  retrospective matched studies and prospective  comparative studies are needed to determine which  of the methods brings an efficacy level equivalent or  possibly superior to open surgery while providing  the most favorable morbidity and reasonable cost  profile.    Upper tract TCC is an uncommon disease.  Primary upper tract TCC represents approxi-  mately 5% of all urothelial carcinomas and 10%  of all primary renal tumors. Like TCC of the  bladder, upper tract urothelial carcinoma repre-  sents a field defect that can occur, recur, and  progress in any location in the urinary tract. The  most common location for ureteral TCC is the  distal ureter (70%), followed by the middle ureter  (25%) and proximal (5%) ureter [54]. Recurrence  in the ipsilateral kidney is common and can be as  high as 84%. Upper tract TCC is frequently mul-  tifocal (up to 44%). Recurrence rates in the  contralateral ureter are less common. The inci-  dence of contralateral synchronous and metachro-  nous recurrence ranges from 1.8% to 5% [55,56].  The risk for contralateral recurrence persists even  at 5 to 10 years. Surveillance for contralateral  recurrence should continue for up to 10 years.   The diagnosis of upper tract TCC is most often  made by contrast-enhanced imaging. Cytology is  useful mostly in the setting of high-grade TCC or  carcinoma in situ (CIS). Selective cytology for CIS  of the upper tract has a reported accuracy rate as  high as 80% [57]. Voided urine cytology for low-  grade lesions (grade 1) can have a false-negative  rate as high as 96%, however. The combination  of a filling defect on CT scan, intravenous pyelo-  gram, or retrograde urography with positive  cytology often makes the diagnosis. The addition  of ureteropyeloscopy and biopsy or ureteral  brushings increases the diagnostic yield from  58% to 83% [58]. Prognosis is closely linked to  location, stage, and grade. CT has often been  inaccurate in determining the invasiveness of up-  per tract lesions. Therefore, ureteropyeloscopy is  as essential to staging as it is to grading. Unlike  bladder cancer, which typically has a thick muscle  layer protecting against extravesicular extension,  the smooth muscle covering the ureter and renal  pelvis is much thinner. Tumors therefore have  less time to remain organ confined, and there is  less tissue to preserve a clear margin with extirpa-  tive procedures. Pathologic findings in large series  of upper tract TCC revealed that upper tract  tumors tend to present with a higher grade and  stage than bladder cancer. Indeed, approximately  70% of upper tract TCCs were of moderate or  high grade, and more than half had some degree  of invasion [59].   Treatment options for upper tract TCC are  numerous. Because of the high ipsilateral    recurrence rate associated with upper tract TCC,  nephroureterectomy with an open or laparoscopic  technique remains the gold standard. In patients  who cannot tolerate extirpative surgery because of  serious comorbidities, however, or in patients who  have renal insufficiency or solitary (or solitary  functional) kidneys and may require dialysis after  surgery, endoscopic management may be a reason-  able alternative. As advances in endoscopy and  ablative treatments have been made, the indica-  tions for endoscopic minimally invasive treat-  ments have been increasing. The authors review  all the minimally invasive treatment options for  upper tract TCC.    Along with solitary (or solitary functional)  kidneys, contemporary indications for uretero-  scopic treatment of upper tract TCC includes  significant renal insufficiency, bilateral upper tract  tumors, and patients who have comorbidities that  preclude extirpative surgery. Experience, advances  in technology, and our improved understanding of  the biology of upper tract TCC have proved that  a more conservative strategy can be successfully  adopted in well-selected cases. The indications for  ureteroscopy have expanded to include patients  who have low-grade and low-stage tumors. In this  patient population, meticulous and rigorous sur-  veillance protocols must be maintained. Patients  must be able and willing to follow up carefully with  frequent urinary cytology and contrast-enhanced  upper tract imaging to ensure prompt diagnosis  and management of recurrence. Often, repeated  and frequent endoscopic surveillance is appropri-  ate in this population. Endoscopic therapy offers  the advantages of minimally invasive surgery, and  in highly selected patients, it may provide results  equivalent to radical extirpative surgery [60,61].   In addition to patient characteristics, tumors  amenable to ureteroscopic treatment are usually  solitary, small (<1.5 cm), low grade, and amena-  ble to complete resection [62]. In contrast, higher  grade tumors, larger size, and multifocality have  been associated with tumor persistence and recur-  rence. Recently, Sowter and colleagues [63] found  that the highest rate of patients needing nephrour-  eterectomy after ureteroscopic resection was in  patients who had grade HI TCC. In their review,  there was an overall survival rate of 80%, with  a disease-specific survival rate of 100%.   Because it is less invasive and does not open  any closed tissue planes, ureteroscopy is usually    the preferred access technique for small upper  tract TCC of the ureter, renal pelvis, and upper  calices. Ureteroscopic treatment of focal low- and  intermediate-grade superficial upper tract TCC is  a safe alternative to nephroureterectomy in select  patients when vigilant ureteroscopic follow-up is  applied. Larger less accessible lesions that cannot  be resected or fulgurated adequately can be  treated percutaneously [64]. Primary tumors  greater than 1 cm that are challenging to ablate  or that result in bleeding or poor visibility can  be treated in a staged manner with multiple ure-  teroscopic procedures.   Ureteroscopy can be performed in an ambula-  tory setting and requires minimal anesthesia and  minimal postoperative analgesia. The disadvan-  tages of ureteroscopic management are the chal-  lenges of long-term surveillance, patient anxiety,  the potential for tumor seeding, and the require-  ment for multiple repeated procedures.   Midureteral or distal tumors can be accessed  with a semirigid ureteral resectoscope, which offers  excellent visualization and the ability to get deep  resections, fulgurations, and negative margins.  Tumor ablation is now an acceptable substitute  for resection. Energy sources, such as the holmiu-  m:yttrium-aluminum-garnet (YAG) laser and  neodymium:YAG laser delivered through small  fibers (approximately 270 u), can be used to ablate  or coagulate tumors. Operative technique has been  previously described by several researchers [64,65].  Although the initial experience with endourologic  management of upper tract TCC made almost  exclusive use of electrocautery and fulguration,  more recent reports have emphasized the potential  utility of lasers in this setting [66]. If an urothelial  lesion is identified ureteroscopically, biopsy is  usually the first management step. For papillary  exophytic lesions, a small nitinol basket, a 2.4-  French flat wire basket, or 3-French flexible cup  biopsy forceps may be used to avulse a section of  a tumor [64]. Other reported devices include the  Segura helical, Bagley round-wire, Nitinol baskets,  wire prong grasper, or 3-French Piranha biopsy  forceps. More recently, the Bigopsy device has  been introduced and may afford the surgeon the  ability to obtain more robust endoscopic biopsies.  After biopsy, the remaining tumor is ablated with  laser or fulgurated with a 2-French electrode. In  a comparative study evaluating local recurrences  between tumors ablated with electrocautery and  tumors treated with laser ablation, Krambeck    and colleagues [67] noted a recurrence rate of 38  (62.3%) in patients treated with cautery ablation  compared with 14 (58.3%) in patients treated  with laser ablation.   No standardized surveillance protocol for  upper urinary tract TCC after endoscopic man-  agement has been established. In the authors’  experience, however, surveillance includes urinary  cytology and an endoscopic inspection of the  bladder and upper urinary tract with urinary  cytology on a 3- to 4-month schedule for the first  2 years. The upper urinary tract evaluation can be  performed on an outpatient basis under sedation  or regional or general anesthesia.   Ureteroscopic surveillance has been performed  by urologists experienced with ureteroscopic tech-  nique in the office setting under topical lidocaine-  based anesthetic in select patients with dilated  systems [65]. More recently, Reisiger and col-  leagues [66] have reported on their long-term  experience with the use of office-based uretero-  scopy for upper tract TCC surveillance. In this  series, these investigators performed ureteral un-  roofing after management of upper tract TCC  that later facilitated the office surveillance. The  most important aspect of office-based uretero-  scopy is immediate termination of the procedure  and rescheduling of the procedure in the operating  room if any technical challenges are encountered.  After the procedure, a quinolone antibiotic is  given for 1 day. Patients can be followed up  with a standard surveillance protocol, paralleling  cystoscopic evaluation for bladder TCC (usually  every 3 to 4 months for 2 years, every 6 months  for 2 years, and annually thereafter), provided  that no recurrence has developed [66].   Ultimately, treatment options and follow-up  surveillance are based on tumor grade and stage.  Unfortunately, with the limitations of upper tract  ureteroscopic biopsy relating to depth of inva-  sion, tumor staging information is limited. There-  fore, clinical decision making is often determined  by tumor grade alone. Low-grade (I) TCC is  usually associated with a low stage, and superfi-  cial (Ta) TCC has a lower recurrence rate and  does not frequently progress to muscle invasive  or metastatic disease. As such, low-grade super-  ficial TCC typically has an excellent outcome  when treated endoscopically. Grade II TCC has  more variable behavior and has a higher ipsilat-  eral recurrence rate. Grade III tumors are often  invasive, with significant metastatic potential,  and have a poor prognosis regardless of the  surgical approach.    Percutaneous access allows larger tumors to be  resected throughout the collecting system [68,69].  The percutaneous approach is best indicated for  patients who have larger renal pelvic tumors, col-  lecting system tumors (greater than 1.5 cm), or  bulky proximal ureteral tumors. The percutane-  ous approach is advantageous because it permits  a better working environment. The larger endo-  scopes provide better optics and irrigant flow for  superior vision in addition to larger working  instruments that facilitate the treatment of larger  tumors. The percutaneous tract can be maintained  for a “second look," and it provides an opportu-  nity for the administration of adjuvant chemo-  therapy or immunotherapy through the matured  tract.   The most important criterion for using the  percutaneous approach is tumor grade. In a 13-  year retrospective study, grade was the most  important prognostic indicator in patients who  had renal TCC regardless of the surgical ap-  proach. Grade III tumors were more aggressive,  presenting in an advanced stage with invasion,  and recurrences were usually associated with  metastasis. Therefore, nephroureterectomy is  most often indicated in this setting. The percuta-  neous option is best for grade I or II disease and  may be extended beyond patients with solitary  kidneys or chronic renal failure [70]. Percutaneous  treatment can be offered to healthy individuals  with normal contralateral kidneys who are willing  to abide by a strict and lengthy follow-up [69].   The disadvantage to the percutaneous ap-  proach is the increased morbidity associated  with percutaneous renal surgery compared with  retrograde endoscopy. A second disadvantage is  the unproved yet significant concern of a tumor-  seeding tract through the access tract.   The percutaneous technique has been de-  scribed previously [70-72]. The resection begins  with obtaining proper access into the preferred  calyx. The most direct accessible posterior calix  should be punctured. Caliceal tumors are best  approached as distal in the calyx as possible. Tu-  mors in the pelvis are best approached through  a midpole or upper pole calix [73]. It is useful to  dilate up to a 30-French sheath to ensure minimal  intrapelvic pressure. Endoscopy involves a resecto-  scope or flexible ureterorenoscopy under fluoro-  scopic guidance. To remove the bulk of the    lesion, a cutting loop electrode using monopolar  energy or biopsy forceps is commonly used. The  neodymium:YAG and holmium:YAG lasers can  ablate or resect the lesion as well. Typically, a sec-  ond look procedure is performed within several  days of the initial procedure, and any remaining  tumor is treated. Intracavitary adjuvant therapy  (bacille Calmette-Guerin [BCG] or mitomycin)  can be administered 2 weeks after the resection,  assuming that the access tract has matured and  a nephrostogram is normal. Recently, the use of  bipolar energy has been described for the resec-  tion of large renal pelvic tumors [74]. The advan-  tage of bipolar energy is that normal saline can be  used, limiting the incidence of dilutional hypona-  tremia secondary to water reabsorption.   The ipsilateral recurrence rate after percutane-  ous resection is 33%. Initially, 67% of the re-  currences were grade 2 or 3 [71]. Only clinical  stage and grade were prognostic factors for recur-  rence and survival. When carefully selected, the  percutaneous approach can have comparably  low recurrence rates to more aggressive therapies.  Roupret and colleagues [75] performed a retro-  spective review of patients who underwent percu-  taneous surgery for upper tract TCC and reported  5-year disease-specific and tumor-free survival  rates of 79.5% and 68%, respectively, for low-  grade or superficial TCC localized in the kidney.  Jabbour and colleagues [68] reported disease-free  rates comparable to those of nephroureterectomy  in patients who had grade II TCC treated percuta-  neously. After a mean follow-up of 51 months,  these investigators described an overall tumor-  specific survival rate of 84%; the rate was 100%  for grade 1, 94% for grade 2, and 62% for grade  3 disease. Goel and colleagues [76] treated 20 pa-  tients who had TCC with percutaneous resection,  with a mean of 64 months. All patients who had  high-grade disease were treated with early neph-  roureterectomy. Six of the 15 patients who had  low-grade noninvasive TCC went on to nephrour-  eterectomy follow-up because of progression of  disease, concomitant tumor, or as a result of com-  plications. Sixty percent of the renal units with  low-grade disease were preserved at a mean fol-  low-up of 64 months. There was no evidence of  any tumor seeding after a mean follow-up of  48 months. All excised tracks from patients under-  going nephroureterectomy were free of tumor.  Tumor dissemination may be directly related to  manipulation. As such, a single-stage percutane-  ous nephrostomy access tract dilation and  maintaining a low renal pelvic pressure with    a 30-French working sheath are advised. Still,  there has been only one reported case of nephros-  tomy track seeding in the literature, which was of  a high-grade lesion [77].    Since Clayman and colleagues [78] performed  the first laparoscopic nephroureterectomy (LNU)  in 1991, LNU with an excision of a bladder cuff  has been rapidly replacing open nephroureterec-  tomy (ONU) as the standard-of-care treatment  of high-grade multifocal disease of the upper  urinary tract for the extirpative management of  upper tract TCC. When compared with its open  counterpart, LNU offers patients the advantages  of a laparoscopic access approach, minimizing  the perioperative morbidity, decreasing the post-  operative pain, and expediting convalescence, all  while duplicating the oncologic outcome of open  surgery. Table 4 compares the surgical outcomes  for ONU and LNU. Shalhav and colleagues [79]  reported that when compared with open surgery,  patients who underwent LNU manifested half  the estimated blood loss, required fourfold less  morphine sulfate equivalents, resumed oral intake  six times faster, were discharged three times ear-  lier, and returned to normal activity two times  more quickly. Despite these advantages, there  are two limitations associated with LNU: longer  operative time and the need for significant laparo-  scopic surgical experience. These disadvantages  may be lessened by the use of the hand-assisted  technique for nephroureterectomy. Indeed, hand-  assisted nephroureterectomy (HALNU) is the  most commonly reported technique for perform-  ing minimally invasive nephroureterectomy.   A series by Muntener and colleagues [85] re-  ported that after LNU, tumor stage was the  only factor significantly associated with death  from the disease and that tumor location (ureter)  was the only factor significantly associated with  disease recurrence. Wolf and colleagues [86] pub-  lished intermediate outcomes for HALNU. They  demonstrated CSS rates of 94%, 86%, and 80%  at 1, 2, and 3 years, respectively. When they strat-  ified patients, patients who had stage 0 to I tumors  had a 100% CSS at 26.5 months, whereas those  who had stage II to IV tumors had rates of 53%  and 36% at 2 and 3 years, respectively. Similarly,  CSS in patients who had grade 1 to 2 tumors was  100% at 27 months of follow-up, whereas patients  who had grade 3 tumors had CSS rates of 71%  and 57% at 2 and 3 years, respectively.    Table 5 lists the most recent oncologic  comparisons between ONU and LNU. Bariol  and colleagues [87] found the 1- and 7-year metas-  tasis-free survival rates were 80% and 72% for  LNU compared with 87.2% and 82.1% for  ONU (P = .33 and P = .26, respectively). Tumor  grade and stage influenced the incidence of meta-  static and contralateral disease but not the inci-  dence of local or bladder recurrence.   Since the initial reports of LNU, there are  several techniques that have been described for  performance of the procedure. Regarding the  nephrectomy component of the procedure, reports  have described the application of a standard  transperitoneal approach, a retroperitoneal ap-  proach, and a hand-assisted technique. All three  are known to be safe and effective. Most of the  controversy regarding LNU has been the optimal  technique for management of the distal ureter and  bladder cuff. Techniques for distal ureteral and  bladder cuff management have included stapling  and unroofing [89], a transvesical dissection [90],  a pluck technique [91], and open distal ureteral  management. Detailing the differences among  these techniques is beyond the scope of this arti-  cle. A complete extraction of the entire ureter  with a bladder cuff is mandatory, however.   A second option, and the one that is most  commonly used, is HALNU. The application of  the hand-assisted device offers the urologic sur-  geon several advantages. First, by allowing one  hand to remain in the realm of open surgery while  the other hand and the surgeon’s field of view are  in a laparoscopic setting, the technique provides  the newer laparoscopist a logical segue into  minimally invasive surgery. The hand provides  the surgeon with security, knowing that he or she  can get out of trouble with his or her hand in the  operative field. Thus, the hand-assisted technique  decreases operative time and may allow less  experienced laparoscopic surgeons to expand the  scope of cases performed laparoscopically (ie,  larger and more extensive tumors). Furthermore,  removal of the kidney, ureter, and bladder cuff  can easily be accomplished intact through a stra-  tegically placed hand-assisted device incision.   A disadvantage of LNU compared with ONU is  exemplified by the two case reports on trocar site  metastasis after LNU [92]. In a study of 97 patients,  54 had ONU, 27 had ureteroscopy, and 16 under-  went percutaneous resection. The 5-year disease-  specific survival rates after nephroureterectomy,    Table 4  Comparative nephroureterectomy trials (laparoscopic and hand-assisted laparoscopic versus open trials)  Complete  Operative OR time Analgesic Hospital convalescence Follow-up Major  Series approach N (hours) EBL (mL) (mg MSO4) stay (days) (weeks) (years) complications   Shalhav et al [79] LPN 25 7.7 199 37 3.6 2.8 2.0 8  Open 17 3.9 441 144 9.6 10 3.6 29  Seifman et al [80] HALN 16 5:3 557 48 3.9 2:5 1.5 19  Open 11 33 345 81 212 7.5 1.2 2]  Keeley and Tolley [81] LNU 22 2.4 NA NA 5.5 NA NA NA  Open 26 2.3 NA NA 10.8 NA NA NA  Hattori et al [82] HALN 36 5.1 580 NA NA 5 5 2  LNU 53 4.3 354 NA NA 4 5 1  Open 60 5.4 665 NA NA 8 5 3  Rassweiller et al [83] LNU 23 3.3 450 18 10 NA 5 9  Open 21 3.1 600 33 13 NA 5 10  Roupert et al [84] LNU 20 27 274 NA 377 NA 5.75 15  Open 26 2.6 338 NA 9.2 NA 6.5 15  Total LNU 195 4.5 389 29.3 5.5 3.9 4.4 6.6  Total Open 161 3.8 538 82 10.1 8.4 4.8 10.4    Table 5  Comparative of oncologic outcomes (laparoscopic and hand-assisted laparoscopic versus open trials)  Short term Intermediate  Port site disease-free disease-free  Authors Access N Tumor free metastasis survival survival  Bariol et al [87] LNU 25 1 (4%) 0 80% at | year 72% at 7 years  Open 40 6 (15%) 0 87.2% at 1 year 82% at 7 years  Hsueh et al [88] HALN 66 23% at 2 years NA 93.6% at 1 year 85% at 5 years  Open T] 27% at 2 years NA 82.9% at 1 year 77% at 5 years  Roupert et al [84] LNU 20 71% 0 NA 90% at 5 years  Open 26 51% 0 NA 61.5% at 5 years  Rassweiller et al [83] LNU 23 65% 0 89% at 2 years 81% at 5 years  Open 21 81% 0 83% at 2 years 63% at 5 years    ureteroscopy, and percutaneous resection were  84%, 80.7%, and 80%, respectively (P = .89);  the corresponding 5-year tumor-free survival rates  were 75.3%, 71.5%, and 72% (P = .78) [93].    Based on the well-characterized success of  intravesical therapy in the treatment of bladder  TCC and because of upper tract TCCs’ similarly  high rate of recurrence and progression, topical  agents, such as thiotepa, mitomycin C, and BCG,  have been used for the upper tract as well. First  described by Herr [94] and Studer and colleagues  [95] using BCG, topical therapy for upper tract  TCC as an adjunct to ureteroscopic ablation has  been used. Delivery of topical therapy accurately,  reliably, and under low pressure to the upper  tracts is much more complex than for bladder can-  cer, however. There are several techniques for  instillation, which are briefly mentioned; however,  no technique has emerged as a current standard.  Agents can be instilled under gravity drainage  by means of a preexisting or newly placed neph-  rostomy tube. A manometer is used to ensure  that intrapelvic pressure remains less than 25 cm  H5O. In patients with double-J stents, which facil-  itate reflux, agents can be placed intravesically  into the upper tract [96]. Finally, agents can be  instilled in a retrograde fashion by means of an  open-ended ureteral catheter.   Indications for the use of intracavitary chemo-  therapy or immunotherapy include bilateral dis-  ease, the presence of a solitary kidney (or solitary  functional kidney), or significant renal insufficiency  in which more aggressive surgical treatment risks  placing the patient on permanent dialysis. A final  indication is in patients at high operative risk, and  alternative treatment forms are therefore necessary.    As in the bladder, the two most used agents are  BCG and mitomycin. BCG is most commonly  used for CIS, especially for higher risk patients  who need close surveillance. Patel and Fuch [96]  reported on 17 patients with a mean follow-up  of 14.6 months. In 2 of 17 patients, multifocal  tumors recurred within 12 months, which were  ultimately treated with nephroureterectomy. The  remaining 15 renal units have been preserved  and remained tumor-free. In another series of 37  patients, the short-term efficacy of BCG perfusion  therapy was reported to be 62.5% to 100%. Four-  teen (38%) patients died of urothelial cancer,  11 died of other causes (29%), and 12 (33%)  were still alive [97]. Katz and colleagues [98] stud-  ied 10 patients using a 6-week induction of BCG  and interferon. With a median follow-up of  24 months, 8 patients (80%) demonstrated a com-  plete response (CR) to therapy and 2 had a partial  response (decrease in tumor size, number, or  both). Six patients with a CR have continued on  maintenance therapy. There were no side effects  or complications with the instillation therapy.  Among the disadvantages of BCG therapy is the  fact that it is similar to the side affects of bladder  instillation therapy. An additional disadvantage is  the short dwell time, which is a result of our  inability to keep it in sufficient contact with the  urothelium to maximize its effect.   Mitomycin C has the same indications as BCG.  These include multifocal disease, higher grade  tumor, or rapid recurrence after previous treat-  ment. Keeley and Bagley [99,100] reported their ex-  perience with mitomycin C in 19 patients during  a 5-year period. They showed a 35% CR rate,  a 27% partial response rate, and no response in  38%. With 30 months of follow-up, there was no  progression, no dialysis, no systemic toxicity, and  no deaths (Table 6). Despite the encouraging   Follow-up  Authors No.patients Agent Access Stage/grade Recurrence  (months)  Sharpe et al 17 BCG Retrograde Ta,T1/CIS/G2-G4 28.5 11-64  Bellman 14 BCG Percutaneous n/a 12.5 n/a  Patel 13 BCG Percutaneous Ta low grade 13 6-36  Vasavada 8 BCG Percutaneous n/a 12.5 9—59  Nonomura 9 BCG Retrograde 22 22 4-41  Eastham 7 Mitomycin C Percutaneous n/a 28.5 1-12  Keeley 20 Mitomycin C Retrograde G1-G3 54 30    Data from O'Donoghue JP, Crew, JP. Adjuvant topical treatment of upper urinary tract urothelial tumors, BJU Int    data, large prospective multicenter trials are needed  to elucidate the role of intravesical therapy.    The number of available patients who meet the  criteria for endoscopic treatment of upper tract  TCC is small, and treatment algorithms are based  more on experience than on large retrospective  studies. Until such studies are available, experi-  ence reveals that minimally invasive options may  be best suited for patients who have unifocal low-  grade disease or for those patients who have  bilateral disease, a solitary kidney, or comorbid-  ities that contraindicate extirpative therapy.  Upper tract TCC recurrences are to be expected  after endoscopic resection, especially with high-  grade and high-stage disease. Therefore, close  endoscopic follow-up needs to part of the decision  tree. Similar to TCC of the bladder, surveillance  must be performed at regular intervals. The choice  of endoscopic management must be offered on  a case-by-case basis with the understanding that  close surveillance is a requirement, and a key  aspect of surveillance is the need for multiple and  frequent procedures.    [1] Hollingsworth JM, Miller DC, Daignault S, et al.  Rising incidence of small renal masses: a need to  reassess treatment effect. J Natl Cancer Inst 2006;  98:1331-4.   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BJU Int 2004;94(4):483-5.    “Smith Institute for Urology, North Shore-Long Island Jewish Health System, 450 Lakeville Road, Suite M-41,  New Hyde Park, New York, NY 11040, USA  > Department of Urology, Elisabethinen Hospital, Fadingerstrasse 1, 4010 Linz, Austria    Renal cell carcinoma (RCC) is the most  common malignancy of the kidney and accounts  for approximately 3% of adult cancers [1]. It com-  prises 85% of newly diagnosed malignancies of  the kidney, with an age-adjusted incidence of  12.8 cases per 100,000 population and age-  adjusted mortality rate of 4.2 deaths per 100,000  population [2]. Incidence rates have been increas-  ing over the last 30 years in the United States, par-  ticularly among African Americans [3]. During  2007, it was estimated that approximately 51,190  new cases of kidney cancer would be diagnosed,  and 12,890 people would die of the disease in  the United States [4]. Factors such as increased  resolution and application of imaging modalities  have led to an increase in the incidental detection  of renal masses. Classically, radical nephrectomy  has been described as the standard surgical ther-  apy for renal masses. Several studies, however,  have indicated that partial nephrectomy provides  cancer control similar to radical nephrectomy  [5]. Furthermore, partial nephrectomy has been  shown to decrease risk of end-stage renal failure  requiring renal replacement therapy when com-  pared with radical nephrectomy [6-8]. Laparo-  scopic partial nephrectomy (LPN), introduced in  1993, has become an acceptable alternative to  open partial nephrectomy for expert laparoscopic    This work was supported in part by grants from  the Quebec Urological Association Foundation and  Frank McGill Travel Fellowship to Sero Andonian.    urologists [9-11]. Initially, LPN was used for  benign disease such as lower-pole calyceal  diverticulum containing a calculus, or atrophic  hydronephrotic moiety [9,10]. Laparoscopic  hemi-nephrectomy also has been successful for  nonfunctioning renal moieties in the pediatric  population [12,13]. This article presents some of  the earliest series and the latest largest series  (Table 1).    Initially, absolute indications for partial  nephrectomy included localized enhancing renal  masses in solitary kidneys, bilateral synchronous  renal masses, or chronic renal insufficiency  [5,21—23]. Relative indications for partial nephrec-  tomy are hereditary forms of renal cell carcinoma  such as von Hippel-Lindau disease (VHL), hered-  itary papillary renal cell carcinoma, Birt-Hogg-  Dubé syndrome, or tuberous sclerosis, where  there is increased risk of metachronous renal ma-  lignancies. These tumors often present at a youn-  ger age and are more likely to be multifocal and  bilateral [21]. Relative indications for partial ne-  phrectomy also exist when the contralateral kid-  ney is at increased risk of failure because of  hypertension, diabetes mellitus, nephrolithiasis,  or chronic pyelonephritis [24]. Finally, elective  indications include localized incidental renal-  enhancing masses with a normal contralateral kid-  ney. These indications originally were described  for open partial nephrectomy, but they are also  applicable to LPN. Contraindications to partial  nephrectomy include renal vein or inferior vena    0094-0143/08/$ - see front matter © 2008 Elsevier Inc. All rights reserved.    Table 1  Comparison of operating room time, ischemia time, pathology, and follow-up data  Operating  Senior Size Trans/ room Ischemia EBL LOS Follow-up Local  author Years # Age (cm) retro (minutes) (minutes) (mL) Histology Stage (days) (months) Rec Mets  Clayman [9]? 93-98 3 68 1.2 (1-1.5) 1 Trans; 210 (120-324) 0 92 (75-100) 2 (66%) Benign; N/A 2.7 46 0 0  2 retro 1 (33%) RCC  Abbou [14] 95-98 13 42.9 3.2 (2-6) Retro 113 (60-200) 7.4(2-10) 72 (0-400) 8 (61%) Benign; 3 pTla 6.1 22 0 0  5 (39%) RCC  Janetschek 94-99 25 62.9 1.9 (1-5) 15 Trans; 163.5 (90-300) N/A 287 (20-800) 6 (24%) Benign; — 18pTI N/A 22.2 (1-65) 0 0  [15] 10 retro 19 (76%)RCC 1pT3a  Janetschek 04-05 25 604 2.6 (1.1-3.9) Trans 211.7 28.9 (19-40) 1774 6 (24%) Benign; — 24pTla 8.3 (5-13) 6.2 (1-15) N/A N/A  [16] (40-74) (155-260) (50-1500) — 19 (76%) RCC; IpT1b  0% +M  Gill [11,17] 99-01 58 64 (30-85) 2.9 (1.3-7) Trans and 180 (45-348) 23 (9.8-40) 270.4 37 (66%) RCC 32pT1  22(1-9) 68.4 1/37 (2.7%) 0  retro (40-1500) 2pT2 (60-82.8)  Gill [18] 01—04 100 64 32 4L5 Trans 208452 31.1 + 9.2 221 + 226 75994 RCC; N/A 2941.7 N/A N/A N/A  2% +M  Gill [18] 01-04 63 60 25°09 Retro 73354 28.0+9.0 217 £285 67% RCC N/A 2.2+1.6 N/A N/A N/A  Kavoussi 99-04 217 56.6 2.6 (1-10) 199 Trans; 186 (75-400) 27.6 (5-60) | 385 +377 66% RCC; N/A 3.141.6 24412 2 (1.4%) 0  [19] 18 retro 3.5% +M  Ramon [20] 02-06 110 62 3.9 (1.4-6.2) Trans 00 (75-140) 30 (18-49) 510 15 (14%) N/A N/A 16 (4-42) 0 0  (2nd (20-1200) Benign;  group) 95 (86%)  RCC; 3.6% +M  Average 93-06 614 60 (30-85) 3.1 (1-10) 449 Trans; 171 (45-400) 27.8 (2-60) 332 178 (2994) TIpTI 3.2(1-13) 26.8(1-83) 1.796 0  (range) 91 retro (0—1500) Benign; 2pT2 (1.4-2.7)  436 (71%) IpT3a  RCC; 3.2% +M    Abbreviations: EBL, estimated blood loss; LOS, length of stay; Mets, metastasis; +M, positive surgical margin rate; RCC, renal cell carcinoma; Rec, recurrence; Retro, retroperitoneal; Trans,  transperitoneal.  è Patients with exophytic renal masses who underwent wedge resection were included in the table.    cava tumor thrombus, massive tumor size, and lo-  cal invasion. Relative contraindications include  lymphadenopathy and bleeding diathesis [21]. Al-  though initially partial nephrectomy was limited  to 4 cm masses because of lower risk of local re-  currence and multifocality, recently size criterion  has been abolished as long as the tumor can be re-  sected effectively with a negative margin [25,26].  This has been shown for open partial nephrec-  tomy (OPN) versus radical nephrectomy, and it  also may be applicable for LPN versus laparo-  scopic radical nephrectomy. This remains a con-  troversial issue.   When there is a normal contralateral kidney,  increased risks of peri-operative complications of  partial nephrectomy, local recurrence, and tumor  multifocality have to be balanced with decreased  risk of developing chronic renal insufficiency  [6-8,27]. In a review of 878 patients who had  OPN, the rate of operative mortality was 1%,  urine leak 7%, abscess 1%, bleeding 2%, and  reoperation 2% [24]. In addition, the overall risk  of local recurrence in partial nephrectomy series  has been found to be 0% to 10% depending on  tumor size, histology, and stage. For tumors  4 cm or less, the local recurrence risk is even  lower, at 0% to 3% [5]. Furthermore, histologic  pattern, such as papillary, rather than tumor  size, has proven to be the most reliable predictor  of multicentricity [28,29].   As with any new laparoscopic procedure,  patient selection is crucial for success. Initially,  LPN focused on those patients who had unifocal,  small, polar, exophytic lesions, with a limited  depth of penetration of less than 1 cm through  the renal cortex. With evolution of the technique  and improved methods of hemostasis, hilar and  endophytic lesions, and masses abutting the  collecting system can be resected [30].    There are several retrospective series demon-  strating advantages of LPN over the traditional  OPN. These include lower narcotic requirements,  improved cosmesis, earlier resumption of diet,  shorter hospitalization, and lower expense  [31,32]. Furthermore, in a larger series from the  Cleveland Clinic, LPN, as compared with OPN,  was associated with a shorter surgical time, lower  blood loss, longer warm ischemia (27.8 minutes  versus 17.5 minutes), and higher rate of intra-  operative complications (5% versus 0%) [33].    In a multicenter comparison of 771 LPNs versus  1028 OPNs, LPN was associated with longer  ischemia time and more postoperative complica-  tions (especially urological), in addition to its ben-  efits of shorter operative time, decreased blood  loss, and shorter hospital stay [34]. Selection bias  of more complicated patients for OPN is evident  from these retrospective studies. The advantages  of lower blood loss, shorter hospitalization, and  convalescence, however, are evident. To provide  level 1 evidence, randomized trials comparing  the two procedures are needed.    The technique of LPN, both transperitoneal  and retroperitoneal, has been detailed in schematic  form in a recently published atlas [21,22]. The au-  thors would like to emphasize certain points.  Knowledge of the tumor in relationship to the col-  lecting system, renal hilum, as well as proximity to  the vascular structures, will help guide dissection,  isolation, and resection of the mass. Three-dimen-  sional reconstruction following helical CT scan or  magnetic resonance angiography allow high-qual-  ity images of the renal artery and vein and provide  multiple views of the intrarenal anatomy [35]. Pre-  operative knowledge of the number and location  of renal arteries and veins improves intraoperative  planning and surgical dissection.    The earliest LPN series was performed on  small (less than 2 cm) exophytic lesions without  hilar dissection or clamping. Janetschek and  colleagues [15] reported on 25 patients who under-  went wedge resection of small (less than 2 cm)  exophytic lesions with an average blood loss of  287 mL (range of 20 to 800 mL). In this technique,  bipolar coagulation forceps were used for simulta-  neous dissection and hemostasis. In this series,  there was 8% rate of urinary fistula postopera-  tively. This technique of resection without hilar  clamping may be applicable for small exophytic  lesions with depth of invasion less than 1 cm  from the surface [36]. For larger and central  lesions, however, hilar control is essential. A novel  technique of clamping the renal parenchyma with  a Satinsky clamp (Aesculap Inc., Center Valley,  Pennsylvania) inserted through a separate 1 cm  stab incision has been described [37]. Preliminary  results in five patients with polar lesions averaging  3 cm showed the mean blood loss was 250 mL,    and none required transfusions. This technique,  however, is not applicable to renal masses involv-  ing the hilum or deeper invasion into the collect-  ing system.    Another way of minimizing warm ischemia  time without clamping the renal hilum is the use  of a laparoscopic Habib probe (AngioDynamics,  Queensbury, New York). It is a four-pronged bi-  polar radiofrequency device that ablates tissue be-  tween the probes in a bipolar fashion. Using the  Habib probe, an avascular plane is created 10  mm away from the renal lesion. Its use has been  shown to reduce transfusions in liver resections  [38]. The Habib probe was evaluated in a pilot  study of three patients undergoing LPN without  hilar clamping. The mean estimated blood loss  was 100 mL, and none of the patients required  transfusions [39]. Cautery artifact, however, can  cause difficulty in interpreting the frozen section  margin. Randomized studies are needed to further  evaluate its impact on blood loss, frozen section  analysis, and long-term renal function.    To replicate OPN and perform LPN on larger  (greater than 2 cm), endophytic, central, or hilar  lesions, it is essential to control the renal hilum  (either the renal artery alone or together with the  renal vein). The advantage of hilar control is the  ability to tackle lesions that once were thought to    be only amenable to OPN. This has two primary  functions: decreasing intraoperative hemorrhage  and improving access to the renal collecting  system for repair [40]. There are three techniques  of hilar control.   Gill was the first to demonstrate that LPN can  duplicate open surgical principles [11]. Laparo-  scopic bulldog clamps are the most widely used  instruments to clamp the renal artery alone, or  together with the renal vein (Aesculap Incorpo-  rated, Center Valley, Pennsylvania) (Fig. 1 A, B).  The advantages include ability to individually  clamp the artery, and the ease of applying and re-  moving. It also frees up a port for the most crucial  part of the surgery: reconstruction of the nephrot-  omy defect. It is the personal preference of the au-  thors to use the same instrument to place and  remove the bulldog clamp. Disadvantages include  difficulty in removing the clamp if not aligned  well with the applicator.   Another option of clamping the renal vessels  laparoscopically is the use of laparoscopic Satin-  sky clamps, which allow en bloc clamping of the  entire renal hilum (Fig. 2). The advantage is that  the renal artery and vein can be taken en bloc  and do not have to be dissected individually.  The disadvantage is that an additional port must  be employed to place the instrument. In addition,  the assistant must take care not to exert excessive  traction or pressure on the clamp inadvertently to  avoid stretch or intimal injury to the vessel.   Finally, a Rumel tourniquet can be used to  efficiently achieve vessel control and occlusion.    Fig. 1. A: A schematic diagram of laparoscopic bulldog clamps on the right renal artery and vein. The right kidney has  an exophytic mass. B: A photograph of laparoscopic straight and curved bulldog clamps and the applicator.    Fig. 2. A schematic diagram of the Satinsky technique  of hilar clamping on the right kidney with an exophytic  mass.    The renal vein and artery are secured en bloc by  an umbilical tape (Bard PTFE, Braided tape,  4 mm x 61 cm) (Bard Inc., Murray Hill, New  Jersey), inserted through a 10 mm trocar. The  tape is left in place until the end of the procedure  and can achieve rapid reocclusion of the vessels if  needed. To free the trocar from the umbilical tape,  the trocar is removed and repositioned with the  tape on the outside of the trocar. The Rumel tour-  niquet consists of a 5 cm piece of silicone drainage  tube (10F) and a 20 cm vascular loop folded over  once to form a U loop (Fig. 3).   Besides being able to perform LPN on more  complex renal lesions, the advantages of hilar  control also include lower rates of urinary fistula  (1.4% to 4%) (Table 2). The most significant dis-  advantage of hilar control, however, is ischemia.  Prolonged periods of ischemia result in acute  tubular necrosis and renal failure. Intravenous  mannitol 12.5 g is often administered before  clamping. This has several protective mechanisms,  such as: free radical scavenger, decreased intra-  cellular edema, decreased intrarenal vascular  resistance, increased blood flow and glomerular  filtration rate of superficial nephrons, and osmotic  diuresis [43,44]. Furthermore, furosemide is ad-  ministered to promote diuresis after unclamping  of the renal vessels.    Fig. 3. A schematic diagram of the Rumel technique of  hilar clamping on the right kidney with an exophytic  mass.    One way of decreasing ischemic injury is early  unclamping after a running suture on the tumor  bed [45]. The vascularized renal parenchyma then  is closed over a surgical bolster. With this tech-  nique, the warm ischemia time was reduced from  27.2 minutes to 13.7 minutes, without increasing  intraoperative bleeding or postoperative compli-  cations. The decreased ischemia time also may be  attributed to increased expertise, as the early un-  clamping group was performed later on. Another  method of reducing ischemia time is on-demand  clamping of the hilum [46]. In this technique, the  hilum is dissected early but clamped only in the  case of excessive bleeding. Out of 39 patients, 31 re-  quired on-demand clamping, with a mean ischemia  time of 9 minutes. There was a high rate of blood  transfusions (8 of 39 patients, or 21%), however,  and two patients required open conversion because  of excessive bleeding.   Animal studies have shown that clamping of  the renal artery alone during open surgery better  protects the kidney from warm ischemia com-  pared with renal artery and vein clamping. This  benefit, however, was not observed in laparo-  scopic surgery [47]. The authors speculated that  this could be because of partial occlusion of the    renal vein secondary to pneumoperitoneum, thus  negating any benefit of clamping only the renal  artery. In a similar study in a porcine model,  warm ischemia of up to 90 minutes resulted in  an initial renal dysfunction. However, this was  not statistically different by 2 weeks postopera-  tively [48]. Therefore, at least in the porcine  model, clamping of the renal artery alone or  artery and vein together has similar effects in lap-  aroscopic approach. Similarly, warm ischemia of  up to 90 minutes is tolerated well.   Thirty minutes of warm ischemia arbitrarily  have been designed as the safe warm ischemia time  in LPN. Even though there is no absolute cut-offfor  warm ischemia time, the longer it is, the worse the  renal dysfunction. This cut offhas been examined in  terms of long-term renal injury. For example,  Bhayani and colleagues [49] compared patients  who had no hilar clamping versus two groups of pa-  tients who had hilar clamping of less than and more  than 30 minutes. The median creatinine did not  change significantly postoperatively, and none of  the 118 patients required dialysis. Porpiglia and col-  leagues [50] confirmed these results. The glomerular  filtration rate (GFR) was not significantly different  3 months after LPN with warm ischemia of more  than 30 minutes in 18 patients. On renal scintigra-  phy, however, the contribution of the affected kid-  ney decreased from 48% to 36% on postoperative  day 5, then increased to 40% at 3 months and  43% at | year postoperatively. Therefore, in these  limited retrospective studies, despite decreasing  contribution of the affected renal moiety, the over-  all GFR was maintained, and no patients required  dialysis in the presence of a normal contralateral  kidney. Furthermore, patients who have renal dys-  function (creatinine greater than 2 mg/dL), hyper-  tension, or diabetes mellitus do not tolerate warm  ischemia well and may be more susceptible to ische-  mic injury when this exceeds 30 minutes. The au-  thors agree with Bhayani and colleagues [49], in  that efforts to minimize warm ischemia are impor-  tant but should not jeopardize cancer control,  hemostasis, or collecting system closure. In partic-  ular, when more complex renal lesions are tackled  and the surgeon feels that the ischemia time to  resect and reconstruct the kidney would be longer  than 30 minutes, then the following techniques of  cold ischemia should be contemplated.    151 (19%)  Abbreviations: ARF, acute renal failure; Retro, retroperitoneal; Trans, transperitoneal.    There have been three methods of inducing  cold ischemia in an effort to minimize the    ischemic injury to the kidney. Gill and col-  leagues [51] described the ice slush technique  that replicates OPN. A laparoscopic Endocatch  II (US Surgical, Norwalk, Connecticut) was  placed through a 12 mm port site around the  mobilized kidney. A Satinsky clamp was used  to en bloc clamp the renal artery and vein. After  placement of 600 mL of ice slush around the  kidney, LPN was performed in 12 patients,  with an average ischemia time of 43.5 minutes  (range 25 to 55 minutes) Renal parenchymal  temperature was kept between 5°C to 19°C.  Postoperative renal scans confirmed functional  renal moieties. There were two intra-operative  complications, however, partial bag slippage in  one and Satinsky clamp malfunction in another  patient [51].   A second technique of cold ischemia during  LPN uses a 7F ureteral catheter and cold (4°C)  saline irrigation [52]. This technique also identified  the open collecting system secondary to saline  outflow. Although the postoperative creatinine  was higher in the group with cold ischemia  as compared with no ischemia (1.45 mg/dL ver-  sus 1.26 mg/dL), this was not statistically  significant.   Janetschek and colleagues [53] described  another technique of cold ischemia using an  angiocatheter inserted through a percutaneous  femoral puncture and advanced under fluoro-  scopic guidance to the renal artery. Two hundred  milliliters of 20% mannitol are administered  15 minutes before the renal artery occlusion. The  renal artery is occluded using the Rumel tourni-  quet technique. At this point, 1 L of Ringer's  lactate with 100 mL of 20% mannitol at a temper-  ature of 4°C is infused at a rate of 50 mL/min.  Parenchymal temperature is monitored and kept  at 25°C. This technique has been used in 28 pa-  tients with mean ischemia time of 40.8 minutes  (25 to 101). Parenchymal transit time on Techne-  tium-99m mercaptoacetyltriglycine (MAG-3) re-  nal scan has been shown to be a good indicator  of ischemic damage to the kidney [54]. MAG-3  clearance decreased on the operated side, but the  peak concentration times were not different pre-  and postoperatively, indicating no postoperative  dysfunction of the remnant moiety [55]. In a retro-  spective comparison of 12 patients who had warm  ischemia with 14 patients who had cold ischemia,  there was one loss of function in the group with  cold ischemia. Therefore, LPN even with short  periods of cold ischemia can lead to loss of function  in that moiety [54].    In a large comparative study, the renal func-  tional outcomes at 3 months postoperatively were  similar in LPN and OPN, with 97.9% and 99.6%  of renal units retaining function [34]. In another  study, despite a lower mean calculated postopera-  tive split, MAG-3 clearance on the operated side  (74.0 mL/min versus 110.7 mL/min), there was  no difference in the mean postoperative concentra-  tion time between the two sides, indicating absence  of renal dysfunction on the operated side [56,57].    There are three ways of achieving hemostasis  of the nephrotomy defect. The first is by using the  bipolar coagulation forceps [15]. Its advantages  include simultaneous dissection and hemostasis.  The second is the argon beam coagulator. In addi-  tion to the cost and nonavailability in some  centers, one disadvantage is the sudden rise of  peritoneal pressure, which can lead to pneumo-  thorax. Therefore, it is important to vent the  trocar while activating the argon beam, and to  closely monitor the intra-abdominal pressure  [15]. It is also important to note that it can only  handle superficial (interlobular) vessels and is  unlikely to handle interlobar or segmental  branches very effectively.   Hemostatic agents such as fibrin gel (Tisseel)  (Baxter, Deerfield, Illinois), gelatin matrix throm-  bin (FloSeal) (Baxter, Deerfield, Illinois), bovine  serum albumin (BioGlue) (CryoLife Inc., Kenne-  saw, Georgia), cyanoacrylate glue (Glubran)  (GEM, Viareggio, Italy), and oxidized regenerated  cellulose (Surgicel) (Ethicon Inc., Somerville, New  Jersey) have all been used to cover the nephrotomy  defect and to reconstruct the kidney after resection.  Their use varies by surgeon preference. One study  comparing Fibrin glue with sutured bolster repair  of the collecting system found that there was 41%  postoperative hemorrhage or urinary leakage after  Fibrin glue, compared with 11% when sutured  bolsters were used [36]. A retrospective survey of 18  centers with 1347 cases of LPN found that 16 cen-  ters used haemostatic agents in addition to per-  forming concomitant suturing of the nephrotomy  bed. The overall postoperative hemorrhage requir-  ing transfusion was 2.7%, and the rate of urinary  leakage was 1.9% [58].    Table 1 lists the percentage of benign and  malignant tumors in the earliest and the most recent    largest series. In the early series, most (61% to 66%)  lesions resected were benign [9,14]. In more recent  series, most (66% to 86%) lesions resected have  proven to be malignant, reflecting the etiology of  renal masses determined from open partial and  radical nephrectomy series [17,20].   The positive margin rate in the final pathology  has ranged from 2% to 3.6% (see Table 1).  During OPN, when a positive margin is found  on frozen sectioning, a deeper resection margin  is obtained before reconstructing the nephrotomy  and unclamping the vessels. In LPN, however, by  the time the results of a frozen section are  obtained, the nephrotomy defect already is closed,  and the hilum is unclamped to minimize warm  ischemia. Taking down the nephrotomy repair is  difficult and may warrant conversion to open sur-  gery to safely complete the partial nephrectomy to  negative margins. The classical teaching after  a positive margin with a partial nephrectomy is  to consider proceeding with completion radical  nephrectomy as a measure of cancer control. In re-  trospective multi-institutional survey of 17 centers  performing laparoscopic partial nephrectomy, the  rate of positive margins on frozen sections was  2.4%. Out of 21 cases that had positive margins,  14 underwent immediate radical nephrectomy  based on positive frozen sectioning, and the rest  were followed. Data regarding recurrence, how-  ever, were not obtained [59]. A positive margin  may not indicate residual disease. In a multicenter  study of 511 LPNs, there were nine patients  (1.8%) who had positive margins. Two underwent  completion radical nephrectomies revealing no re-  sidual tumor. One patient who had VHL died of  metastatic RCC 10 months postoperatively. The  rest of the six patients were disease-free at a me-  dian follow-up of 32 months [60]. The authors  recommend vigilant monitoring with CT every  6 to 12 months. Recently, data from OPN with  10-year follow-up has shown that positive surgical  margins were not associated with an increased  risk of local recurrence or metastatic disease  [61]. Therefore, patients should be given the op-  tion of completion radical nephrectomy versus  close monitoring until long-term rate of recur-  rence post LPN is determined.    Laparoscopic port site metastasis is defined as  early recurrent malignant lesions developing  locally in the abdominal wall within the scar  tissue of one or more trocar sites, without    evidence of peritoneal carcinomatosis [62]. In a ret-  rospective review of over 1000 laparoscopic cases,  there were only two cases (0.18%) of port site  metastases [63]. There have been five reported  cases of port site metastasis after LRN [62].  Recently, the first case of port site metastasis after  a LPN was reported [64]. Several correctable fac-  tors have been identified from animal models. The  following precautions have resulted in decreased  recurrence from 63.8% to 13.8% [65]. These are:   Addition of heparin to irrigation solution or  alternatively irrigation of the surgical field  with sterile water to lyse floating tumor cells   Exsufflation of pneumoperitoneum through  the trocar valve rather than through the  skin incisions    The most important factors remain avoiding  direct contact of instruments and trocars with  tumor cells and removal of tumors within an  entrapment bag [15].    Cancer-specific survival rates in patients with-  out metastases were 91% at 5 years and 80% at 10  and 20 years. In an aggregate review of  1800 patients, after a mean follow-up of 2 to  6 years, the cancer-specific survival rate exceeded  90% [5]. Negative predictors of survival include:  high tumor grade, high tumor stage, bilateral dis-  ease, and tumors greater than 4 cm [66]. Location  of the tumor (central versus peripheral, endo-  phytic versus exophytic) is a significant technical  consideration for nephron-sparing surgery; it has  a less important biological role for determining  cancer-specific outcomes [67].   Multifocality risk increases with larger tumors  (greater than 4 cm) and stage pT3 disease. In  a review of 1800 cases, the incidence of multifocal  tumors with primary renal masses 4 cm or less was  found to be 4.9% [5]. Furthermore, the risk of  local recurrence was found to be 0% to 10%,    and lowest for patients who underwent nephron-  sparing surgery for lesions less than or equal to  4 cm [5].   In one retrospective series, the 3-year cancer-  specific survival for cTINOMO tumors was 99.3%  for LPN and 99.294 for OPN [34]. Another study  found the 3-year cancer- specific survival to be  100% and overall survival to be 96.2% [65].  Similarly, there was no difference in 5-year  cancer-specific survival (91.4% versus 97.4%)  and actuarial survival (93.8% versus 95.8%)  between LPN and OPN, respectively [68].    Table 2 lists the complications reported in  LPN series. In a review of 878 patients, the rate  of operative mortality was 1%, urine leak 7%  (1.4% to 17.4%), abscess 1%, bleeding 2%, and  reoperation 2% [24]. In LPN, the rate of urinary  leak varies from 0% to 15%. Urinary fistula usu-  ally is managed conservatively with insertion of  ureteral stent and Foley catheter. Alternatively,  percutaneous nephrostomy may be placed. The  diagnosis is made with biochemical evaluation of  the drainage fluid, which demonstrates elevated  creatinine (drainage fluid to serum ratio greater  than 2).   With OPN, the need for temporary or perma-  nent dialysis occurs in 4.9% of patients, post-  operative hemorrhage in 2.8% of cases, injury to  adjacent organs such as spleen in 0.6%, and the  overall reoperative rate after nephron-sparing  surgery is 1.9%. Bleeding after partial nephrec-  tomy may be acute or delayed and presents  typically with hypotension, distended abdomen,  and decreased hematocrit. In a retrospective series  examining predictors of hemorrhage following  LPN, Ost and colleagues [69] found that older  patients (age greater than 64 years) who have  renal insufficiency are at increased risk of transfu-  sion. Interestingly, increased tumor size, obesity,  hypertension, diabetes, and smoking do not  predispose patients who have LPN to increased  risk of bleeding. Furthermore, certain tumor char-  acteristics strongly correlate with risk of technical  complications in other series. For example, pa-  tients at highest risk include those who have func-  tionally solitary kidney, bilateral lesions, and large  or centrally located tumors [70]. There recently  has been a shift in management of postoperative  bleeding, with a greater role of percutaneous  embolization of pseudoaneurysms that develop.    Recently, two groups have studied the com-  parative costs of nephron-sparing surgeries. OPN  was found to be more expensive than LPN  (1.2 times more expensive) [19]. OPN could  achieve cost equivalence to LPN, when the opera-  tive time of the OPN is less than 2.8 hours, or  when the length of hospitalization of OPN  patients was less than 3 days [19]. Similarly,  LPN was found to cost less than OPN in another  study ($7013 versus $7767). There was no statisti-  cal significance, however [71]. Whereas surgical  supply costs were significantly higher for LPN  than OPN, LPN had less than a third of the  room and board costs of OPN. Therefore, LPN  is cost-equivalent to OPN, as the shorter stay  compensates for significantly higher surgical  supply costs [71].    There are two small series on robotic-assisted  LPN [72,73]. So far, there is limited experience  with this mode of laparoscopic partial nephrec-  tomy. The advantages of three-dimensional  vision, 540? movement, motion scaling, and  tremor elimination have not translated into lower  rates of complications or shorter ischemia [72,74].  The disadvantages include the extra cost of the  disposables, use of the robot surgical platform,  and the requirement of two laparoscopic sur-  geons, who are expert in robotic techniques [74].  Randomized trials are needed to better evaluate  this technology in terms of its added costs com-  pared with decreased ischemia time.    LPN is a technically challenging procedure,  successfully performed by expert urologic lapa-  roscopists in centers of excellence. 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Recovery  of renal function after complete renal hilar versus ar-  tery alone clamping during open and laparoscopic  surgery. J Urol 2007;177(6):2371-4.   Laven BA, Orvieto MA, Chuang MS, et al. Renal  tolerance to prolonged warm ischemia time in a lap-  aroscopic versus open surgery porcine model. J Urol  2004;172(6 Pt 1):2471-4.   Bhayani SB, Rha KH, Pinto PA, et al. Laparoscopic  partial nephrectomy: effect of warm ischemia on  serum creatinine. J Urol 2004;172(4 Pt 1):1264—6.    Porpiglia F, Renard J, Billia M, et al. Is renal warm  ischemia over 30 minutes during laparoscopic partial  nephrectomy possible? One-year results of a prospec-  tive study. Eur Urol 2007;52(4):1170-8.   Gill IS, Abreu SC, Desai MM, et al. Laparoscopic  ice slush renal hypothermia for partial nephrectomy:  the initial experience. J Urol 2003;170(1):52-6.  Guillonneau B, Bermudez H, Gholami S, et al. Lap-  aroscopic partial nephrectomy for renal tumor:  single-center experience comparing clamping and  no clamping techniques of the renal vasculature.  J Urol 2003;169(2):483-6.   Janetschek G, Abdelmaksoud A, Bagheri F, et al.  Laparoscopic partial nephrectomy in cold ischemia:  renal artery perfusion. J Urol 2004;171(1):68—71.  Abukora F, Albqami N, Nambirajan T, et al. Long-  term functional outcome of renal units after laparo-  scopic nephron-sparing surgery under cold ischemia.  J Endourol 2006;20(10):790-3.   Beri A, Lattouf J-B, D’Ambros OFJ, et al. Partial  nephrectomy using renal artery perfusion for cold  ischemia: functional and oncologic outcomes.  J Endourol 2008;22(6):1285—90.   Lattouf J-B, Beri A, D'Ambros OFJ, et al. Laparo-  Scopic partial nephrectomy: functional and onco-  logic outcomes with up to 6 years follow-up.  Manuscript in preparation.   Lattouf J-B, Beri A, D'Ambros OFJ, et al. Laparo-  Scopic partial nephrectomy for hilar tumors: tech-  nique and results. Eur Urol, in press.   Breda A, Stepanian SV, Lam JS, et al. Use of haemo-  static agents and glues during laparoscopic partial  nephrectomy: a multi-institutional survey from the  United States and Europe of 1347 cases. Eur Urol  2007;52(3):798—803.   Breda A, Stepanian SV, Liao J, et al. Positive margins  in laparoscopic partial nephrectomy in 855 cases:  a multi-institutional survey from the United States  and Europe. J Urol 2007;178(1):47—50.  Permpongkosol S, Colombo JR Jr, Gill IS, et al.  Positive surgical parenchymal margin after laparo-  scopic partial nephrectomy for renal cell carcinoma:  oncological outcomes. J Urol 2006;176(6 Pt 1):  2401-4.   Yossepowitch O, Thompson RH, Leibovich BC,  et al. Positive surgical margins at partial nephrec-  tomy: predicors and oncological outcomes. J Urol  2008;179(6):2158—63.   Lee BR, Tan BJ, Smith AD. Laparoscopic port site  metastases: incidence, risk factors, and potential pre-  ventive measures. Urology 2005;65(4):639—44.  Rassweiler J, Tsivian A, Kumar AV, et al. Oncolog-  ical safety of laparoscopic surgery for urological  malignancy: experience with more than 1000 opera-  tions. J Urol 2003;169(6):2072-S.   Castillo OA, Vitagliano G, Diaz M, et al. Port-site  metastasis after laparoscopic partial nephrectomy:  case report and literature review. J Endourol 2007;  21(4):404-7.    [65] Schneider C, Jung A, Reymond MA, et al. Efficacy  of surgical measures in preventing port-site recur-  rences in a porcine model. Surg Endosc 2001;15(2):  121-5.   Bostwick DG, Murphy GP. Diagnosis and progno-  sis of renal cell carcinoma: highlights from an inter-  national consensus workshop. Semin Urol Oncol  1998;16(1):46—52.   Black P, Filipas D, Fichtner J, et al. Nephron-  sparing surgery for central renal tumors: experience  with 33 cases. J Urol 2000;163(3):737-43.  Permpongkosol S, Bagga HS, Romero FR, et al.  Laparoscopic versus open partial nephrectomy for  the treatment of pathological TINO0MO renal cell  carcinoma: a 5-year survival rate. J Urol 2006;  176(5):1984-8.   [70] Campbell SC, Novick AC, Streem SB, et al. Compli-  cations of nephron-sparing surgery for renal tumors.  J Urol 1994;151(5):1177-80.   [71] Lotan Y, Cadeddu JA. A cost comparison of neph-  ron-sparing surgical techniques for renal tumour.  BJU Int 2005;95(7):1039-42.   [72] Caruso RP, Phillips CK, Kau E, et al. Robot-  assisted laparoscopic partial nephrectomy: initial  experience. J Urol 2006;176(1):36—9.   [73] Kaul S, Laungani R, Sarle R, et al. da Vinci-assisted  robotic partial nephrectomy: technique and results  at a mean of 15 months of follow-up. Eur Urol  2007;51(1):186—91.   [/4] Phillips CK, Taneja SS, Stifelman MD. Robot-  assisted laparoscopic partial nephrectomy: the  NYU technique. J Endourol 2005;19(4):441-5.    Samuel P. Sterrett, DO?, Stephen Y. Nakada, MD®*,  Marshall S. Wingo, MD”, Steve K. Williams, MD”,  Raymond J. Leveillee, MD, F RCS-G”    * Department of Urology, G5/339 Clinical Science Center, University of Wisconsin, 600 Highland Drive,  Madison, WI 53792-7375, USA  ? Radiology and Biomedical Engineering, Department of Urology, University of Miami Miller School of Medicine,  Dominion Tower, 5th Floor, 1400 NW I0th Avenue, Miami, FL 33136, USA    Widespread use of abdominal imaging has  increased the number of incidental tumors found  in greater than 38,000 renal masses diagnosed in  the United States in 2006 [1]. It is estimated that  as many as 51,190 cases of renal cancer were diag-  nosed in 2007 and that the disease would cause  12,890 deaths [2]. By the mid-1990s, incidental  lesions accounted for 60% of all renal masses  [3]. These incidental lesions present at a lower  stage, grade, and likelihood of metastasis and  have improved survival outcomes compared with  tumors detected in symptomatic patients [3—5].  The frequency of detection of small, asymptom-  atic, solid renal masses with low biologic activity  continues to increase [6]. The management of  these tumors over the past decade has shifted  from radical nephrectomy to NSS. The potential  "overtreatment" of incidental small renal lesions  with radical nephrectomy, along with a desire to  reduce patient morbidity and preserve renal func-  tion, led to the development of nephron-sparing  techniques and minimally invasive methods to  manage renal tumors. Nephron-sparing surgery  (NSS) was initially indicated for patients who  have localized renal cell carcinoma (RCC) com-  bined with a compromised contralateral kidney  and a need to preserve overall renal function but  now has become applicable in patients who have    single, unilateral, localized RCC with a normal  contralateral renal unit [7].   Partial nephrectomy has proved to be effective  for patients who have small single renal tumors  that do not involve the collecting system. It is also  associated with significant morbidity, however,  including longer operative time, increased blood  loss, and prolonged hospital stay compared with  radical nephrectomy [8-10]. Minimally invasive  approaches, such a laparoscopic partial nephrec-  tomy, are rapidly gaining acceptance for treat-  ment of small localized renal tumors; however,  laparoscopic partial nephrectomy is associated  with increased complications compared with  open partial nephrectomy [11]. Renal ablative  techniques were developed to offer widespread ap-  plication, improved patient procedural morbidity,  and reduced potential for complications. A large  variety of generators, ablation probes, and energy  delivery systems are now commercially available.  In addition to their efficacy and safety, oncologic  outcomes have been excellent to date, which sup-  ports the rationale of in situ tumor destruction to  reduce morbidity and invasiveness further [12,13].  In situ thermal destruction of RCC uses tech-  niques that destroy tumor tissue through freezing  (cryotherapy) or heating (radiofrequency ablation  [RFA], microwave ablation, laser interstitial ther-  apy, high-intensity focused ultrasound [HiFU]),  and radiosurgery). Each of these techniques relies  on controlled energy delivery in an attempt to  minimize collateral damage to normal renal pa-  renchyma and other surrounding structures.    0094-0143/08/$ - see front matter © 2008 Elsevier Inc. All rights reserved.    The term cryotherapy refers to the therapeutic  use of cold. Cryosurgery is the use of cold as  a means of tissue destruction. The Egyptians be-  gan using cold to treat injuries and inflammation  around 2500 sc [14]. The first application of cryo-  therapy to treat malignancy was described in the  mid-nineteenth century by Arnott [15], who used  a salt solution containing crushed ice at —18°C  to —24°C to shrink breast, cervical, and skin can-  cers. Technologic advances leading to the inven-  tion of an automated cryosurgical apparatus in  the early 1960s and vacuum-insulated liquid nitro-  gen or argon-cooled probes led to a renewed inter-  est in cryosurgery and its possible application in  renal cancer [14,16].   Animal models of renal cryoablation were first  published in 1974 [17]. Human literature was not  reported until more than 2 decades later when  Uchida and colleagues [18] first published their  reports of percutaneous cryoablation of renal  lesions. Soon after, reports on open and laparo-  scopic approaches appeared in 1996 [19] and  1998 [20], respectively. Many of these early studies  demonstrated that renal cryoablation was techni-  cally feasible, safe, and initially efficacious. As  new 5-year postoperative data emerge, cryoabla-  tion is finally gaining acceptance as a standard op-  tion for the treatment of patients who have  localized renal masses less than 4 cm.    The key factors involved in freezing injury  include direct mechanical shock, osmotic shock,  and cellular hypoxia. Cryotherapy-induced necro-  sis is essentially a three-step process. Initially,  extracellular ice formation increases the osmolar-  ity in the extracellular space, leading to a shift of  fluid from the intracellular to extracellular space.  As a result, changes in pH lead to protein  denaturation and accumulation of toxins within  the cell. Next, intracellular ice forms with lower  temperatures, and disruption of cellular mem-  branes occurs. Finally, delayed microcirculatory  failure occurs with the thaw phase of the freeze-  thaw cycle, resulting in further cell disruption,  endothelial damage, microvascular thrombosis,  and eventual tissue ischemia. This last process  may take days to weeks and is ultimately re-  sponsible for the coagulative necrosis, fibrosis,  and collagen deposition seen by 1 month [21].    The lethal temperature for achieving reliable  deaths of normal and cancerous renal cells is  near —20°C. Investigators have shown that expo-  sure of renal cancer cell lines to —10°C for  60 minutes resulted in cell death in only 5% of  cells. Exposure to —20?C, however, resulted in  85% cell death [22]. Despite the low temperatures  created near the tip of the cryoprobe, or center of  the ice ball, there is rapid warming of the tissue  toward the periphery of the ice ball (Fig. 1).  Campbell and colleagues [23] showed in a canine  model that the edge of the ice ball had to extend  at least 3.1 mm beyond the edge of the target  lesion for adequate cell death to occur. We rou-  tinely extend the ice ball at least 10 mm beyond  the edge of the tumor to ensure an adequate mar-  gin of tissue death. In addition to the temperature  that should be achieved, the duration of freezing  has been demonstrated to be an important factor  leading to tissue destruction. Once the tissue tem-  perature reaches a certain level, more cellular  destruction can be achieved by prolonged freezing  at this temperature [24]. Not all structures are  equally cryosensitive. The renal collecting system  has been shown to remain intact after ice ball  involvement if the tissue has not been lacerated  mechanically [25].   As outlined, thawing of the cryoablated tissue  is as instrumental as the freezing process to ensure    Fig. 1. Cryoprobe isotherm. The temperature within the  cryolesion is not uniform. From cryoprobe to ice ball  edge, the temperature continues to increase in a predict-  able pattern. The —40°C isotherm should completely  cover the tumor to ensure complete ablation.    tumor destruction. It has been reported that  repeating the freeze-thaw cycle exacerbates tissue  damage and increases liquefaction necrosis [26].  The authors currently use two freeze-thaw cycles.  Optimal freeze times have also been studied in  swine. Five-minute freeze times were shown to  be inadequate to cause tissue necrosis and were as-  sociated with excessive bleeding, whereas 15-min-  ute freeze times produced consistent necrosis but  were associated with renal fracture. It was con-  cluded that the 10-minute freeze time seems to  be optimal to produce necrosis without complica-  tions [27]. Still debated, however, is whether  a slow passive thaw is more effective than a rapid  active thaw. Finally, clamping the renal artery be-  fore cryotherapy to avoid the heat sink effect of  renal blood flow has been shown to increase the  size of the cryolesion only marginally [28].    The goal of cryotherapy is to freeze a specified  volume of tissue resulting in necrosis without  significant damage to the surrounding healthy  tissue. With this in mind, cryoprobes have been  developed with characteristics, such as variable  diameter and length of the freeze zone, to produce  a specific size of cryolesion. In addition, the  velocity of the temperature change and the nadir  probe temperature affect the dimensions and  temperature gradient of the ice ball. Finally,  thermal conductivity of the target tissue affects  the volume of tissue that is ablated. For example,  a 3.4-mm probe cooling at the rate of 50°C per  minute to a nadir probe tip temperature of —175°C  creates a cryolesion 4 cm in diameter in 20 minutes.  In comparison, an 8-mm probe cooling at the rate  of 100°C per minute to a nadir tip temperature  of —190°C results in a cryolesion 7 cm in diameter  in 20 minutes [29]. Knowing this, a cryoprobe may  be chosen on the basis of the size of the lesion to be  ablated. Alternatively, a single probe may be  placed repeatedly to achieve a larger cryolesion  in large or irregular tumors.   Various clinically relevant cryogens are avail-  able, with the boiling point of each determining  the nadir temperature that the specific cryoprobe  can produce. Liquid argon and liquid nitrogen,  the two most commonly used cryogens, have  boiling points of —186°C and —196°C, respec-  tively. Liquid nitrogen—based systems circulate the  compressed nitrogen within the cryoprobe, allow-  ing it to boil at the tip, thereby extracting the    latent heat of boiling from its surrounding envi-  ronment. Liquid argon—based systems rely on the  Joule-Thompson effect, in which compressed gas  or liquid under high pressure is allowed to expand  rapidly through a narrow orifice in the tip cavity  of the cryoprobe. The rapid cooling that results  creates an ice ball [30].    Cryotherapy can be delivered by means of an  open, laparoscopic, or percutaneous surgical ap-  proach. Open cryotherapy requires an incision  large enough for kidney mobilization and tumor  exposure. This approach is typically entertained  when a concomitant open abdominal procedure is  being performed. Although invasive, the open  approach allows for excellent sonographic moni-  toring with ultrasound.   Laparoscopy has been the preferred method  for renal cryoablation, especially for anterior and  anteromedial tumors. The transperitoneal ap-  proach offers the advantages of familiarity to  most urologic surgeons and a distensible cavity  to provide a large working space. Retroperitoneo-  scopy offers the advantages of working away from  other organs and limitation of hematoma spread  with the protection of the perirenal fat and  Gerota’s fascia. Advantages of laparoscopy in-  clude careful visual monitoring of probe place-  ment and ice ball progression in relation to the  mass under laparoscopic ultrasound guidance;  mobilization of vital structures away from the  treatment area, including bowel, liver, and spleen;  and easy establishment of hemostasis.   The percutaneous approach can also be used  successfully under cross-sectional imaging or ul-  trasound guidance. The advantages of a percuta-  neous approach over the laparoscopic approach  include less invasiveness, shorter hospitalization,  excellent ice ball monitoring with cross-sectional  imaging, less pain medication requirement, de-  creased operating time, and cost-effectiveness.  Disadvantages include the lack of visual cues for  probe placement, inability to separate vital struc-  tures from the treatment area, and radiation  exposure during CT treatment.   Regardless of the approach used, the funda-  mentals are the same. The procedure involves  real-time imaging of the tumor, needle biopsy of  the tumor, insertion of the cryoprobe perpendic-  ular to the tumor, placement of the distal tip of  the probe at the deep margin of the tumor,    ensuring that the probe is not in contact with  surrounding viscera, creation of an ice ball ex-  tending approximately 10 mm beyond the tumor,  and achievement of adequate hemostasis after  removal of the cryoprobe.   In most series, the investigators follow the  ablated lesion using contrast-enhanced CT or  MRI every 3 to 6 months initially. Lack of  enhancement on CT or MRI, with stable or  decreased tumor size, can be considered a sign  of successful cryoablation (Fig. 2). Signs of recur-  rent cancer include increased tumor size, lack of  tumor shrinkage, and nodular or lesion enhance-  ment greater than 10 Hounsfield units (HU).   At the University of Wisconsin, select patients  are offered cryoablation or laparoscopic partial    nephrectomy for most localized renal tumors 4 cm  or less in size. Laparoscopy is the preferred  technique for anterior and lateral tumors, and  percutaneous cryoablation is preferred for poste-  rior tumors with a clear window for probe place-  ment. Cryotherapy is administered under general  anesthesia, although some centers use local seda-  tion, and is performed using an argon gas-based  system that operates on the Joule-Thompson  principle. Cryoprobes are available in diameters  of 1.4 mm, 2.4 mm, 3.4 mm, and 3.8 mm. The  number and size of cryoprobes used in individual  cases vary because of differences in tumor size and  location. Most probes can typically be passed  percutaneously or laparoscopically, because vari-  able lengths are offered with each probe size. For    Fig. 2. (A) CT and (B) MRI scans of a 2-cm right upper pole renal mass before treatment. MRIs demonstrate lack of  enhancement over a previous tumor site 3 months (C) and 7 months (D) after cryoablation.    the laparoscopic approach, we now leave Gerota's  fascia intact to tamponade the bleeding from the  cryoablated site and minimize tumor spillage.  Laparoscopic ultrasound is used to confirm tumor  and proper probe placement, and cryotherapy is  initiated using two 10-minute freeze cycles (Fig. 3).  The freeze cycles are monitored so that the ice ball  extends 1 cm beyond the tumor margin. The cryo-  lesion is monitored with real-time sonography  performed by a radiologist experienced in laparo-  scopic ultrasound, which we believe better confirms  adequate treatment of the margin. A passive thaw  is allowed between the freezing cycles, and an ac-  tive thaw is allowed after the second freeze. The  authors allow the probe to loosen spontaneously  before removing it during the active thaw. Hemo-  static matrix is then injected into the cryoprobe de-  fect (Fig. 4) and covered with absorbable hemostat.  Direct pressure is applied for 10 minutes. With the  insufflation pressure decreased, the cryolesion is  observed for 15 minutes to confirm hemostasis.  For the percutaneous approach, the cryoprobes  are placed under ultrasound or CT guidance with  the patient in the prone position. After the cryo-  probe is removed, images are routinely obtained  to rule out postoperative hemorrhage.   All patients are admitted overnight after sur-  gery for observation. Serum creatinine and he-  matocrit are measured on the day after surgery,  and patients are discharged home once they  tolerate diet with their pain controlled on oral  analgesics. The ablated lesions are followed using  contrast-enhanced CT or MRI every 3 months  during the first year, every six months during the  second year, and then yearly. If a lesion does not    Three clinical series have recently matured to  provide us with 5-year follow up data for renal  cryoablation. Hegarty and colleagues [31] re-  ported on 194 patients undergoing laparoscopic  renal cryoablation since 1997, with 66 patients  having more than 5 years of follow up with  MRI surveillance. Of the 66 patients with long-  term follow-up, the indication for treatment was  a solitary sporadic renal lesion in 48 (7394).  Mean patient age was 66 years. Mean tumor size  was 2.3 cm (range 1—4.5 cm). Three patients  (6%) developed tumor recurrence requiring ne-  phrectomy. One patient was diagnosed with  metastatic RCC shortly after treatment and died  19 months later. The authors report an overall  5-year survival of 81% and a 5-year cancer-  specific survival of 98% [31].   The second series with a 5-year follow-up  included 48 patients, all with more than a 3-year  follow-up (median of 64 months). Twenty-four  patients were treated with the open technique,  whereas the other 24 were treated with the  laparoscopic technique. The median lesion size  was 2.6 cm (range: 1.1-4.6 cm). The overall  survival rate was 89.5%. Five patients (12.5%)  were diagnosed with persistent disease and treated  with repeat renal cryoablation (n — 1), laparo-  scopic nephrectomy (n = 2), laparoscopic partial  nephrectomy (n = 1), and observation (n = 1).  The cancer-specific survival rate was 10095, and    Fig. 3. (A) Cryoprobe is inserted into the renal mass under laparoscopic ultrasound guidance. (B) After confirming  proper probe placement at the deep margin of the tumor, cryotherapy is initiated.    Fig. 4. (4) The cryoprobe loosens spontaneously during the active freeze of the second freeze thaw cycle and is removed.  (B) Hemostatic matrix is placed into the cryoprobe defect with the aid of a laparoscopic applicator.    the cancer-free survival rate after a single cryoa-  blation procedure was 87.5%. This improved to  97.5% after repeat treatment. No complications  were observed [32].   Bandi and colleagues [33] recently reported the  first series with 5-year data using percutaneous  cryoablation. A total of 78 patients had 88 small  renal masses treated by laparoscopic cryoablation  (n — 58) and percutaneous cryoablation (n — 20).  Mean tumor size was 2.6 cm. Mean follow-up was  19 months. The overall, cancer-specific, and recur-  rence-free survival rates were 88.5%, 100%, and  98.7%, respectively. Four patients required a re-  peat treatment because of persistent disease, and  1 had progression to locally advanced disease.  Five patients had complications during cryoabla-  tion, and 7 had complications afterward [33].   Table 1 summarizes the largest cryotherapy tri-  als (>20 patients) to date. These studies suggest  that cryotherapy is a safe minimally invasive treat-  ment option for patients who have small renal  masses at the intermediate follow-up.    The complications of renal cryotherapy are  rare and have rates similar to those of other  laparoscopic and percutaneous procedures. Com-  plications stem from the technical approach and  from the ablation. Pain or paresthesia at the probe  site seems to be the most common complication,  occurring in approximately 5% of all patients [41].  Because the entire probe is cooled in cryotherapy,  care must be taken to avoid injury to the sensory  nerves at the body surface. Other complications in-  clude hemorrhage, urinary infection, pneumonia,    renal insufficiency, wound infection, ileus,  adjacent organ injury, and respiratory difficulty.  The complications of the larger cryotherapy se-  ries are listed in Table 2.   In a multi-institutional study evaluating com-  plications after 139 cryoablation procedures, with  2 major and 18 minor complications, was re-  ported. Overall, 4 complications were reported  in the laparoscopic group and 16 were reported in  the percutaneous group. Of these 20 complica-  tions, only 2 were reported as major complica-  tions and no deaths were reported. The  investigators also reported that all major compli-  cations occurred early in the series, suggesting  that experience with laparoscopy and percutane-  ous procedures is important for preventing and  managing these complications [41].    RFA is a heat-based method of tissue de-  struction originally developed for the treatment  of aberrant cardiac pathways. The first oncologic  application involved the treatment of primary and  metastatic liver tumors [42,43]. Current applica-  tions include the treatment of breast malignancy,  aberrant cardiac pathways, gynecologic tumors,  prostate disease, bone lesions, pancreatic cancer,  renal tumors [44], and metastatic lesions.   With reports of RFA success in renal tumors  ranging from small incidental lesions to metastatic  deposits, how do we determine who is appropriate  for renal RFA treatment? Prospective randomized  clinical series to identify patients appropriate for   Study (year) Approach Patients (cm) (months) (minutes) (mL) Complications (days) Recurrence   Hegarty et al Lap 66 2:3 NA NA NA NA NA 3  (2006) [31]    RFA therapy have not been performed to date.  Phase II trials have included patients receiving  RFA simultaneously with open or laparoscopic  nephrectomy before nephrectomy, in patients  deemed inappropriate for extirpative surgery be-  cause of comorbidities, and in patients who had  hereditary RCC. Most clinicians agree that pa-  tients with a solitary kidney, multiple synchro-  nous RCC, von Hippel-Lindau disease, familial  RCC, or limited renal function are appropriate  candidates for RFA treatment, but controversy  exists in younger patients without significant  comorbid conditions, normal contralateral renal  function, and minimal future risk for renal func-  tion loss. As experience with RFA accumulates  and intermediate and long-term oncologic results  become available, favorable outcomes may justify  the treatment of smaller and potentially less  aggressive tumors in younger and healthier pa-  tients with RFA.    RFA techniques convert radiant energy into  thermal energy in the tissues, ultimately leading to    coagulative necrosis. The results are less dramatic  than with cryoablation, but there is no evidence  that RFA is less effective. Damage is believed to  manifest through protein denaturation, DNA/  RNA chain disruption, and vascular congestion.  Effective ablation and cell damage are time- and  temperature-dependent processes. (Fig. 5) Various  ranges of temperature (heat) damage tissue and  result in cell death equivalently, but more time is  required at lower temperatures. High tempera-  tures (7 100*C) result in immediately identifiable  cellular changes, including obvious structural  damage, desiccation, vaporization, and carboniza-  tion. Lower temperatures (45°C—55°C) are associ-  ated with less grossly apparent changes, including  denatured cellular enzymes; damaged membrane  channels; and cellular edema, organelle swelling,  and blebbing after several hours. Elevated temper-  atures cause the intracellular buffering capacity  and transport mechanisms to fail, resulting in an  overload of intracellular calcium and cell death.  Disruption of the delicate intracellular balance  causes localized inflammatory changes to appear,  followed by an ischemic response, leading to aci-  dosis and eventual coagulative necrosis.    Major Minor  Study (year) complications complications  Shingleton and None Wound  Sewell (2001) infection  Cestari et al (2004) UPJO Fever (3)  Hematoma (2)  Hematuria  Schwartz (2006) Renal fracture Hydronephrosis  CVA (resolved)  Gill et al (2005) Splenic Pleural effusion  hematoma . Herpetic  CHF esophagitis  Davol et al (2006) None Capsular  fracture (4)  Transfusion (2)  Ileus  Polascik et al (2007) None Transfusion  Ileus  Tillet et al (2006) None Transfusion (2)  Urinary fistula  (resolved)  Beemster and None Pneumonia    Skin paresthesia  Urinary tract  infection  Hematoma (4)  Neuropathic  pain (2)  Urine leak  Narcotic  overdose    Abbrevations: CV A, cerebrovascular accident; CHF,  congestive heart failure; UPJO, ureteropelvic junction    cell is preserved. Three to 7 days after RFA  treatment, the damaged tissue begins to show  signs of coagulative necrosis with interspersed    inflammatory cells. The necrotic debris is then  removed by fragmentation or phagocytosis. Con-  comitant apoptosis can increase the total area of  cell kill through the promotion of nuclear pyk-  nosis in cells adjacent to directly injured cells [45].  All evidence of organized renal cellular architec-  ture disappears by 30 days. The necrotic tissue  absorbed with fragmentation and phagocytosis  transforms into avascular scar tissue that may be-  come smaller in size and does not enhance on con-  trasted imaging [46,47].    Tissue vascularity within and surrounding the  renal tumor may affect the volume of the ablated  area. Adjacent blood flow may dissipate the  generated heat, resulting in a "heat-sink" phe-  nomenon, making it more challenging to treat  highly vascular lesions and lesions adjacent to  larger blood vessels, such as the renal hilum.  Attempts have been made by researchers to  reduce this effect by clamping the renal hilum  during treatment. Corwin and colleagues [48] used  clamping of the renal hilum in a swine model and  demonstrated that the ablated lesion size was  larger in the ischemic kidneys than in the normally  perfused cohort. When researchers examined the  kidneys 1 month after treatment, however, no dif-  ference in lesion size was detectable. Although  clamping of the renal hilum is not possible in  percutaneous procedures, research examining se-  lective arterial constriction and embolization of  renal tumor vasculature before RFA is ongoing.    Radiofrequency energy is composed of an  alternating electrical current (alternating current  [AC] with a wavelength between 10 kHz and  900 MHz. Commercially available radiofrequency  generators typically produce current at frequen-  cies from 400 to 500 kHz [45]. Energy is typically  delivered through a monopolar circuit. Current  emanates from the radiofrequency generator  through the electrode, passes through the patient's  tissues, and returns to the generator through  a grounding pad on the skin. Bipolar systems  for which no grounding pad is required exist but  are not commonly used. Impedance (Q) or resis-  tance to flow of current exists within the circuit  and varies depending on the tissue density  and composition. Alternatively, radiofrequency    energy delivered through a bipolar circuit begins  at the electrode and returns through an additional  electrode in close proximity to the point of origin.  This circuit type minimizes the amount of tissue  traversed by the electrical current and offers ad-  vantages and disadvantages but is not discussed  here.    Plain electrode RFA involves the delivery of  current through a single, expandable, or bipolar  electrode. Conventional plain radiofrequency  electrodes are limited in tissue ablation efficiency  by high-current densities at the metal electrode—  tissue interface. High-current densities result in  high temperatures (> 100°C) followed by tissue  desiccation and charring close to the electrode  surface (<1 mm) as described previously [49]. In  attempts to improve the propagation of radiofre-  quency energy and reduce high electrode tissue  density, investigators have tried to manipulate  several variables in the radiofrequency circuit. En-  gineers have developed a negative feedback circuit  limiting the applied power when the impedance  increases and have installed a thermal sensor at  the electrode tip to maintain the temperature at  less than 100°C by reducing the power applied  to the circuit. These maneuvers have resulted in  mixed success. Attempts to reduce the electrode  temperature and tissue impedance through reduc-  tion of the power applied to the circuit limit the  amount, rate, and total volume of tissue treated.   Strategies to manipulate the tissue-electrode  interface resulted in the development of alterna-  tive radiofrequency probe configurations. Single-  shaft radiofrequency electrodes include plain,  cooled, expandable, bipolar, and wet configura-  tions. Multiple electrode systems are also avail-  able and classified according to probe number,  electric mode, activation mode, and electrode type  (ie, plain, wet, cooled, expandable). Detailed de-  scriptions of these numerous systems are beyond  the scope of this article [50].    The goal of therapy should be the creation of  a zone of heat that includes the entire volume  of the mass and extends beyond the tumor edge to  achieve an acceptable treatment margin. Ade-  quacy of partial nephrectomy is considered if the  entire tumor is removed (ie, as long as the margin    is negative). At the University of Miami, the  authors perform ablations with the goal of  achieving at least a 5-mm zone of “adequate”  thermal intensity and duration (ie, 60°C for  ] second).    Mulier and colleagues [50] proposed a stan-  dardized nomenclature for radiofrequency elec-  trode systems.  Single-shaft radiofrequency  electrodes are described as plain, cooled, expand-  able, bipolar, or wet. Cooled electrodes are further  classified as single or clustered. Expandable elec-  trodes include the subcategories multitined and  coiled. Some of these features can occur simulta-  neously along a single-shaft electrode and are  referred to as double-and triple-combination  designs. Multiple electrode systems are classified  by the number of probes, circuit type (monopolar  or bipolar), activation mode (consecutive, simul-  taneous, or switching), site of insertion, and elec-  trode system (wet, cooled, or expandable) [50].  A standardized nomenclature system allows  more accurate comparison of technologies and  a better understanding of published radiofre-  quency techniques. Almost all the published liter-  ature regarding renal RFA has primarily involved  centers using two systems. Further detailed dis-  cussion of the other types of electrode systems is  beyond the scope of this article.    Much like cryoablation, radiofrequency treat-  ment may be performed through a percutaneous  or laparoscopic approach. Anteriorly or laterally  oriented renal tumors are best approached by  laparoscopic mobilization of the bowel, exposure  of the tumor surface, and direct visualized in-  sertion of the ablation probe into the tumor  parenchyma for efficacy and safety (Fig. 6). Lapa-  roscopic exposure reduces the risk for thermal  injury to adjacent organs, such as the liver, spleen,  and bowel, in addition to other vital structures, in-  cluding the ureter and renal pelvis from the abla-  tion zone. Posterior tumors can also be accessed  through retroperitoneal laparoscopic approaches.  Laparoscopy requires small port incisions, and ab-  dominal insufflation. Multiple percutaneous core  biopsies are done with a spring-loaded (16- or  18-gauge) needle before ablation. This is guided    visually and confirmed with laparoscopic ultraso-  nography. Because heat is not detectable with  ultrasound, the authors use temperature monitor-  ing at the tumor margin. If peripheral temperature  monitoring is performed, they then place three and  four fiberoptic temperature sensors at the pe-  ripheral (superior, inferior, lateral, and medial)  and deep margins of the tumor, 5 mm from the  tumor-parenchymal interface (Fig. 7A).   The RFA probe(s) is then positioned under  direct visualization and ultrasound guidance to-  ward the center of the tumor. The ablation is  complete after a specified time interval; the  temperature or impedance goal is reached; or in  the case of peripheral temperature monitoring,  when all temperature monitors reach the target  temperature (see Fig. 7B, C). Manipulation and  alternate targeting of the radiofrequency probe  and repeat application of radiofrequency energy  may be necessary to achieve complete thermal  coverage of the lesion. After the completion of  the ablation procedure, all the probes are re-  moved. Because the heat acts to coagulate blood  vessels, unlike cryoablation, we have not found  it necessary to add any topical hemostatic agents.    CT-guided RFA can be performed under  general anesthesia, under intravenous sedation,  or after infiltration of a local anesthetic. At the  University of Miami, general anesthesia is pre-  ferred for all treatments because of the precision  with which all probes must be positioned to  ensure effective tumor ablation and to minimize    collateral damage. In the authors’ unit, the  ablation “team” consists of the urologic surgeon,  interventional radiologist, anesthesiologist, surgi-  cal nurse, and CT technician. Purely percutaneous  radiofrequency treatment with the assistance of  radiologic imaging may be performed in posteri-  orly oriented tumors (Fig. 8). Several methods of  bowel manipulation have been described. Saline  solution or co» injection has been used with  RFA to increase the separation between vital  structures and the renal lesion. The patient is  placed in a prone or full-flank position to provide  percutaneous access to the retroperitoneum. After  preoperative imaging is reviewed by the team,  probe type, location, and circuit type are deter-  mined based on tumor characteristics, size, and  anatomic relation to other structures.   If peripheral temperature monitoring is per-  formed (as is the case for all the authors'  treatments), a minimum of three fiberoptic tem-  perature sensors are placed under CT guidance  at the peripheral (superior, inferior, lateral, and  medial) and deep margins of the tumor, 5 mm  from the tumor-parenchymal interface (Fig. 9).  The probes are inserted through nonconducting  18-gauge sheaths. These are placed before biopsy  to avoid the possibility of bleeding, obscuring  the radiographic planes. Contrast is not routinely  used if the preoperative imaging done with con-  trast demonstrates a well-defined border. The ra-  diofrequency probe(s) is positioned under CT  guidance percutaneously and directed toward the  center of the tumor and advanced until the deep  margin is reached with the probe tip. Conversely,  for those who use expandable ablation needles,  the needles are deployed according to the manu-  facturer's algorithm. After the ablation needle is  properly positioned the radiofrequency cycle is ini-  tiated. The ablation is complete after a specified  time interval, when a target temperature or imped-  ance is reached at the probe tip or, in the case of  peripheral temperature monitoring, when all the  target temperatures have been achieved at the tu-  mor margins (75 mm, 60*C). Manipulation and  alternate targeting of the radiofrequency probe  and repeat application of radiofrequency energy  may be necessary to achieve a compete ablation.  Based on the authors' experience, we recommend  that all tumors positioned within 1 cm of the bowel  should be considered for a laparoscopic approach  to provide definitive separation between the tumor  and all vital structures. After the CT-guided RFA,  patients are discharged home the same day and re-  sume normal activities within 1 week.    Fig. 7. (A) Laparoscopic-assisted RFA temperature fiber placement before ablation. (B) Laparoscopic-assisted RFA  temperature fiber placement: three fibers exceed the 60°C targeted area adequately treated requirement, and the proce-  dure can be terminated. (C) Laparoscopic-assisted RFA ablation tumor surface immediately after ablation.    Lewin and colleagues [51] described the  application of RFA using MRI guidance.  Radiofrequency energy is delivered through  custom-fabricated MRI-compatible *cooled-tip"  radiofrequency electrodes using a temperature-  controlled system. Treatments are administered  for 12 to 15 minutes at 90°C with real-time tem-  perature monitoring of the radiofrequency lesion  identified by changes in the MRI enhancement  patterns. If intraoperative imaging suggests in-  complete treatment, the electrode is repositioned  and additional radiofrequency cycles are per-  formed. Follow-up is obtained through serial  MRI scans to confirm the absence of persistent  enhancement or radiographic recurrence.    You cannot see heat. Determining the size of  the radiofrequency lesion in real-time is difficult,    Fig. 8. Posteriorly oriented renal tumor for CT-guided  RFA (prone position).    because most tissue changes are not immediately  visible. Ultrasound, CT, and MRI have been  investigated in RFA therapy.   Peripheral fiberoptic temperature monitoring  has been developed as a means to perform real-  time monitoring during the RFA treatment as  described previously [52]. Continuous tempera-  ture measurements are returned from each probe  during the ablation. RFA continues until all pe-  ripheral temperatures exceed the predetermined  level and duration. RFA probes can be reposi-  tioned and a treatment cycle repeated if a region  of the tumor periphery does not reach the desired  temperature. Carey and Leveillee [52], have dem-  onstrated that large tumors, up to 3 to 5 cm in  diameter, can be treated successfully with infre-  quent need for retreatment.    Success is defined in many series by radio-  graphic follow-up imaging. After RFA treatment,  tumors are monitored by contrasted MRI with  "no lesion enhancement" or CT (preferable and  quantifiable) lack of enhancement by an increase  in HU less than 20 HU and no evidence of growth  indicative of a treatment success (Fig. 10). Long-  term experience with following ablated tumors  radiographically is lacking and optimal surveil-  lance intervals are yet to be determined. Unlike  cryoablated lesions, RFA lesions tend not to  shrink in size. Matsumoto and colleagues [53]  described the typical characteristics of the RFA    mass. These characteristics include a nonenhanc-  ing wedge-shaped lesion, frequently with a thin  rim of fat between the lesion and the normal pa-  renchyma. Exophytic tumors tend to retain their  preablation shape and size. Imaging characteris-  tics can change at any time and a regimented fol-  low-up protocol is encouraged in all patients.  Recurrences have been documented as late as  31 months. Table 3 summarizes single treatment  success with renal RFA in larger series. Mixed  success in these studies emphasizes the need to  perform RFA in a meticulous manner with excel-  lent targeting and lesion monitoring. Full ablation    Single treatment success with renal radiofrequency ablation series with 10 or more patients    Authors Tumor no. Tumor size (cm) ^ Approach Single treatment success  Pavlovich et al [55] 24 2.4 Perc (US and CT) 19/24 (79%)  Roy-Choudhury et al [56] 11 3.0 Perc (US and CT) 9/11 (82%)  Gervais et al [57] 42 3.2 Perc (US and CT) 36/42 (86%)  Su et al [58] 35 2:2 Pere (CT) 33/35 (94%)  Mayo-Smith et al [59] 36 2.6 Perc (US and CT) 26/32 (81%)  Farrell et al [60] 35 1.7 Perc (US and CT) 35/35 (100%)  Hwang et al [61] 24 2.2 Perc (CT) and lap 23/24 (96%)  Matsumoto et al [62] 64 N/A Perc (CT), lap, and open 62/64 (97%)  Zagoria [63] 24 3.5 Perc (CT) 20/24 (83%)  Lewin et al [51] 10 2.3 Perc (MR) 10/10 (100%)  Varkarakis et al [64] 56 N/A Pere (CT) 47/56 (84%)  McGovern et al [65] 62 1-5.5 Perc (CT) 55/62 (8994)  Ogan and Cadeddu [66] 13 2.4 Perc (CT) 12/13 (9294)  Jacomides et al [67] 17 1.96 Lap (US) 17/17 (100%)  Park et al [68] 109 N/A Perc (CT) and lap 106/109 (97%)    should always be performed, and multiple probes  should be used when necessary to ablate com-  pletely beyond the interface between tumor and  normal parenchyma in larger tumors. The authors  advocate the use of peripheral temperature moni-  toring to ensure that lethal temperatures reach  beyond the tumor margin.    Although patients and clinicians expect mini-  mal morbidity, complications are still possible.  Uzzo and Novick [54] reviewed the literature from  1980 to 2000 and found a complication rate for  nephron-sparing procedures (most were partial  nephrectomies) ranging from 4% to 30%, with  an average of 13.7%. To become an accepted  form of nephron-sparing therapy, RFA must  demonstrate equivalent oncologic efficacy with  lower complication rates.   Most complications reported in the literature  are minor and include subcapsular or perinephric  hematomas that do not require treatment. Ureter-  opelvic junction (UPJ) obstructions have been  described requiring pyeloplasty in one and ne-  phrectomy secondary to pain and loss of renal  function in another [69,70].   A multi-institutional review of complications  of cryoablation and RFA was performed. [41]  Eleven complications were seen in 133 cases  (8.3%) of RFA. Eight complications were listed  as minor, requiring no intervention, and 3 were  considered major. Minor complications were    described as pain and paresthesias at the probe  puncture site in addition to transiently increased  serum creatinine. Major complications included  an ileus, a UPJ obstruction that ultimately led to  renal loss and nephrectomy, and a urinary leak.   The 8.3% complication rate is certainly com-  parable to the 13.7% overall experience with  partial nephrectomy and is more impressive con-  sidering that many patients who underwent RFA  were deemed inappropriate for more invasive  surgical therapies.    HiFU focuses ultrasonic waves that pass  through human tissues onto a target lesion within  the body. The aim of HIFU technology is the  "noncontact" destruction of tissues by extracor-  poreally applied ultrasound energy by means of  an acoustic window. HiFU applies the same  principles as diagnostic ultrasound (frequencies  in the range of 1-20 MHz), which can propagate  harmlessly through living tissue. Unlike diagnos-  tic ultrasound, HiFU uses frequencies several  orders of magnitude greater with focal zones  that are cigar shaped, measuring a height of 12  to 32 mm and a width of 3 to 4 mm [71,72] with  depths limited to 10 to 16 cm [73].   HiFU causes tissue insult by two mechanisms:  a thermal effect and a mechanical effect [74]. As  the power intensity increases, heat is generated  as a result of absorption of the acoustic energy.    This causes an increase in the tissue temperature,  leading to protein denaturation and cell death.  This is the primary mechanism for tumor cell  destruction in HiFU therapy.   Focusing also results in high intensities at  a specific location and over a small volume (eg,  ]-mm diameter and 9-mm length). With high-  intensity energy over shorter periods, mechanical  effects are achieved by bubble implosion, leading  to mechanical disruption. Mechanical effects in-  clude cavitation, microstreaming, and radiation  forces [75,76]. This occurs because of alternating  compression and expansion of tissue as an ultra-  sound field passes through it. If the tissue disrup-  tion is of sufficient magnitude, gas may be  extracted from the tissue, resulting in the  formation of bubbles. These bubbles may remain  relatively stable and simply oscillate, or they  may collapse spontaneously, causing mechanical  stresses and generating temperatures of 2000 to  5000 K in the microenvironment [77]. Micro-  streaming may produce high shear forces close  to the bubble, leading to the disruption of cell  membranes [78].    HiFU represents an attractive modality for the  noninvasive treatment of tumors. The main  advantage of HiFU is its ability to deposit large  amounts of energy to targeted tissue, with  millimeter accuracy and little or no damage to  intervening tissue. Insufficient long-term data  exist, although emerging data suggest that extra-  corporeal HiFU ablation is possibly facing severe  technical challenges with recent evolution toward  laparoscopic HiFU applications.   Clinical studies have all been preliminary, and  further investigation is necessary before the wide-  spread use of HiFU can be recommended.    The CyberKnife is a frameless image-guided  radiosurgery device that uses a linear accelerator  mounted on a robotic arm and divides the high-  dose radiation into up to 1200 beams. Thus, the  individual dose of each beam is relatively benign  to adjacent tissue, although at the focal point of  these beams, the dose is additive and the desired  ablative dose is attained. Radiotherapy exerts its  effect at the cellular level by induction of single-  and double-stranded DNA breaks, which induce  apoptosis and prevent successful cell division.  Programmed cell death is not the only method    of tissue destruction possible by radiotherapy,  however [79]. High enough doses of radiotherapy,  when applied to a tumor or any tissue, can com-  pletely ablate the tumor or tissue. The use of  external beam radiotherapy allows the delivery  of high-energy radiation to tumor tissue and kills  cancer cells. Such an approach subjects the sur-  rounding tissue to the deleterious effects of radia-  tion as well, however, and the treatment margins  are indistinct.    Initial preclinical and clinical series of the  Cyberknife for extracorporeal renal tissue abla-  tion seem to be promising and demonstrate its  ability to ablate a targeted area with relative spar-  ing of the surrounding tissue precisely and com-  pletely, because no acute toxicities have been  reported. It is still, however, not “noninvasive,”  because there is a need for biopsy and placement  of fiducial markers. Further research is necessary  before the role of radiosurgery in the management  of renal tumors can be established.    For solid renal masses there are few data  currently available pertaining to microwave ther-  motherapy. Energy is delivered by means of an  antenna placed directly into the target lesion. The  antenna generates an electromagnetic filed, caus-  ing rapid ion oscillation resulting in frictional  heat. In principle, it is similar to RFA but has the  advantage of delivering heat 100 times faster.  Preclinical data exist and have been summarized  by Wen and Nakada [80].   Clark and colleagues [81] recently published  their work in humans. A phase I study was per-  formed in humans evaluating ablation zones  before surgery just before radical or partial ne-  phrectomy. Ten tumors were ablated with no  “skip” areas (visual, histologic, and NADH stain-  ing used) seen within the ablated zones. Further  studies allowing for *ablate and leave" rather  than resect are warranted.    Laser interstitial thermal therapy: inadequate  human data, paucity of preclinical data    The first clinical series of laser thermal ablation  was reported by Dick and colleagues [82] in 2002.  Using MRI guidance, they performed real-time  thermal mapping in nine patients who had renal  masses and were not surgical candidates. They    used a neodymium-yttrium-argon laser delivered  with a 600-um fiber for 10 to 30 minutes (one or  two sessions). Mean tumor size was 3.7 cm, and  mean follow-up was 16.9 months. Metrics were  a percentage of enhancement change (73.7% be-  fore ablation to 29.5% after ablation). A second  subset of patients was reported by Williams and  Swishchuck [83] in abstract form. Data on 10 pa-  tients demonstrated in an “ablate and resect"  study that coagulative necrosis could be achieved  at 85°C. No pathologic findings were reported.  There are no other instances of laser interstitial  renal ablation that the authors are aware of.    Pulsed cavitational ultrasound, also known as  “histotripsy,” is the transcutaneous noninvasive  delivery of ultrasound energy that uses cavita-  tional effects to damage target tissue by varying  acoustic parameters. The nonthermal mechanical  effects attributable to ultrasound are thought to  have advantage over temperature-based ablation  systems, whereby lesion precision is limited be-  cause of local factors. There is no thermal  collateral damage to the surrounding tissue and  skin or to the collecting system. A potential  theoretic complication is the dissemination of  malignant cells from the shear forces generated  by the procedure, although this has not been seen  experimentally. Two studies are available in  rabbit and porcine kidneys. [84,85] There are no  human data to date; thus, this form of ablation  is still considered experimental.    Renal cryoablation is an excellent minimally  invasive treatment option for small renal masses  in appropriately selected patients. The ability to  monitor the ice ball is a distinct advantage.  Radiofrequency, likewise, has distinct procedural  advantages and favorable outcomes. Five-year  outcomes are now available confirming it as  efficacious and with low morbidity.   Energy targeting is greatly enhanced through  imaging modalities, which greatly assist needle  placement or energy delivery to the optimal  location for maximal effectiveness. When vital  structures obscure access to the renal lesion,  laparoscopic mobilization of these structures  with direct visualization of the tumor can increase  the likelihood of ablation success and minimize  complication risk. Monitoring the size and    geometry of the ablation lesion ensures that the  outermost reaches of the renal tumor have been  completely treated. For most of the newer tech-  nologies (HiFU, radiosurgery, interstitial laser,  microwave, and pulsed cavitational ultrasound),  there is insufficient evidence to make them the  forerunners currently. Independent of the ablation  type or control method, when sustained lethal  temperatures are verified at the tumor margins,  the clinician can be confident that the treatment is  complete. Ablative therapies are attractive be-  cause of their minimal impact on patient quality  of life in addition to their morbidity and cost.  Although they show promise of efficacy, they  must be evaluated with long-term follow-up  before they are considered the standard of onco-  logic care. Safety profiles thus far are excellent,  and as technology and techniques advance, abla-  tive therapies should gain more widespread use  and acceptance. 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Micro-  wave ablation of renal parenchymal tumors before  nephrectomy: phase I study. AJR Am J Roentgenol  2007;188:1212.   Dick EA, Joarder R, De Jode MG, et al. Magnetic  resonance imaging-guided laser thermal ablation of  renal tumours. BJU Int 2002;90:814.   Williams Jc MP, Swishchuck PN, et al. Laser  induced thermotherapy of renal cell carcinoma   Roberts WW, Hall TL, Ives K, et al. Pulsed cavita-  tional ultrasound: a noninvasive technology for con-  trolled tissue ablation (histotripsy) in the rabbit  kidney. J Urol 2006;175:734.   Kieran K, Hall TL, Parsons JE, et al. Refining histo-  tripsy: defining the parameter space for the creation  of nonthermal lesions with high intensity, pulsed  focused ultrasound of the in vitro kidney. J Urol  2007;178:672.    Laparoscopic Donor Nephrectomy  David A. Duchene, MD**, Howard N. Winfield, MD?    “Department of Urology, University of Kansas Medical Center,  MS 3016, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA  Department of Urology, University of Iowa Hospitals & Clinics,  RCP 3235, 200 Hawkins Drive, Iowa City, IA 52242, USA    Renal transplantation is the definitive therapy  for patients who have end-stage renal disease.  The number of patients awaiting renal transplan-  tation, however, far exceeds the number of cadav-  eric organs available. Approximately 74,000  patients are on the renal transplant waiting list  in the United States (based on the United Net-  work of Organ Sharing Web site, which provides  frequently updated data: http://www.unos.org).  In 2006, 13,615 renal transplants were performed,  of which nearly half (6434) were from living do-  nors (http://www.unos.org). In fact, since 2001,  the number of living persons donating kidneys  in the United States exceeded that of cadaveric  donors, but a higher number of cadaveric kidneys  still exist. Living donor kidneys have excellent  graft survival rates at 1, 3, and 5 years of 95%,  88%, and 80% respectively [1]. This is compared  with cadaveric donors graft survival rates of  87%, 77%, and 65% [1]. The differences in graft  survival are caused by decreased ischemia time be-  tween procurement and transplantation into a re-  cipient and ability to optimize the recipient’s and  donor’s medical status before transplantation.   Ratner and associates [2] first performed lapa-  roscopic donor nephrectomy (LDN) in 1995. This  first case was attempted 5 years following the first  laparoscopic nephrectomy [3] and after the feasi-  bility of donor nephrectomy was demonstrated  in a porcine model [4]. Early in the experience,  concerns were raised concerning early graft dys-  function, ureteral complications, and loss of    right-sided donor kidneys [5,6]. Experience with  the LDN technique, however, has demonstrated  equivalent outcomes for the grafts [7]. LDN now  is considered the standard of care in most trans-  plant centers in the United States.   This article reviews the current indications,  selection criteria, surgical approaches, outcomes,  and complications of LDN.    Prospective kidney donors represent unique  surgical candidates. The donor patient is an  otherwise healthy individual with a solely altruis-  tic motive to undergo a potentially harmful  operation. Therefore, extreme care must be taken  by all providers to minimize the risk to the donor.  Likewise, the donor organ is essential to benefit  the quality of life of another individual, so  everything must be done to preserve the best  function of the kidney. Preoperative evaluation  is the first essential step in selecting kidney  donors.   It is recommended that each transplant center  organizes a transplant committee to discuss all  cases of live organ donation. Potential donors  must go through extensive medical and psycho-  logical evaluation in accordance with guidelines  published by the American Society of Transplant  Physicians [8]. Patients undergo a comprehensive  history and physical, complete blood count, meta-  bolic panel, chest radiograph, electrocardiogram,  and screening for potentially transmissible dis-  eases. In addition to the medical examination,  all patients are required to have a preoperative  psychological examination. To emphasize the im-  portance of the psychological aspect, the Live    0094-0143/08/$ - see front matter © 2008 Elsevier Inc. All rights reserved.    Organ Donor Consensus Group published recom-  mendations for organ donation [9]. The statement  emphasizes the need for full informed consent of  the procedure the patient will undergo to include  all the immediate possible peri-operative compli-  cations and potential unforeseeable or long-term  complications. Ample time should be provided be-  tween the initial discussion and the actual surgery,  so donors have time to consider their decision.  Psychological stressors surrounding donation  and the patient's motivation for donation need  to be defined. Family and interpersonal relation-  ships may have long-term consequences on both  the donor and recipient, and any hint of coercion  renders a donor ineligible [9].    LDN requires accurate preoperative radio-  graphic imaging to identify any vascular or  anatomic variations that may influence operative  technique and/or exclude a potential donor. MR  imaging angiogram and CT angiogram have  replaced standard renal arteriography in defining  the vascular anatomy [10,11]. Both modalities also  allow evaluation of the kidneys for any stones, le-  sions, malformations, and approximate estimates  of differential renal function [10,11]. Bhatti and  colleagues [12] prospectively compared CT and  MR imaging angiography for evaluating the renal  vascular anatomy in potential living donors and  found that both had good sensitivity for detecting  major arteries and veins (100% for CT, 97% for  MR imaging). CT angiography, however, did  much better at detecting small accessory renal  arteries and accessory renal veins. Bhatti and col-  leagues felt a multidetector CT angiography  should be the study of choice [12]. Either  modality, however, requires three-dimensional  reconstruction of the images, which can be  labor-intensive for radiology technicians/radiolo-  gists. Schlunt and colleagues [10] found that the  sensitivity of CT angiogram also was improved  when the films were reviewed by the radiologist  and operative surgeon together. Therefore, the  decision on preoperative imaging choice often de-  pends on the resources available at the institution  and the radiologist's and urologist's preference to  obtain the most accurate imaging.    The selection of which kidneys are acceptable  for transplantation and the donor side varies  widely among transplant centers. The left donor    kidney generally is preferred because of the longer  renal vein length in both open and laparoscopic  donor nephrectomy. This facilitates implanting  the kidney into the recipient. The favored use of  left kidneys was especially true during the early  LDN experience because of a high rate of vascular  complications, such as renal vein thrombosis and  graft loss in the initial attempts at right-sided  LDN [13]. Many centers in the early experience  (and some currently) offered left-sided laparo-  Scopic procedures, but obtained right kidneys in  an open fashion [14].   At the same time that right-sided LDN was  being approached cautiously, several studies dem-  onstrated arterial and venous anomalies were not  a contraindication to left-sided LDN. Lin and  colleagues [15] demonstrated that circumaortic or  retro-aortic renal veins in left-sided LDN had sim-  ilar surgical variables such as operative time,  warm ischemia time, blood loss, and length of ves-  sels. Likewise, Troppman and colleagues [14]  showed that multiple renal arteries in left-sided  kidneys undergoing laparoscopic donation were  not associated with significant changes in ischemia  time or recipient function, although operative  time was longer in those patients. Many laparo-  scopic surgeons felt that multiple left renal arteries  were less problematic than obtaining a right do-  nor kidney [16].   Subsequently, experience with right-sided LDN  has made it an option for laparoscopic donation  [17,18]. Buell and colleagues [17] reported on a mul-  ticenter review of 97 attempted right-sided LDNs.  Ninety-four were completed laparoscopically with  98% graft success rate and no major complications  after overcoming the initial learning curve. The au-  thors found the same patient benefits and no in-  creased risk of complications when compared  with left-sided laparoscopic donors. Therefore,  when evaluating patients for LDN, the goal to leave  the best kidney with the donor patient should be ap-  plied. Typical indications to require a right-sided  nephrectomy include: smaller right kidney, right  renal cysts, multiple left renal arteries, left renal  vein anomaly, right nephrolithiasis, and right renal  artery stenosis [17-19] (Movie 1: Laparoscopic  Right Donor Nephrectomy”) (Courtesy of Iowa  Hospitals & Clinics, Iowa City, IA; with  permission.).    * Videos for this article can be accessed by visiting  www.urologic.theclinics.com. In the online table of con-  tents for this issue, click on *add-ons."    The term laparoscopic donor nephrectomy  actually encompasses a large variety of surgical  approaches. LDN can be performed either  transperitoneally or retroperitoneally, and by  a pure-laparoscopic, hand-assisted, robotic, or  a combination of these techniques.    Most institutions use a transperitoneal tech-  nique, because it provides a large working space  that is familiar to the laparoscopist. The patient is  placed in the modified flank position, with the  planned extraction site facing upwards at approx-  imately 70°. This allows access to both the flank  and the abdomen for specimen retrieval. The  patient must be supported with the assistance of  an axillary roll and beanbag device cushioned  with a Gelpad (Keomed Inc., Minnetonka, Min-  nesota). The patient is secured to the table with  wide-cloth tape. All pressure points are padded.  A pneumoperitoneum is achieved with Veress  (Covidien, Norwalk, Connecticut) needle access  for a pure-laparoscopic approach, or a hand-  assistant port is placed.   A pneumoperitoneum of 12 to 15 mm Hg  pressure is created. It is important to attempt to  keep the pneumoperitoneum at the minimal  possible working pressure, because elevated in-  tra-abdominal pressure has been shown in animal  models to decrease the renal blood flow and  theoretically could decrease renal function and  lead to delayed graft function [20]. An argument  against LDN is the potential for delayed graft  function from the intraperitoneal pressures during  the laparoscopic case. Although more recent ani-  mal studies have demonstrated no delirious effect  of pneumoperitoneum on kidney function, most  surgeons still attempt to keep low intraperitoneal  pressure [21]. To counteract the pneumoperito-  neum, patients generally are given a large amount  of intravenous crystalloids (up to 2 L/h) to main-  tain adequate kidney perfusion. Donors also may  benefit and have less vascular compromise to the  kidney if given an overnight intravenous infusion  of fluids and a fluid bolus before the creation of  pneumoperitoneum [22]. Bergman and colleagues  [23], however, recently challenged the fluid dogma  and found no difference in short- or long-term  graft function between aggressive (greater than  10 mL/kg/h) or conservative (less than 10 mL/kg/h)    intraoperative fluid management, but this needs  confirmation with a prospective study.   A 5 (or 10) mm port in the midclavicular line  two finger breaths below the costal margin   A 12 mm port in the lower quadrant in the  midclavicular line   An optional 5 mm port in the anterior axillary  line just above the umbilical line for assistant  retraction   A 5 mm trocar in the midaxillary line at the  umbilical level for liver retraction (right  side only)    The colon is reflected medially by incising  along the white line of Toldt. Wide mobilization  of the colon is necessary to provide maximal  exposure of the kidney and renal vessels. Pro-  ponents of a retroperitoneal approach believe that  mobilization of the colon during transperitoneal  surgery may risk injury to the intestine and lead to  prolonged postoperative ileus [24]. A retroperito-  neal technique may lead to less ileus and shorter  operative times due to not requiring colon mobili-  zation. Ruszat and colleagues [25] compared the  retroperitoneal approach with  hand-assisted,  pure laparoscopy, and open techniques. The  authors confirmed a lower incidence of ileus and  shorter operative time for retroperitoneal  approach versus the other laparoscopic tech-  niques. Overall complications, however, were  similar among the different modalities [25]. Expe-  rience with retroperitoneal laparoscopic donor  nephrectomy varies greatly between institutions  and remains less used than a transperitoneal  approach. Surgeons should perform the technique  most likely in their hands to provide good results  without complications.   Once the colon has been reflected to enter the  retroperitoneal space, the gonadal vein generally  is identified and followed up to the left renal vein  or inferior vena cava (IVC). The renal vein should  be identified and cleared of all surrounding  adventitial tissue. All lumbar and other accessory  veins also are identified at this time. To gain  maximal length of the renal vein, the gonadal  vein, lumber veins, and adrenal vein (on left) are  isolated, clipped, and divided. This is especially  important on right-sided donor nephrectomy to  obtain maximal vein length. The artery then is  identified and cleared of surrounding tissue to the    junction of the aorta (on the left), or the level the  artery goes posterior to the IVC (on the right).    The ureter and its associated attachments are  dissected away from the psoas muscle. Care must  be taken not to compromise the vascular supply of  the ureter. Careful retraction should be used, and  the ureter should be grasped (only if necessary)  gently with laparoscopic bowel graspers. The  gonadal vein also can be mobilized without  detaching it from the ureter to minimize risk of  vascular compromise [26]. The ureter is dissected  down to the level of the iliac vessels.   The kidney then is mobilized completely by  incising through Gerota's fascia and dissecting it  free from the surrounding perirenal fat. The  kidney then is rotated anteriorly, and the poste-  rior attachments of the renal vein and artery are  completely freed to ensure maximal vessel length.   Once the dissection is completed, the ureter is  clipped distally and divided to observe for adequate  urine output. Most surgeons administer 12.5 g of  mannitol and 20 mg of furosemide in addition  to the crystalloid fluids to ensure a brisk diuresis.    Proper handling of the vessels is a key step in  LDN. Multiple variations of vessel division have  been reported. The essential aspects include prop-  erly securing the vessel stump remaining with the  donor, preservation of maximal arterial and  venous length of the donor organ, and avoidance  of vessel damage [24]. As in a radical nephrec-  tomy, the renal artery should be divided first. Al-  though renal artery length is not generally the  limiting factor in transplanting the organ into  the recipient, care should be taken to preserve  maximal length, especially on the left side. Early  experience with nonlocking 10 mm titanium clips  resulted in nonsufficient vessel occlusion [27]. An-  imal studies confirmed that three clips needed to  be placed 2.5 mm apart to secure the vessel [28].  Obviously, this limited artery length.   Therefore, many surgeons routinely and suc-  cessfully have used 10 mm Hem-o-Lok clips  (Weck Closure Systems, Research Triangle Park,  North Carolina) for the artery, leaving the graft  end unclipped [29]. The authors have placed two  clips on the arterial stump approximately 2 mm  apart, although some authors only use one clip  for the arterial stump [30]. Unfortunately, in  April 2006, Teleflex Medical (the manufacturer    of Hem-o-lok clips) issued a product safety warn-  ing stating that the clips were contraindicated for  ligating the renal artery during LDN because of  nine reported cases of severe hemorrhage from  the renal hilum. The US Food and Drug Admin-  istration, however, did not issue a statement on  the issue. Good data do not exist on the technique  used to apply the clip or numbers of clips in  these cases. The decision to continue to use this  device for LDN is difficult, however, and must  be discussed openly by each individual surgeon's  hospital and applied against the standard of  care in the surrounding community [31]. Most  surgeons have switched to alternative forms of  vascular division.   The renal vein is generally too large to undergo  division with titanium clips or Hem-o-lok clips, so  vascular staplers are used. The vascular staplers  now also usually are employed for arterial ligation.  The choice of staplers can be an Endo-TA or an  Endo-GIA vascular stapler (Autosuture, Covidien,  Norwalk, Connecticut). The Endo-GIA stapler  can lead to a loss of 1 cm of vessel length and  requires a row of staples to be removed before per-  fusion of the donor kidney. It is not recommended  to remove the lateral rows of the Endo-GIA clips  before stapling because of increased likelihood of  stapler misfire [24]. The Endo-TA stapler does  not articulate and sometimes is difficult to get flush  with the aorta and/or IVC. It will get additional  length, however, because it does not leave a lateral  row of staples. This is very important to get extra  length on the right renal vein during a right  LDN. The Endo-TA also has been used in con-  junction with Hem-o-loc clips to get maximal  occlusion of the renal artery [32].   Alternatively, for right-sided donors, an endo-  scopic Satinsky atraumatic vascular clamp  (Aesculap Inc, Center Valley, PA) can be placed  on the side of the caval vein, so the renal vein  can be excised in full length [33]. It is important  to pay meticulous attention to any method used  to transect the vessels to prevent significant intra-  operative and postoperative hemorrhage. Linear  stapling devices can lead to multiple complica-  tions. Primary stapler malfunction is rare (0.3%  in review of donor nephrectomy stapler compli-  cations), but interposition of titanium clips or im-  proper usage leads to most failures [34]. Friedman  and colleagues [35] reported on hemorrhagic com-  plications of LDN and found that the use of non-  locking clips on the renal artery was associated  with the most frequent and severe hemorrhages,  but that locking clips and staplers also caused    occasional significant hemorrhage in the postoper-  ative period. The important point all these find-  ings show is that the vessels should be  skeletonized completely and the tips of the sta-  pling or clipping device must be visualized clearly  before engaging the instrument. Proper use will  limit complications, and the surgeon should con-  firm correct placement of the device before activa-  tion. Although the extra confirmation time may  increase warm ischemia time slightly, it may save  a major hemorrhagic complication.    The site of organ extraction largely depends on  the approach used for the LDN. During a retro-  peritoneal approach, it generally is removed  through a lower quadrant incision just off the  anterior superior iliac spine [36].   For hand-assisted laparoscopy, the kidney is  removed through the hand port. Wolf and col-  leagues [37] first described hand-assisted LDN in  1998. Proponents of the hand-assisted technique  argue that using the already-placed hand port  will decrease warm ischemia time, and the extrac-  tion incision is used better during the procedure  [38]. The hand assistance also gives the surgeon  better tactile sensation for dissection, retraction,  and controlling the vascular structures. Compara-  tive studies have shown an overall decrease in op-  erative time with the hand-assisted technique, but  the operative times achieved in the comparative  studies varied widely and more likely reflected  the surgeons’ experience with their chosen tech-  nique [24].   Extraction site, however, may be a disadvan-  tage for the hand-assisted technique and favors  the pure-laparoscopic approach. In a pure-lapa-  roscopic approach, the kidney may be extracted  through an upper flank, subumbilical midline, or  Pfannenstiel incision per the patient's preference.  A low transverse Pfannestiel incision is too low to  perform a hand-assisted LDN through, and the  hand port usually is placed in the para-umbilical  region. An increased number of hernias and  postoperative ileus has also been found with the  hand-assisted technique, felt to be caused by more  stretching of the incision during hand assistance  and manipulation of the intestines with the use of  the hand [38,39].   Experience with robotic-assisted LDN remains  limited. One of the major concerns is anticipated  increased warm ischemia time and difficulty    removing the specimen with the robotic platform  docked. The kidney usually is removed through  a low midline incision with the robotic technique.  One of the largest published series on robotic  LDN reports using a hand-assist port from the  beginning of the case in the low midline, which  allows for specimen extraction at the conclusion  of the case [40].   Regardless of the approach, all attempts  should be made to limit warm ischemia time.  Prolonged warm ischemia has been criticized as  a risk factor during LDN. Early experience with  the pure laparoscopic technique involved placing  the specimen in an extraction bag and then  removing the specimen. The kidney therefore  was detached from its blood supply, placed in  a bag, and then removed. Several reports of bag  breakage and difficult entrapment led to occa-  sional prolonged warm ischemia times [41]. There-  fore, many authors use a technique described by  Shalhav and colleagues [42] during pure LDN.  The technique also addresses important points  that can be used with retroperitoneal, robotic, or  hand-assisted extraction. The technique involves  placing an assistant's hand through a small Pfan-  nenstiel incision (to maintain pneumoperitoneum)  before dividing the vessels. The kidney is secured  by the assistant's hand, and the ureter is retracted  away from the vessels. Once the hilum is con-  firmed to be free of surrounding tissue and ready  to divide, the artery and vein are divided, hemo-  stasis confirmed, and the kidney is removed  quickly by the assistant and passed off the back  table. With this technique, Shalhav demonstrated  a significant decrease in warm ischemia time (101  seconds versus 173 seconds; P<.001). The key  features are the ability to perform a desirable  low Pfannenstiel incision and complete control  of the donor kidney during the crucial steps of  vessel division and retrieval.    Ratner and colleagues [2] were attempting to  decrease kidney donor morbidity and increase  live kidney donation when they applied concepts  of laparoscopy to donor nephrectomy in 1995.  The goal was to provide a donor nephrectomy  technique to cause less pain, shorter hospital  stay, reduced time away from work, and a better  cosmetic result. The technique, however, also  had to demonstrate equal outcomes from a donor,  graft, and recipient standpoint. Numerous studies  have been published demonstrating the    advantages of laparoscopic over open donor ne-  phrectomy. Several of these studies have had  high levels of evidence-based results, either ran-  domized, controlled trials or prospective, non-  randomized trials [43-49]. The studies find that  compared with open donor nephrectomy, LDN  provides equal graft function, rejection rate, uro-  logical complications, and patient and graft sur-  vival. LDN has the advantage of decreased pain,  decreased analgesic requirement, shorter hospital  stay, and earlier time to return to work. These  studies, however, suggest slightly increased opera-  tive time, marginally increased warm ischemia  time, and increased major complications requiring  reoperation (especially in the early learning phase)  in the laparoscopic cases compared with the open  approach [43-49].   Current anticipated outcomes for LDN at an  experienced, high-volume center can be high-  lighted in a large series from the University of  Maryland, in which 738 consecutive patients un-  dergoing LDN were reviewed [50]. The study  found that 57% of donors were female. Nephrec-  tomy was left-sided in 96% of patients; operative  time was 202 minutes, and mean warm ischemia  time was 169 seconds, Additionally, extraction  site length was 6.6 cm; estimated blood loss was  128 cc, and mean number of arteries was 1.3  [50]. Average hospital stay was 64.4 hours, with  clear liquid diet beginning at 26.5 hours, regular  diet at 46.8 hours, bowel sounds recorded at  32.1 hours, flatus recorded at 48.1 hours, and  bowel movements recorded at 63.5 hours after  surgery [50]. Postoperative donor serum creatinine  level was 1.5 times the preoperative level [50]. A  summary of outcomes from current series of  LDN is shown in Table 1.   In attempts to further decrease pain and length  of stay after donor nephrectomy, Breda and  colleagues [51] recommended a strict implementa-  tion of preoperative bowel rest combined with ke-  torolac for pain control. All patients underwent  a bowel preparation regimen to include clear liq-  uid diet beginning 2 days before surgery, two bot-  tles of magnesium citrate orally the day before  surgery, and a self-administered Fleets enema  the evening before surgery. Postoperatively, the  patients received ketorolac 30 mg intravenously  every 6 hours for a maximum of 48 hours. The  mean donor stay was only 1.1 days, with no read-  missions for ileus. Many surgeons are reluctant to  administer ketorolac in the postoperative setting  to a patient who has a solitary kidney, but the au-  thors found no instances of long-term kidney   Lind and colleagues [52] explored the effect  LDN had in time to return to work. They found  laparoscopic donors returned to work at some ca-  pacity at 6 weeks after surgery (5 weeks earlier  than open or hand-assisted donors) and had com-  plete return to work 9 weeks earlier than the open  or hand-assisted groups [52]. Much of the differ-  ence, however, was accounted for by expectations  given to the patients by the physician. It empha-  sizes the need to discuss realistic expectations  about activity restrictions with potential donors  before surgery and the power of positive sugges-  tion in the recovery process.    Complications occur with all laparoscopic pro-  cedures, but the consequences of subjecting an  otherwise healthy individual to a potential long-  term problem causes extra scrutiny of a technique.  The learning curve definitely attributed to some  early complications, with reports from 20% major  complications occurring in the first 50 cases  decreasing to 6% in cases 200 to 250, to 30%  complications in the first 30 cases with no  complications during the next 50 [41,53]. Others  reported series without significant effect of the  learning curve as long as experienced laparosco-  pists with a dedicated team performed the proce-  dure [54].   Two large series from the United States  examined major and minor complications and  found rates of 2.8% to 6.8% of major intra-  operative complications and 10.3% to 17.1%  postoperative complications [50,55]. The rate of  open conversion was 1% to 2%. One series found  that obesity increased operative time, but neither  series showed increased complication rate because  of obesity [50,55]. The rate of delayed graft func-  tion was 2.6% to 4.4% [50,55].   A critical analysis of delayed graft function  after LDN found that female donor kidneys into  male recipients and highly HLA- mismatched  donors were significant factors in delayed graft  function, but that no variable related to the  laparoscopic procedure itself (prolonged carbon  dioxide pneumoperitoneum, warm ischemia time,  renal artery length, use of right kidney) affected  the functional outcome of the allografts [56].   An interesting topic that rarely is reported  because of lack of extended follow-up is the effect  of kidney donation on long-term donor kidney    Author/ Pts WIT OR time EBL Conversion LOS Complications DGF Recipient  institution (n)  Left/right (min) (min) (mL) (n)  (days) (major/minor) (n) (94) Cr (mg/dL) Graft survival  Breda et al [61]/ 300 297/3 4+2 180+55 80+50 3 (196) 1.1 (1-3) 5(1.6%)/ = — —  University 7 (2.3%)  of California  Los Angeles  2007  Sundaram et al 253 237/16 2.2+1.05 19950 1154285 3(1.2%) 2.80.9 10 (3.9%)/ 11 (4.4%) 1.9041.87 (7 days) —  [55]/ Indiana 16 (6.3%) 1.3940.53 (1 year)  University 2007  Simforoosh et al 100 100/0 8.7(4-17) 270.8t:58.5 — 1 (1%) 2.26 (2-5) 4 (4%)/ 11 (11%) 2.01 (0.7-12.5) 93.8% (1 year)  [46]/ Tehran, 19 (19%) (3 days) 1.32  Iran 2005 (0.8-2.8) (1 year)  Jacobs et al [50]/ 738 709/29 2.28:1.5 202.1+52.4 1284179 12 (1.6%)  2.68+1.6 5 (2.0%) 19 (2.6%) 2.01.5 (7 days) —  University of 50 (6.8%) 1.61.4 (1 year)  Maryland 2004  Su et al [62]/ 381 362/19 4.93.4 253455.7 3344690  8(2.199) 3.34.5 29 (7.6%)/ 17 (4.5%)  2.642.3 (4 days) 65.5+25.8  Johns 34 (8.9%) (5 years)  Hopkins 2004  Rawlins et al [54]/ 100 100/0 2.3 231 102 1 (1%) 3.3 0 (0%)/6 (6%) — 1.47 (5 days) 97% (6 months)    Abbreviations: Cr, creatinine; DGF, delayed graft function; EBL, estimated blood loss; LOS, length of stay; OR, operating room; Pts, patients; WIT, warm ischemia time.    function. A retrospective study of 736 patients  with mean time since donation of 3 years showed  that serum creatinine, systolic and diastolic blood  pressure, and urinary protein excretion all in-  creased significantly from preoperative values.  Twenty-four percent developed proteinuria, and  10% developed hypertension. Obese donors had  a higher rate of hypertension and new-onset  diabetes [57]. Another smaller study of 162 living  donors with a mean of 8-year follow-up, however,  found normal residual kidney function and the  same incidence of diabetes and hypertension in  donors as in the normal population [58].   The true complication rates are difficult to  completely ascertain because of a lack of a central-  ized donor registry. Therefore, they often rely on  short-term reports from single institutions. Many  authors have argued for a national/international  donor registry to determine the impact living donor  nephrectomy has on donor and graft health [50,59].  For instance, Shokeir recently reported a signifi-  cant under-reporting and underestimation of com-  plications from LDN. More surprising, no new  series reporting open donor nephrectomy had  been published since 1991, making the incidence  of open donor nephrectomy complications and  long-term outcomes in recent years unknown [59].    LDN has been a major advancement in the  procurement of living kidneys for donation.  The increase in living donors correlates with the  advent of laparoscopic harvesting, as shown by  the 11% increase in living donation from 2000 to  2001 [55]. Although many believe that the  increased living donor pool is exclusively because  of the application of LDN, it is difficult to defi-  nitely prove, and many other factors (such as  extending the donor criteria) may play important  roles [60]. Nonetheless, LDN is a known safe and  effective alternative for living donor nephrectomy  at centers with laparoscopic experience. Improve-  ments continue to emerge in surgical techniques  and perioperative management of the donors  and recipients, which will continue to lead to the  best possible outcomes for all parties involved.    The authors would like to acknowledge Dr.  Henrique Melquiades, Professor, Recife, Brazil  for his instrumental help in the preparation of the  video.    [1] 2006 Annual report of the US Organ Procurement  and Transplantation Network and the Scientific  Registry of Transplant Recipients: transplant data  1996-2005. Department of Health and Human Ser-  vices, Health Resources and Services Administra-  tion, Healthcare Systems Bureau, Division of  Transplantation, Rockville (MD); United Network  for Organ Sharing, Richmond, VA; University  Renal Research and Education Association, Ann  Arbor, MI.   ureteral complications in the recipients and improv-  ing the laparoscopic technique. Transplantation  1999:68(4):497—502.   practice guidelines. 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Laparoscopic  donor nephrectomy: the University of Maryland  6-year experience. J Urol 2004;171(1):47—51.   Breda A, Bui MH, Liao JC, et al. Association of  bowel rest and ketorolac analgesia with short hospi-  tal stay after laparoscopic donor nephrectomy.  Urology 2007;69(5):828—31.   Lind MY, Liem YS, Bemelman WA, et al. Live donor  nephrectomy and return to work: does the operative  technique matter? Surg Endosc 2003;17(4):591—5.  Leventhal JR, Deeik RK, Joehl RJ, et al.  Laparoscopic live donor nephrectomy—is it safe?  Transplantation 2000;70(4):602—6.    Rawlins MC, Hefty TL, Brown SL, et al. Learning  laparoscopic donor nephrectomy safely: a report  on 100 cases. Arch Surg 2002;137(5):531-4.  Sundaram CP, Martin GL, Guise A, et al. Compli-  cations after a 5-year experience with laparoscopic  donor nephrectomy: the Indiana University Experi-  ence. Surg Endosc 2007;21(5):724-8.   Abreu SC, Goldfarb DA, Derweesh I, et al. Fac-  tors related to delayed graft function after lapa-  roscopic live donor nephrectomy. J Urol 2004;  171(1):52-7.   Rizvi SA, Naqvi SA, Jawad F, et al. Living kidney  donor follow-up in a dedicated clinic. Transplanta-  tion 2005;79(9):1247—51.   Sansalone CV, Maione G, Aseni P, et al. Early and  late residual renal function and surgical complica-  tions in living donors: a 15-year experience at a single  institution. Transplant Proc 2006;38(4):994—5.  Shokeir AA. Open versus laparoscopic live donor  nephrectomy: a focus on the safety of donors and  the need for a donor registry. J Urol 2007;178(5):  1860—6.   Schweitzer EJ, Wilson J, Jacobs S, et al. Increased  rates of donation with laparoscopic donor nephrec-  tomy. Ann Surg 232(3):392-400.   Breda A, Veale J, Liao J, et al. Complications of  laparoscopic living donor nephrectomy and their  management: the UCLA experience. Urology 2007;  69(1):49-52.   Su L, Ratner LE, Montgomery RA, et al. Laparo-  scopic live donor nephrectomy: trends in donor  and recipient morbidity following 381 consecutive  cases. Ann Surg 2004;240(2):358-63.    David Canes, MD*, Andre Berger, MD",  Matthew T. Gettman, MD^, Mihir M. Desai, MD**    “Department of Urology, Center for Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute,  Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA  ^Department of Urology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA    Ureteropelvic junction obstruction (UPJO) is  the most common congenital abnormality of the  ureter, with an annual incidence of 5 per 100,000  population. For many years, open pyeloplasty  remained the ‘gold-standard’ treatment, with  success rates greater than 90%. During the last  2 decades, multiple minimally invasive methods  have been used for the surgical management of  UPJO, including endopyelotomy, endopyelo-  plasty, and laparoscopic and robotic pyeloplasty.  The choice of initial surgical intervention is  important because it is likely to influence the final  outcome.   This review covers minimally invasive  treatments for UPJO in the adult, including  endopyelotomy (antegrade and retrograde),  endopyeloplasty, laparoscopic pyeloplasty (LP),  and robotic pyeloplasty. The relevant literature  is summarized, and a rational algorithm for  management is proposed.    The goals of diagnostic evaluation in a patient  suspected of having a UPJO are to confirm  functional obstruction, determine differential  renal function, and assess the anatomy at the  uteropelvic junction (UPJ). Mercaptoacetyl-Tri-  Glycine (MAG3) diuretic renal scan typically  achieves the first two goals. A retrograde pyelo-  gram (usually at the time of surgical procedure)    confirms the length of stricture and degree of  hydronephrosis. A spiral CT angiogram may be  useful in preoperative detection of a crossing ves-  sel in a patient in whom endopyelotomy is being  considered as a treatment option.    In 1903, Albarran [l] first described full-  thickness incision of a narrow ureteral segment  followed by prolonged stenting. Endoscopic pye-  lolysis was first described by Wickham and Kellett  [2] and popularized by Badlani and colleagues [3]  as endopyelotomy. The key concept of endopye-  lotomy is based on the principle of intubated  ureterostomy developed by Davis [4]: regeneration  of the ureter over a stent for 6 weeks after a full-  thickness incision, causing a durable increase in  the caliber of the strictured segment. The exact  mechanism of ureteral healing, however, remains  unclear. A combination of wound contracture  and smooth muscle regeneration likely contributes  to healing of the endopyelotomy defect.   Many variables have been suggested as pre-  dictors of poor prognosis after endopyelotomy,  including the presence of crossing vessels, severe  hydronephrosis, long (>1.5 cm) stricture length,  poor ipsilateral renal function, and previous failed  endopyelotomy. The discussion of the impact of  crossing vessels on the outcome after endopyelot-  omy continues to be debated. Van Cangh and  colleagues [5] reported 46% success in patients  with crossing vessels and 86% without. Evaluat-  ing the Acucise technique, Nakada and colleagues    0094-0143/08/$ - see front matter © 2008 Elsevier Inc. All rights reserved.    [6] reported lower success in patients with crossing  vessels (96% versus 64%). One would expect  a higher incidence of crossing vessels found at  secondary pyeloplasty after failed endopyelotomy,  but results are inconsistent. Knudsen and col-  leagues [7] and Van Cangh and colleagues [8]  found crossing vessels in 83% and 87% of their  cases, respectively. In contrast, Gupta and  colleagues [9] attributed only 4% cases of endo-  pyelotomy failure to crossing vessels.   Poor renal function and significant hydroneph-  rosis seem to predict a higher failure rate after  endopyelotomy. In patients with poor renal func-  tion, the success rate was 54% compared with  94% in patients with normal renal function [9].  Danuser and colleagues [10] described a success  rate of 87% in patients with a pyelocalyceal vol-  ume less than 50 cm?, 81% with a volume from  50 to 100 cm?, and 69% with a volume greater  than 100 cm’.    Initially reported by Ramsay and colleagues  [11] in 1984, the technique has several variations:  cutting between two wires, cutting over a stent  [12], invagination of the UPJ [13], and external  incision of the UPJ through a transpelvic route  [14]. Cold knife, electrocautery, and laser have  each been reported, with none conclusively  demonstrated to be superior over the others.  Antegrade endopyelotomy is particularly suitable  in patients who have concomitant large-volume  stone disease. Success rates with antegrade  endopyelotomy range between 67% and 88%  (Table 1).    Ureteroscopic retrograde endopyelotomy was  initially reported by Inglis and Tolley [18] in 1986.  The most attractive feature of the ureteroscopic  approach is the potentially reduced morbidity  when compared with the percutaneous approach.  The risk for subsequent ureteral stricture was  historically higher with the use of large-diameter  ureteroscopes and electrocautery [19]. Whereas  preemptive stenting was previously necessary to  achieve passive ureteral dilatation, current small  profile semirigid ureteroscopes and flexible ure-  teroscopes have practically abolished this need  and significantly reduced ureteral complications  with this procedure. The incision is performed    using the  holmium:yttrium-aluminum-garnet  (YAG) laser at 10 W through a 200- to 365-p laser  fiber. Symptomatic and radiographic success  range from 65% to 91% and from 73% to 85%,  respectively [20-24]. Geavlete and colleagues [25]  reported a success rate of 83.3% (18 months of  follow-up) in 30 patients who had secondary  UPJO (failed pyeloplasty [17 cases], failed endo-  pyelotomy [13 cases]) (Table 2).    Acucise endopyelotomy consists of a balloon  electrocautery incision performed under fluoro-  scopic control and was first proposed by Chand-  hoke and colleagues [26] in 1993. Drawbacks of  cutting-wire endopyelotomy include difficulty in  controlling the rate and depth of the incision and  the risk for hemorrhage because ofthe lack of direct  visual control. Bleeding complications have been  reported in 3% to 10% of cases [27,28]. Results  from select series of cutting-wire balloon endopye-  lotomy are summarized in Table 3.   El-Nahas and colleagues [35] compared  Acucise with ureteroscopic endopyelotomy in  40 patients who had UPJO in a prospective ran-  domized trial (follow-up of 30 months). Exclusion  criteria included the presence of crossing vessels,  renal function less than 20%, or hydronephrosis  of grade 3 or greater. Success rates were 85%  for the ureteroscopic group and 65% for the  Acucise group. There was no difference in the  complication rate.   Preference of the surgeon, anatomic factors,  and concomitant calculi are the main factors  considered in the choice between the percutaneous  and ureteroscopic approaches for endopyelotomy.  The main advantage of percutaneous approaches  is the ability to treat concomitant calculi. Body  habitus or anatomic issues that may have pre-  viously limited retrograde access have decreased  with modern ureteroscope technology, and  decreased morbidity makes retrograde endopye-  lotomy an attractive option for the appropriate  short-segment stricture.    Stenting after endopyelotomy is still debated.  No consensus exists regarding optimal stent size  or duration of stenting. The assumption that  a larger stent would result in a larger final caliber  if healing occurs around the stent has been  analyzed. Danuser and colleagues [36] evaluated  the influence of stent size in two consecutive series    Primary Crossing Open OR Hospital  First Senior UPJO vessels conversion time stay Follow-up Symptomatic Radiographic Complications  author author Year Cases Technique (n)  (minutes) (days) (months) success (o) success   Motola [15] Smith 1993 212 Cold knife 110 79 1.5 119 4.1 25 85 86 1695  Van Cangh Lorge 1994 102 Cold knife 81 57 0 252 3:3 26 Not stated 73 Not stated  5]  Kletscher ^ Patterson 1995 50 Cold knife 49 42 54 185 4.5 14 92 88 Not stated  16]  Gupta Smith 1997 401 Cold knife 235 42 2.9 164 2.6 19 Not stated 85 Not stated  9]  Danuser Studer 1998 80 Cold knife 80 57 0 165 3:3 23 Not stated 81 13  10]  Shalhav Clayman 1998 63 Electrocautery 40 16 6.4 179 4 12 89 85 27  17]  Knudsen Denstedt 2004 80 Electrocautery 61 54 Not 246 3.1 24 Not stated 67 Not stated  7] (77), laser (3) reported    Abbreviation: OR, operation.  Data from Desai MM, Hegarty N. Contemporary surgical management of adult ureteropelvic junction obstruction. AUA Update Series 2007;26.   [22 stated  of patients who had UPJO managed by antegrade stents after endopyelotomy, Kletscher and    endopyelotomy. In group 1 (77 patients), a 14/8.2-  French graduated stent was used. In group 2 (55  patients), a 27-French catheter was used for  3 weeks, followed by the same 14/8.2-French  graduated stent for 3 weeks. The early success  rates after 6 to 8 weeks in groups | and 2 were  83% and 94%, respectively. The long-term  success rates after 2 years were 71% and 93%,  respectively, suggesting that the benefit in the  group with larger stents was durable. Similarly,  Wolf and colleagues [37] evaluated 69 patients  undergoing 77 endoureterotomies for ureteral  strictures and found that for strictures longer  than 1 cm, use of a stent sized 12 French or  greater seems to be beneficial.   Series of retrospectives nonrandomized studies  did not support any benefits from using larger  stents. Comparing 14/7-French versus 8-French    colleagues [16] found no statistically significant  difference. Hwang and colleagues [38] evaluated  40 patients after percutaneous endopyelotomy,  and the difference between 6-French and 14/7-  French stents was not statistically significant.   What about duration of stenting? The classic  study of Davis [4] still drives the empiric 6-week  stenting time. In contrast, Mandhani and  colleagues [39] compared 57 consecutive patients  who had primary UPJO randomized to undergo  7/14-French internal endopyelotomy stent place-  ment for 2 weeks (group 1) and 4 weeks (group  2), and no difference was found in drainage  pattern stent-related symptoms, suggesting that  6 weeks may not be required. Properly conducted  studies are required to establish evidence-based  guidelines for stenting practice after endopy-  elotomy.   [28]  Faerber [30] Ohl 1997 32 27 14 Not stated 81 15.6  Gelet [27] Dubernard 1997 44 21 12 Not stated 78 4.6  Kim [31] Albala 1998 77 61 12 Not stated 78 4  Lechevalier Coulange 1999 36 23 24 Not stated 75 Not stated   [32]  Biyani [33] Hetherington 2002 42 34 27 64 52 10  Weikert [34] Schrader 2005 24 24 32 58 (overall) 58 (overall) 12.5    Data from Desai MM, Hegarty N. Contemporary surgical management of adult ureteropelvic junction obstruction.    Ng and colleagues [40] evaluated 42 patients  (mean follow-up of 47.7 months) who underwent  management of failed primary intervention for  UPJO. Secondary intervention. included open  operative repair (n — 20) or percutaneous  (n — 11), ureteroscopic (n — 5), or retrograde  cautery wire balloon endopyelotomy (n — 6).  Long-term success rate of endoscopic treatment  of secondary UPJO was 59.1% overall, including  a 71.4% success rate after a failed open operative  procedure and a 37.5% success rate after a failed  endourologic procedure. Success of open opera-  tive salvage was 95% overall, including 94.1%  after failed endourologic intervention and 10095  after failed open operative intervention. In sum-  mary, endopyelotomy may be the optimal initial  intervention after failed pyeloplasty but has  a poor outcome after failed endopyelotomy.    Endopyeloplasty consists of a Heineke-Miku-  licz repair accomplished entirely through a percu-  taneous tract (Fig. 1). In 1996, Oshinsky and  colleagues [41] reported percutaneous intrarenal  suturing for the first time. Desai and colleagues  [42] reported the use of a laparoscopic suturing  device through a 26-French nephroscope to  perform endopyeloplasty (Fenger) in a porcine  model. Technical feasibility was established, with  a wider caliber of the UPJ after endopyeloplasty  compared with endopyelotomy. Presumably, heal-  ing by primary rather than secondary intention  accounts for this finding.   In a clinical setting, Gill and colleagues [43]  published the results of endopyeloplasty in  9 patients. Inclusion criteria were less than 1-cm  segment stenosis, absence of crossing vessels on  preoperative imaging, and absence of prior UPJ  surgery. Success was defined as absence of pain  and improvement of drainage on an excretory  urogram or diuretic renal scan. Endopyeloplasty  was completed in 53 patients. Mean operative  time was 103 minutes, and suturing time was  27 minutes. Two cases of intraoperative complica-  tions were reported: suture cut-through and irri-  gation fluid extravasation. Prolonged ureteral  stenting was required in five cases for pyrexia.  Surgery relieved obstruction in 96.2% (n = 51)  of the patients and failed in 3.8% (n = 2): one  immediately after stent removal and the other    12 months after the procedure, in whom a crossing  vessel was identified.   In 2004, Desai and colleagues [44] reported  1-year follow-up data retrospectively compared  with matched cohorts undergoing endopyelotomy  and LP in 44 patients who had primary UPJO.  Resolution of symptoms and unobstructed  drainage on intravenous urography or diuretic  renography was noted in 100% and 100% of    endopyeloplasties (n = 15, mean follow-up of  11.6 months), 93% and 88% of percutaneous  endopyelotomies (n = 15, mean follow-up of    31.4 months), and 93% and 100% of LPs  (n = 14, mean follow-up of 20 months). Using  the same technique, however, Ost and colleagues  [45] had only a 40% success rate (2 of 5 patients).  This lower rate was explained by a previous bal-  loon dilation of the UPJ, leading to a thinner ure-  teral wall, resulting in suture pull-through and  fibrosis. Initial data suggest the feasibility and  safety of percutaneous endopyeloplasty in selected  patients who have primary UPJO. In general,  indications are similar to those of endopyelotomy,  and the results may be superior. Longer follow-up  and multi-institutional experience are necessary to  corroborate these promising findings.    Initially reported by Schuessler and colleagues  [46] in 1993, LP has now emerged as a standard  approach to UPJO with results comparable to  the gold-standard open pyeloplasty. LP allows  correction of all anatomic variants of UPJO,  transposition or displacement of crossing vessels  when necessary, treatment of primary and second-  ary UPJO [47], extraction of concomitant renal  calculi [48], and pelvic reduction when indicated.  Indications have recently been carefully expanded  to include pelvic and horseshoe kidneys [49] in  addition to solitary kidneys [50].    The choice of trans- or retroperitoneal  approaches is governed by surgeon preference  and individual patient factors. Although either  approach may be used in most patients who have  primary UPJO, the retroperitoneal approach may  be preferred in patients with obesity or a history  of prior abdominal surgery. The transperitoneal  approach is preferred in patients with prior  retroperitoneal surgery on the ipsilateral kidney  and in complex UPJ repairs in which salvage    Fig. 1. Endopyeloplasty. Vertical incision is made down to peripelvic fat (A) and closed horizontally with an endoclose  device (B-D). (Courtesy of the Cleveland Clinic Foundation, Cleveland, OH; with permission.)    procedures may be required. Most published  series use the classic technique as described by  Andersen and Hynes [51] in an attempt to dupli-  cate established open surgical techniques. Nondis-  membered techniques, including Y-V plasty,  Fengerplasty, and flap pyeloplasty, have all been  described and are technically feasible but are indi-  cated in few situations. Klingler and colleagues  [52] noted higher success rates with dismembered  pyeloplasty (96%) compared with nondismem-  bered techniques (73%), suggesting superiority  of the former, which the authors use in most cases.   A brief description of the authors' preferred  technique is as follows (Figs. 2 and 3). They per-  form retrograde stenting before LP at the begin-  ning of the case. In the authors' opinion,  decompression of the renal pelvis by the stent    does not pose any significant disadvantage during  mobilization of the pelvis and UPJ. The anesthe-  tized patient is placed in the lithotomy position.  A retrograde pyelogram is performed to  confirm the level and extent of anatomic obstruc-  tion. The retrograde pyelogram alters manage-  ment in the occasional patient in whom ureteral  obstruction is revealed that was not apparent on  preoperative imaging. A 4.7-French or similarly  small-caliber ureteral stent is placed at the conclu-  sion of the retrograde pyelogram. In the authors'  experience, the 4.7-French stent easily admits dis-  secting scissors alongside it, facilitating spatula-  tion and subsequent unhindered suturing  compared with a standard 6-French stent. The  patient is placed in a 45° flank position and  a three- or four-port transperitoneal approach is    Fig. 2. Pyeloplasty. An oblique pyelotomy is made. The  lateral edge of ureter is spatulated across the narrowed  segment. A 4.7-French stent facilitates spatulation by  leaving room for the scissors. (Courtesy of the Cleveland  Clinic Foundation, Cleveland, OH; with permission.)    used. Anterior axillary line lateral retraction,  when needed, is accomplished using a needlescopic  grasper through a 2-mm Veres port.   The technique of dissection to expose the UPJ  mimics open surgical principles. Aggressive distal  ureteral dissection is avoided. An inflammatory  rind, if present, is dissected sufficiently to expose  the pelvic wall in the region of the UPJ. The UPJ  is dismembered obliquely, and pelvic reduction  and pyelolithotomy are performed when indi-  cated. The lateral ureteral spatulation proceeds  across the narrowed UPJ, and for a distance such  that reapproximation accomplishes a dependent  funneled configuration without undue tension but  also without redundancy of the ureter. In patients  with a crossing vessel, the decision to transpose  depends on the  surgeon's assessment of  the obstructive nature of the crossing vessel and  the relative position of the vessel in relation to the  neo-UPJ. A 4-0 polyglactin suture on an RB-1  needle approximates the dependent portion of  the pyelotomy to the caudal spatulated portion  of ureter. This suture is run along the anterior  wall as a forehand stitch. A separate 4-0 polyglac-  tin running suture is then run along the posterior  wall as a backhand stitch. Remaining open pelvis    is closed with 4-0 polyglactin if necessary. When  tissue quality or tension is of some concern,  kidney mobilization is performed and interrupted  sutures are placed.   A closed-suction drain is placed in proximity  to the repair. Free oral intake is commenced when  the residua of anesthesia have passed, typically the  evening of surgery or the following morning. The  urethral catheter is removed after 1 to 2 days,  followed by the drain, once output is low. The  stent is removed at 4 weeks.    Worldwide experience with LP is summarized  in Table 4. Success rates of LP range from 88% to  10095, [53—58] depending on subjective (symptom-  atic) or objective (radiographic) measures. These  results generally surpass those of endopyelotomy  and match the established success rates (7 9094)  of open pyeloplasty [61]. Direct nonrandomized  comparisons of open repairs with LP arrive at  similar conclusions. Bauer and colleagues [62]  compared 42 LPs with 35 open repairs. At 1 year  of follow-up, symptomatic improvement was  observed after 90% of LPs and 91% of open  repairs. Radiographic improvement was present  in 98% and 94%, respectively.    The routine transposition of crossing vessels  continues to be the subject of some debate. Aron  and colleagues [63] retrospectively compared  8 patients undergoing transposition with 23 not  undergoing transposition. Obstruction was  successfully treated in all patients, as evaluated  by nuclear scintigraphy. More of the patients in  the nontransposed group were operated on by  means of a retroperitoneal approach, and vice  versa. It seems clear that success has more to do  with meticulous dismembered pyeloplasty than  with the relation to overlying vessels, but the  debate nevertheless continues.   Stern and colleagues [64] took a closer look at  the impact of crossing vessels by performing intra-  operative Whitaker tests in 10 patients at the time  of LP. They measured differential pressures before  any significant dissection and after mobilization  of the vessels from the UPJ. In this small group,  mere mobilization of the crossing vessels brought  pressures down to unobstructed levels. This crea-  tive study has demonstrated that the vessels may  be one of several contributing factors in UPJO.  As others have shown [65], however, concomitant    Fig. 3. (A) Corner is tied with a 4-0 Vicryl suture on an RB-1 needle. (B-C) This is run along the anterior wall as a fore-  hand stitch (pelvis-ureter [right] or ureter-pelvis [/eft]). (D) With the assistant retracting the anterior wall suture, a back-  hand 4-0 Vicryl suture is placed. (E) Posterior wall is completed as a running backhand stitch. (F) U-stitch makes the  transition onto the pelvis. A separate 3-0 or 4-0 running Vicryl suture from a cephalad-to-caudad direction closes the  pyelotomy (varying size depending on need for pelvic reduction). (Courtesy of the Cleveland Clinic Foundation, Cleve-    intrinsic obstruction is present in up to one third  of patients with crossing vessels, necessitating pye-  loplasty and not simple mobilization of the vessel.  In addition, the findings still support the possibil-  ity that obstruction may resolve after nontrans-  posed dismembered pyeloplasty.    Patients requiring pyelolithotomy are excellent  candidates for LP. In the authors' experience,  most pelvic stones and many calyceal stones may    be visualized and removed through the pyelotomy  using standard laparoscopic grasping instruments.  In the remainder, flexible nephroscopy can be  performed through a laparoscopic trocar. In their  report on 147 LPs, Inagaki and colleagues [58]  included 22 renal units requiring simultaneous  pyelolithotomy, with a 90% stone-free rate. Simi-  larly, Ramakumar and colleagues [48] achieved  a stone-free rate of 90% in 20 renal units requiring  LP with pyelolithotomy.   Anatomic anomalies are generally no contra-  indication to LP. In fact, the anteriorly positioned    Open Operative  First Senior Crossing conversion time Hospital Follow-up Symptomatic  author author Year Approach Repair type (n) vessels (96) (96) (minutes) stay (days) (months) success (96)  Janetschek Bartsch 2000 Trans Fengerplasty (67) 79 1.5 119 4.1 25 98  [53]  Soulie [54] Plante 2001 Retro Dismembered (48) 42 5.4 185 4.5 14 100*  Jarrett [55] Kavoussi 2002 Trans Dismembered (71) 57 0 252 3.3 26 98  Turk [56] Loening 2002 Trans Dismembered (49) 57 0 165 34 23 98  Mandhani Bhandari 2005 Trans Dismembered (59), 16 6.4 179 4 12 93  [57] Fengerplasty (7),  Y-V (20)  Inagaki Jarrett 2005 Trans Dismembered (106), 54 Not 246 3.1 24 95  [58] Fengerplasty (11), reported  Y-V (28)  Zhang [59] Ye 2005 Retro Dismembered (50) 12 0 81 7.6 22 98  Moon Eden 2006 | Retro Dismembered (170) 42 0.6 140 3 22 96  [60]    Abbreviations: Retro, Retroperitoneal; Trans, Transperitoneal.  * All patients pain free, with patent UPJ on intravenous pyelogram at 3 months; 88.9% had radiographic success, with decreased hydronephrosis at 3 months.  Data from Desai MM, Hegarty N. Contemporary surgical management of adult ureteropelvic junction obstruction. AUA Update Series 2007;26.    renal pelvis in horseshoe kidneys, for instance,  may make laparoscopy the preferred approach.  Bove and colleagues [66] reported on LP in five  patients with horseshoe kidneys. The overall suc-  cess rate of 91% included dismembered, Y-V,  and Heineke-Mickulicz approaches. Three of  these patients underwent concomitant pyelolithot-  omy. Similarly, Gupta and colleagues [67]  reported two successful dismembered LPs in  horseshoe kidneys. LP is also feasible in solitary  kidneys. Wood and colleagues [68] reported  100% technical success in eight solitary kidneys  undergoing LP, similar to results in a matched  cohort undergoing open repair.   For secondary UPJO, LP has been reported  with success. In general, LP is appropriate for  failed endopyelotomy, and endopyelotomy is  appropriate for failed LP. The first clinical report  of LP for secondary UPJO in 1995 was updated in  2003 by Sundaram and colleagues [69]. This group  of 36 patients had undergone a mean of 1.3 prior  procedures. Radiographic patency was achieved  in 89% of patients. Considering 2 patients with  equivocal radiographic drainage but symptomatic  resolution, the group reported a 94% overall  success rate at 22 months. Other series of LP for  secondary UPJO include those of Jarrett and  colleagues [55] (88% success) and Siqueiria and  colleagues [70] (88% success).    The steep learning curve for intracorporeal  suturing that allows precise mucosal reapproxi-  mation has limited the widespread diffusion of  LP. Just as robotic technology had an impact on  prostatectomy, the application of robotics to  pyeloplasty has found similar enthusiasm. Results  from selected series of robotic-assisted LP are  shown in Table 5. The robotic experience was  built on the principles of LP, and, as expected,  the results have similarly duplicated those of  open repair, with success rates greater than  90%. The largest series by Schwentner and  colleagues [76] includes 92 cases, with 96.7%  radiographic success at 39 months and a mean  operative time just shy of 2 hours. Although these  investigators attribute these impressive results to  the precision of robotic suturing, there is no firm  reason to attribute this success to any factor other  than surgeon experience and meticulous plastics  closure of the UPJ, regardless of the method  used. Experienced freehand laparoscopists can    and do place sutures with the same precision  and have achieved similar results as shown  previously.   Gettman and colleagues [77] reported on  a comparison between robotic and laparoscopic  approaches, with six patients in each group.  Operative times were shorter for dismembered  pyeloplasty in the robotic group (140 versus  235 minutes). This should not necessarily be taken  to suggest that robotic pyeloplasty is a faster pro-  cedure in all hands or at all centers. Today, the  choice between robotic and pure laparoscopic ap-  proaches has more to do with surgeon preference  and availability of the robot. As a community,  one hopes that the relative ease of robotic suturing  may hasten the diffusion of minimally invasive  approaches to UPJO in the future.    Desai and colleagues [78] published the first  clinical case of laparoscopic single-port pyelo-  plasty. Whereas standard LP requires three to  four ports, attempts to minimize morbidity  further prompted exploration of single-port lapa-  roscopy (SPL). A single trocar permitting passage  of three instruments was deployed at the umbili-  cus. The three inlet valves contain a thermoplastic  elastomer allowing the introduction of one 12-mm  and two 5-mm instruments, with a separate dedi-  cated insufflation channel. A combination of rigid  and flexible or bent instruments limits external  instrument crowding and accomplishes triangula-  tion internally. For single-port pyeloplasty,  a 2-mm needlescopic port was used as a left-  handed instrument to aid intracorporeal suturing  that did not require a formal skin incision. Oper-  ative time was 160 minutes, and the patient was  discharged on the second postoperative day. The  ultimate role of SPL remains to be determined.  Theoretic advantages of improved cosmesis and  decreased pain need to be evaluated in larger  series with direct comparison to cohorts undergo-  ing traditional laparoscopy. The same group has  subsequently used the single umbilical approach  for performing bilateral simultaneous pyeloplasty  in two patients who had bilateral UPJO.    When Chen and colleagues [79] summarized  LP for the Urologic Clinics of North America  in 1998, they correctly stated, ‘additional    Operative  First Senior Crossing time Hospital Follow-up Symptomatic Radiographic Complications  author author Year N Approach Repair type (n) vessels (7o) (minutes) stay (days) (months) success (Ve) success (Vo) (9)  Bentas [71] Binder 2003 36 Trans Dismembered 36 197 2:3 21 100? 100 9  Patel [72] Same 2005 33 Trans Dismembered 33 122 1.1 11.7 100 100 0  Palese [73] Del Pizzo 2005 29 Trans Dismembered 29 216 2.8 7.9 94 94 11  Siddiq [74] Bird 2005 42 Trans Dismembered (23), 42 245 2 6 95 100 12  Y-V (3)  Mendez- Thomas 2005 44 Trans Dismembered (31), 44 300 1.1 10.3 94 94 3  Torres [75] Fengerplasty (1)  Kaouk, = 30 Retro Dismembered 30 157 2 15 100 100 0  (unpublished  data, 2005)  Schwentner [76] ^ Peschel 2007 92 Trans Dismembered 49 108 4.6 39 96.7 100 3    Abbreviations: Retro, Retroperitoneal; Trans, Transperitoneal.  * One patient who initially experienced flank pain and hydronephrosis after initial stent extraction responded to an additional 4 weeks of stenting.  Data from Desai MM, Hegarty N. Contemporary surgical management of adult ureteropelvic junction obstruction. AUA Update Series 2007;26.    Fig. 4. Simplified algorithm for surgical management of UPJO. Endopyeloplasty can be used for select patients in place  of endopyelotomy. Hydro, hydronephrosis; mod, moderate; lap, laparoscopic.    developments. ..may further simplify laparoscopic  surgery, allowing laparoscopic reconstructive pro-  cedures to come into widespread use. The dawn  of robotics was imminent and has perhaps offered  this ‘simplification’ to allow diffusion of this min-  imally invasive technique, albeit at a high cost.  Over the past decade, we have seen LP established  as a gold-standard procedure alongside open pye-  loplasty, with commensurate results and lower  morbidity. With the current minimally invasive  treatments available in 2007 for the adult patient,  only the rare patient now undergoes open  pyeloplasty.   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Laparo-  scopic versus open dismembered pyeloplasty in a sol-  itary kidney. J Urol 2006;175(Suppl):20 [abstract  59].   [69] Sundaram CP, Grubb RL III, Rehman J, et al. Lap-  aroscopic pyeloplasty for secondary ureteropelvic  junction obstruction. J Urol 2003;169(6):2037—-40.   [70] Siqueira TM Jr, Nadu A, Kuo RL, et al. Laparo-  scopic treatment for ureteropelvic junction obstruc-  tion. Urology 2002;60(6):973-8.   [71] Bentas W, Wolfram M, Bräutigam R, et al. Da Vinci  robot assisted Anderson-Hynes dismembered pyelo-  plasty: technique and 1 year follow-up. World J Urol  2003;21(3):133-8.   [73] Palese MA, Stifelman MD, Munver R, et al.  Robot-assisted laparoscopic dismembered   Siddiq FM, Leveillee RJ, Villicana P, et al. Com-  puter-assisted laparoscopic pyeloplasty: university  of Miami experience with the daVinci surgical  system. J Endourol 2005;19(3):387-92.  Mendez-Torres F, Woods M, Thomas R. Technical  modifications for robot-assisted laparoscopic pyelo-  plasty. J Endourol 2005;19(3):393-6.   Schwentner C, Pelzer A, Neururer R, et al. Robotic  Anderson-Hynes pyeloplasty: 5-year experience of  one centre. BJU Int 2007;100(4):880—5.    Gettman MT, Peschel R, Neururer R, et al. A com-  parison of laparoscopic pyeloplasty performed with  the daVinci robotic system versus standard laparo-  Scopic techniques: initial clinical results. Eur Urol  2002;42:453.   Desai MM, Rao PP, Aron M, et al. Scar-less  single-port transumbilical nephrectomy and pyelo-  plasty: a first clinical report. BJU Int 2008;101(1):  83-8.   Chen RN, Moore RG, Kavoussi LR. Laparoscopic  pyeloplasty. Indications, technique, and long-term  outcome. Urol Clin North Am 1998;25(2):323-30.    Geoffrey R. Wignall, MD*, Benjamin K. Canales, MD, MPR”,  John D. Denstedt, MD*, Manoj Monga, MD?*    “Division of Urology, University of Western Ontario, 268 Grosvenor Street, London, Ontario, Canada N6A 4V2  PUniversity of Florida, 1600 SW Archer Rd, RM# N-213, Post Office BOX 100247, Gainesville, FL 32610, USA  *Department of Surgery, University of Western Ontario, 268 Grosvenor Street, London, Ontario, Canada N6A 4V2  “Department of Urologic Surgery, University of Minnesota, Mayo 394, 410 Delaware Street  Southeast, Minneapolis, MN 55455-0392, USA    Since the first reported successful shock wave  lithotripsy (SWL) treatment of a patient who had  a renal stone in 1980 [1], urologists increasingly  have employed minimally invasive techniques to  treat patients who have ureteral or renal calculi.  With over 25 years of experience in the techniques  of SWL, percutaneous nephrolithotomy (PCNL),  and ureteroscopy (URS), the amount of informa-  tion available to objectively counsel a stone  former on his/her treatment options can be over-  whelming. This article reviews the recent literature  that may affect surgical decision making for renal  and ureteral calculi, including imaging and patient  selection, and a step-by-step review of surgical  minimally invasive approaches.    Noncontrast, spiral CT has become the imag-  ing modality of choice for assessing urinary stone  disease, offering highly specific information such  as stone location, size, number, density, and renal  anatomy [2]. Because larger cystine, brushite, and  calcium oxalate monohydrate stones are known to  be more resistant to SWL fragmentation [3-5], CT  attenuation values of urinary calculi in Hounsfield  units (HU) have been used to differentiate stone  composition with some degree of success. In vitro    studies have demonstrated that uric acid stones  consistently have attenuation levels below 1000  HU, whereas calcium oxalate and phosphate  stones usually exceed 1000 HU [6-8]. Unfortu-  nately, the range of HU values for calcium oxalate  monohydrate and struvite stones overlap, suggest-  ing that some stone compositions cannot be pre-  dicted reliably by CT [6,9]. In addition, several  studies have shown that stone size plays a role  in HU density calculations. In the early 1980s,  Parienty and colleagues [10] found that stones of  the same composition less than 5 mm in diameter  had lower attenuation value than sized at 5 to  9 mm and proposed that the use of low-resolution  beam collimation (5 mm) can yield artificially low  attenuation values because of volume averaging  [10]. More recently, Saw and colleagues [11]  scanned 127 human calculi (ex vivo) and used  a model, based on the physics of helical CT, to  predict the effect of scan collimation width and  stone size. As stone size decreased, HU for the  same stone types also decreased, implying that  smaller stones may decrease attenuation readings  falsely and produce misleading results.    Recently, correlating SWL success rates with  in vivo CT HU attenuation levels has gained  popularity. Joseph and associates studied 30  patients who had renal calculi undergoing SWL  therapy using an electromagnetic lithotripter [12].  Patients who had calculi less than 500 HU (n = 12)    0094-0143/08/$ - see front matter © 2008 Elsevier Inc. All rights reserved.    had 100% stone clearance and required a median  of 2500 shocks. Those who had calculi of 500 to  1000 HU (n — 7) had a clearance rate of 8695  and required a median of 3390 shocks. Patients  who had calculi HU greater than 1000 (n — 11)  had a clearance rate of 56% and required a median  of 7300 shocks [12]. Similarly, Gupta and col-  leagues [13] used high-resolution CT protocols  to report a linear relationship between calculus  density and number of SWL sessions in patients  who had renal and proximal ureteral stones. For  stones less than 1.1 cm with HU less than 750,  they reported that 34 patients had three or fewer  SWL sessions and a stone-free rate of 9095. In pa-  tients who had HU greater than 750 and stone size  greater than 1.1 cm, almost 80% required three or  more SWL treatments with stone-free rates of  only 60% [13]. Two prospective trials have been  published in this area. The first, Wang and col-  leagues [14] in 2005, described three important pa-  tient factors on SWL multivariate analysis: stone  burden greater than 700 mm’, stone density  greater than 900 HU, and presence of nonoval  (branched, irregular) stones. The second study,  by El-Nahas and colleagues [15], found that stone  density greater than 1000 HU and body mass in-  dex (BMI) were the only variables that predicted  failure of renal stone disintegration using multi-  variate analysis. Leveraging the concept that stone  morphology may be predictive of SWL fragility  [16], this study is unique in that the authors use  high-resolution bone windows to report stone  size and narrow slide width protocols (1.2 mm  versus 3.75 mm sections; stone HU calculated at  lower, middle, and upper portion of stone versus  one calculation) to predict a high-risk SWL failure  group [15]. In contrast, Pareek and colleagues an-  alyzed 64 patients who had lower pole renal cal-  culi sized 5 to 15 mm undergoing SWL and did  not find HU to be an independent risk factor for  stone clearance. Because their stone-free group  had significantly smaller lower pole stone sizes be-  fore SWL (P«.01), it is likely that stone size,  stone density, and stone location, along with other  patient factors are linked in the context of lower  pole clearance rates. Further studies in the clinical  area of HU and stone density, in particular lower  pole stones, undoubtedly will aid in stratifying  SWL outcomes.    As the epidemic of obesity continues to grow in  underdeveloped and developed countries,    urologists increasingly will be presented with the  therapeutic challenge of stone disease in patients  who are obese and morbidly obese [17,18]. Techni-  cally speaking, each different minimally invasive  approach in obese patients who have stone disease  brings about its own unique set of nuances. SWL  may be limited in these patients, as their weight  may exceed gantry or table limits; their size may ex-  ceed lithotripter focal length, or body habitus may  prevent adequate stone visualization at the time of  SWL [19,20]. Proven to be just as safe and effective  as in the nonobese population, PCNL in patients  who are obese requires modifications in technique,  specialized long equipment, and the ability of the  patient to tolerate the prone position [21]. Al-  though no new equipment or techniques are re-  quired for the ureteroscopic approach, the patient  must be able to tolerate general anesthesia and  must be able to fit on the operating table without  interfering with fluoroscopy [22]. In addition, spe-  cial attention to thromboembolic prophylaxis and  prevention of pressure-induced iatrogenic injuries  during prolonged dorsal lithotomy positioning  may be warranted in the morbidly obese.    Excluding positioning and technical concerns,  the obese patient still may receive a suboptimal  outcome after SWL. In 1994, Ackermann and  colleagues [23] first described BMI as an indepen-  dent predictor of SWL failure using a Dornier  HM-3 lithotriptor (Dornier MedTech, Kennesaw,  Georgia). Their data suggested that patients who  had BMI less than or equal to 28 had the best  chance at successful SWL and implied that SWL  failure in obese patients may be because of ham-  pered stone targeting or dampened shock wave  blast path. In two more recent studies using sec-  ond-generation  electrohydraulic — lithotriptors,  Portis and colleagues and Pareek and colleagues  [24,25] both reported a causal relationship be-  tween SWL failures and BMI. Because fat is dis-  tributed in different areas for different patients  who have the same BMI, a quantitative measure-  ment of the distance from the shockhead to the  kidney was introduced in 2005, termed SSD or  "skin to stone distance." SSD is calculated by  measuring three distances from the renal stone  to the skin at the 0°, 45°, and 90? using radio-  graphic calipers or a computational measuring de-  vice [26]. The average of these values represents  the SSD for a given stone. In a series of 64 lower  pole stone patients undergoing SWL, Pareek and    colleagues found that SSD greater than 10 cm was  a more reliable predictor than either BMI or HU  measurements alone for SWL failure. Conversely,  El-Nahas and colleagues [15] published their series  of 120 patients who underwent SWL for solitary  renal stones 5 to 25 mm in size. Although it was  shown to be predictive of SWL stone disintegra-  tion failure by univariate analysis (P — .033),  SSD did not reach significance on multivariate  analysis [15]. Interestingly, BMI predicted need  for more than three SWL sessions and disintegra-  tion failure reliably. Overall, as both imaging  technology and patients’ abdominal girths ex-  pand, predicting SWL success by using surrogate  markers, such as BMI, HU, or SSD, may lead  to alternative stratification protocols.    Although many different stone and patient  factors play roles in the successful surgical man-  agement of upper tract urolithiasis, stones located  in the lower pole of the kidney continue to be  a challenge. In their meta-analysis, Lingeman and  colleagues [27] noted that between 1984 and 1991,  the incidence of lower pole stones treated with  SWL increased from 2% to 48% of all SWL cases.  The authors investigated the outcomes of SWL  for lower pole calculi and found that stone-free  rates ranged from 25% to 84.6%, with a mean  stone-free rate of 59.2%. This falls well short of  the expected stone-free rates for middle and upper  pole stones, which are estimated to be 70% to  90% [28]. Outcomes were more favorable for pa-  tients who had stones less than 1 cm, with an over-  all stone-free rate of 74% for a single treatment as  compared with patients who had stones 1 to 2 cm  or greater than 2 cm (stone-free rates of 56% and  33%, respectively). These findings questioned the  role of SWL in the management of larger, lower  pole stones, and opened the door for numerous  retrospective and prospective studies concerning  the management of these calculi [29-34]. A sum-  mary of the most recent lower pole stone-free suc-  cess rates stratified by procedure type and stone  size is listed in Fig. 1. Where at all possible,  stone-free rates are provided for single treatments,  with the longest recorded follow-up based on  strict CT criteria. Occasionally, mean stone size  was used because of lack of individual stone size  reporting. Multiple explanations have been of-  fered for the poor stone-free rates in lower pole  stones, including anatomic factors and the depen-  dent position of the calculi limiting the passage of    fragments from the kidney. The explanation to  this mystery, however, is likely multifactorial.   In 2001, the Lower Pole Study Group pub-  lished a prospective, randomized trial comparing  SWL and PCNL for treating lower pole stones  [33]. One hundred twenty-eight patients who had  symptomatic lower pole calculi were randomized  to receive either PCNL or SWL. Overall, stone-  free rates at 3 months were 95% for PCNL as op-  posed to only 37% for the SWL group (P « .001).  When stratified by stone size, it became evident  that SWL success rates declined as stone size in-  creased. The stone-free rates following SWL for  stones 11 to 20 mm and 21 to 30 mm were 2395  and 14%, respectively, as compared with 93%  and 86% for PCNL. Retreatment and the need  for auxiliary procedures were more common in  the SWL group, while hospital stay was signifi-  cantly longer in the PCNL group. Overall morbid-  ity was not significantly different between the two  groups. The authors concluded that stones greater  than 10 mm in diameter are managed better ini-  tially with PCNL because of the higher stone-  free rates and acceptable rate of morbidity. An  advantage of this multicenter trial was the fact  that eight different lithotriptors were represented,  minimizing the machine-specific effect on the suc-  cess and complication rates.   In 2005, Pearle and colleagues conducted  a multicenter trial comparing SWL and URS for  treating lower pole calculi less than or equal to 1  cm in diameter [38]. There was no significant dif-  ference in stone-free rates for SWL and URS  (35% versus 50%, P = .92). Additionally there  was no difference in the number of patients requir-  ing retreatment or ancillary treatments. Signifi-  cant differences were found, however, regarding  quality-of-life measures, with a more rapid return  to driving, work, and overall shorter recovery  time with SWL as compared with URS. In total,  90% of patients who underwent SWL would  choose the procedure again as opposed to 63%  in the URS group (P «.05). Complication rates  were not significantly different between groups.  The results of this study seem to support SWL  treatment over URS for stones 1 cm or less in di-  ameter because of superior patient acceptance;  however, the authors point out that many of the  symptoms encountered by the URS group could  be accounted for by the ureteral stent.   In an effort to improve poor outcomes, Pace  and associates investigated the effect of mechan-  ical percussion inversion (MPI) and diuresis on  residual lower pole fragments following SWL [50].    Fig. 1. Lower pole stone-free success rates stratified by procedure type and stone size. Prospective randomized con-  trolled trials are marked by an asterisk. (A) Size «1 cm. Shock wave lithotripsy (SWL): 74% [27]; 74% [35]; 72%  [36]; 63% [33]; 52% [37]; 47% [26]; 35% [38]. Ureteroscopy (URS): 87% [39]; 85% [40]; 82% [41]; 82% [42]; 79%  [43]; 62% [37]; 50% [38]. Percutaneous nephrolithotomy (PCNL): 100% [27]; 100% [33]. (B) Size 1 to 2 cm. SWL:  57% [44]; 56% [27]; 55% [45]; 51% [46]; 51% [36]; 41% [35]; 39% [36]; 23% [33]. URS: 71% [41]; 64% [43]; 63%  [42]; 31% [47]. PCNL: 93% [33]; 89% [27]; 76% [47]. (C) Size >2 cm. SWL: 33% [27]; 14% [33]; URS: 76% [48];    In total, 69 patients who had residual lower pole  fragments 3 months following SWL were random-  ized to receive either MPI or observation for 1  month. The group receiving MPI had a signifi-  cantly better stone-free rate than the observed  group (40% versus 3%) and a greater reduction  in total stone area (—63.3% versus +2.7%) in pa-  tients who were not free of stones. The authors  concluded that MPI is a safe and effective adjunct  to SWL in patients who have lower pole calculi,  significantly improving success rates and reducing  stone burden in SWL failures.    As with SWL, ureteroscopic management of  lower pole stones is frequently challenging, with  lower success rates than for stones located    elsewhere in the kidney. Grasso and Ficazzola  reported overall stone-free rates of 82%, 71%,  and 65% in patients with lower pole stones mea-  suring 10 mm or less, 11 to 20 mm, and greater than  20 mm, respectively, managed with retrograde  ureteropyeloscopy [41]. Several factors contribute  to these poor success rates, including the difficulty  of accessing the stone because of acute infundibular  angles and reduced deflection in ureteroscopes as-  sociated with the passage of even small laser fibers.  With the advent of small, flexible endoscopes and  tipless nitinol stone baskets, many urologists have  taken to relocating lower pole stones into a more fa-  vorable location before fragmentation. Kourambas  and colleagues [40] described the use of either a 3.2F  nitinol basket or 2.6F nitinol grasper in 10 cases  where access to the lower pole was inhibited by de-  creased ureteroscopic deflection. Fragmentation    was achieved in all 10 cases after stones were manip-  ulated into a more favorable location. Schuster and  colleagues reviewed their experience in 78 patients  undergoing ureteroscopy for lower pole stones  [43]. Success rates were significantly better in cases  where stones were displaced into a more favorable  location than in those where lithotripsy was per-  formed in situ. This was statistically significant for  stones measuring | to 2 cm, where only 29% of  cases in the in situ group were successful compared  with 100% success in the displacement group.   Although lower pole calculi continue to pres-  ent challenges for the urologist, new technologies  and improved techniques offer the promise of  better success rates in these cases. As a general  rule, lower pole calculi 1 cm or less are managed  best initially with SWL when feasible, while most  stones between 1 and 2 cm may be well managed  with either URS or PCNL as primary therapy.  Large calculi, especially those greater than 2 cm,  have profoundly lower success rates in the lower  pole and are managed best with PCNL when  possible as this modality is influenced least by  a lower calyceal location. As always, patient and  stone factors, including comorbidities, anatomic  factors, and stone composition, should be taken  into account when choosing the treatment with  the best chance of success.    The management of ureteral calculi has  changed dramatically over the last 10 years because  of an increased awareness and implementation of  medical expulsive therapy (to facilitate ureteral  stone passage) and advances in ureteroscope de-  sign and accessory instrumentation. In general,  SWL remains the mainstay treatment for small  (less than 1 cm) proximal stones. As stone size  increases and as a stone moves distally, most  authors agree that ureteroscopy is the more effec-  tive surgical approach. In early 2007, Nabi and  colleagues [51] summarized results from six pub-    (PRCT) comparing URS head-to-head with SWL  therapy for ureteral stones. Overall, stone-free  rates were found to be lower in the SWL group  (RR 0.84, 95% CI 0.73 to 0.96) with a trend toward  lower retreatment rates in the ureteroscopy group  (RR 3.34, 95% CI 0.82 to 13.62). Tables 1 and 2  summarize the results from the six PRCTs and sev-  eral other recent publications in an attempt to  stratify stone free rates (SWL and URS) based on  stone size and ureteral stone location. If available,  the stone-free rates are reported for single SWL or  URS treatments. Retreatment rates and the time to  complete stone clearance must be entertained when  considering the value of SWL or URS.    Perhaps the more difficult consideration for  patients and urologists is the spectrum of poten-  tial complications that may accompany a given  ureteral stone treatment. The rate of reported  complications in the six PRCTs was lower in the  SWL group (RR 0.48, CI 0.26 to 0.91) with  a significantly lower rate of hospital stay [51],  but no specific details on the exact type of compli-  cations were given, except to say that most were  minor. This review reported that pain symptoms  were higher, but not significantly so, in the stented  ureteroscopy group [51]. In a recent review of over  3000 procedures for ureteral stones (predomi-  nantly retrospective), significant complications  for SWL and URS were 7% for each group [68].  Eighty-seven SWL complications were recognized  (Fig. 2), with the most significant difference be-  tween URS coming in rates of acute ureteral ob-  struction (48% [42 oif 87] versus less than 1% 1  of 151]). Notably, the lack of ureteral obstruction  in URS patients was likely because of stenting,  but no objective measure of stent discomfort  was included in this review. Within the URS  group, 151 complications were recognized, with  ureteral injury (63 of 151 complications, 41%)  and ureteral stricture (7 151 complications) occur-  ring exclusively in the URS (SWL group 09^, see  Fig. 2) [68]. It comes as no surprise that ureteral    lished prospective, randomized controlled trials injuries occur more frequently during  Table 1  Stone-free clearance rates for mid- and distal ureteral calculi, stratified by size and therapy  Therapy <1 cm >l cm  Extracorporeal 51% [52]; 91% [34]; 78% [53]; 85% [54]; 95% [54]; 54% [55]  shockwave lithotripsy 79% [55]  Ureteroscopy 99% [56]; 91% [52]; 91% [34]; 93% [53]; 100% [54]; 94% [57]; 89% [58]; 89% [55]   Stone-free clearance rates for proximal ureteral calculi, stratified by size and therapy   Extracorporeal 78% [59]; 80% [60]; 60% [61]; 85% [62]; 32% [63]; 50% [60]; 45% [61]; 35% [62];  shockwave lithotripsy 70% [55] 43% [55]   Ureteroscopy 90% [59]; 100% [60]; 90% [61]; 91% [62]; 35% [63]; 93% [60]; 93% [61]; 77% [62];   80% [57]; 91% [58]; 75% [55] 65% [57]; 71% [58]; 76% [55]   Percutaneous N/A (Most studies examine large stone 98% [64]; 86% [65]; 79% [66]; 94% [67];    ureteroscopy, and many of the previously men-  tioned studies were performed with older litho-  tripsy options (electrohydraulic, pneumatic),  large semirigid ureteroscopes, and variability in  evaluation for and definitions of complications.  Overall, the potential for complications must be  balanced with the surgeon’s experience, type of  anesthesia used, available equipment, efficacy,  and potential for retreatment.    Ureteral stones in pregnancy and in patients  who have bleeding diathesis represent a high-risk  group of stone patients in whom SWL or PCNL  are absolutely contraindicated, leaving uretero-  scopic lithotripsy as the only effective therapeutic  alternative that treats the stone rather than  temporizes the pain. Most calculi of pregnancy  are eliminated with a combination of analgesia,  rest, and hydration [69] or are managed temporar-  ily with the insertion of a ureteral stent or    Fig. 2. Percent totals of selected complications for ure-  teral stones treated by SWL (n = 87) or ureteroscopy  (n = 151). (Data from Wolf JS Jr. Treatment Selection  and Outcomes: Ureteral Caculi. Urol Clin North Am  2007;34:421-30.)    nephrostomy tube [70]. When necessary, the ure-  teral dilation associated with pregnancy has been  shown to facilitate passage of the ureteroscope  [71], and several case reports of safe and effective  ureteroscopy during pregnancy have been pub-  lished [72,73]. Indeed, with improvement in ure-  teroscopic instrumentation and technique,  primary definitive ureteroscopic stone extraction  can supplant the need for frequent stent changes  during pregnancy. Care should be taken to mini-  mize fluoroscopy time and fetal exposure during  the case. For patients with ureteral stones who  cannot safely stop therapeutic anticoagulation  therapy, ureteroscopy also has been shown to be  safe and effective. In a retrospective series of 25  patients who had significant alterations in bleed-  ing times and international normalized ratio  (INR), Watterson and colleagues [74] successfully  treated 18 of 19 (95%) ureteral stones with mini-  mal morbidity.    SWL has evolved since its introduction in the  early 1980s [1,75]. At present, SWL is the pre-  ferred first-line treatment in most patients who  have renal calculi less than 2 cm in diameter  [76]. Several patient and stone factors affecting  success rates following SWL are described else-  where in this article. This section focuses on  ESWL technique at the authors’ institution,  although the authors recognize that there cer-  tainly will be variations, particularly given the  large number of commercially available SWL  units.   The authors generally reserve SWL for patients  who have renal or ureteral calculi less than 2 cm in  diameter with no evidence of distal ureteral  obstruction. Patients who have a known history  of cystine stones usually are treated with uretero-  scopy or PCNL unless the stone is less than 1 cm.    A urine culture is obtained at the preadmission  visit to document sterile urine. Any bacteriuria is  treated with oral antibiotics, and urine culture is  repeated before SWL to demonstrate resolution of  the infection. Routine laboratory studies includ-  ing coagulation studies are performed the week  before the procedure. Contraindications to SWL  include pregnancy, uncorrected coagulopathy,  distal ureteral obstruction, and untreated urinary  tract infection. The authors typically do not  perform bilateral SWL in a single setting to avoid  potential bilateral ureteral obstruction.   In patients who have a solitary functioning  kidney, the authors routinely place a ureteral stent  to assist with urine passage. Prophylactic antibi-  otics are not administered routinely if the pre-  operative urine culture is negative. Preoperative  broad-spectrum antibiotics (ie, first-generation  cephalosporin), however, are given to high-risk  patients such as those who have indwelling  ureteral stents, prostheses or artificial heart  valves, and patients who have diabetes mellitus.  The patient is counseled on the risk of bleeding  requiring hospitalization (1 in 1000), the risk of  residual stones or steinstrasse (tailored to the  stone size and density), and the possible delayed  increased risk of diabetes mellitus.   Following informed consent, the patient is  placed in the supine position, and a foam bolster  is placed under the knees to flatten the curve of  the lumbar spine. Patients who have stones  overlying the bony pelvis are placed in the prone  position to allow the shockwave front to impact  the stone. Short-acting narcotic sedative anesthe-  sia is administered, and the stone is targeted  with fluoroscopy in both the anteroposterior and  oblique planes.   At this point, cystoscopy is performed if  necessary with the patient supine using the flexible  endoscope. This generally is required only if the  patient requires a ureteral stent or if the stone is  not visible and retrograde pyelography is neces-  sary to identify the calculus. If contrast studies are  required, the authors use a 5F open-ended ure-  teral catheter that is left in place throughout the  case to allow for periodic injection of contrast as  necessary to target the stone. Commonly, the  patient has elected SWL because of concerns of  transurethral instrumentation, in which case, in-  travenous contrast is used to delineate the collect-  ing system.   The authors normally limit the total number of  shocks to 3000 in a single setting with at least 4  weeks between SWL sessions. Stone position is    monitored in the AP plane during the case, with  additional targeting in the oblique plane reserved  for instances where the patient has shifted during  the procedure. The authors use a rate of 60 to 120  shocks per minute starting at a relatively low  energy setting. Several in vitro studies suggest that  slower rates of treatment improve stone fragmen-  tation [77—79].   The patient is monitored continuously for  dysrhythmia during the procedure. If a sustained  abnormal heart rhythm is encountered, the  lithotriptor is gated to the cardiac rate. The  energy gradually is increased over the first 500  shocks to the full dose. This gradual increase is  based on the theory of renal preconditioning,  where a phase of lower energy SWL followed by  a full treatment dose reduces renal injury. Willis  and colleagues [80] studied the damage caused  by SWL in a pig kidney model. It was noted  that pretreatment of the same renal pole with  100 to 500 shocks before the treatment dose re-  sulted in a significantly smaller lesion than in an-  imals that had not received pretreatment. At  present, clinical trials in people have yet to prove  the utility of this approach in practice. In the  setting of multiple calculi, the authors prefer to  treat individual stones until there is radiographic  evidence of good fragmentation, at which point  remaining shockwaves are focused on additional  stones.   Patients are discharged home on the day of  surgery with a prescription for oral analgesia. The  authors also suggest a short course of oral  antibiotics in patients who have indwelling ure-  teral stents or those at high risk of infection (ie,  diabetics, immunocompromised). Follow-up is  arranged for 1 to 2 weeks following surgery with  appropriate imaging, most commonly a plain film  of the kidneys, ureters, and bladder (KUB). If  a ureteral stent has been inserted, it is removed at  this visit with a flexible cystoscope.    Since its first description over 20 years ago, URS  has progressed from an awkward diagnostic pro-  cedure with limited visualization to a precise,  complex surgical intervention allowing access to  the entire collecting system in more than 94% of  cases [43]. A summary of some of the indications for  a retrograde ureteroscopic approach to renal cal-  culi can be found in Box 1. The expansion of these  indications can be attributed primarily to the intro-  duction of the 200 um holmium laser fiber and to    Box 1. Accepted indications  for ureteroscopic treatment of renal  and ureteral calculi    Renal anatomic characteristics  Calyceal diverticulum  Infundibular stenosis  Skin-to-stone distance »10 cm  Horseshoe/ectopic kidney  Concomitant ureteral stricture, UPJ  obstruction, or hydronephrosis  Lower pole anatomy  Infundibular pelvic angle «70?  Infundibular length »3 cm  Infundibular width <5 mm    small- diameter flexible ureteroscopes with active  primary and secondary deflection. As the role of  URS continues to expand, a brief review of uretero-  scopic technique is in order. Informed consent is  obtained emphasizing the risk of minor ureteral  perforation, major ureteral injury, bleeding, infec-  tion, residual stones, and stent discomfort.   For patients with ectopic kidneys in whom  SWL is not feasible, URS is an excellent alterna-  tive with comparable stone-free rates. Many of the  difficulties associated with accessing the pelvic  kidney (ie, tortuous ureter, UPJ obstruction)  have become less of an issue in recent years,  with refinements in flexible,  small-caliber   The patient is positioned in a lithotomy posi-  tion with the ipsilateral leg slightly extended. One  arm is tucked, for easy access by the fluoroscopy  C-arm, while the C-arm monitor, video monitor,  and holmium laser machine are positioned on the  other side of the patient. Following cystoscopic  inspection, the ureteral orifice is cannulated with  a .035 in guide wire and advanced to the renal  pelvis. If resistance is encountered, a 5F open-  ended catheter is advanced to the level of re-  sistance under fluoroscopic guidance, and the  sensor guidewire is withdrawn and a retrograde  pyelogram performed to delineate the ureteral  anatomy. A .035 in hydrophilic wire then is placed  through the open-ended catheter and advanced  beyond the site of obstruction. The open-ended  catheter is advanced to the renal pelvis and the  hydrophilic wire replaced with a more secure wire.  If the guidewire cannot be manipulated past the  site of obstruction, a semi-rigid ureteroscope is  gently advanced and wire advanced under direct  vision. If all attempts to pass a guide wire are  unsuccessful, then the URS is aborted.   The safety wire is secured to the drapes with  a clamp. A semirigid ureteroscope is advanced into  the bladder using a Microvasive single-action,  hand-irrigation syringe (Boston Scientific, Natick,  Massachusetts) as it allows easy intermittent ma-  nipulation of flow. The tip of the ureteroscope is  used to tent the guidewire and open up the ureteral  orifice. If difficulty is encountered in cannulating  the ureteral orifice, a superstiff guidewire can be  advanced through the working channel alongside  the safety wire and used as a filiform to enter the  ureter. After rotating the tip of the semirigid ure-  teroscope so it lies between the two wires, gently  advance the scope into the ureter. It then may be  used to clear the distal and middle ureter of any pa-  thology before placement of a ureteral access  sheath. In addition, the semirigid ureteroscope  passively dilates the ureteral orifice, which the au-  thors believe facilitates sheath placement. Lastly,  the authors place the second working guide wire  zz9superstiff .035 in through the working channel  of the ureteroscope before removal.   A 12/14F ureteral access sheath then is ad-  vanced under fluoroscopic guidance up the ureter.  It is important to liberally wet the sheath before  placement to activate the hydrophilic coating. If  the sheath cannot be advanced up the ureter, the  inner dilator can be removed and a 6 mm x 4 cm  balloon dilator advanced through the sheath to    the site of obstruction and inflated with dilute  contrast. The balloon then is removed and the  inner dilator reintroduced. If the authors remain  unable to advance the ureteral sheath, the ure-  teroscope is advanced over a superstiff guide wire.  If the ureteroscope will not pass the site of  obstruction, then a 6F ureteral stent is placed  and URS reattempted after 2 weeks of passive  dilation by the stent.   Once the sheath has been positioned adequately,  the inner dilator and working guide wire are  removed, leaving the safety wire outside of the  sheath lumen. A flexible ureteroscope is advanced  through the sheath into the proximal ureter and  renal pelvis. The authors inspect the collecting  system starting with the upper pole calyx and  working systematically down to the lower pole  calyx. If laser lithotripsy is required, the authors use  a 200 um laser fiber with a 20 W laser set at 8 Hz and  0.8 J. It is important to pass the laser fiber with the  flexible ureteroscope in a neutral position, as  passage while deflected may damage the working  channel. In the event that the stone cannot be  visualized once the laser fiber is passed, the authors  remove the fiber and reposition the stone in an  upper pole calyx with a tipless stone basket.   If there are stone fragments adherent to the  renal papilla, the authors prefer to use a 2.2F tipless  nitinol basket, as the wires are more pliable and can  be distorted with gentle pressure until they sur-  round and grasp the adherent stone. Gentle partial  opening and closing of the basket can help disen-  gage the stone. Forceful irrigation may be needed  to wash a difficult-to-access stone into the basket.  At the end of the procedure, the ureter is inspected  as the ureteral access sheath is removed.    Technological advancements have improved  the ability to manage renal calculi dramatically.  Unfortunately, stone-free rates for URS and SWL  decrease significantly with factors such as increas-  ing stone size, lower pole stones, and unfavorable  stone composition (ie, cystine, brushier, calcium  oxalate monohydrate). For this reason, percuta-  neous stone removal remains the standard of care  for patients who have large renal stone burdens.  In 1941, Rupel and Brown [81] first described the  removal of a renal calculus through a surgically  established nephrostomy tract. Since that time,  PCNL has virtually eliminated the need for open  stone surgery in patients who have calculi not  amenable to less-invasive therapies. The authors    acquire their own percutaneous access, as they  feel this provides optimal control with the greatest  chance of entry into the desired calyx, and the  ability to obtain additional access points as  required during the procedure.   The authors generally reserve PCNL for man-  aging upper tract stones in patients who have  a body habitus not suitable for SWL, failed SWL  not amenable to ureteroscopy, cystine stones, and  large or complicated stones such as staghorn  calculi. Contraindications to PCNL include un-  corrected coagulopathy and pregnancy. It is  imperative to adequately treat any urinary tract  infection, and sterile urine should be documented  before surgery. Informed consent is obtained after  the risks and benefits of the procedure have been  explained, including bleeding, infection, and asso-  ciated organ injury. Preoperative broad-spectrum  antibiotics are administered on the day of surgery.  The transfusion rate at the authors' institution is  less than 1%, and the authors do not routinely  cross-match patients for blood products before  surgery.   Under general anesthesia, the patient is placed  in the prone position, and all pressure points are  checked carefully and padded. The authors typi-  cally place a pillow under the chest as a support to  allow optimal ventilation. If there is a significant  curvature of the lumbar spine, a 1 L irrigation bag  may be placed beneath the lower abdomen for  support. The flank and genitals are prepared  widely and draped to allow exposure for cystos-  copy and percutaneous renal access. Flexible  cystoscopy is performed, and the ipsilateral ure-  teral orifice is visualized. The orifice is cannulated  with a .038 in Bentson guide wire (Cook Urolog-  ical, Spencer, Indiana). The wire is advanced in  a cephalad direction under fluoroscopic guidance  to the level of the collecting system. The cysto-  scope is removed, and a 5F open-ended ureteral  catheter is advanced over the wire, taking care  to avoid curling in the bladder. A 16F Foley cath-  eter (Bard Medical, Covington, Georgia) is placed  in the bladder, and the guide wire is removed,  leaving the ureteral catheter in place. The authors  then secure a contrast-filled syringe to the ureteral  catheter and cover the area with a sterile towel. At  this point, the authors change for clean surgical  gloves and begin the percutaneous access portion  of the procedure.   Contrast is injected through the ureteral cathe-  ter under fluoroscopy to define the calyceal anat-  omy. The authors prefer to enter by means of  a posterior calyx, as this gives the most direct route    to the renal pelvis and ureter and helps to minimize  unnecessary torquing of the nephroscope during  the procedure. A subcostal access is ideal. Certain  situations, however, require access to be placed  above the llth or 12th ribs, and this may be  accomplished with a slight increase in lung-related  complications such as hydrothorax. Situations  where intercostal access might be required include  large, branched calculi and those cases where access  to the ureteropelvic junction is necessary. In the  setting of an isolated calyceal or diverticular stone,  access is best acquired directly into the stone-  bearing calyx or diverticulum. A small volume of  air injected through the ureteral catheter may assist  in identifying posterior calyces, as these will pref-  erentially fill with air in the prone position. With the  C-arm in the AP plane, an 18G Chiba needle (Cook  Urological, Spencer, Indiana) is positioned over the  tip of the desired entry calyx. The needle is ad-  vanced along the AP plane in a controlled fashion  until the tip of the needle begins to deflect with  the respiratory movement of the kidney. The  C-arm is rotated 30? laterally, and the needle is  advanced carefully until the tip penetrates the entry  calyx. The stylet of the needle is removed, and fur-  ther insertion of the needle should be avoided at this  point. Urine may be seen flowing from the hub of  the needle; however, the absence of urine does not  indicate that the needle is positioned incorrectly.  The authors generally confirm positioning in the  collecting system by the gentle passage of a .035 in  hydrophilic guide wire that should pass easily and  follow the contour of the calyx. In the event that ca-  lyceal puncture is unsuccessful, the needle should  be withdrawn and access reattempted.   Once correct placement of the needle has been  confirmed, the .035 in hydrophilic wire is ad-  vanced into the collecting system. Ideally, the wire  is passed into the ureter and down to the bladder.  The authors routinely employ a 5F Kumpe angled  catheter to assist in the passage of the wire down  the ureter. They then advance the Kumpe catheter  down the ureter and exchange the hydrophilic  wire for a .038 in superstiff guide wire with the  distal end curled in the bladder. Occasionally,  when it is not possible to pass the hydrophilic wire  into the ureter, the authors will curl a Bentson  wire in the renal pelvis and proceed with tract  dilation. Once the nephrostomy tract has been  established, a wire usually can be passed down the  ureter under direct vision. After the stiff guide  wire has been passed, the authors make a 2 cm  skin incision and advance a one-step balloon  dilator with the radio-opaque marker positioned    in the renal pelvis. The tract is dilated, and a 30F  working sheath is advanced under fluoroscopy. It  is important to avoid advancing either the balloon  dilator or the working sheath beyond the renal  pelvis and into the UPJ or proximal ureter. At this  point, the guide wire is secured to the drapes, and  rigid nephroscopy is performed.   Calculi up to 1 cm in diameter often may be  removed through the nephrostomy sheath without  fragmentation. Stones may be removed using  various baskets, forceps, and graspers. Larger  stones are fragmented using an appropriate intra-  corporeal lithotriptor such as pneumatic, laser, or  ultrasonic devices. The authors' preference is to  use ultrasonic lithotripsy, as this offers excellent  stone fragmentation combined with suction to  simultaneously evacuate stone debris. Stones in  the entry calyx and renal pelvis should be cleared  initially to increase the working space. Once these  are clear, attention may be turned to stones in  other calyces. Often the nephroscope may be  maneuvered gently to allow access to opposing  calyces; however, excess torque should be  avoided. Once all accessible calculi have been  fragmented and removed, the authors carry out  flexible nephroscopy to assess the remaining  calyces for further stones. In the event that stones  remain that cannot be reached safely with the  rigid nephroscope, the authors place a second  tract into the calyx containing the stone(s), or use  the flexible nephroscope with either the holmium  laser or electrohydraulic lithotripsy (EHL).   The authors do not routinely place a ureteral  stent following PCNL; however in situations  where the UPJ or proximal ureter have been  manipulated, they will consider passing a stent in  an antegrade fashion before exiting the kidney.  Once lithotripsy is complete, the authors remove  the sheath under direct vision with the rigid  nephroscope, as calculi may be concealed along-  side the sheath. The authors then place a nephros-  tomy tube under fluoroscopic guidance. For this  purpose, the authors most commonly employ  a 16F Council tipped urethral catheter (Bard Med-  ical, Covington, Georgia) with 2 to 3 cc of contrast  in the balloon to confirm position in the renal pel-  vis. Other types of nephrostomy drainage (ie, 8F  pigtail) may be used as per surgeon preference.  Although other investigators have reported the  successful performance of tubeless PCNL, recent  studies suggest a lack of benefit and higher compli-  cation rate [82], and as such, the authors prefer to  maintain drainage and access in the immediate  postoperative period. The nephrostomy is secured    at the skin with a silk suture, and the wound is  cleaned and dressed. Active hemorrhage from the  nephrostomy site often may be controlled by pas-  sage of a larger caliber nephrostomy tube over  a guide wire. In the event that this is not successful,  it may be necessary to use a Kaye tamponade cath-  eter to control bleeding. Finally, if bleeding per-  sists or the patient becomes hemodynamically  unstable, selective embolization may be required.  The authors' patients routinely are admitted for  24 to 48 hours postoperatively, and a plain radio-  graph of the KUB is obtained on the first post-  operative day. If there is no further evidence of  residual calculi, the nephrostomy is clamped, and  the patient is observed for flank pain or fever. The  authors do not typically obtain an antegrade  nephrostogram unless there is a strong clinical sus-  picion of distal obstruction. Provided the patient  tolerates the trial of tube clamping, the nephros-  tomy may be removed and the patient discharged.  In the event that postoperative imaging suggests  small residual calculi, the authors often will take  a second look with the flexible nephroscope in the  clinic and basket remaining stones through the  tract. More extensive residual stone burden might  require a second PCNL under general anesthesia  to render the patient stone-free. If a stent has  been placed, the authors will see the patient in the  clinic the week after surgery and remove the stent  with flexible cystoscopy. All patients are seen in  the clinic 4 to 6 weeks postoperatively to be assessed  and to arrange further follow-up as required.  While the authors have described their tech-  nique for PCNL, there are many variations, from  the access technique to the surgical devices used  during the case. Hosking and Reid [83] described  their experience with over 200 cases of retrograde  nephrostomy. The authors reported successful  establishment of a nephrostomy tract in 98% of  cases, with a mean time of 27.9 minutes to estab-  lish the tract. As with any technique of percutane-  ous access, retrograde access should not be  attempted without a suitable period of mentoring  under a urologist skilled in the technique. As men-  tioned previously, the authors' preferred tool for  dilation of the nephrostomy tract is a one-step  balloon dilator. Other options for tract dilation  include introduction of progressively larger serial  fascial dilators such as Amplatz renal dilators  (Cook Urological, Spencer, Indiana) or Alken  metal coaxial dilators (Karl Storz, Tuttlingen,  Germany). The authors occasionally will advance  a single 8/10F Amplatz coaxial dilator over the  guide wire if resistance is met while passing the    balloon dilator. This maneuver usually will allow  for smooth passage of the balloon into the kidney.  There are many other technical nuances and  equipment types that urologists may find useful  in performing PCNL, and surgeons should exper-  iment with various equipment to find what works  best for them.    Although uncommonly performed, laparo-  scopic pyelolithotomy can be an effective treatment  modality for stone extraction, especially in the  setting of UPJ repair or renal ectopia. A retrospec-  tive case series of 19 patients who underwent  concomitant laparoscopic pyelolithotomy during  pyeloplasty demonstrated stone-free rates of 90%  and 80% at 3 and 12 months respectively [84]. In  a more contemporary series, transperitoneal lapa-  roscopy was shown to be safe and 100% effective  in four patients who had large stone burdens  (mean size 2280 mm?) within either a pelvic or  horseshoe kidney [85]. In both reports, pancalico-  scopy was achieved by guiding a flexible cystoscope  into the renal pelvis through a lap port site. Indwell-  ing stents and peritoneal drains were placed in all  patients. Conversely, although ureterolithotomy  has been described for ureteral stone removal,  most consider this a salvage treatment for the rare  case of endoscopic failure.    The past several decades have seen profound  advancements in the management of upper uri-  nary tract urolithiasis. SWL, URS, and PCNL  have rendered open stone surgery virtually obso-  lete. 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[78] Weir MJ, Tariq N, Honey RJ. Shockwave frequency  affects fragmentation in a kidney stone model.  J Endourol 2000;14:547—50.   [79] Paterson RF, Lifshitz DA, Lingeman JE, et al. Stone  fragmentation during shock wave lithotripsy is im-  proved by slowing the shock wave rate: studies  with a new animal model. J Urol 2002;168:2211—5.   [80] Willis LR, Evan AP, Connors BA, et al. Prevention  of lithotripsy-induced renal injury by pretreating  kidneys with low-energy shock waves. J Am Soc  Nephrol 2006;17:663—73.   [81] Rupel E, Brown R. Nephroscopy with removal of  stone following nephrostomy for obstructive calcu-  lous anuria. J Urol 1941;46:177-82.   [82] Choi M, Brusky J, Weaver J, et al. Randomized trial  comparing modified tubeless percutaneous nephroli-  thotomy with tailed stent with percutaneous neph-  rostomy with small-bore tube. J Endourol 2006;  20(10):766—70.   [83] Hosking D, Reid R. The evaluation of retrograde  nephrostomy in over 200 procedures. In: Walker V,  Sutton R, Cameron E, editors. Urolithiasis: proceed-  ings of the Sixth International Symposium on Uro-  lithiasis. New York: Plenium Press; 1989.   [84] Ramakumar S, Lancini V, Chan DY, et al.  Laparoscopic pyeloplasty with concomitant pyeloli-  thotomy. J Urol 2002;167:1378—80.   [85] Kramer BA, Hammond L, Schwartz BF. Laparo-  scopic pyelolithotomy: indications and technique.  J Endourol 2007;21:860-1.    *Center for Laparoscopy and Robotics, and Comprehensive Center for Urologic Oncology,  Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic,  Cleveland, OH, USA  Cleveland Clinic Lerner School of Medicine at Case Western University,  Cleveland, OH, USA    Bladder cancer accounts for more than 63,000  new cases and 13,000 deaths annually. Radical  surgery remains the mainstay of treatment in cases  of muscle-invasive disease and some cases of  refractory or high-risk superficial bladder cancer,  even with the modern concepts of integrating  neoadjuvant or adjuvant chemotherapy into treat-  ment strategies. A high-quality cystectomy, with  the main objectives of negative surgical margins  and an adequate lymphadenectomy, has been  shown to have significant impact upon patient  survival [1].   The application of laparoscopic techniques to  radical cystectomy has been a recent and natural  evolution of successful laparoscopic applications in  renal surgery and prostatectomy. Initial case re-  ports and small series of laparoscopic radical  cystectomy (LRC) were reported in the early  1990s [2,3], soon yielding to larger series with vary-  ing techniques and dependable results. The au-  thors' ongoing international registry comprises  over 700 cases from 14 countries. Most LRC oper-  ations are performed using standard laparoscopic  technique, with a minority of hand-assisted or ro-  botic-assisted procedures. This article attempts to  provide an overview of the current status of LRC,  with technical details, modifications, and results    * Corresponding author. Center for Laparoscopy  and Robotics, and Comprehensive Center for Urologic  Oncology, Department of Urology, Glickman Urologi-  cal and Kidney Institute, Cleveland Clinic, 9500 Euclid  Avenue, A-100, Cleveland, OH 44195.    of various techniques as reported by the authors'  group and other groups.    Open radical cystectomy (ORC) remains the  gold standard treatment for invasive bladder  cancer, setting the bar for other treatment ap-  proaches to be measured against. Nevertheless,  wide variations in the quality of ORC exist among  academic and community settings, with the expe-  rience of the individual surgeon being a highly  significant variable as regards nodal yield and  positive surgical margins, both factors impacting  on oncologic outcomes of ORC. At centers of  excellence, a contemporary quality ORC is a tech-  nically efficient procedure with positive margin  rates in the 0% to 2% range for organ-confined  disease and less than 10% overall. A critical  component of ORC is an extended lymphadenec-  tomy up to the common iliac and presacral nodes,  and recently, even para-caval, interaorto-caval,  and para-aortic nodes, providing nodal yields  greater than or equal to 20. Cancer-specific  survival correlates with lymph node counts, even  among node-negative patients.   ORC, however, does confer substantial mor-  bidity, even at experienced centers. Major compli-  cation rates are 10% to 12%; overall complication  rates are 30% to 60%, and perioperative mortality  ranges from 2% to 5%. Factors impacting upon  complications of ORC include surgeon experience,  hospital volume, and patient factors such as  advanced age and medical comorbidities.    0094-0143/08/$ - see front matter © 2008 Elsevier Inc. All rights reserved.    Fundamentally, LRC must deliver a high-  quality, technically superb loco-regional onco-  logic clearance comparable to ORC, thereby  guaranteeing equivalent oncologic outcomes. Ad-  ditionally, LRC potentially can reduce morbidity  and shorten convalescence, thereby leading to  improved postoperative quality of life over the  short term. Similar to other laparoscopic onco-  logic procedures (renal, prostate), the excellent  visualization and decreased blood loss during  laparoscopy allows for a highly precise technical  operation. Smaller skin/fascial incisions decrease  pain and convalescence, with the potential for  decreasing certain perioperative complications. By  minimizing bowel manipulation and its exposure  to the atmosphere, postoperative ileus may be  reduced. Partly because of patient demand,  the application of minimally invasive surgery  continues to rapidly increase not only in urologic  oncology, but also across the entire surgical  spectrum. Risks of port site recurrence and  peritoneal seeding are exceedingly rare. LRC  data require careful scrutiny to ensure that soft  tissue margins, nodal yields, local recurrences, and  cancer-specific survival meet the standards estab-  lished by ORC. Such data are accruing. For LRC  to become a widely accepted viable treatment  option for aggressive bladder cancer, considerable  work lies ahead.    Careful selection of patients for LRC is para-  mount for good outcomes. Invasive bladder  cancer is an aggressive tumor; there will be no  second opportunity for surgical cure, given a pos-  itive margin confers a death sentence. Adjuvant  treatments (chemotherapy, radiotherapy) cannot  salvage patients who have had a surgically sub-  optimal excision. Tumor, patient, and surgeon  factors should be taken into account when select-  ing the optimal approach, laparoscopic or open,  for radical cystectomy.   At this time, the authors offer LRC to select  patients who have clinically low volume, organ-  confined tumors without lymphadenopathy.  Patients who have locally advanced or bulky  tumors or gross lymphadenopathy (before or after  chemotherapy) are handled best with an open  surgical approach. In these cases, wide excision    with possible adjacent organ resection may be  necessary, which may require adequate intraoper-  ative palpation to determine local tumor exten-  sion. Also, it is difficult to manipulate bladders  with heavy tumors laparoscopically; these tumors  leave little working space in the pelvis, compro-  mising proper laparoscopic visualization.   Patient factors play a significant role in selec-  tion for LRC. General contraindications to lapa-  roscopy (uncorrected bleeding tendency, active  intra-abdominal infection, ascites) typically will  contraindicate an open surgical cystectomy also.  Other specific factors like previous pelvic radia-  tion, multiple abdominal surgery, or previous  pelvic surgery would favor selection of an open  radical cystectomy. LRC has been reported after  neoadjuvant chemotherapy, without mention of  any added difficulty in such cases. Obese patients  present a particular challenge to laparoscopy,  with difficulty in obtaining access, identifying  planes and landmarks, inability to reach ade-  quately into the pelvis, and operator fatigue  from difficult manipulation. Although robotic  assistance can alleviate some of these difficulties,  open surgery may be a more reasonable (although  still challenging) option.   Finally, LRC should be limited to laparoscopic  surgeons who have adequate experience and skills.  These procedures are long, complicated, and  require detailed knowledge of pelvic anatomy  and bladder cancer pathology. Experience with  laparoscopic pelvic surgery is vital to an oncolog-  ically adequate procedure for the patient. Open  surgical experience is also essential for transfer of  surgical experience to the laparoscopic setting,  possible open conversion if needed, and perform-  ing open urinary diversion. The presence of an  experienced surgical team in a tertiary care setting  is the optimal situation, necessary to cover the  laparoscopic, anesthetic, and postoperative care  of such patients.    Bladder cancer is more common in males, and  as a result 75% to 80% of all radical cystectomies  are performed in male patients. A similar tech-  nique of LRC with minor modifications has been  reported in various initial series [4-7]. LRC is per-  formed transperitoneally, with four to five ports  placed in a peri-umbilical fan arrangement across  the lower abdomen, with a possible sixth port in    the suprapubic area (Fig. 1). The camera port is  placed two fingerbreadths above the umbilicus,  but may be moved to just below the umbilicus in  large patients; this supra-umbilical camera posi-  tion facilitates performance of the high-extended  lymphadenectomy up to the inferior mesenteric  artery. Although surgery can be performed in  the supine position, a low lithotomy is preferred  to allow access to the rectum and allow perineal  pressure as needed during the urethral anastomo-  sis in an orthotopic reconstruction. A steep Tren-  delenburg position is essential to keep the bowel  out of the pelvis during surgery.   Surgery usually starts by visualizing the pelvis  and releasing adhesions of the sigmoid colon to  the pelvic side wall, which are present in almost all  cases. This mobilization of the sigmoid allows  retraction out of the pelvis and identification of  the left ureter, and assists in the subsequent  lymphadenectomy. If the sigmoid continues to  fall into the pelvis, it can be held in place by  a suture placed through an appendix epiploica  and held to the abdominal wall. At this time, the  major landmarks in the pelvis should be visual-  ized; these are the ureters, medial umbilical  ligaments, vasa deferentia, and the urachus. The    Fig. 1. Port placement. (Courtesy of the Cleveland  Clinic Foundation, Cleveland, Ohio; with permission.)    tip of the urethral catheter frequently is seen in the  bladder dome also.   Important planes of dissection for radical  cystectomy are the posterior plane between the  seminal vesicles and prostate anteriorly, and the  rectal wall posteriorly, as well as the lateral plane,  between the bladder within the perivesical fat and  the pelvic side wall including the iliac vessels,  obturator fossa, and pelvic floor muscles. These  planes are generally avascular; understanding and  meticulously developing and following them are  essential for a technically and oncologically sound  operation.   The posterior plane usually is developed first,  keeping the bladder attached to the anterior  abdominal wall to allow exposure (Fig. 2). The  ureters can be dissected and mobilized distally  towards the bladder before or after opening the  posterior plane. This plane is entered by dividing  the peritoneum of the recto—vesical pouch a little  higher than its lowest point. Following the vas  deferens medially can facilitate identifying this    Fig. 2. Pelvic peritoneotomy incision. The initial peri-  toneotomy incision is made posteriorly, deep in the cul-  de-sac, staying posterior to the seminal vesicles and vas.  Dotted line indicates the ultimate peritoneotomy required  as the operation proceeds. (Courtesy of the Cleveland  Clinic Foundation, Cleveland, Ohio; with permission.)    plane in difficult cases. The tips of the seminal ves-  icles are visualized easily, and keeping the seminal  vesicles anterior, the plane is developed distally to-  wards the prostate (Fig. 3). Denonvillier's fascia is  encountered at the level of the prostate-vesicular  junction posteriorly. This fascia needs to be  divided sharply, allowing the posterior plane to  be developed further distally between the prostate  and the anterior rectal surface (Fig. 4). Extreme  care should be exercised at this time to avoid  injuring the rectum, which lies in an oblique,  rather than transverse plane in this area.   If the ureters have not been mobilized pre-  viously, they should be at this time. Proximal  dissection to a level above the iliac vessels greatly  facilitates the subsequent lymphadenectomy and  the urinary diversion. The ureters are divided  distally close to the bladder between clips, and  the distal ureter margin is sent for frozen section  pathological examination.   The lateral planes then are developed. This is  done easiest by dividing the peritoneum over the  obliterated medial umbilical ligaments until the  anterior abdominal wall. The vas deferens is  encountered commonly at this time and can be  divided also. The lateral plane is identified readily  lateral to the ligament, which is retracted medi-  ally. This plane is developed distally into the  pelvis until the pelvic floor muscle and the  endopelvic fascia is reached. The reflection of  the endopelvic fascia over the prostate can be  divided at this time or left for a later stage in the  operation.    Fig. 3. Posterior dissection. Developing the posterior  plane and the right postero-lateral vesicle pedicle.  (Courtesy of the Cleveland Clinic Foundation, Cleve-  land, Ohio; with permission.)    Fig. 4. Incising Denonvillier's fascia. (Courtesy of the  Cleveland Clinic Foundation, Cleveland, Ohio; with  permission.)    The posterolateral bladder pedicles thus are  exposed between the posterior and lateral planes.  These pedicles are sometimes separable into a lat-  eral and posterior portion (with the ureter between  the two), or in some thin patients may be one  posterolateral attachment. The superior and in-  ferior vesical vessels course with the lateral portion  of the pedicle, and accordingly, the pedicles usually  are divided with a laparoscopic linear stapler  (Fig. 5). Other energy-based coagulating instru-  ments or clips can be used also. These pedicles are  followed to the level of the pelvic floor, or if the en-  dopelvic fascia has been opened, along the side of  the prostate as distally as the apex of the prostate.   After the posterior and lateral bladder attach-  ments are freed, the bladder is mobilized from the    Fig. 5. Transecting the right posterior pedicle using the  endo-GIA stapler. (Courtesy of the Cleveland Clinic  Foundation, Cleveland, Ohio; with permission.)    anterior abdominal wall, including a triangle of  peritoneum with the urachus to the umbilicus  (Fig. 6). The pubic bones are exposed, the space  of Retzius developed, and the puboprostatic liga-  ments exposed. The superficial branch of the dorsal  vein is coagulated and divided. The endopelvic fas-  cia is opened on both sides of the prostate at this  time if not previously opened; the pelvic floor mus-  cles are swept off the sides of the prostate, exposing  the apex, urethra, and sides of the dorsal vein com-  plex. The dorsal vein can be controlled by various  techniques (Fig. 7). The authors commonly utilize  a laparoscopic GIA stapler to control the well-  mobilized complex, although a controlling stitch  can be placed across the dorsal vein. Coagulating  instruments like bipolar electrocautery also can be  used, although they are less reliable. After the pu-  boprostatic ligaments and the dorsal vein complex  are divided, the urethra comes into view. The  attachments of the prostatic apex to the pelvic floor  are released, and the urethral catheter can be re-  moved at this time. A locking clip or a suture should  be placed at the proximal urethra to prevent tumor  spillage from the bladder, and the urethra is  divided. Proximal traction on the prostatic apex  allows the final attachments of the prostate to the  anterior rectal surface (rectourethralis muscle) to  come into view; these are divided carefully, and  the specimen is placed in an impermeable laparo-  scopic retrieval sac, which is placed out of the pelvis  to allow subsequent inspection, hemostasis, and  lymphadenectomy.    Fig. 6. Anterior dissection. The triangular inverted V  peritoneotomy is created and space of Retzius entered.  (Courtesy of the Cleveland Clinic Foundation, Cleve-  land, Ohio; with permission.)    Fig. 7. Completing the prostate apical dissection. Tran-  section of the dorsal vein complex and urethra. The  specimen side of the transected prostate apex is secured  with a stitch or clip to eliminate local spillage of urine  from the bladder. (Courtesy of the Cleveland Clinic  Foundation, Cleveland, Ohio; with permission.)    LRC in the female usually involves an anterior  exenteration with en bloc resection of the bladder,  uterus, fallopian tubes, and ovaries. The authors’  technique in females [8] starts similar to a laparo-  scopic cystectomy in the male, with identification  of the ureters and dissection into the pelvis. The  ovarian vessels are divided in the infundibulopel-  vic ligaments, allowing the ovaries to be mobilized  into the pelvis. The bladder is mobilized laterally  in the same manner as in males, using the obliter-  ated medial umbilical ligament as a guide, and  dividing the round ligament of the uterus in the  process. The endopelvic fascia is visualized,  although it does not need to be divided in the  female. Anterior retraction of the uterus is very  helpful, and facilitates identification of the poste-  rior and posterolateral structures. This can be ac-  complished with a laparoscopic instrument held  by an assistant, or by various instruments that  can be placed vaginally and used to manipulate  the uterine cervix. A good example is the RUMI  uterine manipulator with the Koch colpotomizer  system (Cooper Surgical, Trumbull, Connecticut).  The posterolateral bladder pedicles are identified;  these include the uterine vessels and are controlled  with a linear stapler.   The posterior fornix is identified with a sponge  stick placed in the vagina, and the vagina is  opened close to the cervix. The vaginal incision  is continued around the cervix, and distally along  the anterior vaginal wall. The vaginal wall is    well-vascularized, and various cutting/coagulating  instruments (eg, Harmonic scalpel, Ligasure) are  especially useful for this part of the procedure. As  the bladder neck area is reached, this dissection  can proceed closer to the urethra, which is re-  moved in its entirety. If an orthotopic neobladder  is planned, the dissection ends at the bladder neck;  the urethra is transected at the bladder neck, and  the bladder neck is sutured closed immediately to  prevent spillage. The distal dissection of the  bladder neck and urethra can be performed  vaginally, and the specimen can be removed  from the vaginal incision (useful in cases where  intracorporeal diversion is planned). The vagina  then is closed with a continuous Vicryl suture. The  distal part of this closure also can be performed  vaginally according to surgical preference.    Pelvic lymphadenectomy is an integral part of  radical cystectomy, and has been proven to have  a significant impact on patient survival in addition  to accurately staging the tumor. Numerous pub-  lications recently have advocated extension of the  standard pelvic lymph node dissection to a more  extensive template [9,10]. Within the pelvis, the  anatomical limits of the lymphadenectomy are  the genitofemoral nerve (laterally), the obturator  vessels (medially), and the node of Cloquet (dis-  tally). The proximal extent of the dissection has  become an area of significant debate recently,  with most oncologists advocating a common iliac  lymphadenectomy, and a few extending that to  the level of the inferior mesenteric origin from  the aorta. The presacral nodes also should be re-  moved. The number of lymph nodes correlates  well with the extent of the lymphadenectomy.  Difficulty in standardizing a specific number arises  from different surgical practices as far as the num-  ber of packets sent, the pathologist’s diligence in  counting the lymph nodes, and to a certain extent,  interpatient variability.   Keeping all these principles in mind, a laparo-  scopic lymphadenectomy for bladder cancer has  to cover the same template as an open lymphade-  nectomy. Standard lymphadenectomy (to the  bifurcation of the common iliac artery) has been  performed by urologists for decades, being one of  the earliest laparoscopic procedures integrated  into urological practice. The authors prefer to  perform the lymphadenectomy after the bladder is    removed, with the pelvis empty and landmarks  readily visible. An extended lymphadenectomy  can be adequately performed laparoscopically  [11]. Generous mobilization of the sigmoid helps  to achieve exposure of the iliac vessels, especially  on the left side, and vessel loop retraction of the  common iliac arteries may facilitate exposure in  the area just distal to the aortic bifurcation. Inter-  mittent decrease of pneumoperitoneum to 5 mm  Hg is helpful in identifying the veins, which are  typically empty and flat at standard pressure. To  avoid difficulty with the most proximal part of  the dissection, it is advisable to place the main  operating ports slightly more cephalad at the start  of the procedure. The authors routinely perform  extended lymphadenectomy after cystectomy,  with removal of the common iliac and presacral  lymph nodes, with a pathological yield similar to  open surgical extended templates. An average  yield of 21 lymph nodes is the result of this tech-  nique, with an increase of about | hour of operat-  ing time [11]. The authors recently performed  extended lymphadenectomy to the inferior mesen-  teric artery in five patients (A.F. Fergany and LS.  Gill, unpublished data), demonstrating that a lap-  aroscopic lymphadenectomy can cover the same  templates as an open procedure (Fig. 8). Long-  term oncological results are awaited.   Numerous modifications to the standard tech-  nique of radical cystectomy in males and females  have been suggested as a means to minimize the  functional impact of surgery on sexual function  and urinary continence. All of these modifications  have been incorporated readily into the laparo-  Scopic technique, mainly nerve-sparing, female  reproductive organ-sparing, and prostate-sparing  techniques.    Nerve-sparing techniques similar to those per-  formed during prostatectomy have been advo-  cated and applied in select cystectomy situations  with low-stage disease, where tumor control is not  compromised by this modification. Such nerve-  sparing presents patients, especially younger ones,  with the option of retaining erectile activity, and  may improve urinary continence. Laparoscopic  nerve-sparing radical cystectomy has been  performed along the same principles as the open  procedure [12] and is a fairly straightforward    Fig. 8. High extended lymphadenectomy template. This  template excises level I, II, and III nodal tissue. Level I:  bilateral external iliac, internal iliac, obturator, perivesical  packets. Level II: bilateral commoniliac, internal iliac, pre-  sacral packets. Level III: aortic bifurcation and the peri-  caval, interaorto-caval, and peri-aortic packets up to the  inferior mesenteric artery. (Courtesy of the Cleveland  Clinic Foundation, Cleveland, Ohio; with permission.)    modification of the standard technique. The auto-  nomic nerves run in the posterior bladder pedicles,  close to the tip and sides of the seminal vesicles.  At the prostate-vesicular junction, they are some-  what further away from the bladder; then they  become closely applied to the posterolateral  aspect of the prostate, with some neural fibers  running more posterior or more lateral than the  main bundles.   Preserving these nerve fibers requires a careful  dissection. of the posterior bladder pedicles—  applying individual clips rather than a stapler—  very close to the lateral sides of the seminal  vesicles, to preserve as much of the pedicle as  possible. Any energy-producing coagulation  devices should be avoided, as they result in some  degree of thermal damage to the nerves. Only cold  scissors should be used to divide between the clips.  When the inferior bladder pedicle is divided, the  neurovascular bundles should be separated from  the sides of the prostate similar to a radical  prostatectomy, opening the lateral prostatic fascia    and gently dissecting the bundles aside, again with  cold scissors, all the way until the urethra is  reached. The bundles should be separated from  the urethra before it is divided, to avoid injury to  the bundles during division of the urethra or the  subsequent  neobladder-urethral anastomosis.  Using the described technique, two of four pa-  tients maintained postoperative potency; 75% and  100% achieved day and night time continence,  respectively [12].   Female nerve sparing is performed, with the  primary objective of maintaining urethral inner-  vation and urinary continence, although an added  advantage is better preservation of vaginal lubri-  cation and sensation. This also is performed  laparoscopically similar to the open surgical  technique. The surgical goal is avoiding any  dissection on the lateral walls of the vagina, and  avoiding any dissection distal to the bladder neck,  leaving the urethra and distal vagina intact with  the endopelvic fascial covering. In this way, the  nerve fibers coursing along the lateral vaginal  walls, as well as those innervating the urethra  from the pelvic floor, remain undisturbed.    Although bladder cancer is less common in  females, clinicians often are faced with female  patients who are sexually active, premenopausal,  or even within childbearing age. The sexual and  hormonal effects of an anterior exenteration in  such patients are not realistically acceptable; in  addition to loss of hormonal function, most  females will report a decrease or absence of sexual  activity after radical cystectomy. A significant  number of such patients will report dyspareunia  from vaginal stenosis, decreased lubrication, or  shortening of the vagina. At the same time, very  low rates of direct cancer spread to female organs,  especially in patients who have low-stage disease,  warrant a relaxation of the oncologic principle of  wide excision of all female organs in patients who  have bladder cancer.   For premenopausal patients in whom preser-  vation of hormonal function is desirable, sparing  one or both ovaries can be accomplished by  dividing the ovarian ligament (between the ovary  and the uterus) and mobilizing the ovary on its  blood supply cephalad into the abdomen. The  ovary then can be pexed outside of the pelvis to  avoid interfering with the subsequent cystectomy.   For female patients who are sexually active,  (possibly all female patients if tumor control is not    compromised), a vaginal-sparing approach should  be used. If the uterus is in place, the posterior and  lateral vaginal fornices should be opened as close  to the cervix as possible. The anterior vaginal wall  is divided close to the cervix, and with the bladder  retracted anteriorly, the anterior vaginal wall is re-  tracted posteriorly with a laparoscopic Allis  clamp. This exposes the plane between the ante-  rior vaginal wall and the base of the bladder.  This plane is followed carefully to the bladder  neck (if a neobladder reconstruction is planned),  or to the distal urethra if a urethrectomy is  planned. Avoiding entry into the bladder is criti-  cal. After the specimen is removed, a running  closure of the vaginal vault is performed, leaving  a vagina of normal length and capacity.   This type of dissection is oncologically safe  only in low-stage (Ta, T1) tumors and tumors  away from the posterior bladder wall. In higher-  stage posterior wall tumors, resection of the  anterior vaginal wall is safer. In these cases, the  authors try to minimize the extent of vagina  resected, avoiding excision of any part of the  lateral walls. In all cases, the authors attempt to  separate the urethra from the anterior vaginal wall  distal to the tumor-bearing area, preserving the  anterior vaginal wall below the urethra only. This  preserves a full ring of intact vaginal skin at the  introitus, avoiding any scarring in this area. This  rim of vaginal skin also facilitates closure of the  vaginal vault, which always is performed trans-  versely to avoid vaginal stenosis.   In younger female patients within childbearing  age who desire to preserve the uterus, a full  reproductive organ-sparing cystectomy can be  performed [8]. This occasionally can be performed  in the older female patient who has low-stage  disease as a simpler option to an anterior exenter-  ation. With this technique, the ureters are  dissected distal to the crossing of the uterine  arteries; the peritoneum of the vesicouterine fold  is opened, and the plane between the cervix and  the bladder base is developed and followed dis-  tally between the anterior vaginal wall and the  urethra for the desired distance. The distal clipped  ends of the ureters can be used for anterior trac-  tion to facilitate following this plane distally.    Prostate-sparing cystectomy recently was in-  troduced as an alternative to a standard radical  cystectomy in male patients. This is an attractive  option, as it maintains potency and urinary    continence in a much larger percentage of patients,  by removing the bladder above the level of the  seminal vesicles and prostate. In this manner, the  neural pathways for erection, the drainage path-  way for semen, and the continence mechanism  around the prostate are undisturbed. A flurry of  debate surrounds the surgical principles of this  technique, because of concerns about oncological  adequacy. This debate is beyond the scope of this  article, although the authors mention that advo-  cates of the technique recommend careful selection  of patients with low-stage disease, and careful  exclusion of prostatic involvement with urothelial  carcinoma or prostate cancer prior to surgery.   To perform a prostate sparing laparoscopic  cystectomy, the plane between the bladder base  anteriorly and the seminal vesicles posteriorly is  developed and followed to the level of the bladder  neck. At this point, a prostatic enucleation  (adenomectomy) can be performed, leaving the  outside capsule of the prostate. Alternatively,  some authors prefer performing a transurethral  resection of the prostatic adenoma prior to cystec-  tomy, at which time the bladder is divided off the  capsule of the prostate just distal to the bladder  neck. After a neobladder is formed, it is sutured  to the cut edge of the prostatic capsule.   Only one study of adequate sample size in the  literature describes the results of laparoscopic  prostate-sparing cystectomy [13]. The study com-  prised 25 patients in whom a laparoscopic tech-  nique was used, based on experience from about  100 cases of open surgery. The average operative  time was 285 minutes; blood loss was 640 cc,  and the complication rate was 16%. One patient  had a local recurrence; two developed metastatic  disease, and one died of progressive cancer. All  patients were continent without pads; no patient  had urinary retention, and 84% of patients main-  tained preoperative potency. Although this study  clearly shows the functional benefit of the tech-  nique, widespread acceptance remains lacking  because of the perceived risk of local tumor  recurrence. The long-term utility of the technique  remains to be seen.    A current area of debate in the field of LRC is  whether to perform the urinary diversion intra-  corporeally using laparoscopic technique, or extra-  corporeally through a minilaparotomy that is  required for specimen extraction (at least in males).    Early reports of LRC used intracorporeal tech-  nique [4,6,14] for ileal conduit, orthotopic neoblad-  der, and rectal sigmoid pouch, and proved  conclusively that such an endeavor is technically  feasible. Prolonged operative time and significant  complications from the urinary diversion and  bowel reconstruction portions of the operation  have led to a shift favoring extracorporeal bowel  work, with intracorporeal suturing of the pouch-  urethral anastomosis for orthotopic neobladders.  Lack of enthusiasm for rectal urinary diversion  (ureterosigmoidostomy, rectal pouches) within  the United States has decreased the utility of intra-  corporeal diversion using these techniques. Within  the robotic assisted literature, the same situation  has prevailed, with reports of totally intracorporeal  diversion [15,16] giving way to an overwhelming  majority of extracorporeal urinary diversions.   The authors’ experience with both techniques  is representative of the current status on this topic  [17]. The authors compared their initial 17 cases  where intracorporeal urinary diversion was  formed with the subsequent 37 cases where an  extracorporeal diversion was formed. The second  group had decreased operative time, blood loss,  time to ambulation, time to oral diet, and signifi-  cantly fewer complications. Re-exploration for  anastomotic leak, bowel obstruction, or sepsis  was required in 29% of the first group versus  11% of the second group. With this clearly safer  and shorter approach, the authors have aban-  doned intracorporeal urinary diversion altogether.  This experience also has been that of other major  operators in this field [18].    Robotic-assisted laparoscopy has become  prevalent, especially in regards to radical prosta-  tectomy. With increasing robotic experience, it  was natural for surgeons to attempt the more  complex, closely related pelvic surgery, cystopros-  tatectomy. Proponents claim the benefits of im-  proved three-dimensional visualization, freedom  of movement offered by robotic instruments, and  ergonomic comfort. The surgical steps are similar  to the laparoscopic technique. The initial report in  the literature described the nerve-sparing tech-  nique in 17 patients, 14 of whom were males [19].  The same group described the technique for fe-  male cystoprostatectomy, with and without uterus  and vagina sparing, similar to that previously  described in this article [20]. Mean operating    time for the cystectomy and lymphadenectomy  portion was 140 minutes; mean blood loss was  150 cc. Urinary diversion was performed through  a laparotomy. All surgical margins were negative;  one reoperation for bleeding was required. The  complication rate was not reported. The same  group subsequently reported a port site recurrence  (the only one for LRC in the literature) within this  patient group [21]. A more recent study compared  20 patients undergoing robotic cystectomy with  extracorporeal urinary diversion with 24 patients  undergoing ORC [22]. Operating time was longer  (6.1 versus 3.8 hours); blood loss was less (313 ver-  sus 588), and a total complication rate of 30% was  reported. Mean lymph node yield was 19 nodes,  and no positive margins were encountered. Simi-  lar results were obtained in a larger study compar-  ing 21 ORCs with 33 robotic-assisted LRCs [23].   As widespread experience and availability of  robotic systems increases, there no doubt will be  an increase in the overall published experience  with robotic cystoprostatectomy. Reconstruction  and intracorporeal suturing are where the robotic  assistance is most helpful, and single case reports  have performed intracorporeal ileal conduits and  neobladders. Whether a significant advantage is  achieved through robotic assistance in LRC will  remain to be seen, as the operation remains an  extirpative procedure, with the reconstructive  urinary diversion portion being performed  through open surgery in most cases.    Hand-assisted laparoscopic technique has been  used extensively for renal surgery, but has been  significantly slower to permeate into the field of  pelvic laparoscopic procedures. Possible reasons  for lack of widespread use for LRC may be the  inherent length of operative time, making hand  assistance ergonomically more difficult. LRC is  also technically quite challenging, being under-  taken by laparoscopic surgeons with extensive  experience with pure laparoscopic technique,  who do not feel a distinct advantage for hand  assistance.   Hand-assisted laparoscopic technique  (HALRC) first was reported in 2002 [24], with  two small case series appearing in the literature  since then. McGinnis and colleagues [25] reported  seven cases of HALRC with mean operative time  of 7.6 hours, blood loss of 420 mL, and hospital  stay of 4.6 days without reporting oncologic    results. One open conversion was necessary for  unresectable lymph nodes, and surgical margins  were all negative. Taylor and colleagues [26] com-  pared eight patients undergoing ORC with eight  patients undergoing HALRC; all patients had  ileal conduit urinary diversion. Patients in the  HALRC group had less blood loss (637 versus  957 cc), less parenteral analgesia requirement,  faster return of bowel function, and shorter hospi-  tal stay (6.4 versus 9 days). Operative time was not  different. One rectal injury and one positive surgi-  cal margin were reported. All these studies taken  together do not show a distinct advantage for  HALRC over pure LRC.    LRC is a fairly new development in the field of  surgery for bladder cancer, a field where long-  term patient survival and tumor recurrence are the  ultimate measures. As such, long-term studies of  patient survival, let alone randomized studies  comparing laparoscopic with open surgical cys-  tectomy, are not available, although the authors  are starting such a prospective randomized study.  The literature contains retrospective series of  laparoscopic cystectomy, mainly describing oper-  ative, perioperative, and pathological results. Of  these, the authors present the results of the more  mature experiences, disregarding initial experi-  ences and case reports. The perioperative out-  comes of these studies are detailed in Table 1.   Few studies compare LRC with ORC. A  prospective nonrandomized study from Italy [28]  compared 22 ORC patients with 20 LRC patients.  One open conversion in the laparoscopic group  was necessary, and mean lymph node count was  18.4 in the ORC group and 19.5 in the LRC  group; there were no positive surgical margins  in either group. Significantly decreased postopera-  tive narcotics and shorter time to oral diet were  noted. All other parameters including operative  time, blood loss, transfusion rate, and hospital  stay were equivalent.   A retrospective comparison of LRC (13 pa-  tients) versus ORC (11 patients) reported no differ-  ence in operating time, blood loss, or complication  rates between the two procedures [27]. A surprising  finding in this study was the mean blood loss of 1 L  in the laparoscopic cases, much higher than most of  the studies in the literature. Two of the LRC pa-  tients underwent elective open conversion because  of large tumor size and previous pelvic surgery.  LRC patients had a significantly less postoperative    narcotic requirement, earlier resumption of oral  diet (2.8 versus 5 days), and shorter hospital stay  (5.1 versus 8.4 days).   A single report described intermediate-term  (less than 5 years) oncological outcomes [36]. Of  37 patients who had a median follow-up interval  of 31 months, extending to 5 years, two patients  had positive surgical margins and a mean lymph  node count of 6 in early cases (11 patients), and  21 in later cases (26 patients). Surgical pathology  showed tumor stage to be T1, T2a, T2b, T3a,  T3b, and T4a in 29%, 11%, 22%, 11%, 16%, and  11% of patients, respectively. Although 11 patients  (30% of the study) died of various noncancer-  related causes (five unknown cases of death), no pa-  tient in the study had a local recurrence or a port site  metastasis. Two patients developed distant meta-  static disease and subsequently died. Ignoring the  five unknown deaths resulted in a 5-year actuarial  overall and cancer specific survival of 63% and  92%, assuming those five deaths were from cancer  yielded 58% and 68% survival, respectively.   In two other studies with all margin-negative  patients reporting oncological follow- up, 3 of 20  patients (15%) developed metastatic disease with-  out local recurrence within a median follow-up  period of 2.7 years [29]. A smaller study of 10 pa-  tients reported a 40% rate of distant metastases  without local recurrence over a mean follow-up  period of 5 years [37], although this was an initial  experience study. It is also noteworthy that 70%  of patients in this study had pT2b or higher  disease, much higher than contemporary series  (open or laparoscopic).    At experienced centers, LRC is emerging as  a minimally invasive alternative to ORC, offering  reduced blood loss, postoperative pain, and pos-  sibly recovery time. With careful patient selection,  LRC achieves the surgical goals of wide excision,  negative margins, and extended lymphadenec-  tomy. Long-term oncologic data are awaited.    [1] Herr HW, Faulkner JR, Grossman HB, et al.  Surgical factors influence bladder cancer outcomes:  a cooperative group report. J Clin Oncol 2004;  22(14):2781-9.   [2] Puppo P, Perachino M, Ricciotti G, et al. Laparos-  copically assisted transvaginal radical cystectomy.  Eur Urol 1995;27(1):80-4.    [3] Parra RO, Andrus CH, Jones JP, et al. Laparoscopic  cystectomy: initial report on a new treatment for the  retained bladder. J Urol 1992;148(4):1140-4.   [10] Herr HW, Bochner BH, Dalbagni G, et al. Impact of   [14] Gill IS, Kaouk JH, Meraney AM, et al. Laparo-  scopic radical cystectomy and continent orthotopic  ileal neobladder performed completely intracorpor-  eally: the initial experience. J Urol 2002;168(1):13-8.   [15] Beecken WD, Wolfram M, Engl T, et al.  Robotic-assisted laparoscopic radical cystectomy  and intra-abdominal formation of an orthotopic  ileal neobladder. Eur Urol 2003;44(3):337-9.   [16] Balaji KC, Yohannes P, McBride CL, et al.  Feasibility of robot-assisted totally intracorporeal  laparoscopic ileal conduit urinary diversion: initial  results of a single institutional pilot study. Urology  2004;63(1):51—5.   [17] Haber G, Campbell S, Colombo J Jr, et al. Perioper-  ative outcomes with laparoscopic radical cystec-  tomy: pure laparoscopic and open assisted  laparoscopic techniques 2007;70(5):910—5.    [18] Cathelineau X, Jaffe J. Laparoscopic radical cystec-  tomy with urinary diversion: what is the optimal  technique? Curr Opin Urol 2007;17(2):93-7.   [19] Menon M, Hemal AK, Tewari A, et al. Nerve-  sparing robot-assisted radical cystoprostatectomy  and urinary diversion. BJU Int 2003;92(3):232-6.   [20] Menon M, Hemal AK, Tewari A, et al. Robot-assisted  radical cystectomy and urinary diversion in female pa-  tients: technique with preservation of the uterus and  vagina. J Am Coll Surg 2004;198(3):386—93.   [23] Wang GJ, Barocas DA, Raman JD, et al. Robotic vs  open radical cystectomy: prospective comparison of  perioperative outcomes and pathological measures  of early oncological efficacy. BJU Int 2008;101(1):  89-93.    [28] Porpiglia F, Renard J, Billia M, et al. Open versus  laparoscopy-assisted radical cystectomy: results of  a prospective study. J Endourol 2007;21(3):325-9.   [29] DeGer S, Peters R, Roigas J, et al. Laparoscopic  radical cystectomy with continent urinary diversion  (rectosigmoid pouch) performed completely  intracorporeally: an intermediate functional and  oncologic analysis. Urology 2004;64(5):935-9.   [30] Cathelineau X, Arroyo C, Rozet F, et al. Laparo-  scopic-assisted radical cystectomy: the Montsouris  experience after 84 cases. Eur Urol 2005;47(6):  780-4 [Epub 2005 Apr 11].   [31] Castillo OA, Abreu SC, Mariano MB, et al. Compli-  cations in laparoscopic radical cystectomy. The  South American experience with 59 cases. Int Braz  J Urol 2006;32(3):300-5.   [32] Gerullis H, Kuemmel C, Popken G. Laparoscopic  cystectomy with extracorporeal-assisted urinary  diversion: experience with 34 patients. Eur Urol  2007;51(1):193-8.   [33] HuangJ, Xu KW, Yao YS, et al. Laparoscopic radical  cystectomy with orthotopic ileal neobladder: report  of 33 cases. Chin Med J (Engl) 2005;118(1):27-33.   [34] Rassweiler J, Frede T, Teber D, et al. Laparoscopic  radical cystectomy with and without orthotopic  bladder replacement. Minim Invasive Ther Allied  Technol 2005;14(2):78—95.   [35] Sighinolfi MC, Micali S, Celia A, et al. Laparoscopic  radical cystectomy: an Italian survey. Surg Endosc  2007;21(8):1308-11.   [36] Haber GP, Gill IS. Laparoscopic radical cystectomy  for cancer: oncological outcomes at up to 5 years.  BJU Int 2007;100(1):137-42.   [37] Simonato A, Gregori A, Lissiani A, et al. Laparo-  scopic radical cystoprostatectomy: our experience  in a consecutive series of 10 patients with a 3 years  follow-up. Eur Urol 2005;47(6):785—90 [discussion:  790-2].    Minimally Invasive Treatment of Stress Urinary  Incontinence and Vaginal Prolapse  Elizabeth B. Takacs, MD**, Kathleen C. Kobashi, MD^    “Department of Urology, University of Iowa, 200 Hawkins Drive, 3 RCP, Iowa City, IA 52242-1089, USA  Section of Urology and Renal Transplantation, Virginia Mason Medical Center,  1100 Ninth Avenue, Seattle, WA 98111, USA    Disorders of the female pelvic floor, specifically  stress urinary incontinence (SUI) and pelvic organ  prolapse (POP), are prevalent among women of  all ages. Numerous challenges await those who  evaluate and treat these particular disorders,  however. First, the risk factors for prolapse and  incontinence are poorly understood, making it  difficult to implement preventive measures. Sec-  ond, there is no clear definition or agreement on  what defines clinically significant prolapse. Objec-  tive measures of treatment are variable, and the  definitions of success or failure of treatment  options are vague. It has also been well estab-  lished that discrepancies between subjective and  objective outcome measures are not uncommon.  Finally, we are hindered by the fact that much of  the available literature is limited in length of  follow-up and cohort size. These are important  issues to recognize as we review the current  literature.   The estimated lifetime risk for undergoing  corrective surgery for POP is 11% [1,2]. This esti-  mate is based on hospital admission and surgical  codes data and likely underestimates the overall  prevalence of SUI and POP in the general popula-  tion. Two studies examined data on POP from the  large multi-institutional Women's Health Initia-  tive Hormone Replacement Therapy Clinical  Trial. Hendrix and colleagues [3] presented the  baseline data from the 27,342 patients enrolled.  On visual inspection alone during the Valsalva  maneuver, 41.1% of patients with an intact uterus    had some degree of descent versus 38% of patients  who had undergone a hysterectomy. In an ancil-  lary study, Nygaard and colleagues [4] examined  the rate of prolapse in women with an intact  uterus. The mean age of the 270 participants  was 68.3 years, and 65.5% were found to have  stage 2 (leading edge within 1 cm proximal to  hymen) or greater prolapse based on the standard-  ized pelvic organ position quantification descrip-  tion (POP-Q [5]) examination. If the definition  of prolapse was further narrowed to the leading  edge at or beyond the hymen, 25.2% were defined  as having prolapse.   In the past 10 years there has been significant  evolution in the treatment of SUI and POP. The  laparoscopic retropubic urethropexy was first  introduced in 1991 [6] but was abandoned because  of several small studies reporting lower cure rates.  The next major stride in minimally invasive treat-  ment of SUI occurred in 1996 with the introduc-  tion of the tension-free vaginal tape (TVT) [7].  This sling has been a significant impetus for the  development of the vaginal mesh “kits” that are  now available for treatment of SUI and POP.  Attributable in great part to the simplicity of these  techniques, the number of pelvic reconstructive  cases performed per annum has increased signifi-  cantly over the past decade.   In an effort to incorporate minimally invasive  techniques in POP treatment, laparoscopic and  robotic approaches have been applied to several  transabdominal surgical techniques. The often-  cited advantages of laparoscopic and robotic  surgery include improved visualization because  of magnification and insufflation, better cosmesis  and hemostasis, shorter hospital stay and less  postoperative pain with an overall more rapid    0094-0143/08/$ - see front matter © 2008 Elsevier Inc. All rights reserved.    recovery relative to corresponding open  approaches. The disadvantages of minimally  invasive techniques are the long “learning curve,"  the potentially increased difficulty of the retroper-  itoneal dissection, and the potential increase in  hospital costs. It is likely that with the increased  application of robotics and laparoscopy, the  learning curve is eventually likely to become  a less significant barrier.   Only recently have well-designed trials with  longer term and appropriate minimum follow-up  (1—2 years) begun to appear in the literature. The  aim of this article is to review the laparoscopic  and robotic techniques that have been described  for treatment of POP and SUI and to present the  longer term results available to date. Although  considered by many to be “minimally invasive,"  the transvaginal techniques are not covered in this  article.    The indications for a laparoscopic or robotic  approach to surgery for POP or SUI are identical  to those for the open abdominal and vaginal  routes. Repairs are reserved for those patients  who are symptomatic from the prolapse. Symp-  toms may vary from patient to patient. The  obvious bulge protruding from the vagina creat-  ing significant discomfort for the patient provides  a clear indication for repair. More subtle findings  of lower degrees of prolapse with variable associ-  ated voiding symptoms may require more  contemplation.   The decision between a vaginal, abdominal, or  laparoscopic or robotic approach depends on  surgeon experience and patient preference. Other  factors, such as prior prolapse repairs or anti-  incontinence surgery, prior abdominal proce-  dures, vaginal caliber and length in addition to  age, weight, comorbidities, and ability to tolerate  general anesthetic, are all important consider-  ations for a laparoscopic or robotic approach.   The endopelvic fascia contributes to the  integrity of the vaginal wall—anteriorly, the  endopelvic fascia is referred to as the pubocervical  fascia, and, posteriorly, the rectovaginal fascia.  DeLancey [8] described three levels of support to  the vagina and pelvic structures based on suspen-  sion, attachment, and fusion of the pelvic tissues  at the corresponding levels (Fig. 1; Table 1).  POP represents a break in the continuity of the en-  dopelvic fascia or loss of the corresponding    Fig. 1. Three levels of support to the vagina and pelvic  structures based on suspension, attachment, and fusion  of the pelvic tissues at the corresponding levels described  by DeLancey.    suspension, attachment, or fusion. Pelvic recon-  structive surgery aims to re-establish and correct  the defects to restore normal anatomy and visceral  (bowel and bladder) and sexual function.   With any surgical procedure (open, laparo-  scopic, or robotic), there are important anatomic  landmarks with which the surgeon must be  familiar. Pertinent landmarks are discussed as  the various approaches to pelvic floor reconstruc-  tion are reviewed.    In 2004, the Third International Consultation  on Incontinence reported that level 1 evidence to  support the use of open Burch colpopexy for the  treatment of SUI exists; however, data for lapa-  roscopic colposuspension were insufficient, and no  recommendations could be made regarding its  use [9]. Conversely, the 2005 Cochrane review  reported that laparoscopic colposuspension pro-  vided benefits, such as more rapid recovery, but  that long-term efficacy is unknown [10].   In 2006, two randomized trials of open versus  laparoscopic Burch colposuspension with a mini-  mum follow-up of 24 months suggested similar  outcomes between the two procedures. Kitchener  and colleagues [11] reported a 2-year objective    Supportive structures of the vaginal levels as described after hysterectomy by DeLancey and resulting POP when the    Technique Support mechanism Supported structure Result of support failure  Level I Suspension Cardinal/uterosacral Uterus Uterine descensus  complex Proximal one fourth Vaginal vault  of the vagina (vault/apex) (apical) prolapse  Level II Attachment Lateral attachment Middle half of vagina Cystocele  of the pubocervical Bladder, bladder neck Urethral hypermobility  and rectovaginal Proximal rectum Rectocele  endopelvic fascia  to the ATFP  Level III Fusion Fusion to the perineal body Distal one fourth Distal rectocele    Data from DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol    cure rate (<1 g on pad test) of 79.7% in the lap-  aroscopic group versus 70.1% for the open group.  Similar subjective data (never or «1 incontinent  episode per month) of 55.4% versus 53.1%,  respectively, were also demonstrated. Carey and  colleagues [12] reported subjective (no inconti-  nence) results at 24 months of follow-up for all  subjects of 63% and 70% for laparoscopic versus  open approaches, respectively. With an intent-to-  treat analysis, the success rates decreased to  61% and 50%, respectively, but this did not rep-  resent a statistically significantly difference. Nei-  ther study commented on the development of  POP after surgery.   These data suggest that when performed in  a fashion similar to the open procedure, the  laparoscopic Burch colposuspension may be com-  parable to open surgery. Together with the data  supporting the use of the laparoscopic Burch  colposuspension at the time of sacrocolpopexy  for patients without symptoms of SUI [13], there  may still be a role for the laparoscopic Burch  colposuspension in conjunction with other laparo-  scopic or robotic procedures.    Laparoscopic and robotic procedures  for treatment of pelvic organ prolapse:  anatomy and procedures    The fact that a single surgical technique has  not been readily accepted for treating cystoceles  suggests a complexity of the condition beyond    current understanding. Anterior colporrhaphy has  long been the primary approach to correction of  cystoceles despite reported failure rates of 40% to  70% [14,15]. This emphasizes the fact that several  different defects can result in a cystocele, and,  accordingly, the defect specific to a given patient  needs to be identified and corrected.   In 1909, White [16] described the lateral  detachment of the endopelvic fascia from the  arcus tendineus fasciae pelvis (ATFP) as a cause  for anterior compartment prolapse and a transva-  ginal approach for repair. A corresponding ab-  dominal paravaginal repair was described in  1976 [17] and has been replicated laparoscopically  [18].   The anatomic landmarks for a paravaginal  repair are similar to those used for a Burch  retropubic urethropexy. The space of Retzius is  developed to identify the lateral detachment of the  endopelvic fascia from the ATFP. Key structures  include Cooper's ligaments, accessory or aberrant  obturator veins, obturator neurovascular bundles  that lie 3 to 4 cm anterior to the ATFP, the  bladder neck, the ATFP itself, and the arcus  tendineus levator ani.   In a laparoscopic transperitoneal approach,  the bladder must first be mobilized. After filling  the bladder for identification, a transverse incision  2 cm cephalad to the bladder reflection is made  between the medial umbilical folds. Dissection is  performed through the loose areolar tissue in an  infralateral direction, moving toward the poste-  rior-superior aspect of the pubic symphysis until  Coopers ligaments, the bladder neck, the    obturator internus muscle and foramen, and the  ATFP are identified. A vaginal manipulator  (finger) helps to identify the torn edges of the  pubocervical fascia from the ATFP. This para-  vaginal defect is closed with a series of nonabsorb-  able sutures starting distally, alternating sides.  The most distal sutures (generally three sutures)  incorporate vaginal tissue and the obturator  internus and iliopectineal ligaments, whereas the  most proximal suture only incorporates vaginal  tissue and the iliopectineal ligament. The sutures  are then tied without tension. If there is concern  that significant urethral hypermobility is contrib-  uting to the SUI, the sutures may be tied more  tightly [19]. Further level I defects require correc-  tion with hysteropexy or colpopexy. Cystoscopy is  performed to confirm ureteral patency.    Most surgeons prefer a transvaginal route for  rectocele repair [20]; however, a laparoscopic  approach has been described. The important land-  marks for the abdominal approach include the  rectovaginal septum, its lateral attachments to  the medial aspect of the levator ani muscles, and  the perineal body. During the procedure, the  rectovaginal space is developed to the level of  the rectovaginal septum. The perineal body is se-  cured to the rectovaginal septum, and the rectova-  ginal fascial defects are closed with nonabsorbable  sutures. In addition, the iliococcygeus and recto-  vaginal fascia can be reapproximated, and a leva-  tor ani placation can be performed if needed.    Identification and treatment of apical descent  is fundamental to the success of pelvic floor  reconstruction. Apical repair involves obliteration  of the defect responsible for re-establishment of  apical support.   Laparoscopic Moschowitz and Halban proce-  dures are performed in a manner identical to the  open abdominal repairs using nonabsorbable su-  tures to obliterate the cul-de-sac. In the Moscho-  witz procedure, the suture is placed in a purse-string  fashion circumferentially around the cul-de-sac,  whereas the Halban procedure uses sutures placed  longitudinally incorporating the sigmoid serosa,  the peritoneum of the cul-de-sac, and the posterior  vagina. Cystoscopy should be performed after  intravenous administration of indigo carmine or  methylene blue to confirm ureteral integrity,    keeping in mind that the risk for ureteral kinking  is reportedly greater with the Moschowitz pro-  cedure [21]. Cadeddu and colleagues [22] described  a modified Moschowitz procedure in which the pos-  terior vaginal fascia is reapproximated with the an-  terior wall of the rectum.   During a laparoscopic enterocele repair, the  enterocele sac is dissected laparoscopically or  vaginally with identification of defects of the  endopelvic fascia, pubocervical fascia, and recto-  vaginal fascia. For large enteroceles, a transvagi-  nal approach is used to excise the redundant  peritoneum and vagina, with care taken to avoid  foreshortening or narrowing of the vagina. The  vaginal apex and rectum can be delineated during  laparoscopic dissection by intravaginal placement  of an obturator, sponge-stick, or equivalent vag-  inal manipulator. A nonabsorbable suture placed  in an interrupted fashion is then used to reap-  proximate the pubocervical and rectovaginal fas-  cial edges until the defect is closed. Koninckx and  colleagues [23] described vaporization of the  enterocele sac with the carbon dioxide laser.  Enterocele closure and excision performed con-  comitantly with uterosacral ligament suspension  re-establishes support of the vaginal apex.   The uterosacral ligaments have been used as  supporting structures to re-establish level I support  to the vaginal apex or uterus. Important anatomic  landmarks in the laparoscopic uterosacral ligament  vaginal vault suspension (LUSVS) or laparoscopic  uterosacral ligament uterine vault suspension sus-  pension (LUSUS) include the pubocervical and  rectovaginal fascias, the uterosacral ligament, and  the ureters. The ureters are in close proximity (1—1.5  cm lateral) to the uterosacral ligament as it courses  beneath the uterine artery.   For the LUSVS, the uterosacral ligament at  the proximal portion of its break is sutured with  a nonabsorbable suture to the vaginal apex. The  apical stitch is placed through the full thickness of  the uterosacral and cardinal ligament complex  and the rectovaginal fascia, excluding the vaginal  epithelium. Additional sutures are placed more  proximally on the uterosacral ligaments for sup-  port of the rectovaginal fascia. If a concomitant  enterocele repair is planned, the uterosacral liga-  ments are identified and tagged before dissection  of the posterior vagina [24]. Ross [25] described an  apical repair that brought the rectovaginal septum    and uterosacral and cardinal ligaments together  with the use of purse-string sutures and plication  of the uterosacral ligaments. In that procedure,  the peritoneum is dissected free from the vaginal  apex and pubocervical fascia. A series of nonab-  sorbable sutures are placed in a purse-string fash-  ion incorporating the left and right uterosacral  and cardinal ligaments, the rectovaginal septum,  and the posterior vaginal wall. The first sutures  are placed in the uterosacral ligament 3 to 4 cm  proximal to the vaginal apex; subsequent sutures  are placed until the vaginal apex is reached, with  the final suture incorporating the pubocervical  fascia.   Several researchers have described the LUSUS  with minor differences in techniques. The basic  principle involves placement of a nonabsorbable  suture full thickness through the uterosacral  ligament at the level of the ischial spine and then  again at its insertion at the lower uterine segment  to create shortening of the ligament [26,27].   (Movie 1: Robotic assisted laparoscopic sacro-  colpopexy*) Laparoscopic and robotic sacrocol-  popexy (L/RSCP) procedures have been  described with the goal of replicating the open  surgical technique. Important anatomic land-  marks at the sacrum include the middle sacral ar-  tery and vein and the anterior longitudinal  ligament on the sacral promontory. The aortic bi-  furcation and vena cava lie superiorly at L4 to L5.  Along the lateral margins of the presacral space  are the iliac vessels and ureters bilaterally and  the sigmoid colon, which is reflected to the left.   Final port placement configuration between  the laparoscopic and robotic approaches is simi-  lar. For the laparoscopic approach, primary ports  include an intraumbilical port and then a 10- to  12-mm port in each lower quadrant. One to two  ancillary 5-mm ports may be placed at the level of  the umbilicus lateral to the rectus muscle. For the  robotic approach, the primary 12-mm port is  placed at the inferior umbilical crease and two  lateral 8-mm ports are then placed just below the  level of the umbilicus and lateral to the rectus  muscle. Two additional assistant ports are then  placed in the lower quadrants.   Once port placement is complete and the  robot, when employed, is docked, a vaginal    * Videos for this article can be accessed by visiting  www.urologic.theclinics.com. In the online table of con-  tents for this issue, click on add-ons."    obturator is used to delineate the vaginal apex.  The peritoneum overlying the apex is dissected off  the vagina, and the incision of the posterior  peritoneum is extended cephalad toward the  sacral promontory.   Exposure of the presacral space and sacral  promontory can be facilitated by *airplaning" the  patient to the left and using a “snake” retractor.  For improved exposure, retraction of the sigmoid  can be facilitated using a figure-of-eight silk suture  placed through the tenia coli and exiting percuta-  neously. The incision in the peritoneum overlying  the sacral promontory is continued longitudinally  extending through the cul-de-sac, and the presacral  fat is cleared to expose the sacral periosteum.  Hemostasis can be achieved by coagulation or  clip placement. A Y-shaped synthetic mesh or  biologic graft is secured to the vagina with non-  absorbable sutures placed through the full thick-  ness of the vaginal wall. The mesh is secured to the  sacral promontory with two nonabsorbable sutures  preplaced into the anterior spinous ligament or by  means of sutures attached to titanium bone an-  chors. The mesh should be placed without tension  to support the vagina in an anatomic position.  Redundant mesh is excised, and the posterior  peritoneum is reapproximated over the mesh. If  the mesh cannot be completely retroperitonealized,  sigmoid epiploic fat can be used to cover it.   In the presence of a uterus, sacrohysteropexy  can be performed for uterine preservation. This  involves dissecting the rectovaginal space for  approximately one third of the length of the  posterior vaginal wall. The mesh or biologic graft  is secured in several rows along the rectovaginal  fascia and posterior cervix to the level of the  internal os. Peritoneal closure is then performed.   Surgeon preference and anatomic detail should  dictate the use of concomitant procedures. In the  presence of a deep cul-de-sac, a Halban or Mosch-  cowitz "culdeplasty" may be used. Urethral hy-  permobility is addressed with laparoscopic Burch  or paravaginal repair. In the presence of rectal  prolapse, rectopexy with or without the assistance  of a colorectal surgeon can be performed.    Laparoscopic and robotic procedures  for treatment of pelvic organ prolapse: results    Assessment of pelvic floor reconstructive tech-  niques is challenging. As mentioned previously,  objective measures of surgical treatment options  are variable, the definition of success or failure is  vague, and discrepancies between subjective and    objective outcome measures are frequently  encountered. Long-term pelvic floor reconstruc-  tive data are also limited, and correction of pelvic  floor defects often entails a combination of pro-  cedures, making assessment of any single pro-  cedure more challenging. With these limitations in  mind, the data that are available with emphasis on  series with a minimum follow-up of 12 months are  reviewed.    Ostrzenski [28] prospectively evaluated the  effectiveness of an isolated laparoscopic paravagi-  nal repair for SUI and found an objective and  subjective cure rate of 93%. Mean operative  time was 165 minutes with no major perioperative  complications reported.   Behnia-Willison and colleagues [19] reported  on 212 patients who had POP and were treated  with bilateral laparoscopic paravaginal repair  with or without concomitant level I or posterior  repair at a mean follow-up of 14.2 months. Of the  212 patients, 84 (39.6%) had a concomitant  central defect that was not repaired at the initial  surgery. Based on the presence of paravaginal  sulci, only 3 patients had failure. Objective cure,  defined as stage 0 or 1 on POP-Q examination,  was achieved in 76.4% of patients. Twenty-three  of the 40 failures occurred in the anterior com-  partment of patients with combined central and  lateral defects. This article provides evidence  that the laparoscopic paravaginal repair can recre-  ate the lateral vaginal sulcus and, in some patients  with a combined anterior defect, provide adequate  support for improvement in stage. Operative time  varied from 55 to 255 minutes but included con-  comitant procedures. These investigators reported  a major complication rate (bowel, ureter, or blad-  der injury; anesthetic complication; unintended  laparotomy; or blood loss >1 L) of 4.2%.    The vaginal approach to rectocele repair is often  the preferred route of correction. with reported  success rates of 76% to 96% and, importantly, low  rates of complications [29]. There are limited  reports on the success of isolated laparoscopic pos-  terior repair. Lyons and Winer [30] reported that in  20 patients undergoing laparoscopic rectocele  repair with polyglactin mesh with or without con-  comitant hysterectomy, 80% had resolution of  symptoms at 1 year of follow-up.    Three recent series have examined the results  of LUSUS or LUVSV for apical repair. Diwan  and colleagues [26] reported the results of LUSUS  versus total vaginal hysterectomy (TVH) for cor-  rection of uterine prolapse with less than 1 year  of follow-up. Patients who had a TVH had a con-  comitant McCall’s culdoplasty, sacrospinous liga-  ment suspension, or laparoscopic uterosacral  ligament suspension. POP quantification of the  apical data points revealed the LUSUS point  D (—9 cm) compared with the TVH point  C (—7.6 cm). Overall, one apical recurrence was  reported in the LUSUS group compared with  five in the TVH cohort. Schwartz and colleagues  [24] reported statistically significant improvement  in the sum of POP-Q values in 72 patients who  had undergone LUSUS or LUSVS at less than  1 year of follow-up. The only series to report  a mean follow-up greater than 12 months was  that of Medina and Takacs [27]. In this series  with a mean follow-up of 15.9 months (range:  6—40 months), LUSUS resulted in statistically sig-  nificant improvement in points C and D. No  major intraoperative complications were reported.  These studies support LUSUS or LUVSV as  a viable option for recreating level I support; how-  ever, longer follow-up is pending.   In a comprehensive review of the abdominal  sacrocolpopexy, a 78% to 100% success rate was  achieved when defined as no apical recurrence,  and this decreased to 58% to 100% when success  was defined as no postoperative prolapse [31]. The  Third International Consultation on Incontinence  (ICI) issued a grade A recommendation that sac-  rocolpopexy-based abdominal POP surgery is  likely to result in a better and possibly more dura-  ble anatomic outcome than sacrospinous-based  vaginal approaches but is limited by the increase  in short-term morbidity [32]. This has naturally  encouraged progression of laparoscopic and  robotic approaches. The question is whether or  not the long-term success of the open procedures  transfers to the minimally invasive techniques in  terms of efficacy, comparable operative time,  decreased hospital stay, and no increase in  complications.    Paraiso and colleagues [33] published a com-  parison of the first 56 laparoscopic sacrocolpopex-  ies (LSCPs) to 61 open sacrocolpopexies (SCPs)  completed during the same period with mean    follow-ups of 14 and 16 months, respectively.  Mean operative time was significantly longer for  the LSCP (269 versus 218 minutes), but the hospi-  tal stay was significantly shorter (1.8 versus  4 days) There were no differences in clinical  outcomes and reoperation rates. This is the only  report available that compares open and laparo-  scopic techniques.   Other long-term reports continue to support the  feasibility and efficacy of the LSCP (Table 2). Higgs  and colleagues [34] evaluated 103 of 140 patients  who had undergone LSCP. Sixty-six patients un-  derwent repeat physical examination, and 103 re-  sponded to questionnaires. Median follow-up was  66 months, but all follow-ups were at least 36  months from surgery. Median surgery duration  for all procedures was 145 minutes; surgical time  was 107 minutes for those who underwent LSCP  alone. Of the 103 patients evaluated, 4 had intrao-  perative complications (two bladder injuries, two  bowel injuries). Mesh erosion rates were reported  as 20% when placed through a transvaginal route  and as 6% when placed laparoscopically. Subjec-  tively, 71% of patients were very or quite satisfied  with the procedure. The reoperation rate was  16% for all prolapses. On physical examination,  62% had stage 0 or 1 prolapse, 32% had stage 2  (10% apical), and 6% had stage 3. During a fol-  low-up period of 5 years, Ross and Preston [35] an-  alyzed 51 cases of LSCP for grade III and IV apical  prolapse and reported a 93% cure rate.   With increasing documentation of the technical  feasibility of LSCP and its comparable outcomes to  open SCP, more attention is being drawn to the  surgical techniques of LSCP and concomitant pro-  cedures. Antiphon and colleagues [36] sought to an-  swer the question of whether the posterior limb of  support is necessary when there is no evidence of  posterior prolapse. A single anterior mesh (SAM)  was placed in 31 patients and a double-mesh  (DM), with mesh placed both anteriorly and poste-  riorly, was placed in 71 patients. Mean follow-up  times were 16 and 17 months, respectively. A global  failure rate of a Baden-Walker grade II or greater  prolapse for any compartment was 25%, with  43.8% versus 16.2%, respectively, in the SAM ver-  sus DM groups. Furthermore, these investigators  found that in patients who had undergone a prior  or concomitant Burch procedure, the failure rate  was statistically significantly higher in the patients  in whom mesh was placed anteriorly (SAM  [55%]) versus those in whom the mesh was placed  anteriorly and posteriorly (DM [12.5%]). The final  conclusion was that posterior mesh should be    reserved for patients who have a documented recto-  cele or enterocele, or when associated with a Burch  procedure.   In a second study, DM was placed uniformly  in all patients with variability of the anti-inconti-  nence procedure performed [37]. Overall, LSCP  was completed successfully in 41 (86%) of  46 patients; 32% had LSCP alone, 36% had a con-  comitant laparoscopic Burch procedure, and 32%  had concomitant TVT. The median follow-up was  24 months, with a 12-month minimum. The mean  operative time was 206 minutes overall and  171 minutes for LSCP alone. The mean postoper-  ative stay was 4 days overall and 3.1 days for  LSCP alone. There were three intraoperative  bladder injuries and one postoperative fever.  Objective cure of Baden-Walker grade 0 or  1 was achieved in 83% of patients; 5 patients  had recurrence of rectocele, all of whom had  had a concomitant laparoscopic Burch procedure.  In this study, despite placement of a posterior  limb, Burch urethropexy was a risk for recurrent  rectocele formation. Both studies together raise  the question of whether a concomitant Burch ure-  thropexy should be performed.   The overall complication rate for LSCP is low  according to the available studies. The incidence  of small bowel obstruction was 1%, and the rate  of mesh erosion was 3.7% (see Table 2). Both  rates are similar to those reported for open sacro-  colpopexy at 1.1% and 3.4%, respectively [31].   Recently, initial reports on robotic sacrocolpo-  pexy (RSCP) have begun to appear. In 2005, Ayav  and colleagues [38] published a small case series of  18 consecutive patients who underwent RSCP  (n — 12) or rectopexy (n — 6). Mean setup time  (wrapping and positioning the robot and ports)  was 30 minutes, and mean operative time was  170 minutes. All procedures were successfully  completed, and the only reported complication  was in the rectopexy group, in which one patient  had a rectal tear. At 12 months of follow-up, no  patient had evidence of POP. A case series from  the Cleveland Clinic evaluated the use of robotic  abdominal sacrocolpopexy or sacrouteropexy for  stage III and IV POP [39]. The follow-up is short,  with a mean of 3.1 months, but all POP-Q points  demonstrated improvement. The surgery was  completed successfully in 12 of the 15 patients,  with a mean estimated blood loss (EBL) of 81  mL, hospital stay of 2.4 days, and operative  time of 317 minutes. Elliott and colleagues [40]  evaluated 21 patients who had undergone RSCP  with a minimum of 12 months of follow-up and    Table 2  Summary of the perioperative and complication data for laparoscopic sacrocolpopexy and robotic sacrocolpopexy available in the literature  Follow-up Hospital Conversion  Authors Procedure N (months) OR time (minutes) EBL(cm?) stay (days) to open Complications  Paraiso LSCP 56 13.5 (1-46) 269 + 65 (150-467) 172 + 166 (0-1100) 1.8 + 1.0 (1—6)  1(1.796) Excessive Bladder injury/suture,  et al [33] bleeding during 6 (10.7%)  rectopexy Enterotomy, 1 (1.8%)  SBO, 1 (1.8%)  Mesh erosion, 2 (3.6%)  Higgs et al LSCP 140 66 (37-124) 145 (95-265) — 3.8 (2-12) 1 (0.7%) Bladder Cystotomy, 2 (1.4%)  [34] Median perforation Enterotomy, 2 (1.4%)  Mesh erosion, 9 (994)  LSCP portion  — — 107 (62-170) — — —  Ross and LSCP 51 5 years — — — — No intraoperative  Preston [35] complications  SBO, 2 (4%) g  LSCP portion — — 96 + 42 100 + 20 = — Mesh erosion, 4 (8%) a  Antiphon LSCP 108 17+ 16 261 + 79 (120-450) — 7 + 4 (2-32) 3 (2.8%) Bladder injury, 3 (2.8%) 2  et al [36] (1-68) Obesity factor Reoperation, 4 (7.4%) E  SAM 33 16 + 18 261 + 120 (120-450) — — 1: SB injury 8  1: SB ischemia 2  DM 71 17 + 19 261 + 69 (130-430) — = a 1: SBO z  1: Intervertebral  disc infection  Gadonneix LSCP 46 24 (12-60) 206 + 56 (105-360) -— 4.0 € 2.1 5 (1196) Bladder injury, 3 (7%)  et al [37] Median 1: Hypercapnia  4: Difficult  promontory  LCSP portion — — 171 + 37 (105-225) — = — —  Ayav [38] RSCP 12 — 170 (74-280) E 7 (4-13) 0 —  Dangeshgari RSCP 15 3.1 (3-8) 317 (258-363) 81 (50-150) 2.4 (1-7) 3 (20%) Serosal injury, | (6.6%)  et al [39] Wound infection,  0 (0%)  Elliott et al RSCP 30 = 186 (2.15-4.75 hours) — = 1 (3.3%) Bladder Mesh erosion, 2 (6.6%)    Abbreviations: EBL, estimated blood loss; OR, operating room; RSCP, robotic sacrocolpopexy; SB, small bowel; SBO, small bowel obstruction.    a mean of 24 months. In this study, all patients had  a preoperative Baden-Walker grade 4 apical pro-  lapse. Mean total operative time was 186 minutes;  however, with experience, these investigators re-  port routinely completing the procedure in 150  minutes. All but 1 patient were discharged on the  first postoperative day. Complications included  one conversion to an open procedure for anatomic  reasons, port site infections, and one postoperative  vaginal bleed related to the anti-incontinence pro-  cedure. Two patients (10%) developed a small vag-  inal extrusion of the mesh at the vaginal cuff.  Overall, 18 of 20 patients in whom the RSCP was  successfully completed had no evidence of  recurrent prolapse: 1 patient had recurrent vault  prolapse, and 1 patient developed a grade 3/4  rectocele.    POP and SUI are prevalent conditions that  have been approached using a variety of surgical  techniques, with more than 40 procedures  described for correction of POP alone [20]. There  remain many unanswered questions regarding the  optimal management of POP. Whether or not  a graft should be used, whether that graft should  be a biograft or synthetic mesh, and whether min-  imally invasive techniques can achieve outcomes  similar to those of open approaches remain topics  of debate and discussion. How to measure ana-  tomic outcome most accurately and what other  parameters should be assessed remain active con-  siderations within the subspecialty as well.   In 2005, the World Health Organization ( WHO)  Third ICI Committee on Surgery for POP reported  three conclusions based on level 1 evidence:  (1) overall outcomes indicate that abdominal and  vaginal surgery are relatively equivalent; (2) sacro-  spinous-based vaginal procedures have a higher  anterior and apical anatomic recurrence rate than  SCP-based abdominal repairs; and (3) abdominal  surgery has greater morbidity, at least in the short-  term [32]. Many clinicians have started to apply  laparoscopy and robotics to pelvic floor recon-  struction in the hopes of capitalizing on the advan-  tages of minimally invasive surgery. Properly  conducted randomized prospective studies are  needed to definitively establish the advantages of  minimally invasive pelvic floor surgery.    [1] Olsen A, Smith VA, Bergstrom JO, et al. Epidemiol-  ogy of surgically managed pelvic organ prolapse and   [2] Fialkow MF, Newton KM, Lentz GM, et al. Life-  time risk of surgical management for pelvic organ  prolapse or urinary incontinence. Int Urogynecol J  Pelvic Floor Dysfunct 2008;19:437-40.   [3] Hendrix SL, Clark AC, Nygaard I, et al. Pelvic or-  gan prolapse in the women's health initiative: gravity  and gravidity. Am J Obstet Gynecol 2002;186:  1160—6.   [4] Nygaard I, Bradley C, Brandt D. Pelvic organ pro-  lapse in older women: prevalence and risk factors.  Obstet Gynecol 2004;104:489—97.   [5] Bump RC, Mattiasson A, Boo K, et al. The stan-  dardization of terminology of female pelvic organ  prolapse and pelvic floor dysfunction. Am J Obstet  Gynecol 1996;175:10—7.   [6] Vancaillie TG, Schuessler W. Laparoscopic bladder-  neck suspension. J Laparoendosc Surg 1991;1:169—73.   [7] Ulmsten U, Henriksson L, Johnson P, et al. An am-   [15] Weber AM, Walters MD, Piedmonte MR, et al.  Anterior colporrhaphy: a randomized trial of three  surgical techniques. Am J Obstet Gynecol 2001;  185:1299—306.   [16] White GR. Cystocele: a radical cure by suturing  lateral sulci of vagina to white line of fascia. J Am  Med Assoc 1909;53:1707—10.    [17] Richardson AC, Saye WB, Miklos JR. Repairing  paravaginal defects laparoscopically. Contemp Ob  Gyn 1997;42:125-31.   [21] Paraiso MFR, et al. Laparoscopic abdominal sacral  colpopexy. In: Vasavada SP, Appell RA, Sand PK,  et al, editors. Female urology, urogynecology, and  voiding dysfunction. London: Informa Healthcare;  2004. p. 691—700, chapter 49.   [22] Cadeddu JA, Micali S, Moore RG, et al. Laparoscopic  repair of enterocele. J Endourol 1996;10:367—9.   terosacral ligament repair for uterine or vaginal  vault prolapse: interim results from an active multi-   compared with vaginal hysterectomy with vaginal  vault suspension for ureterovaginal prolapse. Int   [29] Cundiff GW, Fenner D. Evaluation and treatment  of women with rectocele: focus on associated   [30] Lyons TL, Winer WK. Laparoscopic rectocele  repair using polyglactin mesh. J Am Assoc Gynecol  Laparosc 1997;4:381-4.   [31] Nygaard IE, McCreery R, Brubaker L, et al.  Abdominal sacrocolpopexy: a comprehensive  review. Am J Obstet Gynecol 2004;104:805—23.   [32] Brubaker L, Bump R, Fynes M, et al. Surgery for  pelvic organ prolapse. In: Abrams P, Cardozo L,  Khoury S, et al, editors. Incontinence, Manage-  ment. Third International Consultation on Inconti-  nence. vol. 2, Monaco: International Continence  Society; 2005. p. 1371-402, chapter 21.   [33] Paraiso MFR, Walters MD, Rackley RR, et al.  Laparoscopic and abdominal sacral colpopexies:  a comparative cohort study. Am J Obstet Gynecol  2005;192:1752-8.   [34] Higgs PJ, Chua H-L, Smith ARB. Long term review  of laparoscopic sacrocolpopexy. BJOG 2005;112:  1134-8.   [35] Ross JW, Preston M. Laparoscopic sacrocolpopexy  for severe vaginal vault prolapse: five-year outcome.  J Minim Invasive Gynecol 2005;12:221—6.   [36] Antiphon P, Elard S, Benyoussef A, et al. Laparo-  scopic promontory sacral colpopexy: is the poste-  rior, recto-vaginal, mesh mandatory? Eur Urol  2004;45:655-61.   [37] Gadonneix P, Ercoli A, Salet-Lizée D, et al. Laparo-  scopic sacrocolpopexy with two separate meshes  along the anterior and posterior vaginal walls for  multicompartment pelvic organ prolapse. J Am  Assoc Gynecol Laparosc 2004;11:29-35.   [38] Ayav A, Bresler L, Hubert J, et al. Robotic-assisted  pelvic organ prolapse surgery. Surg Endosc 2005;19:  1200-3.   [39] Daneshgari F, Kefer JC, Moore C, et al. Robotic  abdominal sacrocolpopexy/sacrouteropexy repair  of advanced female pelvic organ prolapse (POP):  utilizing POP-quantification-based staging and out-  comes. BJU Int 2007;100:875—9.   [40] Elliott DS, Krambeck AE, Chow GK. Long-term  results of robotic assisted laparoscopic sacrocolpo-  pexy for the treatment of high grade vaginal vault  prolapse. J Urol 2006;176:655—9.    Matthew H. Hayn, MD*, Marc C. Smaldone, MD, Michael C. Ost, MD,  Steven G. Docimo, MD    Department of Urology, University of Pittsburgh Medical Center, Kaufmann Medical Building,  Suite 700, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA    Vesicoureteral reflux (VUR) is a common  problem in childhood, affecting approximately  1% to 2% of the pediatric population [1]. Mild  cases of VUR are likely to resolve spontaneously,  but high-grade VUR may require surgical correc-  tion. Pediatric urologists are familiar with open  antireflux operations, which can be accomplished  with minimal operative morbidity. Minimally in-  vasive endoscopic and laparoscopic techniques  now exist that may serve to reduce morbidity fur-  ther. This article reviews the endoscopic materials,  techniques, and outcomes in the treatment of  VUR in addition to the techniques and outcomes  of laparoscopic and robotic ureteroneocystotomy.    Many injectable biomaterials have been pro-  duced as bulking agents for use in the endoscopic  correction of VUR. For an injectable biomaterial  to be ideal, it must be nontoxic and stable without  migration to vital organs and cause minimal local  inflammation while being well encapsulated by  normal fibrous tissue and fibrocytes. It should be  easy to inject through a rigid or flexible needle  that passes easily through standard pediatric  endoscopic equipment.    Polytetrafluoroethylene (PTFE) paste is one of  the most commonly used biomaterials in medi-  cine. It is considered to be relatively inert chemi-  cally and biologically and has not been found to  cause malignancy in humans. PTFE paste has  been used as an injectable agent for the emboliza-  tion of blood vessels [2] and injection of vocal  cords [3], and as a bulking agent for stress urinary  incontinence (SUI) [4-6].   PTFE paste was first reported as a bulking agent  for treatment of VUR in 1981 by Matouschek [7].  This technique was popularized as the STING (sub-  ureteric transurethral injection) procedure by  O'Donnell and Puri [8]. Puri [9] later reported on  a large series of patients treated for VUR who dem-  onstrated a 76% overall success rate after a single  injection, which subsequently increased to 84.9%  with repeat injection. PTFE paste was also used  in a large European multicenter survey reporting  on 6216 ureters in 4166 children with 10 years of fol-  low-up. This survey reported a cure rate of 86%  after one to four injections [10].   Despite its clinical effectiveness and wide-  spread use in Europe, PTFE paste has never  gained US Food and Drug Administration  (FDA) approval because of concerns of distant  particle migration. The rigid PTFE spheres have  been found to migrate into the lymph nodes,  lungs, liver, spleen, and brain in experimental  studies [11]. Subsequent clinical reports confirm-  ing particle migration have been reported, includ-  ing a case with clinically significant particle  migration to the lungs [12] and another with    0094-0143/08/$ - see front matter © 2008 Elsevier Inc. All rights reserved.    migration to the lungs and brain [13]. Because of  these concerns and the availability of other injectable  agents, the use of PTFE has been largely abandoned.    Polydimethylsiloxane (PDS) is a solid, silicone,  elastomer, soft tissue bulking agent that has been  incorporated into a patented medical device. It is  made of 40% solid-textured highly cross-linked  PDS elastomer spheres suspended in a 60% low-  molecular-weight polyvinylpyrrolidone gel. It has  been used clinically in treating SUI in women  [14] and men [15]. The efficacy of this device for  the correction of VUR has been well documented.  Dodat and colleagues [16] reported a success rate  of 79.4% at 5 years of follow-up in 590 refluxing  ureters in 389 patients. Herz and colleagues [17]  reported a success rate of 81% after a single injec-  tion and 90% after a repeat injection in 112 reflux-  ing ureters. In a similar fashion, van Capelle and  colleagues [18] showed an 82.3% success rate in  311 ureters over a 10-year period from two Euro-  pean centers. Oswald and colleagues [19]com-  pared this PDS device versus dextranomer and  hyaluronic acid copolymer and found similar re-  sults after a single endoscopic injection. Although  the PDS device has demonstrated good long-term  results, it has not received FDA approval for cor-  rection of VUR because of concerns about the po-  tential for particulate migration, which has been  demonstrated in one animal model study [20].    Medical collagen is made of bovine collagen,  which is a natural matrix protein commonly  found in bone and connective tissue. It is com-  mercially available in the injectable form as  a solution of 95% type I collagen mixed with  5% type III collagen. Frey and colleagues [21] re-  ported a success rate of 63% after one injection in  204 ureters of 100 girls and 32 boys with varying  grades of reflux. The success rate increased to  79.4% at 3 months after treatment after subse-  quent reinjection. Reunanen [22] showed similar  results, with a success rate of 82% in nondupli-  cated systems at 4 years of follow-up. Collagen,  however, has been shown to lose volume over  time, which has been correlated clinically with  poor long-term results. Haferkamp and colleagues  [23] showed that only 9% of 57 treated units re-  mained reflux free at 37 months of follow-up.  There have also been reports of development of  serum antibodies to bovine collagen [24]. For    these reasons, collagen has not been approved  by the FDA for the treatment of VUR.    Calcium hydroxyapatite has been used as  a biocompatible implant for orthopedic and  dental procedures in humans for more than  25 years [25]. It was approved by the FDA for  use in the treatment of SUI in women and girls  in 2005. Mora Durban and colleagues [26] showed  resolution of reflux in 75% of cases with a single  injection of calcium hydroxyapatite, with 85%  resolution after a second injection. A recent pro-  spective multicenter trial demonstrated ureteral  cure rates of 46% and 40% at 1 and 2 years, re-  spectively. At the primary center, however, the  2-year cure rate was 66% of patients and 72%  of ureters [27]. Merrot and colleagues [28] com-  pared dextranomer and hyaluronic acid copoly-  mer and calcium hydroxyapatite in the treatment  of VUR and found no significant difference in  terms of cure rate, regardless of grade, in a total  of 44 refluxing units. To date, however, calcium  hydroxyapatite has not received FDA approval  for the treatment of VUR.    The need for a nonimmunogenic, biodegrad-  able, injectable bulking agent for the treatment of  reflux prompted Stenberg and Lackgren [29] to  develop a system based on dextranomer micro-  spheres suspended in a sodium hyaluronan solu-  tion in a 1:1 ratio. Dextranomer microspheres  are made up of a network of cross-linked dextran  polysaccharide molecules. After injection, the mi-  crospheres induce fibroblast and collagen deposi-  tion, leading to endogenous tissue augmentation.  After 1 week, the microspheres disappear but the  fibroblast and collagen ingrowth remains stable  [30]. They are nonimmunogenic because of the  lack of free circulating dextran molecules and  nonmigratory because of their spherical shape  and larger particle size (80-120 um) [31]. After  successful animal studies, these investigators in-  jected 101 ureters in 75 consecutive patients and  reported reduction or resolution of reflux in  8195 of ureters at 3 months of follow-up. They  followed 18 ureters for 1 year after treatment,  and of these, 16 remained free of reflux [29]. Dex-  tranomer and hyaluronic acid copolymer was ap-  proved by the FDA in 2001 for the treatment of  VUR in children and is now approved for treat-  ment of VUR grades 2 through 4 [32].    O'Donnell and Puri popularized the classic  subureteric transurethral injection (STING) tech-  nique in 1984. General anesthesia is administered,  a urine culture is obtained, and prophylactic  antibiotics are given. Cystoscopy is performed  before opening any injection materials in case the  procedure is cancelled because of bladder inflam-  mation or infection. Their original description  suggested entering the bladder mucosa 2 to 3 mm  distal to the ureterovesical junction (UVJ) and  advancing the needle in the submucosal plane for  a distance of 4 to 5 mm [8]. To treat high-grade  reflux and ureters without a submucosal tunnel,  Chertin and colleagues [33] suggested inserting  the needle directly into the affected ureteral orifice  to increase the length of the intravesical ureter and  create a slit-like orifice. This modified STING  procedure was popularized by Kirsch and col-  leagues [34], for which they described ureteral suc-  cess rates significantly greater for the modified  STING (92%) versus the standard STING  (79%). They describe inserting the needle approx-  imately 4 mm in the submucosa of the mid- to  distal ureteral tunnel at the 6 o’clock position,  all under the aid of hydrodistention.   The hydrodistention-implantation technique  (HIT) has evolved to now include two intraureteral  submucosal injections proximal and distal HITs, or  “double HIT,” until total ureteral tunnel coapta-  tion occurs [35]. The proximal HIT (site 1) should  lead to coaptation of the proximal ureteral tunnel  (Fig. 1A). The distal HIT (site 2) is performed by  placing the needle to the same depth just within  the ureteral orifice and injecting until the ureteral  orifice is coapted and elevated to the height of the  ureteral tunnel (see Fig. 1B). The end result should  look like a mountain range appearance of the  tunnel and orifice. If the ureteral orifice does not  completely coapt with intraureteric injection,  Kirsch [36] recommends that a classic subureteric  implantation (STING; see Fig. 1C) be performed.  In addition, he recommends that after each injec-  tion, an attempt at ureteral hydrodistention be  done to ensure proper technique, because the ureter  should remain coapted with irrigation.   Independent of the technique used, there exists  a significant learning curve with endoscopic  correction of VUR [37]. Kirsch [37] noted a lower  success rate (60%) in his first 20 patients compared  with an 80% success rate in his last 20 patients.  Herz and colleagues [17] reported a success rate of  46% in 28 refluxing ureters during the first 6 months    of their study. In the remaining 18 months, the  correction rate was 93% in 84 refluxing ureters.  Lorenzo and colleagues [38] reported that physi-  cian experience was predictive of VUR correction  after endoscopic injection on multivariate analysis.  This finding was confirmed by Routh and col-  leagues [39] in their study of 301 patients.    At the present time, dextranomer and hyalur-  onic acid copolymer is the only FDA-approved  material for use in endoscopic correction of VUR.  The authors, therefore, limit their review to series  using dextranomer and hyaluronic acid copolymer .  Lackgren and colleagues [40] published the first se-  ries using dextranomer and hyaluronic acid  copolymer in 2001. A total of 221 patients (335 ure-  ters, grades II-V) were followed 2 to 7.5 years. A  voiding cystourethrogram (VCUG) was performed  at 3 and 12 months after injections. They reported  a 75% success rate (defined as grade I or less) at 1  year of follow-up. Puri and colleagues [41] reported  on 113 children (166 ureters) and found that reflux  was corrected in 86% of ureters after a single injec-  tion, which increased to 99% after a second injec-  tion. Follow-up VCUG was performed at 3  months. Of the 113 patients, only 11 completed 1  year, and none had evidence of reflux on VCUG.  This was followed up by a larger series in 2006, in  which Puri and colleagues [42] treated 692 children  (1101 ureters) and reported success rates of 86.5%  and 98% after first and second injections, respec-  tively. In 2003, Kirsch and colleagues [37] reported  a 72% success rate after a single treatment at  3 months of follow-up. In a large series, Capozza  and colleagues [43] used dextranomer and hyalur-  onic acid copolymer to treat 788 patients (1050 ure-  ters) endoscopically, and reported a success rate of  82% after a single injection. Kirsch and colleagues  [34] reported improved success rates in 459 ureters  using a modified STING approach, with ureteral  success rates greater for the modified STING  (92%) compared with the standard STING  (79%). Of the 8% who failed using the modified  STING technique, a second injection resolved  reflux in 88% of ureters that had grade I to III reflux  [44]. Please refer to Table 1 fora summary of results.    Endoscopic injection of dextranomer and hya-  luronic acid copolymer after failed ureteroneocys-  totomy has been reported. Kitchens and colleagues  [45] reported on 18 patients who had persistent    Fig. 1. Figure demonstrates the hydrodistention-implantation technique (HIT). (A) HIT in the proximal ureteral tunnel,  leading to proximal coaptation. (B) Distal HIT site, performed by placing the needle just within the ureteral orifice. (C)  Picture demonstrates proximal HIT (site 1), distal HIT (site 2), and classic subureteric implantation site (STING; site 3).  (From Kirsch. AJ. Endoscopic management of vesicoureteral reflux. Hinman’s atlas of urologic surgery. 3rd edition.    VUR or de novo ipsilateral VUR after attempted  VUR correction and primary nonrefluxing mega-  ureter or renal transplantation, respectively. Of  the 20 renal units, 16 (80%) had complete resolu-  tion of VUR after a single injection. Similarly,  Jung and colleagues [46] reported on dextranomer  and hyaluronic acid copolymer injection for persis-  tent VUR after ureteroneocystotomy, with a suc-  cess rate of 70% and 90% after first and second  injections, respectively. Chertin and colleagues  [47] reported on endoscopic treatment of reflux in  patients who had undergone ureterocele puncture.  Of the patients with reflux into the lower moiety,  31 (70%) of 44 and 40 (91%) of 44 had resolution  of reflux after one and two injections, respectively.    In a multi-institutional study, Perez-Brayfield  and colleagues [48] reported on 72 patients (93  ureters) that they considered to be complex cases.  Cases included persistent reflux after open surgery  (n = 17), persistent reflux and neurogenic bladder  (n = 11), ectopic ureters to bladder neck (n = 7),  bilateral Hutch diverticulum (n = 6), stump reflux  (n = 6), ureterocele after puncture or incision (n =  5), and ureteral duplication (n = 15). The overall  success rate in their series was 68% after one en-  doscopic injection. Ozok and colleagues [49] per-  formed endoscopic injection of dextranomer and  hyaluronic acid copolymer in 21 renal transplant  candidates (29 ureters) with reflux grades I  through IV and reported success rates of 79.3%   follow-  Published No. children/ VUR up Long-term  report No. ureters grade Technique (years) Success rate  follow-up (months)  Lackgren et al [40] — 221/335 II-V STING 7 75 72  Puri et al [41] 113/166 II-V STING 1 86, 99° N/A  Kirsch et al [37] 180/292 LIV STING 1 72 N/A  Capozza et al [43] 788/1050 II-V STING 1 82 N/A  Kirsch et al [34] 70/119 LIV HIT 1 92 N/A  Puri et al [42] 692/1101 II-V STING 3 86.5, 98" N/A    and 82.7% after one and two injections, respec-  tively. They did not report any adverse effects.    It seems reasonable to state that dextranomer  and hyaluronic acid copolymer injection is a safe  and efficacious procedure, at least in the short  term. What is less obvious, however, are what  factors predispose patients to success or failure.  Capozza and colleagues [50] noted that uncon-  trolled voiding dysfunction contributed to endo-  scopic failure with dextranomer and hyaluronic  acid copolymer in their series of 320 children. In  contrast, Lackgren and colleagues [51] reported  that endoscopic treatment with dextranomer and  hyaluronic acid copolymer was similarly effective  in patients with and without bladder dysfunction  (urge syndrome and dysfunctional voiding). The  data demonstrating any affect of voiding dysfunc-  tion dextranomer and hyaluronic acid copolymer  results, however, are weakened by the lack of  standard assessment for voiding dysfunction. Lav-  elle and colleagues [52] examined 52 patients (80  ureters) and found that mound morphology was  the only statistically significant factor predictive  of a successful outcome, using Fisher’s exact  test. No difference was found in terms of volume  injected or the presence or absence of voiding dys-  function. In a multivariate analysis on 168 pa-  tients (259 ureters), Yucel and colleagues [53]  found that reflux grade, volume of dextranomer/  hyaluronic acid injected, and mound appearance  correlated with outcomes. Factors not correlated  with outcomes included gender, age, unilateral  versus bilateral, ureteral duplication, subureteral  versus intraureteral, and presence of voiding dys-  function. Further prospective studies are required    to elucidate fully what determines outcomes in pa-  tients who undergo endoscopic correction of their  VUR. Lackgren and colleagues [54] retrospec-  tively reviewed 68 children with duplex ureters  and 40 children with a small kidney (contributing  10%-35% of total renal function) and found sim-  ilar results when compared with their main study  population.    Recently, Elmore and colleagues [55] reported  on new contralateral reflux after dextranomer and  hyaluronic acid copolymer injection. Of 126 pa-  tients who underwent unilateral dextranomer and  hyaluronic acid copolymer injection, 17 (13.5%)  developed contralateral reflux on follow-up  VCUG. They found that girls younger than 5 years  of age had the highest incidence of new reflux. Sim-  ilarly, in another series, de novo contralateral reflux  was reported in 10 (8.3%) of 120 patients who had  unilateral VUR [56]. Menezes and colleagues [57]  reported that 10.1% of children developed new  contralateral reflux after dextranomer and hyalur-  onic acid copolymer injection. They were unable  to identify any risk factors and did not recommend  prophylactic treatment of nonrefluxing contralat-  eral ureters. As of yet, the natural history and clin-  ical sequelae of new contralateral reflux have not  been fully elucidated. In the future, high-risk  groups may benefit from prophylactic injection of  the contralateral side.   Ureteral obstruction after dextranomer and  hyaluronic acid copolymer injection is a rare event.  Snodgrass [58] reported persistent asymptomatic  obstruction of a dysmorphic ureter after dextr-  anomer and hyaluronic acid copolymer injection  that required open reimplantation. A recent    multi-institutional review reported on 745 patients  (1155 ureters) and found postoperative obstruction  in 7 ureters (0.6%) in 5 patients (0.7%). Four of the  5 patients were immediately symptomatic with nau-  sea or vomiting in 2 patients and anuria within 24  hours in 2 patients. All patients had resolution of  symptoms with stent placement, with no recurrence  after stent removal [59].    Costs are assuming increasing importance in  health care, and costs of new interventions must  be considered. Benoit and colleagues [60] exam-  ined the cost-effectiveness of dextranomer/hyalur-  onic acid copolymer injection as a substitution to  surgical management. They found that dextrano-  mer and hyaluronic acid copolymer injection in-  jection may be more cost-effective than ureteral  reimplantation for children who meet standard  criteria for surgical therapy, especially for lower  grades of reflux. If an increased volume of dextra-  nomer and hyaluronic acid copolymer injection is  needed for higher grades of reflux, injection would  then only be cost-effective for grades I and II uni-  lateral and bilateral reflux, and possibly unilateral  grade III reflux. Benoit and colleagues [61] also  compared the cost-effectiveness of performing  dextranomer and hyaluronic acid copolymer in-  jection at the time of diagnosis with that of tradi-  tional management. Two models were used:  injection at diagnosis proceeding to traditional  management if injection failed (scenario 1) and in-  jection at diagnosis proceeding to ureteral reim-  plantation if injection failed (scenario 2). They  found that in both scenarios, dextranomer and hy-  aluronic acid copolymer injection can never  achieve cost-effectiveness for grades I and II uni-  lateral and bilateral reflux and that high success  rates of dextranomer and hyaluronic acid copoly-  mer injection are needed to achieve cost-effective-  ness for higher grades of VUR.    The current follow-up paradigm for endo-  scopic injection of dextranomer and hyaluronic  acid copolymer injection is variable. Most clinical  studies recommend renal and bladder ultrasound  2 to 4 weeks after surgery [37,40] and VCUG at 3  months [37,40,41]. Yu and colleagues [62] believe  that routine renal ultrasound scans are unneces-  sary after endoscopic injection of dextranomer  and hyaluronic acid copolymer in uncomplicated  cases of VUR. Because of the known risk for    late recurrence, some advocate follow-up VCUG  at 1 year, although few series document this type  of long-term follow-up.    Ureteral reimplantation has proved to be the  “gold standard" therapy for VUR. Traditional  open ureterovesical reimplantation procedures  have been extremely successful in children with  success rates approaching 95% to 98% [63]. Re-  cent efforts have been directed toward reducing  the perioperative morbidity of open reimplanta-  tion, however, including hematuria, irritative  bladder symptoms, and postoperative pain. Ini-  tially described in the mid-1990s [64,65], laparo-  scopic antireflux surgery has never achieved  popular consensus because of the technical diffi-  culty in dissection and suturing required. Pro-  posed advantages of the laparoscopic approach  include better cosmetic results, shorter hospitali-  zation, decreased analgesic requirement, faster  recovery, and improved visualization. These theo-  retic advantages are not always easy to demon-  strate in the pediatric population, however, and  early outcomes have not demonstrated the laparo-  scopic approach to be as efficacious as the open  ureteral reimplant.    An alternative to open and endoscopic in-  jection procedures, the percutaneous endoscopic  trigonoplasty was introduced in the early 1990s. A  combination of intravesical cystoscopy and lapa-  roscopy, the bladder is filled with carbon dioxide  through percutaneously placed ports to improve  visibility and the reimplant is performed using  a Gil-Vernet or Cohen technique. First described  by Okamura and colleagues [66] in 6 children  (mean age of 7 years) with grade II through V (bi-  lateral reflux in 5 children), they reported a 100%  reflux correction rate, a mean operative time of  149 minutes, and a mean postoperative catheteri-  zation time of 4.6 days. No major complications  were observed at a median follow-up of 8.5  months. In a larger series of 22 children (mean  age of 7 years) and 32 refluxing units (grades I-  V), Cartwright and colleagues [67] reported  a reflux correction rate of 62.5%, with follow-up  ranging from 4 to 11 months. Operative time  ranged between 60 and 240 minutes, and compli-  cations included a vesicovaginal fistula, hypona-  tremia, and perivesical fluid collection. In an    extension of this series, Gatti and colleagues [68]  reported outcomes in 29 children with 46 refluxing  ureters using the Gil-Vernet and Cohen reimplan-  tation techniques. Success rates improved from  63% to 83% with the Cohen technique, but the  operative time nearly doubled as well. In a com-  parison of children and adults with reflux,  Okamura and colleagues [69] reported a 59% suc-  cess rate in 15 children and trigonal splitting in  13%, causing recurrence of reflux greater than  grade II. To improve success rates, this technique  was modified to elongate the intramural ureter  with reliable muscular backing. The initial success  rate in 8 female children with 14 refluxing ureters  was 86%, with a mean operative time of 245 min-  utes [70]. Despite the proposed advantages of a re-  duction of postoperative urgency and a shorter  recovery time, reduced success rates and increased  operative times in these early series are clearly in-  ferior to those of traditional open techniques and  this procedure has largely been abandoned.    In a more recent application of the pneumo-  vesiscopic approach, the laparoscope is placed  transabdominally instead of per urethra, which  had previously limited mobility. First successfully  described using a pig model [71,72], the increase in  maneuverability facilitates a Cohen type cross-  trigonal ureteral implantation using standard lap-  aroscopic instruments (Table 2). In 2001, Gill and  colleagues [73] described the use of this approach  in 2 children and one adult demonstrating that  this procedure was effective and technically feasi-  ble. Yeung and colleagues [74] reported their ini-  tial experience with this technique in 16 children  (mean age of 4.1 years) with 23 refluxing ureters.  They reported a mean operative time of 136  minutes (112 minutes unilateral, 178 minutes bi-  lateral), and an overall success rate of 96% with  one conversion to an open procedure after dis-  placement of a port into the extravesical space  [74]. In 32 children (mean age of 5 years), Kutikov  and colleagues [75] reported 93% and 80% suc-  cess rates in ureters treated for primary VUR  with the Cohen cross-trigonal technique and pri-  mary megaureter obstruction treated with the  Glenn-Anderson technique, respectively. Compli-  cations included urine leak in 12.5% of patients  and ureteral stricture in 6.3% of patients, with  most occurring in children 2 years of age or youn-  ger with a bladder capacity less than 130 mL. In    the most recent series, Canon and colleagues [76]  compared 52 children undergoing vesicoscopic  ureteral reimplantation with 40 children  undergoing open reimplantation. They reported  a significantly decreased postoperative analgesic  requirement in the vesicoscopic group and a simi-  lar hospital length of stay when compared with  the open management group. The mean operative  time was significantly elevated (199 versus 92 min-  utes; P = .001), however, with a higher complica-  tion rate (6% versus none), including | child with  bilateral ureteral obstruction in the vesicoscopic  group.   Challenges with this technique include gaining  and maintaining bladder access [77]. Access sites  must be well sealed to maintain optimal operative  exposure and avoid carbon monoxide leakage into  the retroperitoneum. Preplaced sutures are used to  close these sites at the conclusion of the procedure  to prevent urine leakage, which can be difficult in  older children with more subcutaneous tissue.  Other limitations include the significant learning  curve inherent to working within the small work-  ing space of the bladder, need for extended  postoperative catheterization, and need for intra-  vesical laparoscopic freehand suturing. Although  few studies have explored this technique’s benefits  compared with open surgery, it is unlikely that  this more complex approach is going to replace  an operation performed through a small bikini  incision with high success and minimal  complication rates unless some additional benefit  is proved.    Initially described in animal models [78-81],  the most common laparoscopic approach used  to date has been extravesicular reimplantation  with ureteral advancement (detrusorrhaphy) by  the Lich-Gregoir technique (Table 3). Assuming  that the primary benefits of the laparoscopic  approach are a shorter length of hospital stay,  less morbidity, and better cosmesis, recent efforts  have focused on minimal tissue dissection, achiev-  ing reliable detrusor closure, and downsizing ports  and instruments. In a large series of 71 reimplants  in 47 children (23 unilateral and 24 bilateral),  Lakshmanan and colleagues [82] reported  a 100% success rate with no persistent reflux or  obstruction. They recommended careful selection  of operative candidates, speculating that ureters  requiring tapering are unsuitable and that the  working space in the pelvis of children younger    Table 2  Pneumovesicoscopic ureteroneocystostomy outcomes  Mean  No. children VUR OR time  Report No. ureters grade Technique (minutes) Success  Complications   Okamura 6/11 H-V G-V 100 Hematuria (16.7)  et al [66 Mechanical failure (16.7)  Cartwright 22/32 II-V G-V 60-240 62.5 Vesicovaginal fistula (4.5)  et al [67 Hyponatremia (4.5)  Perivesical fluid collection (4.5)  Okamura 15/27 I-V G-V 201 59 Trigonal splitting (13.3)  et al [69  Gatti 29/42 LV G-V, C 60-240 47 (G-V), Vesicovaginal fistula (3.4)  et al [68 (G-V) 83 (©) Hyponatremia (3.4)  197 (©) Perivesical fluid collection (3.4)  Hydronephrosis (6.8)  Bilateral pneumothoraces (3.4)  Tsuji 8/14 I-IV G-V 245 86 Ureteral injury (14)  et al [70]  Yeung 16/23 II-V C 96 Scrotal and suprapubic  et al [74] emphysema (12.5)  Port displacement (18.8)  Peters 6/12 2.3 Cc 210 91.7 Urine leak (16.7)  et al [77,87]  Kutikov 27/54 H-V C 92.6 Urine leak (7.4)  et al [75] Ureteral stricture (3.7)  Canon 52/87 LV C 91 Urine leak (1.9)  et al [76] Bladder stones (1.9)    than 4 years of age may be inadequate for laparo-  scopic techniques. In a series of 15 children with  19 refluxing ureters, Riquelme and colleagues  [83] reported a 95% success rate with no major  complications. Mean operative time was 110 min-  utes in cases of unilateral reflux and 180 minutes  in cases of bilateral reflux, with 3 children requir-  ing catheterization for 3 to 4 days for mucosal  perforation. These results have been duplicated  in a small cohort of postpubertal children with  VUR. Shu and colleagues [84] reported a 100%  reflux correction rate in 6 children (mean age of  18.7 years), with a mean of 11.4 months of fol-  low-up. Mean operative times for unilateral and  bilateral procedures were 1.75 and 3.75 hours, re-  spectively, and mean hospital stay was 36 hours.   Although division of the lateral bladder pedicle  is thought to contribute to transient postoperative  urinary retention in some patients, proposed  benefits of the extravesical repair include sparing  a trigonal incision and anastomosis, resulting in  fewer postoperative bladder irritative symptoms.    Using a combination of intra- and extravesical  principles, Simforoosh and colleagues [85] have  recently described a novel technique of extraperi-  toneal laparoscopic trigonoplasty. In their series  of 27 children with 41 refluxing units, after gaining  extraperitoneal access, the bladder was opened  with laparoscopic scissors and the ureters were ap-  proximated in the midline after a trigonal incision.  With a mean operative time of 147 minutes,  a 93% success rate was reported with a mean of  8.2 months of follow-up. These investigators pro-  pose that their high success rate is a result of ease  of intracorporeal free hand suturing afforded by  the increased extraperitoneal space when com-  pared with pneumovesiscopic procedures.    The goal of robotic surgical assistance in  pediatric urology is to gain the advantages of  laparoscopy, including reduced pain and morbid-  ity, while shortening the steep learning curve of    Table 3  Laparoscopic ureteroneocystostomy outcomes  No.  children/ Mean OR  No. VUR time  Report ureters grade Technique (minutes) Success Complications  Lakshmanan 47/71 LV L-G N/A 100 Ureteral injury (4.2)  et al [82]  Shu 6/6 N/A L-G 105 100 Hydronephrosis (16.7)  et al [84] Abdominal pain (16.7)  Peters 17/17 2.9 L-G* 120 88.2 Urine leak (5.9)  et al [77]  Riquelme 15/19 II-HI L-G 110 unilateral 94.7 Mucosal perforation  et al [83] 180 bilateral (15.8)  Simforoosh 27/41 LIV G-V 147 93 Peritoneal tear (3.7)  et al [85]    Abbreviations: C, Cohen cross-trigonal ureteral reimplantation; G-V, Gil-Vernet trigonoplasty; L-G, Lich-Gregoir    traditional laparoscopy without sacrificing recon-  structive precision. Potential advantages of ro-  botic-assisted laparoscopy include an increased  ability to perform precise suturing for reconstruc-  tion because of stereoscopic three-dimensional  vision, increased instrument dexterity, and  tremor-filtered instrument control with movement  scaling. The chief deterrents include increased  cost, lack of tactile feedback, and lack of pediat-  ric-sized ports and instruments [86].   Initial efforts with robotic-assisted laparoscopy  have focused on performing an extravesical trans-  peritoneal Lich-Gregoir procedure in a similar  manner to the described straight laparoscopic  method in children with unilateral reflux. Because  of concerns regarding increased risk for urinary  retention with bilateral extravesical reimplanta-  tion [82] however, an intravesical robotically assis-  ted bilateral ureteral reimplantation technique has  been developed in a similar manner to the trans-  trigonal (Cohen) laparoscopic repair [87]. Ports  are placed in the dome of the bladder, and after  takedown of periureteral attachments to the blad-  der, submucosal transtrigonal tunnels are created  with sharp dissection to the opposite side of the  trigone. In a recent review of the applications of  robotic technology to pediatric urology, Peters  [77] described his unpublished outcomes in the ro-  botically assisted treatment of VUR. Unilateral  Lich-Gregoir procedures were performed in 17  children, intravesical cross-trigonal Cohen proce-  dures were performed in 3 children with bilateral  reflux, and contralateral nephrectomies were    performed in 4 children. Of these 24 children, cor-  rection of reflux was achieved in 89% of refluxing  units, with two cases of bladder leak, one case of  transient obstruction, and a mean operating room  time ranging from 2 to 3.5 hours.    As management of VUR continues to evolve,  laparoscopic and robotic-assisted reflux corrective  procedures remain in their infancy. Overall, early  results demonstrating feasibility with pneumo-  vesiscopic-, laparoscopic-, and robotic-assisted  techniques are encouraging and warrant further  evaluation in the management of pediatric VUR.  Nevertheless, limited patient numbers and lack of  stratification by grade of reflux make interpreting  these results difficult. Although theoretic benefits  include reduction in postoperative bladder  spasms, decreased incisional pain, more rapid  catheter removal, and improved cosmesis, these  have yet to be clearly demonstrated in available  series, and significant improvement is needed to  match the efficacy and cosmetic outcomes  achieved with traditional open repairs.   Open ureteral reimplantation remains the gold  standard in the surgical treatment of VUR.  Endoscopic correction of VUR is a reasonable  alternative to open surgical reimplantation, par-  ticularly in cases of low-grade VUR, although  long-term results into adulthood remain  unknown. 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Olsen LH, Deding D, Yeung CK, et al. Computer  assisted laparoscopic pneumovesical ureter reim-  plantation a.m. Cohen: initial experience in a pig  model. APMIS 2003;109(Suppl):23-5.   Gill IS, Ponsky LE, Desai M, et al. Laparoscopic  cross-trigonal Cohen ureteroneocystostomy: novel  technique. J Urol 2001;166:1811—-4.   Yeung CK, Sihoe JD, Borzi PA. Endoscopic cross-  trigonal ureteral reimplantation under carbon  dioxide bladder insufflation: a novel technique.  J Endourol 2005;19:295-9.   Kutikov A, Guzzo TJ, Canter DJ, et al. Initial  experience with laparoscopic transvesical ureteral  reimplantation at the Children’s Hospital of Philadel-  phia. J Urol 2006;176:2222—5 [discussion: 2225-6].  Canon SJ, Jayanthi VR, Patel AS. Vesicoscopic  cross-trigonal ureteral reimplantation: a minimally  invasive option for repair of vesicoureteral reflux.  J Urol 2007;178:269—73 [discussion: 273].   Atala A, Kavoussi LR, Goldstein DS, et al. Laparo-  scopic correction of vesicoureteral reflux. J Urol  1993;150:748-S1.   Schimberg W, Wacksman J, Rudd R, et al. Laparo-  scopic correction of vesicoureteral reflux in the pig.  J Urol 1994;151:1664-7.   McDougall EM, Urban DA, Kerbl K, et al. Laparo-  scopic repair of vesicoureteral reflux utilizing the  Lich-Gregoir technique in the pig model. J Urol  1995;153:497—500.   Baldwin DD, Pope JC, Alberts GL, et al. Simplified  technique for laparoscopic extravesical ureteral  reimplantation in the porcine model. J Endourol  2005;19:502-7.   Lakshmanan Y, Fung LC. Laparoscopic extravesic-  ular ureteral reimplantation for vesicoureteral  reflux: recent technical advances. J Endourol 2000;  14:589—93 [discussion: 593-4].   Riquelme M, Aranda A, Rodriguez C. Laparoscopic  extravesical transperitoneal approach for vesicoure-  teral reflux. J Laparoendosc Adv Surg Tech A 2006;  16:312-6.   Shu T, Cisek LJ Jr, Moore RG. Laparoscopic  extravesical reimplantation for postpubertal vesi-  coureteral reflux. J Endourol 2004;18:441—6.  Simforoosh N, Nadjafi-Semnani M, Shahrokhi S.  Extraperitoneal laparoscopic trigonoplasty for treat-  ment of vesicoureteral reflux: novel technique dupli-  cating its open counterpart. J Urol 2007;177:321-4.  Smaldone MC, Sweeney DD, Ost MC, et al. Lapa-  roscopy in paediatric urology: present status. BJU  Int 2007;100:143—50.    Mark L. Gonzalgo, MD, PhD’, Nilesh Patil, MD”,  Li-Ming Su, MD*, Vipul R. Patel, MD^*    “Department of Urology, James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions,  600 North Wolfe Street, Marburg 145, Baltimore, MD 21287, USA  PGlobal Robotics Institute, Florida Hospital, 601 East Rollins Street, Orlando, FL 32803, USA    Prostate cancer is the second most common  cancer in men in the United States. It has been  estimated that 218,890 men would be diagnosed  with prostate cancer in 2007 and 27,050 would die  from this disease [1]. Prostate-specific antigen  (PSA) screening, which started in the 1980s, has  brought about a significant increase in the detec-  tion of prostate cancers at an earlier stage. Urolo-  gists are now frequently treating younger men  with less advanced disease who have excellent pre-  operative urinary and sexual function. Today, if  a patient is diagnosed with prostate cancer, he is  more likely to have clinically nonpalpable disease  than his counterparts in the pre-PSA era.   For clinically localized prostate cancer, radical  prostatectomy remains the “gold standard" treat-  ment. New forms of minimally invasive therapies  are sought out by patients, however, because of  the potential morbidity associated with open  surgery. With quality-of-life aspects influencing  patient decision making, minimally invasive ther-  apeutic modalities have generated great interest  among patients. Laparoscopic radical prostatec-  tomy (LRP), robotic-assisted laparoscopic pros-  tatectomy (RALP), brachytherapy, cryotherapy,  and high-intensity focused ultrasound (HIFU) are  all considered to be minimally invasive treatment  options for the management of clinically localized  prostate cancer.    The first successful LRP in a man was per-  formed in 1997 [2]. This initial experience was  characterized by long operative times (8-11 hours)  and an average hospitalization of 7.3 days. Based  on a limited series of nine patients, it was initially  believed that LRP provided no significant benefit  compared with open radical prostatectomy for  treatment of clinically localized prostate cancer.  Widespread acceptance and application of LRP  was made possible by the efforts of French urolo-  gists who published their experience and early  results with this technique in 2000 [3,4]. These  results demonstrated reduced operative times  (4-5 hours per case), acceptable continence rates  after surgery (7296-8476), and preservation of  erections in approximately 45% of patients with  a sufficient level of preoperative sexual function.    Indications for LRP are identical to those for  open radical prostatectomy: patients who have  clinically localized prostate cancer with no evi-  dence of metastatic disease and are in sufficiently  good health to undergo surgery. There are rela-  tively few contraindications to LRP; however, the  presence of uncorrectable bleeding diatheses or  inability to tolerate general anesthesia or cardio-  pulmonary effects of laparoscopy may warrant  pursuit of alternative treatment methods. LRP  can be safely performed in patients who have  a history of prior abdominal surgery, hormonal  therapy, or morbid obesity [5]. The primary goals    0094-0143/08/$ - see front matter © 2008 Elsevier Inc. All rights reserved.    of LRP remain the same as those of open radical  prostatectomy: (1) cancer control, (2) preservation  of urinary continence, and (3) preservation of  erectile function.    Anatomic principles and surgical dissection of  the prostate are similar regardless of whether  a pure laparoscopic or robotic-assisted approach  is used. LRP is performed under general anesthe-  sia with the patient in a supine position. The  patient is secured to the table at the shoulder level  to prevent movement when placed in a steep  Trendelenburg position during a transperitoneal  approach. LRP can also be performed in an  extraperitoneal fashion; in that case, the patient  can remain in a more neutral position. The legs  are slightly spread apart to permit access to the  perineum during the operation. A Foley catheter  is inserted at the beginning of the procedure, and  a nasogastric tube is used to decompress the  stomach.   Pneumoperitoneum can be established with the  use of a Veress needle and the abdominal cavity  entered under direct vision through a periumbilical  incision using a Visiport device. Additional tro-  cars are placed inferiorly and laterally for passage  of laparoscopic instrumentation (Fig. 1). Once all  trocars have been inserted and the patient has  been positioned in a steep Trendelenburg position  to facilitate retraction of the small bowel out of  the operative field, a transverse incision is made  in the peritoneum below the base of the bladder  in the region in which the vas deferens joins the  seminal vesicles. The seminal vesicles are dissected  free from surrounding tissues, and vascular pedi-  cles are ligated with titanium or Hemolockclips  (Movie 1: Dissection of seminal vesicles and vas  deferentia*). Every attempt is made to avoid the  use of electrocautery during lateral dissection of  the seminal vesicles to prevent thermal injury to  the nearby cavernous nerves responsible for  erections.   Once the seminal vesicles have been mobilized,  a transverse incision is made in Denonvilliers’  fascia to dissect the plane between the prostate  and rectum (Movie 2: Posterior prostatic dissec-  tion*) (Fig. 2). To maximize neurovascular bundle    * Videos for this article can be accessed by visiting  www.urologic.theclinics.com. In the online table of con-  tents for this issue, click on “add-ons.”    preservation, a closer dissection to the prostate  posteriorly can be performed that leaves Denon-  villiers’ fascia on top of the perirectal fat. Alterna-  tively, a deeper plane of dissection between  Denonvilliers’ fascia and perirectal fat can be per-  formed when more extensive or palpable cancer is  present. Once the plane between the prostate and  rectum has been developed, attention is then  turned to the anterior prostatic dissection.   The space of Retzius is entered transperito-  neally by dividing the urachus above the bladder  and incising the peritoneum just medial to the  medial umbilical ligaments (Movie 3: Developing  the space of Retzius*) (Fig. 3). Mobilization of  the bladder is performed, and the alveolar tissue  anterior to the bladder within the extraperitoneal  space is dissected to expose the prostate. The  endopelvic fascia and puboprostatic ligaments  are sharply divided to mobilize the prostate and  expose the levator muscle fibers. The deep dorsal  venous complex (DVC) can be suture ligated for  hemostasis (Movie 4: Ligation of the deep dorsal  venous complex*); however, the DVC is typically  divided later during the operation before the api-  cal dissection of the prostate and division of the  urethra (Movie 5: Division of deep dorsal venous  complex*).   At this point in the operation, a transverse  incision is made in the anterior bladder neck  (Movie 6: Bladder neck transection and prostatic  pedicle ligation*). This plane of dissection is car-  ried through the posterior bladder neck to ex-  pose the previously dissected seminal vesicles.  The seminal vesicles can then be pulled through  this working space to provide mobilization of  the prostate for the remainder of the operation  (Fig. 4). The vascular pedicles to the prostate  can be ligated with titanium or Hemolock clips  to avoid the use of electrocautery, which may  damage the neurovascular bundles (Movie 7:  Antegrade neurovascular bundle preservation*).  Once the neurovascular bundles have been dis-  sected away from the prostate, the DVC and  urethra can be transected from the apex of the  prostate (Movie 8: Prostatic apical dissection  and division of urethra*). The vesicourethral  anastomosis may be accomplished using an  interrupted closure or a running continuous  suture with a single knot (Movie 9: Interrupted  vesicourethral anastomosis*) [6]. An anterior or  posterior tennis racquet closure of the bladder  neck may be required if there is a significantly  sized discrepancy in the bladder neck urethral  opening.    Fig. 1. Operating room, port, and personnel configuration for laparoscopic radical prostatectomy. (Courtesy of Johns  Hopkins University, Baltimore, MD; with permission. Copyright © 2005.)    LRP can also be performed by means of an  extraperitoneal approach. An infraumbilical  incision is made, and the space of Retzius is  entered under direct visualization with a Visiport  device. The trocar and camera are removed,  and the extraperitoneal space is developed  using a trocar-mounted balloon dilator device  (Movie 10: Extraperitoneal baloon access*)  (Fig. 5). The balloon is inserted into the preperito-  neal space and insufflated under direct vision.  Additional trocars are inserted, and transection  of the bladder neck occurs as one of the initial  steps in this surgical approach. The remainder of    * Videos for this article can be accessed by visiting  www.urologic.theclinics.com. In the online table of con-  tents for this issue, click on add-ons."   Some studies have reported improved out-  comes for extraperitoneal LRP compared with  the transperitoneal approach. Extraperitoneal  LRP has been associated with less operative time  and has enabled faster recovery of continence  compared with the transperitoneal approach [7].  Other groups have found no significant differences  in clinicopathologic outcomes between the two  techniques [8,9].    Laparoscopic pelvic lymphadenectomy may be  performed in patients when indicated (ie, Gleason  score >7, palpable disease, preoperative PSA  > 10). Laparoscopic PLND can be performed by  the transperitoneal or extraperitoneal approach  and using a pure laparoscopic technique or with    Fig. 2. Posterior dissection of the prostate. The bedside assistant retracts the seminal vesicles and prostate in an upward  direction. A transverse incision is made in Denonvilliers’ fascia, and the plane between the prostate and rectum is de-  veloped. The plane of dissection toward the prostate is indicated by the dashed arrow. (Courtesy of Johns Hopkins Uni-  versity, Baltimore, MD; with permission. Copyright © 2005.)    Fig. 3. Division of urachus and entry into the space of  Retzius. The urachus is retracted in a cephalad direction  to assist with identification of the alveolar tissue anterior  to the bladder. The medial umbilical ligaments demar-  cate the lateral extent of the bladder dissection.  (Courtesy of Johns Hopkins University, Baltimore,  MD; with permission. Copyright © 2005.)    robot assistance (Movie 11: Laparoscopic pelvic  lymph node dissection*). The same limits of lym-  phadenectomy are respected as with open surgery,  including the external iliac vein, pubis, obturator  nerve, and bifurcation of the iliac vessels. Thermal  energy and sharp dissection should be minimized  to avoid vascular and neural injury. Clips should  be applied to lymphatic channels to prevent post-  operative lymphocele.    The primary goal of radical prostatectomy is  complete removal of the entire prostate. The most  common site of a positive margin during LRP is at  the prostatic apex [10]. Positive margin rates for  pT2 and pT3 disease have been reported to range    * Videos for this article can be accessed by visiting  www.urologic.theclinics.com. In the online table of con-  tents for this issue, click on “add-ons.”    Fig. 4. Ligation of the prostatic pedicles and antegrade  dissection of the neurovascular bundle. Anterior traction  can be applied to the seminal vesicles and vasa to iden-  tify the prostatic pedicles. Titanium or Hemolock clips  can be used for hemostasis to avoid the use of electro-  cautery. The direction and course of antegrade neuro-  vascular bundle dissection can be guided by initially  defining the lateral neurovascular bundle groove.  (Courtesy of Johns Hopkins University, Baltimore,  MD; with permission. Copyright © 2005.)    from 4.7% to 18.4% and from 26.2% to 45.7%,  respectively [11-14]. Increasing experience has  been shown to be associated with a decrease in  the rate of positive surgical margins, suggesting  that inexperience with the laparoscopic surgical  approach may contribute to a higher rate of pos-  itive surgical margins.   A recent prospective analysis of clinical and  pathologic outcomes of 508 men who underwent  LRP at Johns Hopkins Medical Institutions    Fig. 5. Extraperitoneal approach for LRP by creation  of working space with a trocar-mounted balloon dilator  device. (Courtesy of Johns Hopkins University, Balti-  more, MD; with permission. Copyright O 2005.)    demonstrated positive margin rates of 8.2% for  pT2 disease and 39.3% for pT3 disease [15]. Three-  year actuarial biochemical recurrence-free survival  was 98.2% for pT2NO0/Nx disease, 78.7% for  pT3NO/Nx/NI disease, and 94.5% overall.    Avoidance of energy sources, such as monop-  olar or bipolar electrocautery and harmonic  scalpel, during dissection of the neurovascular  bundles has been associated with improved return  of potency after surgery [16,17]. Potency rates  after LRP have been reported to range from  46% to 88% (Table 1). Hemolock clips can be  used to ligate vessels during dissection of the neu-  rovascular bundles to minimize or eliminate the  use of thermal energy.   A combined antegrade and retrograde  laparoscopic approach for neurovascular bundle  dissection with minimization of thermal energy  can be accomplished with minimal blood loss and  with excellent anatomic nerve preservation. The  authors' experience with this technique has dem-  onstrated that approximately 7695 of patients  engaging in sexual intercourse before surgery  who underwent bilateral nerve preservation  reported the ability to engage in sexual intercourse  1 year after LRP [11]. Improved potency out-  comes have also been reported with a technique  that incorporates temporary control of the lateral  prostatic pedicle with bulldog clamps and real-  time intraoperative transrectal ultrasound to  visualize pulsations of the cavernous vessels  within the neurovascular bundle [18,19]. Among  patients with excellent preoperative potency  (SHIM > 22), the l-year intercourse rate when  using this technique was 88%. Faster recovery  of erectile function using this technique was also  observed and was found to be correlated with  preserved pulsatile blood vessels within the  neurovascular bundle on power Doppler transrec-  tal ultrasonography [19].    Urinary incontinence after LRP is typically  manifested by stress incontinence attributable  primarily to intrinsic sphincter deficiency. Differ-  ences in surgical technique may account for  variability in the levels of continence after LRP;  however, the exact physiologic mechanisms that  contribute to urinary control after surgery are not  entirely understood. Continence rates after LRP   Total Evaluable Definition Method of Assessment Potency  Reference patients patients used assessment time rate  Hoznek et al [80] 200 82 Intercourse Questionnaire 1 month 46%  Turk et al [81] 125 44 Intercourse Physician 12 months 59%  Salomon et al [82] 235 43 Intercourse Questionnaire 12 months 58.8%  Eden et al [83] 100 100 Erections Physician 12 months 62%  Guillonneau et al [84] 550 47 Intercourse Physician 1.5 months 66%  Anastasiadis et al [85] 230 230 Intercourse Questionnaire 12 months 53%  Roumeguere et al [14] 85 85 Intercourse Questionnaire 12 months 65.3%  Stolzenburg et al [86] 700 185 Intercourse Questionnaire 6 months 47%  Rassweiler et al [12] 5824 NA Intercourse Questionnaire 12 months 52.5%  Su et al [11] 177 177 Intercourse Questionnaire 12 months 76%  Goeman et al [87] 550 NA Intercourse Questionnaire 12 months 56%  Gill and Ukimura [19] 76 54 Intercourse Questionnaire 12 months 88%    Data from Su LM, Smith JA. Laparoscopic and robotic-assisted laparoscopic radical prostatectomy and pelvic lym-  phadenectomy. In: Wein AJ, editor. Campbell-Walsh Urology, 9th ed. Philadelphia: Elsevier, 2007.    have been reported to range from 71% to 92% at  various follow-up times (Table 2). It has been  demonstrated that reconstruction of the posterior  rhabdomyosphincter may lead to more rapid  recovery of continence after radical prostatectomy  [20]. At the time of catheter removal, 74.2% of  patients were continent using this reconstructive  technique after LRP [21].    In 1495, Leonardo da Vinci designed a “‘mech-  anized" mannequin in the form of an armed  knight. During the Renaissance, this became  a model from which numerous other mannequins  were constructed for entertainment [22]. The term  robot was first coined by Karel Capek in the 1923  book, Rossum's Universal Robots and relates to  the Czech word for slave labor, robota [23]. The  word robot and its practical applications  increased only in the twentieth and twenty-first  centuries, however.   The earliest uses of robots were for military  purposes. The first surgical application was in  1985 in a neurosurgical procedure [24]. It was used  to orient a needle for a brain biopsy under CT  guidance. In 1992, International Business  Machines (IBM) and associates developed a proto-  type for orthopedic surgery. The “ROBODOC”  was used to assist surgeons in milling out a hole  in the femur for total hip replacements [25]. A  new era was beginning, and the concept of telepre-  sence technology, which would allow the surgeon  to operate at a distance from the operating room,    was being intensively researched simultaneously at  the Stanford Research Institute, Department of  Defense, and National Aeronautics and Space  Administration (NASA). Intuitive Surgical  acquired the prototype and commercialized the  system. Soon thereafter, Computer Motion un-  veiled the first laparoscopic camera holder. Com-  puter Motion later created a surgical system,  which is an integrated robotic system [26].  In March 2003, the fusion of both companies  was announced under the name of Intuitive  Surgical, Inc.   The Intuitive Surgical system’s main compo-  nents are a control console that is operated by  the surgeon and the surgical cart, which consists  of four arms. The arms are operated by manipula-  tion of two master controls on the surgeon  console. The Intuitive Surgical system has tremor  filtration, movement scaling, increased range of  motion, three-dimensional vision, and ergonomic  advantages. All these features make it ideal for  complex laparoscopic movements in an anatomi-  cally confined space.   Binder and Kramer [27] from Germany  reported on the first RALP in 2001. In 2002,  a team from Henry Ford Hospital in Detroit  reported on their initial experience with the use  of the Intuitive Surgical robot [28]. Since then,  a tremendous growth has been seen all around  the world in adoption of this technique. In the  year 2007, it was estimated that more than  40,000 radical prostatectomies would be per-  formed robotically (personal communication,  Intuitive Surgical).   Total Definition Method of Follow-up Continence  Reference patients used assessment (months) rate  Hoznek et al [80] 200 No pad Questionnaire 12 86%  Turk et al [81] 125 0-1 pad Physician 9 92%  Olsson et al [88] 228 No pad Questionnaire 12 78.4%  Salomon et al [82] 235 No pad Questionnaire 12 90%  Eden [83] 100 No pad Physician 12 90%  Guillonneau et al [84] 550 No pad Physician 12 82.3%  Anastasiadis et al [85] 230 No pad Questionnaire 12 71.6%  Roumeguere et al [14] 85 No pad Questionnaire 12 80.7%  Stolzenburg et al [86] 700 No pad Questionnaire 12 92%  Rassweiler et al [12] 5824 No pad Questionnaire 12 84.9%  Goeman et al [87] 550 No pad Questionnaire 12 82.9%    Data from Su LM, Smith JA. Laparoscopic and robotic-assisted laparoscopic radical prostatectomy and pelvic lym-  phadenectomy. In: Wein AJ, editor. Campbell-Walsh Urology, 9th ed. Philadelphia: Elsevier, 2007.    Similar to LRP, RALP can be performed  transperitoneally or extraperitoneally. Pneumo-  peritoneum is generated using a Veress needle or  Hasson technique. The abdomen is insufflated  using carbon dioxide at 15 mm Hg, and trocars  are placed under direct vision. The patient is  placed in a lithotomy position and in a steep  Trendelenburg position. The robot is docked to  the trocars, and the procedure is begun using  a 0° binocular lens, monopolar scissors in the  right arm, PK dissecting forceps in the left arm,  and the Prograsp in the fourth arm.   The anterior peritoneum is incised (bladder  takedown) to enter the retropubic space of  Retzius. The endopelvic fascia is then incised,  and the levator ani fibers are separated from the  prostate. The DVC is ligated, and a suspension  stitch is placed with a 1-0 Monocryl suture on  a CT-1 needle.   To proceed with the bladder neck dissection,  a scope with a 30° down angle is used. Dissection  proceeds in a downward direction until the  urethra and catheter are visualized. The posterior  wall of the bladder neck is dissected, and the vas  deferens and the seminal vesicles are exposed. The  seminal vesicle is dissected by approaching its  medial wall initially in an atraumatic and athe-  rmal fashion.   Denonvilliers’ fascia is then incised, and the  posterior rectal plane is developed distally toward  the urethra. The pedicles are ligated with hemo-  static clips, and an athermal early retrograde  release of the neurovascular bundle is performed.    Apical dissection is then performed using cold  scissors to divide the DVC and urethra. The  vesicourethral anastomosis is performed using  a modified technique by Van Velthoven and col-  leagues [6]. A single continuous running suture is  used by tying two separate 20-cm length 3-0  Monocryl sutures together with 10 knots. The pos-  terior anastomosis is performed with one arm of the  suture beginning at the 5 o’clock position running  clockwise to the 10 o'clock position. The anterior  anastomosis is completed with the second arm of  the suture starting in the 5 o'clock position and pro-  ceeding in a counterclockwise fashion. Both sutures  are tied in the 10 o'clock position on the urethral  stump. A Foley catheter is left in place for 4 to  7 days. As with LRP, pelvic lymphadenectomy  may be performed using robotic assistance when  indicated.   Comparing operative times is difficult in large  series because they include setup time and pelvic  lymph node dissection (Table 3). Operative times  may also vary according to the learning curve.  The operative time decreases as surgeon experi-  ence grows. In a previously reported series by  Patel and colleagues [29], mean operative time  was 130 minutes in their first 500 cases. With the  authors' experience now having passed 1500 cases,  the operative time has been reduced to 90 minutes  [30]. This decrease in time has been noted despite  adding a few new surgical variations to the  authors' previously described technique (ie, DVC    Table 3  Operative time, blood loss, and transfusion data for robotic-assisted laparoscopic prostatectomy   Operative Blood loss Transfusion In-hospital Catheter  Authors No. cases time (minutes) (mL) rate  stay (days) removal (days)  Patel et al [29] 500 130 50 0% 1 6.9  Joseph et al [89] 325 130 196 1% 1 —  Bhandari et al [90] 300 177 109 0% 1.2 6.9  Ahlering et al [38] 60 231 103 0% 1 7  Farnham et al [37] 176 = 191 0.5% R =  Cathelineau et al [91] 105 180 500 6% 5.5 7  Menon et al [31] 200 160 153 0% 1.2 7    and urethral suspension, posterior rhabdosphinc-  ter reconstruction). The mean operative time  reported by Menon and colleagues [28] in 2002  was 274 minutes in their first 40 patients. In  recently published data by the same investigators,  the mean operative time reported was 154 minutes  [31].   Decreased blood loss is one of the key advan-  tages of minimally invasive surgery (see Table 3).  Because most blood loss arises from the venous  sinuses, the tamponade effect of pneumoperito-  neum helps to diminish blood loss. Improved  three-dimensional vision and precise ligation of  vessels are contributing factors to the decreased  amount of blood loss in RALP.   The overall transfusion rate reported in series  beyond the learning curve varies from 0% to 12%  [32-34]. Decreased blood loss has been a distin-  guishing feature of LRP and RALP. In many se-  ries, the rate of transfusion has been 0% [35,36].  Patel and colleagues [29] reported a blood transfu-  sion rate of 0.4% in their initial RALP series.  Farnham and colleagues [37] have reported in  a prospective comparative study between RALP  and radical retropubic prostatectomy (RRP) that  the median serum discharge hematocrit was  higher with RALP (38%) than after open radical  prostatectomy (33%).   Health care policies practiced in different  centers around the world influence the duration  of hospitalization (see Table 3). It is considered an  important feature of patient recovery, however,  and a measure of cost expenditure on the part of  the hospital and patient likewise. The advantage  of LRP and RALP is with respect to less postop-  erative pain and blood loss. The mean length of  stay in larger series has been shown to be 1.08  to 1.5 days. Ahlering and colleagues [38] reported    a shorter length of stay in patients after RALP  compared with RRP (25.9 versus 52.8 hours). It  is becoming increasingly evident that a large  number of patients undergoing RALP can be dis-  charged within 24 hours of the surgery. In a pro-  spective evaluation of short-term impact and  recovery of health-related quality of life in men  undergoing RALP versus open radical prostatec-  tomy, Miller and colleagues [39] showed that there  was decreased morbidity associated with RALP.  Physical Component Score scores returned to  baseline sooner in the RALP group compared  with the open surgical group. Smith and col-  leagues [40] showed that discharge on the first  postoperative day can also be achieved in most  patients who undergo open radical prostatectomy,  however.   RALP has the potential to allow for an earlier  return of continence in patients (Table 4). Earlier  return of continence is thought to be possible  because of improved preservation of urethral  sphincter and urethral length. The hypothesis is  that better visualization of the apex allows the  surgeon to sweep away urethral sphincter muscu-  lar tissue from the anterior prostate gently and  improved hemostasis prevents blood from obscur-  ing the apex, leading to inadvertent injury to the  sphincter [38].   Urinary continence recovery, defined as use of  no protection system or use of a single liner for  security reasons, has been reported to vary from  72% to 95% [34,41,42]. A comparative study be-  tween RRP and RALP by Tewari and colleagues  [43] showed that robotic surgery allowed earlier  continence recovery compared with the traditional  retropubic approach. Walsh and colleagues [44]  reported their continence results in open RRP to  be 54% at 3 months, 80% at 6 months, 93% at  12 months, and 93% at 18 months. Patel and    Table 4  Continence data for robotic-assisted laparoscopic prostatectomy  Continence Method of Continence rates (18)  Authors No. cases definition data collection 3 months 6 months 12 months  Patel et al [29] 500 No pad Questionnaire 89% 95% —  Joseph et al [89] 325 No pad Questionnaire 93% 96% m  Ahlering et al [51] 90 No pad Questionnaire 81% — —  Bentas et al [52] 41 0-1 pad Questionnaire — — 84%    colleagues [29] reported their continence data in  500 patients to be 89%, 95%, and 97% at 3, 6,  and 12 months, respectively. Continence in this  study was defined as no pad use. Body mass index  (BMI) has been shown to be closely related to re-  covery of continence. Patients who had a BMI  greater than 30 had a 6-month continence rate  of 47% compared with 91% observed in patients  who had a BMI less than 30 [45].   Posterior reconstruction of the rhabdosphinc-  ter or pelvic floor has been described in open  prostatectomy and LRP, in which it was found to  improve early postoperative urinary continence  rates [20,21]. The authors use a modification of  this technique for RALP with an aim to improve  early continence after surgery. At 1 week, of  50 patients, 29 (58%) were completely continent,  7 (14%) had mild incontinence, 8 (16%) had  moderate incontinence, and 6 (12%) had severe  incontinence (unpublished data).   Factors like age, preoperative potency, nerve  sparing, and individual surgical technique all seem  to affect postoperative recovery of erectile func-  tion (Table 5). The anatomic basis for nerve spar-  ing during RRP was initially described by Walsh  and Donker [46]. After their description, a large  number of modifications and different techniques  have been described. Series with follow-up of  data for more than 12 months have reported  potency percentages ranging from 20% to 78%  [29,33]. This is the percentage of patients who    are able to have intercourse after nerve-sparing  RALP. Patel and colleagues [47] described the  Ohio State technique of early retrograde release  of NVB while using an antegrade approach for  nerve sparing. The early retrograde release helps  in identifying the prostatic pedicle and prevents  undue traction on the NVB. This allows a more  efficient nerve-sparing procedure to be performed.   Ahlering and colleagues [48] have reported on  a prospective, nonrandomized, comparative study  adopting a cautery-free technique for neurovascu-  lar bundle preservation that allows for a higher  potency rate at 3 months of follow-up compared  with standard techniques. Chien and colleagues  [49] have demonstrated that avoiding the use  of clips or monopolar cautery during robotic  LRP may result in early return of sexual function.  Potency was defined as return to baseline  function, and they reported 3-, 6-, and 12-month  potency rates of 54%, 66%, and 59%,  respectively.   The team at Henry Ford Hospital has  described a *veil of Aphrodite" technique for  nerve preservation. A plane of dissection between  the prostatic fascia and the prostate capsule is  established to enhance nerve preservation. Among  patients with no preoperative erectile dysfunction  (SHIM >21) who underwent bilateral veil nerve-  sparing surgery, intercourse was successful in 70%  and 97% of the patients at 12 and 48 months  of follow-up, respectively. Approximately half of  these patients attained a normal SHIM score  without medication [50].    Data collection 3 months 6 months 12 months  UCLA-PCI 54% 66% 69%  IIEF-5 25% 64% =   Surgical technique and expertise are considered  to be important factors in the progressive re-  duction in the rates of positive surgical margins  (Table 6). Positive margin rates vary in reported  series from 2% to 36% [50,51]. After data are  stratified by pathologic staging, positive margin  rates are between 4.7% and 27% for pT2 and  26% and 67% for pT3 disease [33,52]. It has  been shown that as surgeon experience increases,  the rate of positive margins decreases. Patel and  colleagues [33] have reported a reduction in over-  all positive margin rates from 13% in the first 100  patients to 8% in the next 100 patients. Positive  margin was defined as presence of cancer cells at  the inked margin.   One of the criticisms of RALP has been that  there is no tactile feedback from the robotic arms  to the surgeon. The fear was that this would lead  to poorer oncologic results compared with open  surgery. In two prospective, nonrandomized,  comparative studies, Ahlering and colleagues  [38] and Tewari and colleagues [43] have shown  that the positive surgical margin rates were higher  in patients who underwent RRP compared with  RALP [38,43]. The 5-year actuarial biochemical  free survival rate among 2766 patients who under-  went RALP at a single institution was reported to  be 84% [53].   Minimally invasive surgery has considerably  changed the surgical treatment of prostate cancer.  Critical analysis of the data available for LRP and  RALP suggests that results are similar to open  retropubic prostatectomy. Reduced blood loss,  decreased postoperative pain and convalescence,  and possibly early return to continence are their  main advantages. Midterm results of LRP and    RALP are encouraging. These excellent outcomes  have to await long-term oncologic and functional  data, however, to define the precise role of LRP  and RALP as alternative surgical treatments to  open radical prostatectomy.    External beam radiation therapy (EBRT)  typically requires multiple administration doses  referred to as fractions. Simulation is performed  as part of pretreatment planning to generate  a model of the patient that is used for radiation  therapy. Intensity-modulated radiation therapy  (IMRT) uses three-dimensional conformal recon-  struction to optimize angles and shapes for  radiation delivery. This technique provides more  accurate delivery of radiation to prostate tissue  and is currently the most widely used form of  external beam radiation for definitive manage-  ment of prostate cancer [54].   Prostate brachytherapy is typically performed  under spinal or general anesthesia as an out-  patient procedure. The most commonly used  isotopes for brachytherapy seeds are iodine-125  CID or palladium-103 (!?Pd). Pretreatment  imaging may include transrectal ultrasound and  CT-based volumetric studies to assist with plan-  ning three-dimensional seed distribution. Brachy-  therapy seeds are placed under direct transrectal  ultrasound guidance during the procedure. Low-  energy radiation is emitted from implanted seeds  for a period of weeks to months to destroy pros-  tate cancer cells. Relative contraindications for  prostate brachytherapy include large prostate  size (> 50-60 cm?), prior history of transurethral  resection of the prostate (TURP), and irritative  or obstructive voiding symptoms. A trial of  androgen deprivation may be used for men with  larger prostates to reduce the size of the gland  to an acceptable range for brachytherapy.    Authors No. cases p12 pT3a pT3b rate   Patel et al [29] 500 78% 15% 5% 9.4%  Bentas et al [52] 41 63% 22% 15% 30%  Costello et al [92] 122 80% 16% 4% 16%  Ahlering et al [51] 50 62% 36% 36%  Chien et al [49] 56 82% 18% 11%    HIFU is a technology that causes thermal  tissue destruction with precision and minimum  damage to the surrounding structures. It was  discovered in the early 1940s and has been used  to destroy tumors. Its use to treat localized  prostate cancer has been increasing in Europe. A  probe is inserted transrectally, and a high-energy  ultrasound beam is focused into the prostate.  Acoustic energy absorbed by the prostate tissue  is converted into thermal energy, with intrapro-  static temperatures reaching upward of 98.6 °C.  The result is a focal area of coagulative necrosis.  Tissue outside the focal zone, including rectal  mucosa and serosa, has no significant temperature  increase, and therefore no tissue damage.   The mechanism of action of HIFU is based on  mechanical and thermal effects to achieve  destruction of prostate tissue. Thermal energy is  associated with absorption of ultrasound energy  by the prostate and generation of heat. Ultra-  sound waves are delivered by a transducer. As  they travel through tissues, ultrasound waves  deposit energy into tissues. HIFU uses a high  intensity of the waves and focuses them on a single  point to deposit large amounts of energy into  a focal area, thus resulting in tissue destruction  [55]. Tissue damage occurs by two different  mechanisms: thermal effect and cavitation [56].  Absorption of ultrasound energy into the tissue  gets converted into heat, causing the thermal ef-  fect. An increase in temperature of up to 70 °C  to 100 *C can be achieved in a few seconds with  each pulse. The interaction of ultrasound and  microbubbles in the sonicated tissue is responsible  for the cavitation mechanism. Both of these  mechanisms cause the destruction of the cells by  coagulative necrosis.   HIFU is generally indicated for patients who  have localized prostate cancer and are not candi-  dates for surgery because of age, medical comor-  bidities, or preference. HIFU has largely been used  and is typically recommended for patients who  have localized prostate cancer with clinical stage T1  to T2 NxM0 to NOMO prostate cancer who are not  suitable candidates for radical prostatectomy (eg,  age >70 years, life expectancy <10 years, major  comorbidities precluding surgery) or who refuse  to undergo surgery [57,58]. HIFU can also be  used for local recurrence of prostate cancer after  radiation or brachytherapy failure.   Unlike other nonsurgical treatments for clini-  cally localized prostate cancer, HIFU treatment    can be repeated for local recurrence and can also  be used as salvage therapy. Prostate gland size  greater than 40 cm? is a relative contraindication  for the use of this technique because of the focal  length of HIFU [59]. Larger glands can be treated  with certain HIFU devices after downsizing by  means of TURP or hormonal therapy. Because  treatment is administered by means of a transrec-  tal probe, any rectal pathologic finding is a relative  contraindication. Finally, major prostatic calcifi-  cations can lead to ultrasonic wave transmission  impairment and should be considered a contrain-  dication unless TURP can remove them.    Two commercially available devices for HIFU  are currently in use: the Sonablate and Abla-  therm. Both devices use transrectal ultrasound-  guided imaging for treatment with a probe that  is encased within a degassed fluid-filled coupling  balloon to cool the rectum. Several differences  between the two devices exist with respect to  patient positioning, treatment, planning, ultra-  sound frequency, intraprostatic treatment mode,  and rectal wall control.   The Ablatherm has imaging (7.5 MHz) and  therapeutic (3 MHz) transducers included in  a unique endorectal probe focused at 40 mm. It  requires a specific bed with a patient in the lateral  position. It includes three treatment protocols  with specifically designed treatment parameters  depending on the clinical use (standard, HIFU  retreatment, and radiation failure).   The Sonablate uses a single transducer  (4 MHz) for imaging and treatment. Several  probes are available with many focal lengths  (25-45 mm). The procedure is conducted in a dor-  sal position with the patient lying on a regular  operating table. It uses a single treatment protocol  in which the power is manually modified by the  operator. This visually directed HIFU treatment  is based on gray-scale ultrasonographic changes  observed during treatment, which allows the oper-  ator to change the power level for each HIFU  pulse [60].   Both devices offer real-time ultrasonic moni-  toring of the treatment. Because the rectal wall is  sensitive to temperature changes, precise rectal  monitoring is required. Hence, both devices pro-  vide active cooling of the rectal wall during  treatment, continuous temperature monitoring of  the rectal wall, and constant distance measuring  between the rectal wall and the prostate.    Early data regarding the use of HIFU for  treatment of prostate cancer is primarily from  Europe (Table 7). There are no randomized con-  trolled studies available to compare the outcomes  of HIFU with those of other therapies. Various  studies have reported a disease-free survival rate  ranging from 66% to 84% [61,62]. The first  long-term study of 140 patients who had clinically  localized prostate cancer treated with the  Ablatherm demonstrated actuarial biochemical  failure-free survival rates at 5 and 7 years of  77% and 69%, respectively. The actuarial dis-  ease-free survival rates at 5 and 7 years were  66% and 59%, respectively [63]. In summary,  HIFU is still evolving as a treatment modality  for clinically localized prostate cancer. The main  advantages of HIFU seem to be its low morbidity  and the possibility of repeated treatments.    Cryotherapy involves the freezing and thawing  of tissue with the use of probes inserted into  prostate tissue. Isotherms are created around each  probe that radially extend into surrounding tis-  sues until a normothermic temperature is attained.  Temperatures can reach as low as —190 °C at the  cryoprobe and warm to 0 °C at the periphery of  the ice ball [64]. The freeze margin can be visual-  ized under direct ultrasound guidance by the  hyperechoic appearance of the cold zone. Tissues  transition to normothermic temperatures beyond  this margin. Cellular tissue near the probe is  cooled more rapidly and to a lower temperature  than tissue further away from the probe. Cellular  injury and death are attributable to mechanical  destruction from ice formation and cellular  biochemical injury resulting from ischemic effects,  endovascular cell death, and apoptosis.   There are two mechanisms responsible for  direct cellular injury during cryotherapy. The first  results from rapid cooling of cells closest to the  cryoprobe, with formation of intracellular ice  crystals that cause mechanical disruption of cell    membranes [65]. The critical temperature for cel-  lular destruction has been reported to be —40 °C  [66,67]. The second mechanism for cellular injury  and cell death involves slow cooling and a dehy-  dration effect resulting from ice formation in the  extracellular space further away from the  cryoprobe [65]. This process is cumulative, time-  dependent, and most damaging during the thaw  phase. Biochemical effects from this process lead  to cell membrane injury and an increase in cellular  ion permeability; they also weaken the cytoskele-  ton, leading to increased sensitivity to mechanical  injury. Damaged endothelial cells can also become  more permeable and increase the likelihood of  platelet aggregation and microthrombus forma-  tion [68].   Cryoablation has been used for primary treat-  ment of clinically localized prostate cancer and  also as salvage therapy. Robinson and colleagues  [69] have shown excellent quality-of-life outcomes  using validated questionnaires after cryoablation.  A total of 69 men were studied and found to have  a high level of return to baseline quality of life in  all domains by 12 months, except for sexual func-  tioning. At 3 years after cryoablation, quality of  life was found to be stable with no new complica-  tions [70]. Approximately 13% of men returned to  baseline levels of sexual function, with an  additional 34% of patients able to resume sexual  activity with treatment [70]. Another retrospective  study of 223 patients managed with primary cry-  oablation found a 4.3% incidence of incontinence,  an 85% incidence of erectile dysfunction, and  10% of men who required a subsequent procedure  to manage urethral sloughing. Despite these  reported complications, 96% of the men in this  study reported a high degree of satisfaction with  their choice of cryotherapy as treatment [71].   One of the earliest studies examining the  efficacy of salvage prostate cryoablation demon-  strated an 86% negative biopsy rate at 3 months  after treatment but was associated with a high  complication rate because of the early use of  liquid nitrogen-based cooling systems [72]. Other   Mean pre- Mean Mean Disease-free  Authors No. patients Clinical stage HIFU PSA follow-up follow-up survival rate (96)  Poissonnier [61] 227 T1-2N0M0 6.99 27 27 66%  Blana et al [62] 146 T1-2N0M0 11.3 22.5 22.5 84%  Chaussy and 271 T1-2N0M0 8.3 14.8 14.8 82.1%    studies demonstrated negative biopsy rates for  salvage cryoablation as high as 93% [73]. The  introduction of gas-based cryoablation equipment  has been shown to achieve similar oncologic effi-  cacy as earlier systems with a significant reduction  in the incidence of complications, such as rec-  tourethral fistula formation and urinary inconti-  nence [74]. The incidence of rectourethral fistula  has been reduced to 0% to 3%, and urinary in-  continence has been reported to range from to  0% to 13% after treatment [75,76]. The negative  prostate biopsy rate for salvage cryoablation has  been shown to range from 86% to 95% and is  associated with a 5- to 7-year biochemical dis-  ease-free survival rate of 40% to 68% for a PSA  cutoff less than 0.5 ng/mL [77—79].    1] Jemal A, Siegel R, Ward E, et al. Cancer statistics,   6] Van Velthoven RF, Ahlering TE, Peltier A, et al.  Technique for laparoscopic running urethrovesical  anastomosis: the single knot method. Urology  2003;61(4):699—702.   [7] Porpiglia F, Terrone C, Tarabuzzi R, et al. Trans-  peritoneal versus extraperitoneal laparoscopic  radical prostatectomy: experience of a single center.  Urology 2006;68(2):376—80.   [8] Erdogru T, Teber D, Frede T, et al. Comparison of  transperitoneal and extraperitoneal laparoscopic  radical prostatectomy using match-pair analysis.  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Anastasiadis AG, Salomon L, Katz R, et al. Radical  retropubic versus laparoscopic prostatectomy:  a prospective comparison of functional outcome.  Urology 2003;62(2):292-7.   Stolzenburg JU, Rabenalt R, Do M, et al. Endo-  scopic extraperitoneal radical prostatectomy:  oncological and functional results after 700 proce-  dures. J Urol 2005;174(4 Pt 1):1271—5 [discussion:  1275].   Goeman L, Salomon L, La De Taille A, et al. Long-  term functional and oncological results after  retroperitoneal laparoscopic prostatectomy accord-  ing to a prospective evaluation of 550 patients.  World J Urol 2006;24(3):281-8.   Olsson LE, Salomon L, Nadu A, et al. Prospective  patient-reported continence after laparoscopic radi-  cal prostatectomy. Urology 2001;58(4):570—2.    [89] Joseph JV, Rosenbaum R, Madeb R, et al. Robotic [91] Cathelineau X, Cahill D, Widmer H, et al. Transper-  extraperitoneal radical prostatectomy: an alterna- itoneal or extraperitoneal approach for laparoscopic  tive approach. J Urol 2006;175(3 Pt 1):945—50 radical prostatectomy: a false debate over a real  [discussion: 951]. challenge. J Urol 2004;171(2 Pt 1):714—6.   [90] Bhandari A, McIntire L, Kaul SA, et al. Perio- [92] Costello AJ, Haxhimolla H, Crowe H, et al. Installa-  perative complications of robotic radical prosta- tion of telerobotic surgery and initial experience with  tectomy after the learning curve. J Urol 2005; telerobotic radical prostatectomy. BJU Int 2005;    Jean J.M.C.H. de la Rosette, MD, PhD*^*,  Stavros Gravas, MD, PhD”,  John M. Fitzpatrick, MCh, FRCSI, FC Urol (SA), FRCSGlas, FRCS‘    “Department of Urology, Academic Medical Center, University of Amsterdam,  Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands  PDepartment of Urology, University Hospital of Larissa, Mezourlo 411 10, Larissa, Greece  *Department of Surgery, Mater Misericordiae Hospital, University College, 47 Eccles Street, Dublin, Ireland    Scientific and technological advances during  the last years have challenged the established  surgical treatment patterns regarding lower uri-  nary tract symptoms (LUTS) caused by benign  prostatic obstruction (BPO) such as transurethral  resection of the prostate (TURP) and open  prostatectomy (OP). The driving forces behind  the development of minimally invasive methods  were:    The rather unchanged morbidity of transure-  thral resection of prostate in terms of early  (bleeding, TURsyndrome)    Various minimally invasive treatments (MITs)  have been developed using new techniques  including thermal-based therapies, laser therapy,  and other treatment modalities such as prostatic  ethanol injection.   Most of MITs use thermal energy to coagulate  and not really ablate prostate tissue. Nonablative  thermal therapies include hot water-induced ther-  motherapy (WIT), transurethral microwave ther-  motherapy (TUMT), transurethral needle ablation  (TUNA), and high-intensity focused ultrasound  (HIFU). Injectables (including anhydrous ethanol    and Botox) into the prostate result in improvement  of lower urinary tract obstruction with a different  mechanism. On the other hand, ablative surgical  treatments alternative to TURP include laser  prostatectomy with the most dominants being the  holmium enucleation and the emerging photo-  selective vaporization of the prostrate (PVP),  bipolar TURP, and laparoscopic prostatectomy.  It is obvious that the minimally invasive nature of  these treatments significantly varies from true  ambulatory ones to surgical procedures that  require anesthesia, but they are less invasive than  TURP.    During the last decade, numerous studies have  been published presenting the clinical results from  the application of TUMT. These studies have used  different devices with different treatment protocols  and have had different follow-up periods.   Recently, a systematic review of all available  randomized comparative trials (RCTs) on TUMT  attempted to quantify the therapeutic efficacy [1].  TUMT was somewhat less effective than TURP in  reducing LUTS. The weighted mean difference  (WMD) for the symptom score at the 12-month  follow-up was —1.83, favoring TURP. TURP  achieved a greater improvement in Qmax than  TUMT (WMD of 5.37 mL/s in favor of resection)  [1]. Data on TUMT efficacy from this study are  presented in Table 1. Gravas and colleagues [2]    0094-0143/08/$ - see front matter © 2008 Elsevier Inc. All rights reserved.    Treatment Patients Preop Postop Change Preop Postop Change Type of study Level of evidence  TURP [100] 1480 NA NA 70.6% NA NA 125% Systematic review la  HoLEP [29] 100 22.1 1.7 20.4? (92%) 4.9 27.9 23.0 (469%) RCT Ib  TUMT [1] 322 19.4 6.7 12.7 (65%) 7.9 13.5 5.6 (7094) Systematic review la  TUNA [12] 182 NA NA 12.1 (55%) NA NA 6.5 (76%) Meta-analysis la  Bipolar [78] 120 23.0 4.0 19.0 (83%) 7.2 19:5 12.3 (171%) RCT Ib  PVP [45] 60 27.2 12.2 15.0 (54%) 8.5 20.6 12.1 (167%) RCT Ib  WIT [19] 125 24.0 12.0 12.0 (50%) 8.7 15.7 7.0 (8094) Noncomparative 3  Ethanol [64] 93 20.6 10.3 10.3 (50%) 9.9 13.4 3.5 (3594) Noncomparative 3  BONT-A [70] 17 232 8.9 14.3* (6294) 8.1 15.0 6.9 (8594) RCT? Ib  HIFU [22] 20 14.7 4.3 10.4 (71%) 9.2 13.1 3.9 (4294) nRCT 2a  LapProst [57] 20 20.9 2.5 18.4 (88%) 8.8 34.5^ 25.7 (292%) nRCT 2a    Abbreviations: BONT-A, botulinum toxin type A; HIFU, high-intensity focused ultrasound; HoLEP, holmium laser enucleation of the prostrate; LapProst, laparoscopic  prostatectomy; NA, not available; nRCT, nonrandomized clinical trial; postop, postoperative; preop, preoperative; RCT, randomized clinical trial; TUMT, transurethral    microwave thermopathy; TUNA, transurethral needle ablation; TURP, transurethral resection of the prostrate; WIT, water-induced thermotherapy.    * American Urological Association (AUA) Symptom Index.  P Patents who reached follow-up.    performed a pooled analysis of three studies (two  RCTs and one open-label study) of ProstaLund  Feedback TUMT with 12-month follow-up. The  responder rate was 85.3% and 85.9% in the Pros-  taLund Feedback Treatment (PLFT) and TURP  groups, respectively.   High-quality data regarding morbidity come  from the pooled analysis of published randomized  studies comparing TUMT with TURP [1,3,4]. For  patients treated with TURP, the mean length of  hospitalization and catheterization time was  4.0 days and 3.6 days, respectively, while in the  TUMT group, the corresponding mean values  were 0 days and 13.7 days, respectively. More  patients treated with TUMT developed dysuria/  urgency and urinary retention compared with  the TURP subjects. The incidence of hematuria,  clot retention, transfusions, TUR syndrome, is re-  ported to be significantly less for TUMT than for  TURP. The impact of TUMT on sexual function  in terms of erectile dysfunction and retrograde  ejaculation also has been studied in comparison  with pooled data to be in favor of TUMT [3].   Retreatment of TUMT is related to treatment  failure, whereas retreatment of TURP is related to  complications of resection. Reported retreatment  rates after TUMT range from 19.8% to 29.3%, but  with different mean follow-up durations (from 30  to 60 months) [5-8]. Hoffman and colleagues found  that TUMT patients (7.54 events/100 person-  years) were more likely than TURP patients  (1.05 events/100 person-years) to require addi-  tional treatment for benign prostatic hyperplasia    (BPH) symptoms, while in contrast, the retreat-  ment rate for strictures (meatal, urethral, or blad-  der neck) was found to be 5.85/100 person-years  and 0.63/100 person-years for the TURP and  TUMT groups, respectively [1].   It is very difficult to identify predictive baseline  parameters for TUMT, because different devices  have been used, and studies suggest that a pre-  dictive factor for a particular device cannot be  applied to the other devices necessarily [9]. Ad-  vanced age of the patient, small prostate volume,  mild-to-moderate bladder outlet obstruction, and  low amount of energy delivered during treatment,  however, are considered to be independent baseline  parameters predicting unfavorable outcome [10].   The reported low morbidity and the absence of  any anesthesia (spinal or general) needs make  TUMT a true outpatient procedure representing  an excellent option for patients in high operative  risk (American Society of Anesthiologists classifi-  cations 3 and 4) who are unsuitable for an  invasive treatment [11]. Recommendations from  the most popular BPH guidelines on the use of  TUMT are given in Table 2.    A significant number of clinical studies on  TUNA have been published with different number  of patients in each study and different follow-up  period. A recent meta-analysis provides high level  of evidence on the efficacy and safety of TUNA  [12]. Results on Qmax and International Prostate    Abbreviations: BONT-A, botulinum toxin type A; E, emerging; HoLEP, holmium laser enucleation of the prostrate;  I, investigational; IS, inadequately studied; LapProst, laparoscopic prostatectomy; NR, not recommended; ND, not  discussed; PVP, photoselective vaporization of the prostrate; R, recommended; TUMT, transurethral microwave  thermopathy; TUNA, transurethral needle ablation; WIT, water-induced thermotherapy.    Symptom Score (IPSS) are listed in Table 1. Com-  parisons with TURP showed that in the short  term, TUNA achieves a similar level of efficacy,  but at 12 months the degree of improvement in  both subjective and objective variables was signif-  icantly lower than of TURP [12]. An older meta-  analysis reached to similar conclusions [13].   TUNA can be performed as an outpatient  procedure under local anesthesia and sedation in  most patients. The excellent adverse effect and  safety profile of TUNA has been documented in  several short- and long-term studies. Analysis of  pooled data showed that TUNA resulted in  a significantly lower number of complications  than TURP [12]. The estimated odds ratio of expe-  riencing an adverse event (AE) following TUNA is  0.14 (95% CI 0.05 to 0.41) compared with TURP.  This indicates that TUNA has an absolute risk  reduction of complications of 19.4% [12].   The only post-treatment complications having  a higher incidence in patients undergoing TUNA  include transient urinary retention (from 13.3% to  41.6%) and dysuria [12]. All the other AEs,  including mild hematuria, urinary infections,  strictures, and sexual dysfunction (erectile dys-  function and ejaculation disorders), are more  common in patients undergoing TURP than in  those undergoing TUNA.   The combined results of the available studies  demonstrated that TUNA had a retreatment rate  significantly higher than that of TURP, given that  10% (21/206) of patients undergoing TUNA  versus only 1% (3/282) of patients undergoing  TURP required new treatments [12].   Few selection criteria have been identified.  TUNA is not suitable for patients who have  prostate volumes exceeding 75 mL or isolated  bladder neck obstruction [14]. Other studies, how-  ever, found that prostate size and shape were not  related to treatment response [15,16]. TUNA is  not recommended in patients who have metallic  pelvic prosthesis and pacemaker [17].   Available data suggest that TUNA is an  effective and safe MIT for men with even severe  symptoms who do not wish to undergo long-term  medical therapy, or who are poor candidates for  surgery or who are concerned about the adverse  effects of TURP [13].    WIT is another thermal-based therapy for BPO  that aims to produce heat-induced coagulative  necrosis using heated water as a source. The    treatment is performed as a 45-minute outpatient  procedure without requiring systemic analgesia,  because topical lidocaine jelly provides sufficient  analgesia [18].   Limited data on WIT efficacy and morbidity  are available [18]. Evidence comes mainly from  a single international, uncontrolled, multicenter  trial demonstrating symptom reduction and safety  (see Table 1) [19]. Overall, short-term results seem  to be inferior to TURP. No significant ablation is  achieved, because the procedure has been associ-  ated with a median post-treatment prostate  shrinkage of 3.2 cc at 12 months compared with  baseline [19].   Published studies have not reported significant  morbidity [18]. Main AEs included prolonged or  excessive dysuria (11.2%), prolonged and exces-  sive hematuria (22.496), bacteriuria or urinary  tract infection (32.8%), and urinary retention  subsequent to the post-treatment catheterization  period (12.0%). No patient suffered from newly  occurring permanent erectile dysfunction or retro-  grade ejaculation, while interest in sex and sexual  activity were not affected or were slightly  improved by WIT [20].   Data regarding durability are lacking. On an  intention-to-treat basis, the retreatment rates  were higher: 10.4% after 12 months, 23.2% after  24 months, and 36% after 36 months [21]. No pre-  dicting parameters have been identified using  logistic regression models to evaluate baseline pa-  rameters for successful outcome [19]. Protrusion  of a median prostate lobe is a relative contraindi-  cation for this therapy [18].   Itisobviousthat randomized studies against one  ofthe standard treatments are required, thus WIT is  not recommended by clinical guidelines and is  considered to remain investigational (see Table 2).    Randomized controlled studies comparing  HIFU to the standard therapy have not been  published. A non-RCT comparing TURP with  four MITs including transurethral electrovapori-  zation (TUVP), visuallaser ablation of the prostate  (VLAP), TUNA, and HIFU has performed [22].  The clinical results of HIFU are presented in Table  1. Increase in Qmax after HIFU was smaller than  the improvement achieved after TURP. Data anal-  ysis from a study with the longer follow-up showed  that 43.8% (35/80) of the patients required TURP  within 4 years [23]. In the group of responders,  IPSS improved from 19.6 to 8.5 after 12 months    and remained practically unchanged during the  4-year follow-up, while Qmax increased from  9.1 mL/s to 11.8 mL/s at 12 months and subse-  quently deteriorated to 10.2mL/s at 4 years.   In general, the treatment is tolerated well but  requires general or regional anesthesia. The most  prominent AE is prolonged urinary retention,  thus a suprapubic catheter is offered to the  patients postoperatively [24]. Complication rates  are low because of absence of any urethral mani-  pulation. Effects on erectile and antegrade ejacu-  lation are uncommon. Hematospermia can be  noticed up to 4 to 6 weeks in up to 80% of sexu-  ally active men [25].   Predictors of unfavorable outcome include  large prostates (greater than 75 mL), presence of  a pronounced middle lobe, presence of prostatic  calculi (caused by attenuation of ultrasound), and  higher grades of bladder outlet obstruction [26].   To date, the interest for treating BPH patients  with HIFU has declined while there is a shift  toward the use of HIFU for the treatment of  prostate cancer. Because of the lack of high-  quality data, HIFU is considered as an investi-  gational treatment modality by most of the  guidelines (see Table 2).    Several clinical studies have shown the efficacy  and safety of holium laser enucleation of the  prostate (HoLEP) [27-30]. A recent meta-analysis  of the available RCTs comparing HoLEP with  TURP showed that there was no statistically  significant difference between HoLEP and  TURP in terms of Qmax (WMD was 0.59) at  12 months after treatment [31]. Unfortunately,  this meta-analysis does not provide the pooled  values of Qmax and IPSS at baseline and during  follow-up; therefore it has not included in Table 1.  Thus the results from the largest RCT compar-  ing HoLEP with TURP are presented there [29].  On the other hand, this meta-analysis offers signi-  ficant information regarding perioperative  variables and AEs [31]. No statistically significant  differences between pooled estimates were noted  between HoLEP and TURP for urethral stricture  (2.6 versus 4.4%), blood transfusion (0 versus  2.2%), and reintervention (4.3 versus 8.8%). The  overall complication rate, however, was 19 of  232 (8.1%) in the HoLEP group and 37 of 228  (16.2%) in the TURP group, with a statistically  significant difference in the pooled estimates.  Pooled data suggest that HoLEP is superior to    TURP in terms of catheterization time, hospital  stay, and blood loss. In contrast, pooled estimates  showed a benefit of TURP over HoLEP for dura-  tion of operation [31]. Montorsi and colleagues  [32] reported that there was no TUR syndrome  in the HoLEP group, versus 2.2% of patients in  the TURP group.   The impact on erectile dysfunction and retro-  grade ejaculation is very similar between the two  groups. The erectile function did not show  a decrease from baseline in either group. In addi-  tion, Kuntz and colleagues [29] reported that 74%  of sexually active patients in the HoLEP group  and 70.3% in the TURP group had retrograde  ejaculation.   Gilling and colleagues [33] performed a meta-  analysis of four RCTs comparing HoLEP and  TURP. They found that urodynamic relief of  obstruction (PdetQmax and Schaffer grade) was su-  perior with HoLEP compared with TURP, but only  when prostate volumes were greater than 50 g.  Studies evaluating durability of HoLEP are now  available. Recently, Gilling and colleagues [34]  reported the results from a series of patients with  a mean follow-up of 6.1 years. HoLEP achieved du-  rable resultsin terms of Qmax, quality oflife (QOL),  and IPSS, while the reoperation rate was 1.4%.  Similarly, Elzayat and Elhilali [35] found that the  objective and subjective improvements after  HoLEP remained sustained at 6 years, with a reop-  eration rate of 4.2% for recurrent BPH obstruction.   HoLEP has no size limitation and has been  shown to be effective for large prostates that  traditionally have been treated by open prostatec-  tomy [36-38]. The main evident advantages are  reduced blood loss and shorter catheterization  and hospitalization time. Recent, long-term  (5 years) data from a RCT comparing HoLEP  with OP demonstrated similar durable subjective  and objective improvement for both groups and  a reoperation rate of 5% in the HoLEP group  and 6.7% in the OP group [39].   HoLEP is recommended by the guidelines (see  Table 2); however, the main criticism of HoLEP  includes a significant learning curve (requiring  30 to 50 cases), purchase cost, and the difficulty  in tissue removal.    PVP using the high-power (80 W) potassium-  titanyl-phosphate (K TP) laser represents the latest  evolutionary development in laser and is attract-  ing the interest of urologists.    Initial studies on the 80 W setting have shown  promising outcomes [40-44]. Mean increase in  Qmax ranged from 106% to 253%, and mean  IPSS improvement varied from 59% to 84%. Re-  duction in prostate volume ranged from 37% [40]  to 53% [44]. There is only one randomized study;  however, that compares PVP with TURP, and re-  sults are displayed in Table 1 [45].   Catheterization time is generally less than  24 hours, while in one study, 44 patients (32%)  were left without a catheter at the end of the  procedure [40]. The perioperative morbidity is  low, with the most frequent complications being  the need for recatheterization (range from 1% to  15.4%), dysuria (from 6.2% to 30%), and minor  hematuria (up to 18%). One of the main advan-  tages of PVP is the virtually bloodless tissue abla-  tion, resulting in absence of significant bleeding  and need for blood transfusion. No TUR syn-  drome rate was reported in any study. Between  36% and 55% of sexually active men experienced  retrograde ejaculation after treatment [40-44]. In  the only RCT, PVP was superior to TURP in  terms of blood loss, catheter time, and duration  of hospital stay [45].   Long-term results of this technique are still  missing. A study with the longest follow-up  (5 years) showed that a significant improvement  in American Urological Association (AUA)  symptom index and Qmax after PVP that re-  mained durable during follow-up [46]. This study,  however, suffered from a very high attrition rate  (68% and 85% at 3 and 5 years, respectively).   Published studies also demonstrated that the  80 W KTP laser seems to be a safe and effective  means for treating men who have large prostates  (mean volume greater than 100 mL) [47-49]. The  mean lasing time ranged from 79 to 123 minutes.  Qmax, IPSS, and QOL scores showed significant  improvements without the presence of TUR syn-  drome or the need for blood transfusions. The  new 120 W high-performance system (HPS)  recently was introduced, aiming at a faster tissue  removal in less lasing time and the ability to treat  large glands in an acceptable time. A consider-  ation, however, is that the high-power settings  may result in higher complication rates including  capsule perforation, bladder perforation, or injury  of the orifices and decreased haemostatic capa-  bility [50].   KTP laser vaporization has a relatively short  learning curve, but caution is required when the  prostate gland or the median lobe is very large.  Another consideration is that the recently    introduced 120 W HPS with the high-power  settings may require a longer leaning curve.   The lack of randomized studies and long-term  data does not allow definitive recommendations  about the position of PVP for managing LUTS  (see Table 2).    The laparoscopic prostatectomy for large  benign prostatic adenomas causing bladder outlet  obstruction recently was introduced [51]. Several  studies have shown the feasibility of the technique  (either the Millin's or transvesical procedure)  [52-59] with functional outcome comparable  with those of open prostatectomy (see Table 1).   The main advantage of laparoscopic simple  prostatectomy over the conventional open  approach is the significantly lower blood loss  [57,58]. In a study presenting the 6-year experience  with laparoscopic prostatectomy, the most fre-  quent long-term complication was retrograde  ejaculation, which occurred in all patients after  6 months of follow-up [59]. The erectile function  was preserved in all those patients who were  potent before surgery, while none of the patients  experienced urinary incontinence.   Laparoscopic prostatectomy, however, requires  a long learning curve and significant laparoscopic  expertise; therefore it is performed in centers with  considerable experience in laparoscopic urology.  In addition, the reported results regarding opera-  tive time, hospitalization time, and length of  hospital stay were controversial [57,58] and have  questioned the position of laparoscopic prostatec-  tomy as a true minimally invasive alternative to  open prostatectomy.   Therefore, further randomized studies with  long follow-up are required to evaluate laparo-  scopic prostatectomy for managing patients who  have very large adenomas, in comparison with OP  and endoscopic methods including HoLEP.  Guidelines do not discuss laparoscopic prostatec-  tomy yet.    Transurethral ethanol ablation of the prostate  (TEAP) aims at effectively treating patients who  have symptomatic BPO by injecting anhydrous  ethanol into the prostate under continuous ure-  throscopic irrigation. The exact mechanism is not  known, but it seems that there is coagulative tissue  necrosis with associated protein denaturation, and   Although there are no randomized studies,  available data show that there is a significant  improvement in terms of IPSS and Qmax after  TEAP that remains durable at 12 months [60—64].  Table 1 presents the clinical results from a multi-  center, noncomparative study [64].   It recently has been shown that TEAP can be  performed in an outpatient setting using local  anesthesia and oral-only sedation [65]. Patients  require a catheter after TEAP, but more than  9095 of them are able to void after 96 hours.  The most commonly reported AE (of mild or  moderate severity) included hematuria (42.9%),  irritative voiding symptoms (40.396), pain/dis-  comfort (25.6%), and urinary retention (22.1%).  Erectile dysfunction occurred in less than 5% of  the patients. The most serious complication was  ethanol-induced bladder necrosis, which occurred  in three cases [66].   Long-term studies are limited. Goya and  colleagues [64] followed 17 patients and found  that IPSS and Qmax improved after TEAP and  were stable at 3-year follow-up without any major  complications associated with the procedure.  Durable improvement, however, was reported in  only 59% of patients. The reported reintervention  rate after TEAP ranged from 7% by 1 year to  26% by 3 years [63,64].   Again, the main limitation of this MIT is the  lack of randomized studies comparing this pro-  cedure with other minimally invasive procedures  or with TURP. TEAP seems to be effective up to  12 months, but long-term data are required to  define its potential role for managing lower  urinary tract obstruction.    The use of intraprostatic injection of botuli-  num toxin type A (BONT-A), an exotoxin pro-  duced by Clostridium botulinum, very recently has  been introduced for treating BPH [67—71]. The ex-  act mechanism of action remains unknown, but  possible mechanisms include neurotoxin-induced  denervation atrophy, induction of apoptosis, and  decreased proliferation and down-regulation of  a A-adrenergic receptors [72].   BONT-A has been injected into the prostate  using transperineal, transurethral, or transrectal  approaches [71,73—75]. The transurethral appli-  cation requires cystoscopy under anesthesia,  when transperineal (most commonly reported) or    transrectal approaches can be used without even  local anesthesia. In these studies, different thera-  peutic doses have been reported (range from 100  to 300 U Botox) in different volumes (from  4 to20 mL) [71,73-75]. To date, the number of  available published studies is limited, and they  suffer from the small patient numbers, short  follow-up, and differences in study design. The  preliminary results, however, seem to be encour-  aging, because injection of BONT-A achieves sig-  nificant improvement with persistent effects for 6  to 12 months after treatment. The clinical out-  comes from the double-blinded placebo-con-  trolled study by Maria and colleagues [70] with  the larger follow-up (19.8 months) are listed in  Table 1. The procedure also has proven safe  without report of any serious AE. Intraprostatic  BONT-A, however, has not been approved for-  mally by the US Food and Drug Administration  (FDA) for treating BPH [72].   Controversial results have been reported  regarding the impact of BONT-A in prostate  volume. Chuang and colleagues [68] also found  no change in prostate volume in 12 of 41 patients,  while seven had improved IPSS, QOL, and Qmax  indices, suggesting that BONT-A may affect not  only the static but also the dynamic component  of BPH.   It is obvious that intraprostatic injection of  BONT-A has to run a long distance before one  can define its position into the armamentarium  of urologists for managing LUTS obstruction.  Understanding of the mechanism of action, stan-  dardization of both technique and doses, large  randomized comparative studies against estab-  lished MIT, and longer follow-up of the patients  are required.    To date, five types of bipolar resection devices,  with technical differences in delivering bipolar  current flow to achieve the plasma effect, have  been used:    Plasma kinetic (PK) system (Gyrus Interna-  tional, Ltd., Berkshire, United Kingdom)  Vista Coblation/CTR (controlled tissue re-   section) system (ACMI, Maple Grove,  Minnesota)  Transurethral resection in saline (TURIS) sys-  tem (Olympus, Center Valley, Pennsylvania)  Karl Storz (Karl Storz GmbH & Company  KG, Tuttlingen, Germany)    The efficacy and safety of those bipolar devices  have been demonstrated by RCTs and case series  [76—80]. All studies found that the clinical efficacy,  in terms of Qmax and IPSS, was similar in both  bipolar and monopolar TURP. The results of  the largest RCT comparing bipolar (PK system)  with monopolar TURP are listed in Table 1 [78].   Main advantages of bipolar resection include  the reduced blood loss and the decreased in-  cidence of postoperative clot retention and blood  transfusion requirement [78,79]. TUR syndrome  had not been observed with bipolar TURP  because of the use of saline irrigation and the  reduced fluid absorption during bipolar TURP.  Both the postoperative catheterization and hospi-  talization time were significantly less (40% on av-  erage) in the bipolar arm of RCTs compared with  monopolar TURP [76,79,80] and were attributed  to the reduced bleeding associated with improved  coagulation. Postoperative irritative LUTS, par-  ticularly dysuria, was observed less commonly  with bipolar TURP. Urethral stricture is observed  more commonly with bipolar TURP (range from  4.0 Voto 6.1%). Larger resectoscope size (27 F),  the type of return electrode, and the higher cur-  rent densities may contribute to this risk [76,79].   In a RCT comparing bipolar TURP with  plasma kinetic energy and monopolar TURP  with a mean follow-up of 18.3 months, the  reoperation rate was 4.1% and 2.1% for the PK  system and TURP groups, respectively [81].   Available data suggest that bipolar resection  devices seem to achieve results comparable to  conventional TURP, with decreased bleeding and  shorter catheterization and hospital stay and  without the occurrence of TUR syndrome.    Longer-term outcomes on the durability and in-  cidence of urethral strictures are required to  strengthen the position of bipolar resection as  a less-invasive alternative to TURP.    Historically, patients in retention are considered  to be associated with a higher complication rate  and sometimes a poorer outcome in terms of  voiding parameters. In the first studies on the  efficacy of most MITs, urinary retention was one  of the exclusion criteria. Urologists, however, have  become more confident and offered MIT to this  specific group of patients. Table 3 presents the suc-  cess rate of MITs on patients in retention, defined  as the percentage of patients who regained the abil-  ity to void spontaneously [12,82-87]. All these stud-  ies reported the short-term results and it should be  underlined that long-term results for this group of  patients are limited. Gravas and colleagues [88]  followed 213 patients with or without retention  treated with the TUMT 3.5 protocol for up to  5 years. It was found that 28.6% of patients without  urinary retention required additional treatment,  while treatment failure was 37.8% in the retention  group. Additionally, the cumulative risk at 5 years  was 42.3% and 58.8%, respectively. Therefore,  long-term studies are required to evaluate the dura-  bility of MITs on patients who have retention.    With the growing life expectancy, urologists  face with an increasing number of patients re-  quiring prostatectomy, who suffer from serious  comorbidities. Nonablative MITs require minimal    HoLEP [84] 164/164 (100%)  TUMT [82] 48/61 (79%)  TUNA [12] 78/112 (70%)  PVP [85] 68/70 (97%)  WIT [83] 12/13 (92%)  Ethanol injections [86] 17/21(81%)  BONT-A [87] 17/21 (81%)   NA Systematic review  12 mo^ Noncomparative  12 mo Noncomparative  16 mo* Noncomparative  3 mo Noncomparative    Abbreviations: BONT-A, botulinum toxin type A; HoLEP, holium laser enucleation of the prostrate; PVP, photo-  selective vaporization of the prostrate; RCT, randomized clinical trial; TUMT, transurethral microwave thermotherapy;  TUNA, transurethral needle ablation; WIT, water-induced thermotherapy.    anesthesia/analgesia and offer low morbidity, low  incidence of adverse events, and low potential  mortality for those at high surgical risk.  Recently, studies on the 80 W KTP laser have  indicated that the procedure seems to be safe and  beneficial for patients who have coagulopathies,  platelet disorders, and those considered to be of  high cardiopulmonary surgical risks who could not  discontinue oral anticoagulant therapy [89-91].  Similarly, HoLEP has been performed successfully  in patients who normally are considered unfit for  a TURP, including those with significant comor-  bidities, such as coagulopathy, anticoagulant  dependency, and significant anemia [92].    The introduction of new technology in health  care sometimes is charged as one of the major  causes of escalating costs because of the purchase  of the capital equipment and failure in terms of  efficacy, morbidity, and durability. High costs  frequently are cited as a major drawback of the  new laser techniques. Different economic models  evaluating the cost-effectiveness of MITs for BPO  have been introduced [93,94]. Performance of  treatment on an outpatient basis represents a crit-  ical factor that reduces the direct cost and renders  MITs economically advantageous compared with  surgical treatments. This benefit, however, may be  balanced by the higher retreatment rate of most  ambulatory MITs.   Data from the Urologic Diseases in America  BPH project showed that BPH therapy trends are  moving away from the gold standard operation of  TURP and toward less- invasive pharmacologic  options and MIT in an outpatient setting [95].  Reimbursement policy encourages the outpatient  performance of MITs. TUMT and TUNA have  an extremely high in-office reimbursement, with  Medicare rates of $4272 and $4098, respectively,  compared with $552 and $585 for the respective  hospital procedures [96].   Disantostefano and colleagues [97] showed  that the best treatment for BPO varies depending  on the value that individuals and society place on  costs and consequences, including disease progres-  sion, clinical outcomes, hospitalization, and cath-  eterization time.   In addition, the cost-effectiveness of all tech-  niques depends on the existence of long- term  data, costs of complications, and the different  reimbursement systems in different countries.    Therefore, it is difficult to draw solid conclusions  that are applicable to every country.    The range of therapeutic options for the man-  agement of BPO continues to widen as technology  continues to evolve and improve. Increased choice  creates the increased need for clarity in selection  and application of various treatment options based  on the clinical outcomes, morbidity, and technical  improvement of these technologies. Clinical prac-  tice guidelines (CPGs) have been developed to help  practitioners and patients decide about appropri-  ate health care for specific clinical circumstances.  Table 2 presents the current recommendations  of the most popular CPGs [26,98,99]. Recently in-  troduced MITs, however, have not been included,  or data were insufficient when CPGs were rele-  ased, underlying the need for regular updating of  guidelines.   TURP remains the gold standard for surgical  treatment, and indeed new MITs have not dem-  onstrated better outcomes than TURP in terms of  efficacy and retreatment rate. Table 1 presents the  clinical results at 12 months after treatment based  on the highest quality study for each of the treat-  ment options. The available type of study also  indicates how extensively these MITs have been  studied. TUNA and TUMT are the best-studied  MITs; thus data come from meta-analyses of  RCTs. An ablative therapy like TURP or ablative  laser therapy therefore should be advocated as  first-line treatment for patients with an absolute  surgical indication. In terms of minimal morbidity  however, MITs are considered to be superior. In  general, an increased ablative power results in  increased relief of BPO at the expense of higher  morbidity.   The algorithm for the instrumental treatment  of lower urinary tract obstruction outlines the  authors’ approach to this controversial issue  (Fig. 1). Patients are classified on the basis of op-  erative risk of patients, because TURP morbidity  was the main reason for the search of alternative  treatment modalities. Grades (1, 2, 3, 4) have  been allocated to the procedures based on clinical  efficacy, morbidity, durability, and strength of  evidence. When two procedures were considered  to be equally useful, were been graded with the  same number. The first alternative has the number  1. WIT, HIFU, BONT-A, and laparoscopic pros-  tatectomy were not included in this algorithm  because of limited data or decline in their use in    Patients  Low Risk High Risk  Prostate volume Can receive anesthesia?  «100ml »100ml No Yes  Middle Open TUMT (1) Can stop oral  lobe HoLEP (1) TUNA (1) anticoagulants?  PVP (2) TEAP (2)  Yes No Yes No  TURP PVP (1)  TURP TURP T patients. | HoLEP (2) | | HoLEP (1  HoLEP (1)| HoLEP (I) |. ? Patient's f$ Bipolar s 0. a)  Bipolar (1) | | Bipolar (1) | X preference |7 | TUMT (2)  PVPQ) | TUMTQ) | "—— ——  TUNA (2) =  PVP (3)  TEAP (4)    Fig. 1. Algorithm for instrumental treatment of lower  urinary tract obstruction.    the clinical practice. In the future, modifications  of this algorithm may prove necessary as more  RCTs and studies on the long-term outcome of  MIT will come into light.   The present algorithm is indicative, but  patients also should be involved in treatment  selection. It also should be underlined that best  data and clinical expertise should be combined  with patients’ preferences (including interest in  sexual function and perioperative morbidity). In  addition, management is influenced by other  factors, including availability of MIT and urolo-  gists’ beliefs.    In line with many other urological diseases, the  treatment of prostate-related pathologies has un-  dergone numerous improvements during the last  decades, with a major impact on the incidence of  intra- and postoperative complications. On one  hand, these improvements are because of the  introduction of new minimally invasive technolo-  gies, whereas on the other hand, the established  technologies have evolved. At present, TUNA  and TUMT have been established as valuable  ambulatory treatments, and clinical outcomes are  in between medical management and surgical  treatments. HoLEP and Greenlight laser    treatment, however, have challenged the so-called  gold standard, and at present, the balance be-  tween clinical outcomes versus morbidity seems to  swing in their favor. The different minimally  invasive treatment modalities currently available,  however, have paved the way for further improve-  ments of TURP. For 80 years, TURP has been  the cornerstone of minimally invasive surgical  management of BPO. With the introduction of  bipolar technology, TURP has reinforced its  position.    [1] Hoffman RM, Monga M, Elliot S, et al. Microwave  thermotherapy for benign prostatic hyperplasia.  Cochrane Database Syst Rev 2007;17(4):CD004135.   [2] Gravas S, Laguna P, Ehrnebo M, et al. Seeking for  evidence that cell kill-guided thermotherapy gives  results not inferior to transurethral resection of  prostate: results of a pooled analysis of 3 studies  on feedback transurethral microwave thermother-  apy. J Urol 2005;174(3):1002—6.   [3] Walmsley K, Kaplan S. 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J Urol 2003;169(Suppl):392, A1466.  Chuang YC, Chiang PH, Huang CC, et al. Botuli-  num toxin type A improves benign prostatic   Chuang YC, Chiang PH, Yoshimura N, et al. Sus-  tained beneficial effects of intraprostatic botulinum  toxin type A on lower urinary tract symptoms and  quality of life in men with benign prostatic hyper-  plasia. BJU Int 2006;98:1033-7.   Geurcini F, Giannantoni A, Bard R. Intrapro-  static botulin toxin injection in patients with  severe benign prostatic hyperplasia: a multicenter  feasibility study [abstract]. J Urol 2005;  173(Suppl):376.   Maria G, Brisinda G, Civello IM, et al. Relief by  botulinum toxin of voiding dysfunction due to be-  nign prostatic hyperplasia: results of a randomized,  placebo-controlled study. Urology 2003;62:259-64  [discussion: 264—5].   Park DS, Cho TW, Lee YK, et al. Evaluation of  short-term clinical effects and presumptive mecha-  nism of botulinum toxin type A as a treatment  modality of benign prostatic hyperplasia. 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Simulation and Computer-Animated  Devices: The New Minimally  Invasive Skills Training Paradigm  Robert M. Sweet, MD?^, Elspeth M. McDougall, MD, FRCSC°**    “Simulation PeriOperative Resource for Training and Learning, University of Minnesota,  D509 Mayo Memorial Building, 420 Delaware Street SE, Minneapolis, MN 55455, USA  > Department of Urologic Surgery, University of Minnesota, D509 Mayo Memorial Building,  420 Delaware Street SE, Minneapolis, MN 55455, USA  “Surgical Education Center, University of California, Irvine, USA  “Department of Urology, University of California, Irvine Medical Center, Building 55,  Route 81, Room 302, 101 The City Drive South, Orange, CA 92868-3201, USA    The rapid development of complex surgical  technologies, particularly in minimally invasive  therapy, has resulted in challenging learning curves  for surgeons. In addition, limited case experience as  a result of restricted resident work hours and  limited case volumes in surgical practice add  additional challenges to surgical education in the  21st century. Meanwhile, surgeons are finding it  increasingly important to not just maintain skills,  but to develop new skills, especially those new  technically challenging skills related to minimally  invasive surgical therapies. In addition, minimally  invasive therapies are highly dependent on  uniquely specialized teams of health care workers.  For all of these reasons, simulation is gaining in-  creasing attention as an additional component to  the surgical education armamentarium for the de-  velopment and refinement of minimally invasive  surgical skills and technique [1].   Technical skills education in urology, as in  many of the technically oriented fields has its  primary roots in the operating room, augmented  by cadaver and live animal models and, in select  cases, inanimate artificial tissues. In fact *simula-  tors” were used by Susrutha in ancient India in    * Corresponding author. University of California,  Irvine Medical Center, Department of Urology, 101  The City Drive, Building 55, Room 302, Route 81,  Orange, CA 92868-3201, USA.    the form of inanimate artificial tissues and phys-  ical models [2]. With the advent of digital imaging  techniques (CT and MRI), visual-spatial ana-  tomic understanding and “preoperative” planning  rose to a whole new level both from a clinical and  an education standpoint. With the advent of fiber  optics and the video monitor, the trainee and  trainer were able to comfortably view the same en-  doscopic image simultaneously, allowing for more  rapid training. Renewed interest in urologic simu-  lation and a paradigm shift in surgical education  came about with a series of closely related events.  The “To Err is Human" report and the increased  public awareness of surgical errors have brought  medical care in general under greater scrutiny  [3]. Restrictions on residency work hours, the  surge of minimally invasive training procedures  in urology, and the acute rise in health care costs  have all led administrators to seek alternative  learning environments to the operating room for  training. Technologies offering virtual reality,  a term coined in 1987 by Jaron Lanier, opened  up new possibilities in medicine for creating  a practice environment with intelligent data-col-  lection and mentoring. Unfortunately, this con-  cept was overpromised and underdelivered for  many reasons: limitations of computer processing,  lack of organized structure and understanding  around curriculum design, lack of defined “‘stan-  dards" and metrics, the high cost of development,  the multidisciplinary nature of such projects, and    0094-0143/08/$ - see front matter © 2008 Elsevier Inc. All rights reserved.    a lack of fundamental modeling and validation  data during the development process. One of the  largest technical challenges is the application of  this technology. As much as we like to make the  analogy with flight simulation, the human body  is not an airplane. The human body is a very com-  plex “model,” with many unknown components,  and so is difficult to accurately and consistently  simulate. Such complexity becomes magnified  when one considers the relatively unknown dy-  namic impact that the brain has on the body at  the microcellular, macrocellular, tissue, physio-  logic, and behavioral levels.   Simulation is the technique of imitating the  behavior of some situation or process by means of  a suitable analogous situation or apparatus espe-  cially for the purpose of study or training [4]. This  has been used extensively in economics, the mili-  tary, and the aeronautics and space industry and  is now becoming an important part of medical  education. Learning devices that produce simula-  tion are training simulators. The terms /ow- and  high-fidelity refer to how closely the simulator  itself and the environment in which the training  occurs represent reality. To be most effective,  high-fidelity simulation must lead learners to sus-  pend their disbelief. To do this, the interactive  sights, sounds, smells, and feel of the simulated  experience must mimic reality and subsequently  elicit the emotions and generate the behaviors  that would be observed in a real situation. The  difference between a low-fidelity simulation and  a high-fidelity simulation can be significant. A  low-fidelity trainer, for example, may be a simple  abstract box-model for use in a nonclinical envi-  ronment, such as a living room, to practice a pro-  cedure. By contrast, the highest-fidelity simulation  currently for the same procedure would involve an  operation on a live animal in a real operating  room under supervision. Anatomic models made  in virtual reality represent an attempt to recreate  the environment of real tissue. However, unlike  either the abstract box model or the live-animal  situation, they have the exciting capability of  generating data on everything the user does in  the environment and of incorporating a virtual  instructor. These simulation formats can be used  for skills training, task training, and procedure  training. They can also provide high reliability  team training for such environments as the oper-  ating room, the intensive care unit, and the emer-  gency department. Many surgical courses now  rely on simple abstract material-based trainers to  teach novice surgeons basic skills and techniques.    These are excellent tools as long as proper tech-  niques are conveyed. Courses use higher-fidelity  tissue or virtual reality trainers to make assess-  ments and provide training for tasks requiring  higher-level skills and to provide a means to prac-  tice acquired skills. Virtual reality trainers that are  software-based and can incorporate curricula, as-  sess formative metrics, recognize errors, and con-  tain management features are gaining more  interest as a means of learner-centered, indepen-  dent, and deliberative practice with feedback.  One of the newest additions to continuing  medical education is high reliability team training  [5,6]. Much can belearned by experiencing errors as  they occur and studying how these errors can be  successfully managed by the team vis-à-vis a debrief  exercise. As such, simulation has a profound ability  to provide significant advantages as a platform for  repetitive practice by both the team and the individ-  ual in a no-risk environment away from patients.  Simulation technologies can build in every poten-  tial error and thereby provide acute-scenario train-  ing so that the trainees can learn to recognize, avert,  and resolve these events in a no-risk environment.  This better prepares them for a similar clinical situ-  ation. In addition, virtual reality and other dry-lab-  oratory simulation exercises are helping to reduce  the reliance on animal and cadaver laboratories,  and have shown the capability to reduce operative  times and errors in the operating room [7].  Inclinical teaching, it is essential that the teacher  be focused on the patient first and the trainee  second. Dedicated facilities with a curriculum em-  bedded with simulation enable teachers to focus  all of their attention on learners. The curriculum  involves creating a comprehensive knowledge base  so that the trainee understands what is to be  learned, why it should be learned, and how it can  be learned. Of equal importance is teaching the  trainee how to recognize an error, why it is an error,  and what to do to avoid and recover from the error.  It is the combination of basic knowledge and ma-  nipulative skills, along with the development of  judgment during clinical experiences, that creates  the master surgeon. Simulation provides both an  opportunity to study and commit to memory how  master surgeons attain and perform their skills  and an environment by which learners can refine  and perfect their skills to achieve such mastery.  The adult learner is a unique student in the  environment of health care education. These  learners tend to have a problem-centered orienta-  tion to their learning and a readiness to learn, as  well as increased self-directedness [8]. Residents    and fellows as a group of learners comprise  a unique group of students who are in Erickson’s  seventh stage of development [9]. These middle  adult learners have a significant need to develop  knowledge and skills, and to be able to apply  them effectively to their clinical practice as part  of their quest for generativity rather than stagna-  tion. However, as learners, they also have weak-  nesses and therefore strategies must be devised  to overcome these. Research has shown that phy-  sicians are pretty awful at self-assessment. It is  part of the human condition to suppress our inad-  equacies to both others and ourselves. As such,  these learners like the reward that comes from  success and, left to their own devices, gravitate  to studying things they enjoy and are already  good at. While self-directed learning may be ap-  propriate for an evening pottery class, it is less  appropriate for the learning and application of  medicine and surgical skills. People increasingly  expect doctors to have a reasonable amount of  cognitive and technical skill before embarking  on the practice of medicine and surgery.   An effective curriculum must clearly identify  the goals of the educational program. This is  based on a defined desired outcome and a needs  assessment that directs the development of the  educational program. This assessment generates  the specific learning objectives of the curriculum  as they relate to the cognitive and skills perfor-  mance that is to be learned in the training  program. The objectives clearly outline not only  the material to be covered but also the format that  will be used to assess the student for each of the  curricular objectives. The curriculum will include  a clear delineation of all teaching methods and  strategies as they relate to the curricular objec-  tives. Appropriate formative student assessment  must be incorporated into the curriculum to pro-  vide ongoing feedback to help guide and shape  learning, The curriculum must also include sum-  mative assessment opportunities to determine if  the student has achieved the required level of pro-  ficiency before advancing to the next stage of  training. Finally, the curriculum must be subject  to ongoing evaluation by both the students and  the instructors to direct curriculum growth and  improvement.   Several researchers have shown that didactic  lectures by themselves do not play a significant  role in immediately changing physician perfor-  mance or improving patient care [10]. Education  programs that use interactive techniques are gen-  erally more effective in changing physician    performance or improving patient care outcomes.  In addition, educational sessions delivered in  a longitudinal or sequenced manner also appear  to have a more beneficial impact on physician  learning [11]. The provision of enabling methods  to facilitate implementation of the new knowledge  or skill in the practice setting appears to have  a positive effect on the success of medical educa-  tion programs.   Gallagher and colleagues [12] have clearly  shown the importance of the knowledge and psy-  chomotor curriculum in surgical education. Hu-  mans have a limited capacity for attention. This  limitation becomes extremely important in plan-  ning the education of novice surgeons or in learn-  ing a new surgical technique. These surgeons are  trying to gain additional knowledge while com-  prehending instruction from their mentor in the  operating room. At the same time, they are deal-  ing with the challenges of depth and spatial judg-  ment as this affects their psychomotor  performance, especially during minimally invasive  therapy. Add to this the demand for operative  judgment and decision-making and they may  well exceed their attention capacity, which results  in their inability to cope with an error or compli-  cation. In contrast, the master surgeon has the  fundamental knowledge, requires less attention  for already well-developed spatial judgment and  surgical skills, and therefore can devote more  attention to a situation in which an error may  be about to occur. Simulation can provide an  opportunity for trainees to gain the knowledge  and develop better psychomotor and spatial judg-  ment skills so that they too can apply more atten-  tion to other skills and learn more about operative  judgment and decision-making in the clinical  setting. As surgeons, we have long understood  our lifelong commitment to education and this  concept must be further instilled in our trainees  as they become self-directed learners. "Practice  makes perfect" is a concept that is well under-  stood by pilots learning to fly, dancers rehearsing  complex dance routines, and golfers perfecting  their swings. The concept is just as valid in the  field of surgery.   Surgical practice is a concept that has been  highlighted in a recent report by Kahol and col-  leagues [13] in their study on the effect of short-  term, pretrial practice on surgical proficiency in  simulated environments. In this study, subjects  performed standardized exercises as a preoperative  warm-up, after which the standardized exercises  were repeated in a random order. The    experimental group was allowed to warm up with  the standardized exercises, after which a different  task (electrocautery stimulation) was performed.  The study participants included experienced lapa-  roscopic surgeons, fellows, and residents. The  results of this study provide substantial evidence  that short-term practice (warm-up) with exercises  designed to target both the psychomotor and cog-  nitive skills involved in surgical procedures can  greatly enhance surgical proficiencies during  a follow-up procedure. Similar practice techniques  enhanced gesture proficiency and made general  movements and movements involving tools  smoother. Interestingly, the participants of vary-  ing experience levels all benefited from the  warm-up exercises. Perhaps most importantly,  error rates fell significantly following the warm-  up exercises. The time required to complete  a task, which is one important indicator of effi-  ciency, was also reduced significantly in this study  population.   Simulation is also being proposed as an  assessment and credentialing tool similar to that  in the aviation industry [14]. This proposal comes  from a need to measure more than just knowl-  edge, to model real-life situations, and to stan-  dardize the assessment of surgeons. Simulation  has the potential to provide the “vehicle” to mea-  sure skills. However, for simulation assessment to  be of value, it must have a scoring system that  aligns with expert agreement on what and how  a task should be performed and that is subject  to strict research to confirm construct and predic-  tive validity. As an appropriate device for surgical  evaluation, the curriculum must be able to distin-  guish the novice from the expert laparoscopic  surgeon, or have construct validity. In addition,  the simulation-embedded curriculum must be  able, on the basis of the performance of the  trainee, to predict the surgeon's performance in  the corresponding clinical setting and predict the  student's likelihood of eventual success if being  used for screening applicants.   The demonstration of consistent performance at  validated criterion levels within the curriculum is  a clear indicator that the trainee is ready to advance  to the operating room to perform the procedure.  The establishment of such criterion levels is often  done by having experts go through the curriculum  and adjust these based on their performance and  consensus [15]. The curriculum will judge profi-  ciency based on such factors as economy of motion,  target acquisition, and procedural judgment, rather  than just operative time and subjective    performance assessment. Hence a surgeon's ad-  vancement up the training ladder would be more  precisely determined, thereby providing clarity to  trainees and their teachers as to trainees' skill levels  and learning needs, and ensuring that patients are  cared for by doctors with documented expertise in  the procedures they are planning to perform.  Confirmation of predictive validity then allows  a simulator device to be used in the certifying and  recertifying processes for the subspecialty to deter-  mine surgeon competency. Validation studies are  essential to determine whether a simulation-embed-  ded curriculum can teach what it is supposed to  teach, to demonstrate whether the data generated  can distinguish between the novice and the experi-  enced surgeon, and, most importantly, to predict  the current and future performance of the surgeon  in the clinical operating room.   The development of a comprehensive and  effective teaching program depends on the collab-  orative efforts of many educators across multiple  institutions to ensure a robust curriculum that  addresses all the needs of the learner, teacher, and  end user or patient. Multiple, interactive educa-  tional encounters that are longitudinally se-  quenced will provide more productive learning  for the health profession student. Such encoun-  ters, combined with immediate, task-specific feed-  back as to performance and errors, will allow  these learners to better learn new skills and  effectively integrate them into their clinical prac-  tice. However, simultaneous curriculum evalua-  tion is essential to the creation of durable and  relevant education programs. It is through evalu-  ation combined with discussion and deliberative  inquiry that curriculum development will be  achieved. Continuous curriculum revision and  renewal can be expected to meet the educational  demands of a rapidly advancing, technology-  oriented, surgical subspecialty [16]. Curriculum  development should be considered a long-term,  dynamic, and continuous process that anticipates  many revisions and changes to the initial curricu-  lum template. Sustaining the effort of curricular  reform will only happen from a combined bot-  tom-up and top-down approach. Commitment  at the departmental level by academicians who  recognize the advantages of a standardized cur-  riculum and the importance of collaborative  communication will lead to the development of  robust surgical curricula. The incorporation of  appropriate curricular evaluation will allow con-  structive, proactive response to the expectations  of society and the policies of the boards    mandating such standardization. The American  College of Surgeons' recent Accreditation of Edu-  cation Institutes program is an example of this as-  sociation's commitment to the incorporation of  simulation for surgical residency training pro-  grams and the development of dedicated skills  training curricula [17,18].   The creation of a simulator for training begins  with agreement on what is the desired outcome  and the development of learning goals and objec-  tives. Learning objectives are specific and contain  action verbs describing what learners should be  able to do once they have completed the exercise.  The simulation tool is designed specifically to  meet these objectives [19]. The process of task de-  construction into the learning domains described  in Fig. 1 allows for the development and applica-  tion of the appropriate simulated experience.   The cognitive domain is underappreciated in  surgical education and simulation. It has been  estimated that performing an operation properly  is 75% decision-making and 25% dexterity [20].  Bloom's taxonomy [21] describes the transition  from the baseline memorization of material  (knowledge) to synthesis (comprehension). The  ability to appropriately apply this knowledge rep-  resents the next level in ascent toward the higher-  cognitive functions of analysis, synthesis, and  evaluation associated with self-reflection and  teaching. Cognitive “simulation” in surgery has  existed in a "passive form" for over a century in  the form of surgical atlases, for decades in the  form of videos, and more recently in the form of  the Fundamentals of Laparoscopic Surgery, with  its well-validated curriculum and strong cognitive  component [22] It is widely used across the  United States in skills centers. With interactive  video technology, SimPraxis (Red Llama, Seattle  Washington; www.redllamainc.com) has designed    cognitive curriculum for procedures into an inter-  active multimedia trainer that provides virtual  mentorship, error tracking, and scoring [23].   The technical domain has been a focus of  computer-based simulation devices. With a step-  wise curricular approach that is not procedure-  specific, such basic skills as camera navigation  precedes more complex manipulative skills, such  as transfer and cutting exercises [24]. Box trainers  and abstract virtual reality models have been  found to be useful for training these skills. Subse-  quently, such simple tasks as dissection, clipping,  and dividing a vessel can be performed on slightly  more complex virtual reality models, inanimate or  animate tissue, or human cadaver models. It is  only when combined with the cognitive and judg-  ment components of a curriculum that a full pro-  cedural trainer can be created. Outside of the  standard training on actual anesthetized patients,  live animal models remain the gold standard. The  role of virtual reality for training advanced surgi-  cal procedures continues to evolve. The tradi-  tional method of evaluating surgical competence  has been the In-Training Evaluation Report,  which is filled out at the end of rotations by fac-  ulty. Unfortunately, these reports do not provide  formative feedback to the trainee. Many pro-  grams are shifting toward the Objective Struc-  tured Assessment of Technical Skills evaluation  whereby the learner is evaluated on multiple do-  mains, such as tissue handling and flow of the op-  eration. This type of assessment is being done in  both the operating room and in skills-training lab-  oratories [25]. While operating room competency  evaluation in urology residency training programs  is encouraged but not required by the Accredita-  tion Council for Graduate Medical Education  [26], programs struggle with whether or not to  use the Objective Structured Assessment of  Technical Skills (OSATS) evaluation, which is    Fig. 1. Learning domains in surgical training. (Courtesy of RM Sweet and C Schmitz.)    an effective, reliable tool for formative feedback  provided immediately in the form of a debrief.  OSATS is more effective for guiding the surgical  trainee than the less labor-intensive method of  summative end-of-the-rotation feedback. Crite-  rion levels and standards are yet to be established  by the governing bodies and societies for urology  as to competence for specific procedures and,  therefore, these are currently established at the in-  dividual or institutional level.   If one were to mention the word simulation to  an anesthesiologist or an emergency medicine  physician, a much different image would come  to mind than would come to the mind of the sur-  geon. Dozens of truly “high-fidelity” simulation  scenarios have been designed for mass-casualty  and emergent crisis situations. The most common  domain studied and practiced in these scenarios  pertains to communication. The standardized  Objective Structured Clinical Examination allows  this domain to be assessed and is commonly used  in medical school curricula [27]. Its use during  urology residency/credentialing for this domain  has been described and is encouraged by the Ac-  creditation Council for Graduate Medical Educa-  tion [28]. Gettman and colleagues [29] recently  published a study using a high-fidelity simulation  environment to assess the “communication” do-  main for delivering the news of an unexpected  death to a urology patient's family. These scenar-  ios can either be done in a simulation center,  which has the advantage of a more "standard-  ized" and controlled environment like that of  Gettman's study, or they can be done in situ, as  described in work by Riley and colleagues [30],  whereby situational awareness, closed-loop com-  munication, leadership transfer, and team forma-  tion and reformation are studied and practiced  with artificial scenarios at the actual location  where real events normally occur. This approach  increases the fidelity and has value for discovering  latent conditions.   All of these domains ultimately contribute to  performance where the trainee makes the transition  from dependence toward independence and finally  can perform skills automatically. This process of  learning establishes the ability of the trainee to shift  more of his or her attention toward more advanced  decision-making or “judgment.” While all skill sets  have a cognitive component, some clearly rely on  the judgmental aspect more than others.   "Skill sets" specific to urology that have been  successfully simulated include such cognitive skill  sets as pelvic lymph node dissection skills and    laparoscopic skills. The fundamentals of laparo-  Scopic surgery contain cognitive training modules  to accompany their skills modules that have been  well validated by the American College of Sur-  geons. More recently Red Llama has built and  validated an interactive video-based trainer for  training pelvic lymph node dissection [31] (Movie 1:  SimPraxis& open pelvic lymph node trainer").  Technical skills trainers focusing on the Seldinger  technique; endoscopic procedures, such as cystos-  copy, transurethral resection, and ureteroscopy;  and basic laparoscopic and robotic skills have  been designed and are being integrated into curric-  ula primarily focused at the junior urology resident  level. Basic open and laparoscopic surgery skills  simulation exercises in the form of Objective Struc-  tured Assessment of Technical Skills examinations  are being administered at select institutions and  typically use inanimate tissue models with proctors.   Until recently, there has been a general lack of  training tools and curriculum development for  even the most basic of skill sets in urology.  Simulation has primarily consisted of manikin-  based catheterization simulators for the female  and male urethra as well simulators for digital rec-  tal examinations (Simulution, Prior Lake, Minne-  sota; www.simulution.com). However, validation  studies are lacking.   The skills necessary to perform flexible ure-  teroscopy, not unlike skills for other endoscopic  procedures, are quite amenable to simulation.  Current systems reported in the curriculum of  training programs and courses include low-fidelity  bench models, such as the one described by  Matsumoto [32], which consists of a urethra rep-  resented by a Penrose drain, a bladder represented  by an inverted polystyrene plastic cup, and ureters  modeled with latex-embedded straws. Commer-  cially available bench models include the Uro-  Scopic Trainer (Limbs & Things, Bristol, United  Kingdom; www.limbsandthings.com) and the  Scope Trainer (Medi Skills, Edinburgh, United  Kingdom; www.mediskills.com) [33]. McDougall  and colleagues have developed a bench-top ure-  teroscopic model that is being validated (Movie 2:  University of California Irvine (UCI) uretero-  scopy trainer"). Uro Mentor (Simbionix, Lod,  Israel; www.simbionix.com) is the only currently  available virtual reality simulator for ureteroscopy 
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