Patients with higher body mass index, greater stone burden, nonbranched stones and multiple nephrostomy access tracts are at risk for increased radiation exposure during percutaneous nephrolithotomy. Urologists must seek alternative strategies to minimize radiation exposure, such as tighter collimation to the region of interest, judicious use of magnification and the acquisition of as few images as possible during stone removal.

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Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Robotic prostatectomy has now become the most common surgical approach in the United States for patients with prostate cancer. There is a significant learning curve for this procedure and this paper attempts to help understand what factors will make the operative times longer. Very little to date has been written on this topic. OBJECTIVE To determine risk factors for prolonged operative time (OT) during robot‐assisted laparoscopic radical prostatectomy (RALP). Being able to predict prolonged OT is of pivotal importance both to the physician for patient counseling and to the hospital management. PATIENTS AND METHODS Retrospective review of patient records undergoing RALP between 2003 and 2009 at a tertiary academic center with a structured teaching program. The following variables were recorded: age, race, body‐mass index (BMI), previous abdominal surgery (yes/no), nerve‐sparing technique (yes/no), lymph nodes dissection (yes/no), pathological stage (organ‐confined versus non), cumulative surgical experience with RALP (expressed as number of years since introduction of RALP at our center), prostate weight and OT calculated skin‐to‐skin by the anesthesiologists. Prolonged OT was defined as the upper quintile (20%) according to the distribution. Multivariate regression model was generated to assess potential predictors of prolonged OT. RESULTS A total of 523 records were retrieved. Caucasians accounted for 77.8% of the cohort. Median age was 60.3 years (interquartile range, IQR, 55.0–64.6 years), median BMI 28.1 (25.8–30.7 kg/m2), prostate weight 46.0 g (37.0–57.8 g). Eighty‐six (16.4%) patients had previous abdominal surgery, lymph nodes dissection was performed in 341 (65.2%) and nerve‐sparing technique was done in 310 (59.3%) cases. Median OT was 175 min (IQR 146–220 min). Prolonged OT was set at >230 min, thereby 105 (20.1%) records were classified as such. On multivariate analysis, cumulative surgical experience with RALP (P < 0.001), nerve sparing (P= 0.023) and prostate weight (P < 0.001) were independent predictors of prolonged OT. CONCLUSIONS Larger prostates are associated with longer OT and this effect is maintained independently of cumulative robotic experience that represents another independent factor in determining OT.

An air retrograde pyelogram is associated with decreased radiation exposure during PNL when compared with a contrast retrograde pyelogram.

Ureteropelvic junction obstructixon (UPJO) management has undergone significant changes in the past few years. The aim of this review is to establish the role of endopyelotomy in the age of laparoscopic and robot-assisted laparoscopic pyeloplasty (RALP). Open pyeloplasty (OP) has been the gold standard of care for UPJO for the past six decades. Due to lower long-term efficacy, endopyelotomy has failed to replace OP. However, laparoscopic pyeloplasty (LP) has been able to reproduce the high success rates of OP, while also achieving minimal morbidity. Unfortunately, the steep learning curve and technical difficulties have hindered its use. Recently, robot-assisted systems have enabled LP to overcome its disadvantages, and this may render endopyelotomy obsolete. Although LP and RALP are emerging as the gold standard of treatment for UPJO, endopyelotomy could carve out a niche area as a salvage procedure. Endopyelotomy will continue to have a role in the management of UPJO, albeit a smaller one.