Conduit urinary diversion is associated with a high overall complication rate but a low reoperation rate. Long-term followup of these patients is necessary to closely monitor for potential complications from the urinary diversion that can occur decades later.

RESULTS• Of the 2651 patients studied, 182 (6.9%) presented with M1 RCC. Tumour size was significantly greater in patients with M1 RCC than in patients with M0 RCC (a median size of 10 vs 4.5 cm; P < 0.001). Only 1 of the 629 patients (0.2%) with a tumour < 3 cm had M1 RCC and that tumour was 2.5 cm. The risk of M1 RCC increased from 1.1% for patients with tumours 3-3.9 cm to 16.5% for patients with tumours ≥ 7 cm.• Of the 2124 patients with M0 RCC, 430 developed distant metastases at a median (range) of 1.4 (0.1-16.2) years after surgery. Only 9 of the 498 patients (1.8%) with a tumour < 3 cm developed distant metastases after surgery.• Each 1-cm increase in tumour size increased the risk of death from RCC by 20% [hazard ratio (HR) 1.20; 95% confidence interval (CI) 1.18-1.22; P < 0.001] and death from any cause by 10% (HR 1.10; 95% CI 1.09-1.12; P < 0.001).• For the 1346 patients who were still alive at last follow-up, the median (range) duration of follow-up was 6.9 (0.1-19.7) years. CONCLUSIONS• Tumour size is significantly associated with metastases in patients with renal masses.• Patients with tumours < 3 cm have a low risk of synchronous metastatic disease. KEYWORDSkidney neoplasms, renal cell carcinoma, nephrectomy, recurrence, neoplasm staging, neoplasm metastasis Study Type -Prognosis (case series) Level of Evidence 4 OBJECTIVE• To determine the metastatic potential of renal masses based on original tumour size. MATERIALS AND METHODS• We identified 2651 patients who had undergone surgical resection for a unilateral, sporadic renal tumour between 1990 and 2006.• Associations of tumour size with synchronous metastasis at presentation [M1 renal cell carcinoma (RCC)] and development of metastases, death from RCC, and death from any cause after surgery were evaluated using logistic and Cox proportional hazards regression.

Scoring algorithms based on independent predictors of site-specific recurrence were presented. These models may be used to tailor postoperative surveillance to the individual patient based upon clinicopathologic features at the time of cystectomy.

Abbreviations & AcronymsObjectives: To examine the ability of standard and saturation transrectal prostate biopsy techniques to predict appropriate candidates for active surveillance. Methods: Between 2005 and 2007, 500 consecutive patients underwent transrectal ultrasound-guided biopsy by a standard template (12 cores) or saturation template (Ն18 cores, median 27 cores), with subsequent radical prostatectomy. Using the criteria of Gleason score Յ6, clinical stage T1 or T2a, prostate-specific antigen <10 and Յ33% of cores involved, 218 patients were potential candidates for active surveillance. Pathology results from the prostatectomy specimens were used to determine the accuracy of each biopsy technique. Biochemical failure after prostatectomy was evaluated using logistic and Cox proportional hazards regression. Results: A standard biopsy was carried out for 124 patients and saturation biopsy for 94 patients. There was no statistically significant difference between the groups in terms of median age (P = 0.14), preoperative prostate-specific antigen (P = 0.52) and clinical stage (P = 0.23). Similar rates of Gleason score Ն7 at the time of radical prostatectomy were found, with 14% for standard biopsy and 15% for saturation biopsy (P = 0.70). Upstaging was shown in two standard biopsy patients (1.6%) and no saturation biopsy patients (P = 0.62). A multivariate analysis adjusting for prior prostate biopsy, preoperative prostate-specific antigen and clinical stage showed no difference in the rate of upgrading based on biopsy technique (P = 0.26). During follow up, 5-year biochemical failure-free survival estimates were not significantly different (P = 0.11). Conclusions: In men with prostate cancer, standard and saturation transrectal prostate biopsies techniques are equally predictive of candidates for active surveillance.

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Although medical trainees are expected to become expert quickly and safely, limited electronic methods are available to rehearse medical cognition for common outpatient and non-emergent inpatient problems. We conducted a series of formal observational sessions designed to determine what interaction requirements are desirable for student rehearsal of medical management by using an electronic patient. The studies utilized both manual and electronic methods for a student to evaluate and manage patients with medical and surgical problems. We observed the following major requirements for an effective simulation experience: the user must have a trial-and-error experience with the patient; the user must have unconstrained access to query and treat the patient; anatomic and physiologic values in the patient must change appropriately in response to user actions; and the user must be able to control certain time-related aspects of the simulation. When these requirements are implemented within a simulation, user-directed management of an electronic patient, by itself, becomes a strong aid to learning by trial- and-error techniques. We conclude that the heuristic patient is a practical and useful concept. Once fully developed, it would allow rehearsal of patient care decision making, intrinsically demonstrating trainee knowledge deficits, and resulting in self-directed learning.

We describe efficacy and safety of robotic-assisted laparoscopic vaginal vault prolapse repair with long-term follow-up. We reviewed the records of 40 consecutive patients with posthysterectomy vaginal vault prolapse who underwent a robotic-assisted laparoscopic sacrocolpopexy at our institution between September 2002 and September 2006. Patient analysis focused on complications, patient satisfaction, and morbidity, with a minimum of 36 months' follow-up. Median follow-up was 62 months (range 36-84) and mean age was 67 (43-83) years. Mean operating time was 3.1 (2.15-5) h with a median operating time of 2.9 h. All but four were discharged home on postoperative day one; three patients left on postoperative day two and one left on postoperative day seven. Three developed recurrent grade 3-4 rectoceles and two vaginal extrusion of mesh. Thirty-eight of the 40 patients (95%) were satisfied with their outcome. Robotic-assisted laparoscopic sacrocolpopexy is a minimally invasive technique for vaginal vault prolapse repair, combining the advantages of open sacrocolpopexy with the decreased morbidity of laparoscopy. We found a short hospital stay, low complication rates, and high patient satisfaction with a minimum of 3 years' follow-up.

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