a male:female ratio of 1.9 : 1. Similarly sized tumours were identified in each time group [group 1 (1993-1997), 54.8 mm; group 2 (1998-2002), 52.0 mm; group 3 (2003-2007), 52.2 mm, P = 0.6].• Pathological stage II disease decreased from 18.1 to 11.1%, but stage III disease showed an increase from 13.9 to 21.5% over that time period ( P = 0.02).• The proportion of stage I and stage IV disease has remained relatively the same. There has been a statistically significant upward histological migration for the papillary subtype from 1.3 to 10.2% ( P = 0.01).• There has also been an increasing representation of Fuhrman grade III tumours over time, from 17.6 to 30.8%, and a decreasing proportion of Fuhrman grade I tumours from 16.2 to 7.1% ( P = 0.03).• There was a decrease in the incidence of benign tumours originally thought to be malignant on preoperative investigations, from 10% in group 1 to 4% in group 3 ( P = 0.03). CONCLUSION• The recent US phenomenon of migration towards earlier-stage, smaller RCCs as well as increased representation of benign tumours was not observed in the present study. The results of the present study, however, show an upward histological migration for papillary RCCs and an increasing representation of more aggressive Fuhrman grade III tumours.

Inguinal hernia is a known sequel of radical prostatectomy which contributes to patient morbidity and health care expenditure. In this systematic review we evaluated the incidence of inguinal hernia associated with minimally invasive radical prostatectomy, in addition to predictive factors and preventive measures. Materials and Methods: We searched PubMedÒ and EmbaseÒ between 2000 and February 2018 using the search terms inguinal hernia and radical prostatectomy. Results: In concordance with search terms and selection criteria we identified a total of 155 reports with 27 studies eligible for inclusion. Collated results demonstrated a variable prevalence of inguinal hernia after laparoscopic radical prostatectomy and robotic assisted radical prostatectomy ranging from 4.3% to 8.3% and from 3% to 19.4 %, respectively. There was a higher mean prevalence of inguinal hernia after robotic assisted prostatectomy. Factors predicting inguinal hernia following minimally invasive radical prostatectomy included low body mass index, poor stream and straining prior to prostatectomy detected on symptom score instruments, a patent processus vaginalis or an intraoperative incidental inguinal hernia. Herniotomy or herniorrhaphy with onlay mesh repair was the most commonly reported intraoperative repair technique at the time of minimally invasive radical prostatectomy. Recurrence of repaired incidental hernia is rare. Conclusions: Inguinal hernia is common after minimally invasive radical prostatectomy. There is a lack of high level evidence to clarify risk factors and preventive strategies for inguinal hernia after minimally invasive radical prostatectomy. There is a justification for randomized controlled trials to further evaluate this under recognized clinical problem.

Although most partial nephrectomies are performed as primary procedures in the elective or semi-imperative setting on kidneys with relatively normal anatomy, this is not always the case.The indications for partial nephrectomy continue to expand and it is becoming particularly relevant in patients with single functioning kidneys, poor kidney function, anatomical anomalies and hereditary syndromes predisposing to multiple kidney cancers, such as Von Hippel-Lindau syndrome. These, along with previous abdominal surgery, pose surgical challenges. In this article we offer advice as to how to tackle these unusual situations.An ability to master the whole range of indications will allow the modern upper renal tract surgeon to offer partial nephrectomy to a wider range of patients.

Radical cystectomy with pelvic lymphadenectomy and urinary diversion has long been the standard of care for the treatment of non-metastatic muscle-invasive urothelial carcinoma of the bladder. Historically, the procedure was performed using an open technique but, with the potential benefits of less blood loss, quicker return of bowel function and shorter postoperative convalescence, minimally invasive techniques began to be described in the 1990s. Menon et al. [1] performed the first robot-assisted radical cystectomy (RARC) in 2003 and the first centres soon adopted the procedure. Yet surprisingly, unlike other robot-assisted procedures, the technique has not enjoyed a similarly meteoric rise.Robot-assisted radical cystectomy is a technically challenging and complex procedure. Early reports predominantly comprised small series and involved RARC performed in conjunction with an extracorporeal urinary diversion. The reports demonstrated the feasibility and non-inferiority of RARC compared with the traditional open technique [1]. Results showed a peri-operative advantage, with equivalent lymph node yields and surgical margin status comparable with the open procedure. These reports helped established a broad cohort of eligible patients who could benefit from what had become a well-described and reproducible technique.As global experience slowly grew, moderately sized and interim reports of randomized controlled trials revealed an interesting trend. The robot-assisted approach did appear to show an improvement in blood loss and a trend towards quicker return of bowel function compared with the open approach. However, short-term oncological outcomes, complications and length of hospital stay remained similar for the two approaches [2]. Furthermore, despite the peri-operative advantages, Messer et al. failed to show any benefit to health-related quality-of-life from RARC [3], whilst the operating time was significantly longer than for open cystectomy. These controversies have led surgeons to argue against the widespread implementation of the robotic technique.Currently, as larger randomized studies reach their conclusion, we find the pendulum swinging further in the opposite direction with a growing body of evidence showing a lack of benefit for RARC compared with the open technique. Khan et al. [4] recently published the results of their singlecentre randomized controlled trial (CORAL) comparing open, robot-assisted and laparoscopic radical cystectomy. Whilst the overall 30-day complication rate favoured the laparoscopic over the open technique, no differences were found with respect to the robot-assisted technique between the groups or with regard to major (Clavien >3) complications. By 90 days, no significant differences were found among the techniques in terms of either complications or quality-of-life measures. Bochner et al. [5,6] reported similar results in their prospective, randomized trial comparing RARC and open radical cystectomy. Both techniques resulted in similar outcomes for 90-day complications rates, ...

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