Objectives Minimally invasive robotic assistance is being increasingly utilized to treat larger complex renal masses. We report on the technical feasibility and renal functional and oncological outcomes with minimum 1 year follow up of robot-assisted laparoscopic partial nephrectomy (RALPN) for tumors greater than 4 cm. Methods and Materials The urologic oncology database was queried to identify patients treated with RALPN for tumors greater than 4 cm and a minimum follow up of 12 months. We identified 19 RALPN on 17 patients treated between June 2007 and July 2009. Two patients underwent staged bilateral RALPN. Demographic, operative, and pathologic data were collected. Renal function was assessed by serum creatinine levels, estimated glomerular filtration rate and nuclear renal scans assessed at baseline, 3 and 12 months post-operatively. All tumors were assigned R.E.N.A.L. nephrometry scores (www.nephrometry.com). Results The median nephrometry score for the largest tumor from each kidney was 9 (range 6–11) while the median size was 5 cm (range 4.1–15). Three of 19 cases (16%) required intraoperative conversion to open partial nephrectomy. No renal units were lost. There were no statistically significant differences between preoperative and postoperative creatinine and eGFR. A statistically significant decline of ipsilateral renal scan function (49% vs. 46.5%, p=0.006) was observed at three months and at twelve months postoperatively (49% vs. 45.5%, p=0.014). No patients had evidence of recurrence or metastatic disease at a median follow up of 22 months (range 12–36). Conclusions RALPN is feasible for renal tumors greater than 4 cm with moderate or high nephrometry scores. Although there was a modest decline in renal function of the operated unit, RALPN may afford the ability resect challenging tumors requiring complex renal reconstruction. The renal functional and oncological outcomes are promising at a median follow up of 22 months, but longer follow up is required.

bone scan. The mean (range) follow-up was 20.5 (1-77) months. RESULTSThe mean interval from RT to SRARP was 53.2 months; the mean preoperative prostate-specific antigen (PSA) level was 5.2 ng/mL, the operative duration 183 min and the estimated blood loss 113 mL. One patient had prolonged lymphatic drainage, one had an anastomotic leak, and one had an anastomotic stricture requiring direct vision internal urethrotomy at 3 months. The mean duration of catheterization was 10.4 days and the hospital stay 1.4 days.

Robotic instruments used with the fourth robotic arm may give the console surgeon greater independence from the assistant during robot-assisted kidney surgery by facilitating steps such as kidney retraction, hilar dissection, and vascular control. The TilePro feature of the da Vinci S can be used to project intraoperative ultrasonography and preoperative imaging onto the console screen, potentially guiding tumor localization and resection during RPN without the need to leave the console to view external images.

Invasive nature and pain caused to patients inhibit the routine use of tissue biopsy-based procedures for cancer diagnosis and surveillance. The analysis of extracellular vesicles (EVs) from biofluids have recently gained significant traction in the liquid biopsy field. EVs offer an essential "snapshot" of their precursor cells in real time and contain information-rich collection of nucleic acids, proteins, lipids, etc.The analysis of protein phosphorylation, as a direct marker of cellular signaling and disease progression, could be an important stepstone to successful liquid biopsy applications. Here, we introduce a rapid EV isolation method based on chemical affinity called EVtrap (Extracellular Vesicles Total Recovery and Purification) for EV phosphoproteomics analysis of human plasma. Incorporating EVtrap with high performance mass spectrometry (MS), we were able to identify over 16,000 unique peptides representing 2,238 unique EV proteins from just 5 μL plasma sample, including most known EV markers, with substantially higher recovery levels compared to ultracentrifugation. Most importantly, more than 5,500 unique phosphopeptides representing almost 1,600 phosphoproteins in EVs were identified using only 1 mL of plasma. Finally, we carried out quantitative EV phosphoproteomics analysis of plasma samples from patients diagnosed with chronic kidney disease or kidney cancer, identifying dozens of phosphoproteins capable of distinguishing disease states from healthy controls. The study demonstrates the potential feasibility of our robust analytical pipeline for cancer signaling monitoring by tracking plasma EV phosphorylation.

Purpose To evaluate the feasibility of performing robot assisted partial nephrectomy in patients with multiple renal masses and to examine the results of our initial experiences. Materials and Methods We reviewed the records of 10 patients with multiple renal masses who underwent attempted robot assisted partial nephrectomy within the past 2 years. Demographic information as well as intraoperative, perioperative, and renal functional outcome data of these patients were reviewed. Results A total of 24 tumors in 9 patients were removed with robotic assistance. There was 1 open conversion with successful completion of partial nephrectomy. 70% (7 of 10) of patients were affected with a known hereditary renal cancer syndrome, while the remaining patients had multifocal disease with unknown germline genetic alterations. A frozen section from the tumor bed was evaluated in 5 of 10 cases and was negative in each case. 1 patient experienced post operative urinary leak resolving on post operative day 9 without intervention. Twenty-two of the 24 masses resected robotically were malignant. Our most recent 3 patients underwent successful partial nephrectomy without hilar clamping obviating the need for warm ischemia. Overall renal function was unchanged at the most recent follow up with only minimal decrease in differential function of the operated kidney. Conclusions Robot assisted partial nephrectomy for multiple renal masses is feasible in our early experience. Patient selection is paramount for successful minimally invasive surgery. Robot assisted partial nephrectomy without hilar clamping, especially in the hereditary patient population in which repeat ipsilateral partial nephrectomy may be anticipated, appears promising but requires further evaluation.

Objective: To determine the incidence of prostate cancer identified on holmium enucleation of the prostate (HoLEP) specimens and evaluate variables associated with prostate cancer identification.Methods: All patients undergoing HoLEP between 1998 and 2013 were identified.Patients with a known history of prostate cancer were excluded. Multivariable logistic regression assessed variables associated with identification of prostate cancer on HoLEP specimens and Gleason 7 or higher prostate cancer among the malignant cases.Gleason grade was used as a proxy for disease severity. Each of the models was adjusted for age, preoperative PSA, and HoLEP specimen weight. Results:The cohort was comprised of 1272 patients of whom 103 (8.1%) had prostate cancer identified. Prostate cancer cases had higher pre-HoLEP PSA (p=0.06) but lower HoLEP specimen weight (p=0.01). On multivariate logistic regression, age and preoperative PSA were associated with increased odds of prostate cancer being present (p<0.01 each) while increasing HoLEP specimen weight was associated with decreased odds of prostate cancer (p<0.001). Men older than 80 had 20% predicted probability of being diagnosed with prostate cancer. Seventy-eight percent of prostate cancer cases were Gleason 6 or less. Pre-HoLEP PSA was associated with increased adjusted odds of intermediate or high grade prostate cancer. Conclusion:Prostate cancer identified by HoLEP is not uncommon but is generally low risk disease. Older patients with smaller prostate glands have the highest odds of prostate cancer identification.

Background Partial adrenalectomy has recently been advocated to preserve unaffected adrenal tissue during resection of pheochromocytoma. Objective To describe a robot-assisted laparoscopic partial adrenalectomy (RALPA) technique and to report on early functional and oncologic outcomes. Design, setting, and participants From 2007 to 2010, 15 RALPA were performed on 12 consecutive patients with pheochromocytoma. Follow-up data of >1 yr are available on 11 procedures. Median follow-up for the entire cohort was 17.3 mo (range: 6–45). Surgical procedure Positioning and port placement is designed for adequate reach and visualization of the upper retroperitoneum. The plane between the adrenal cortex and pheochromocytoma pseudocapsule is identified visually and with laparoscopic ultrasound. The tumor is dissected away from normal adrenal cortex, preserving normal adrenal tissue. Measurements Preoperative, perioperative, pathologic, and functional outcomes data were analyzed. Results and limitations Fourteen of 15 cases were completed robotically. Among 15 procedures, 4 were performed on a solitary adrenal gland. Four cases required resection of multiple tumors (up to six) with two performed in a solitary gland. The mean age of the patients was 30 yr, and the mean body mass index was 27. The mean operative time was 163 min, the median estimated blood loss was 161 ml, and the median tumor size was 2.7 cm (range: 1.3–5.5). There was one conversion to an open procedure in a patient requiring reoperation on a solitary adrenal gland. One patient who underwent RALPA on a solitary adrenal gland required postoperative steroid supplementation at last follow-up. At a median follow-up of 17.3 mo (range: 6–45), there were no recurrences or metastatic events. Study limitations include small sample size and short follow-up. Conclusions RALPA for the treatment of pheochromocytoma is feasible and safe and provides encouraging functional and oncologic outcomes, even in patients with a solitary adrenal lesion or multiple ipsilateral lesions.

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