Small bowel adenocarcinoma (SBA) is a rare gastrointestinal malignancy, with the majority of cases seen in the duodenum. SBA often poses a diagnostic challenge due to its non-specific presentation. A 46-year-old female smoker presented with a 6-week history of persistent abdominal pain and nausea. The initial workups, including computed tomography and colonoscopy, demonstrated evidence of suspected Crohn's disease (CD). The histopathology of an ileocecal valve ulcer revealed invasive adenocarcinoma. Our case highlights the necessity of considering SBA in the differential diagnosis for patients exhibiting symptoms similar to Crohn's disease, as delays in diagnosis and treatment may result in disease progression and complications, including small bowel obstruction.

Introduction: The gastrointestinal tract (GIT) is a predominant site of extranodal non-Hodgkin lymphoma (NHL) accounting for up to 40% of cases. Duodenal involvement of diffuse large B-cell lymphoma (DLBCL) is extremely rare, occurring in an estimated 1-2% of all GIT lymphomas. It is vital to consider DLBCL when investigating any lesion or ulceration when performing endoscopy. Case Description/Methods: We present the case of a 72-year-old woman with hypothyroidism and arthritis with chronic NSAID use. She had no prior history of cancer, immunodeficiency or inflammatory bowel disease (IBD) and presented with complaints of SOB and 4-5 days of melenic stools. Bilateral pulmonary emboli (PE) was diagnosed on CTA and IV heparin was started. Overnight she developed hematemesis necessitating endoscopy which identified a 2 cm ulcer just distal to the ampulla of Vater. Intervention with epinephrine injection, argon plasma coagulation (APC) and hemospray provided hemostasis. Heparin was reinstated for PE treatment. Melena and hematemesis reoccurred the following day and repeat endoscopy showed an oozing ulcer noted to be irregular and in atypical location. Biopsies were taken and treatment again provided. Pathological results later revealed diffuse large B-cell lymphoma of the duodenum. A CT scan for staging revealed thickening of the duodenum, and a 3.3 cm mesenteric lymphadenopathy in the left pelvis. Oncology initiated rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP). She was discharged to rehab with oncology to follow (Figure 1). Discussion: De novo formation of lymphoma in the duodenum is rare, especially without prior risk factors such as immunodeficiency syndromes, HIV, and IBD. Small intestinal involvement invokes nonspecific symptoms like abdominal pain, nausea, vomiting and weight loss. Melena and hematemesis in an elderly patient as presenting symptoms of DLBCL is rare. Endoscopy with tissue biopsy is the diagnostic modality of choice. An ulcerated, protruded, auriculate mound is characteristic. Due to the low incidence of duodenal DLBCL, concrete guidelines for treatment are debatable. However, treatment with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) remains a cornerstone of treatment. Failure to recognize clinical and endoscopic characteristics of DLBCL and retain de novo lymphoma as a differential can lead to delay in oncological treatment and poor prognosis for patients.Figure 1.: A) 2 cm, bleeding ulcer just distal to the ampulla of vater. B) Subsequent image of ulcer, better visualized.

Introduction: Nissen fundoplication has been an effective and safe procedure for the treatment of refractory gastroesophageal reflux disease (GERD), however, post-surgical complications can arise. We describe a 69-year-old female with a history of Nissen Fundoplication who presented due to dysphagia and concern for food impaction. The patient was found to have an ischemic distal esophagus and perforated gastric mucosa, severe and rare complications of laparoscopic fundoplication, requiring emergent resection. Case Description/Methods: A 69-year-old female with a history of refractory GERD who had a Nissen fundoplication performed seven months prior presented to the ER with dysphagia. The patient reported eating pork the night prior when she felt as if a piece became stuck in her lower chest after swallowing. Following this, the patient experienced an inability to swallow any liquids or solids without regurgitation. Labs including CBC, chemistries, and lactic acid were unremarkable. She underwent urgent esophagogastroscopy, showing a small gastric pouch with retained contents. There was difficulty insufflating the stomach, with friable gastric mucosa and spontaneous bleeding. The esophagogastroscopy (EGD) was aborted and the patient was sent for stat contrasted computed tomography (CT), which showed a large paraesophageal hernia with concern for a gastric volvulus and free fluid surrounding the intrathoracic stomach. The patient ultimately went to the operating room where it was discovered that a large portion of the patient’s stomach had herniated through her fundoplication wrap. Release of the fundoplication and resection of the ischemic distal esophagus and proximal stomach were performed. The patient required transfer to a tertiary care center for reconstruction. (Figure) Discussion: Current guidelines recommend pH monitoring, EGD, and esophageal manometry prior to anti-reflux surgery. The patient's initial high-resolution manometry had findings concerning for possible achalasia. She was reevaluated at a tertiary center with a negative dysmotility work up, deeming her a surgical candidate. Failures of surgery usually occur within two years after operation. The majority of complications are due to breakdown in the structural integrity of the wrap. Late gastric perforation is a rare complication with sparse literature. Careful review of preoperative studies are key to prevent drastic outcomes and endoscopists should keep this in mind with atypical presentations of food impaction in an emergency setting.Figure 1.: CT showing intrathoracic herniation of stomach.

Introduction: RCC, a neoplasm originating in the renal cortex, constitutes 80-85% of primary renal neoplasms, and accounts for approximately 3% of all malignancies in adults. RCC carries a median survival rate of 8 to 31 months, although distant metastases at the time of diagnosis are associated with worse outcomes. Metastasis in RCC is seen in roughly 25% of all cases, and generally involves lungs, bones, liver, and brain. Although RCC has the potential to metastasize to every distant organ in advanced disease, metastases to the gastrointestinal tract are very rare. Case Description/Methods: A 45-year-old African American male with a past medical history of end stage renal disease and hypertension presented to the emergency department with weakness, abdominal bloating, and 15 pound weight loss for 1 month. He had not made urine in years, however in the prior month he began to have painless hematuria. Computed tomography (CT) of the abdomen demonstrated lymphadenopathy throughout the abdomen, ascites, bilateral atrophic, cystic kidneys, and renal transplant in the right pelvis. Paracentesis was performed and cytopathology of the peritoneal fluid collected was suspicious for adenocarcinoma. The patient underwent upper and lower endoscopy that revealed atypical segmental sigmoid colitis, which was biopsied. Biopsy was suggestive of metastatic disease. Immunohistochemical analysis was remarkable for PAX8+, CDX2−, CK20− consistent with a renal cell carcinoma metastasis (Figure). Patient was unable to receive chemotherapy or radiation due to performance status and went into hospice. Discussion: Gastrointestinal metastasis is rare in RCC. Compared to the stomach and small bowel, colon metastasis is even more rare and has little mention in medical literature. The most prevalent malignancies that spread to the colon are breast cancer, stomach cancer and melanoma. The duration between diagnosis of the initial tumor and metastasis may range from months to years. The colon metastasis timing in our example is unknown. Interestingly, the age of presentation in our patient is unusual from most RCC cases with metastasis to the colon. Many cases in prior publications were above 60 years old, with only one case being 35 years old.The overall 5-year survival rate in patients with RCC colonic metastases can be less than 10%, but surgical resection can improve survivability to 88 percent. Unfortunately, our patient was not a candidate for surgery or medication upon presentation and perished soon after his diagnosis.Figure 1.: Hematoxylin and Eosin Staining Demonstrating Normal Colonic Mucosa with Abnormal Renal Cell Carcinoma Metastasis.

OBJECTIVE:To identify preoperative factors that predict positive surgical margins in partial nephrectomy. MATERIAL AND METHODS:Using our institutional partial nephrectomy database, we investigated the patients who underwent partial nephrectomy for malignant tumors between January 2011 and December 2015. Patient, tumor, surgeon characteristics were compared by surgical margin status. Multivariable logistic regression was used to identify independent predictors of positive surgical margins. RESULTS:A total of 1025 cases were available for analysis, of which 65 and 960 had positive and negative surgical margins, respectively. On univariate analysis, positive margins were associated with older age (64.3 vs. 59.6, p<0.01), history of prior ipsilateral kidney surgery (13.8% vs. 5.6%, p<0.01), lower preoperative eGFR (74.7 mL/min/1.73 m2 vs. 81.2 mL/min/1.73 m2, p=0.01), high tumor complexity (31.8% vs. 19.0%, p=0.03), hilar tumor location (23.1% vs. 12.5%, p=0.01), and lower surgeon volume (p<0.01). Robotic versus open approach was not associated with the risk of positive margins (p=0.79). On multivariable analysis, lower preoperative eGFR, p=0.01), hilar tumor location (p=0.01), and lower surgeon volume (p<0.01) were found to be independent predictors of positive margins. CONCLUSION:In our large institutional series of partial nephrectomy cases, patient, tumor, and surgeon factors influence the risk of positive margins. Of these, surgeon volume is the single most important predictor of surgical margin status, indicating that optimal oncological outcomes are best achieved by high-volume surgeons.

Aims There is currently no consensus on the effect of treatment with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), on the prognosis of patients with heart failure and preserved ejection fraction (HFpEF). Therefore, we have analysed the relationship of commencing treatment with ACEIs or ARBs and the prognosis of patients with incident HFpEF. Methods Retrospective study over 15 years on 3864 patients with HFpEF (GAMIC cohort). Main outcomes were mortality (all-cause and cardiovascular) and hospitalisations for HF. The independent relationship between CT-RASIs and the prognosis, stratifying patients for cardiovascular comorbidity after propensity score-matching was analysed. Results During a median follow-up of 7.94 years, 2960 died (76.6%) and 3138 were hospitalised (81.2%). Therapy with RASIs was associated with a lower mortality, all-cause (RR [95% CI] for ACEIs: 0.76 [0.66-0.86], and RR for ARBs: 0.88 [0.80-0.96]; P < 0.001 in both cases), and cardiovascular (RR for ACEIs: 0.72 [0.66-0.78], and RR for ARBs: 0.87 [0.80-0.94]; P < 0.001), a lower hospitalisation rate (RR for ACEIs: 0.82 [0.74-0.90], and RR for ARBs: 0.90 [0.82-0.98]; P < 0.001), and a lower 30-day readmission rate (RR for ACEIs: 0.66 [0.60-0.73], and RR for ARBs: 0.86 [0.75-0.97]; P < 0.001), after adjustment for the propensity to take RASIs or other medications, comorbidities and other potential confounders. Results on the effect of ARBs are compromised by the small number of patients. Analyses of recurrent hospitalisations gave larger treatment benefits than time-to-first-event analyses. Conclusion In this propensity-matched study, commencing treatment with ACEIs is associated with an improved prognosis of patients newly diagnosed with incident HFpEF.

Objectives: To compare the perioperative and functional outcomes after open and robotic partial nephrectomy performed with cold ischemia. Methods: A retrospective chart review was completed of consecutive patients who underwent partial nephrectomy with renal hypothermia between January 2011 and September 2016. The study cohort included both open (Open Cold Ischemia, OCI; n=170) and robotic (Robotic Cold Ischemia, RCI; n=31) patients with complex renal masses (R.E.N.A.L. score >7) who did not meet exclusion criteria. A modified intracorporeal technique 1 was utilized for the introduction of ice slush at the time of hilar clamping in the RCI group. Statistical testing was performed to compare key perioperative and functional outcomes after ensuring equilibration of both groups by clinicodemographic criteria. Results: Both groups were statistically equivalent with respect to baseline characteristics. Median GFR preservation postoperatively was 86.7% for the open group and 86.6% in the robotic group (p=0.49). Cold ischemia time (CIT) in the open group was 35 minutes compared to 28 minutes (p = 0.03) in the robotic group. LOS was significantly shorter by 2 days (p < 0.01) in the robotic group. Positive margins was noted to be 17 (10%) in the open group and 2 (6.5%) patients in the robotic group (p=0.48). Conclusions: We demonstrate an effective and simplified method of intracorporeal ice cooling during robotic partial nephrectomy. Our data suggests that results with this approach compare favorably to open cold ischemia technique. Intracorporeal ice cooling can be considered when performing complex partial nephrectomies with ischemia times expected to exceed 25 minutes.

To describe the pathological characteristics of the peritumoral non-neoplastic renal parenchyma (NNRP) and to investigate their impact on long-term renal function after partial nephrectomy.

Laparoendoscopic single-site (LESS) surgery of the lower urinary tract aims to decrease the morbidity of pelvic surgery and improve cosmesis by minimizing the size and number of surgical incisions while theoretically achieving the same outcomes as open or standard minimally invasive approaches. The robotic surgical platform has greatly facilitated pelvic LESS surgery by overcoming many of the optical, technical, and ergonomic shortcomings of traditional laparoscopy. However, despite its advantages, robotic LESS surgery still has many challenges to overcome. In this chapter, we will discuss the various techniques and outcomes for robotic LESS pelvic surgeries of the lower urinary tract as well as the emerging technologies that may further revolutionize the field of pelvic LESS surgery.

ABSTRACT Introduction and Objectives: Robotic assisted radical cystectomy (RARC) is an alternative to open radical cystectomy. As experience is gained with the RARC approach the technique is being applied to more complex surgical cases. We describe here our technique for RARC with intracorporeal ileal conduit urinary diversion for a renal transplant recipient. Materials and Methods: The patient is a 60-year old man with high-grade muscle invasive bladder cancer. He has a history of renal failure due to polycystic kidney disease and received a deceased donor renal transplant in 2008. His hospital course at time of transplant was complicated by low-level BK virus viremia. Interestingly his trans-urethral bladder tumor resection specimen at time of bladder cancer diagnosis stained positive for SV40. His native kidneys were anuric so bilateral laparoscopic nephrectomy was performed in a staged fashion 2 weeks prior to RARC. Our surgical technique utilizes 6 trocars, of note a 12-mm assistant trocar is placed 1 cm superior to the pubic symphysis, and this trocar is solely used to pass a laparoscopic stapler to facilitate the excision of the ileal segment and the stapled enteric anastomosis. Surgical steps include: identification of native ureters bilaterally (removed en bloc with the bladder specimen); identification of the transplanted ureter at the right bladder dome; posterior bladder and prostate dissection along Denonvilliers’ fascia; development of the space of Retzius; ligation and transection of the bladder and prostate vascular bundles; apical prostate dissection and transection of urethra; left pelvic lymphadenectomy; ilium resection for creation of the ileal conduit; stapled enteric anastomosis; ureteroileal anastomosis; maturation of the ileal conduit stoma. Results: The surgery had no intraoperative complications. Operative time was 443 minutes (7.4 hours). Estimated blood loss was 250 cc. Length of hospital stay was 5 days. The patient did not experience any postoperative complications. The patient maintained good renal graft function with no decline in eGFR to date. Conclusions: As surgeon comfort and experience with robotic assisted surgery grows, robotic surgery can successfully be applied to less frequently performed procedures. Here we successfully performed a robotic assisted radical cystoprostatectomy with intracorporeal ileal conduit urinary diversion for a renal transplant recipient.

INTRODUCTION:Augmentation ileocystoplasty is a common treatment in adults with low capacity bladders due to neurogenic bladder dysfunction. We describe here our technique for robotic assisted laparoscopic augmentation ileocystoplasty in an adult with a low capacity bladder due to neurogenic bladder dysfunction.MATERIALS AND METHODS:The patient is a 35 years-old man with neurogenic bladder due to a C6 spinal cord injury in 2004. Cystometrogram shows a maximum capacity of 96cc and Pdet at maximum capacity of 97cmH2O. He manages his bladder with intermittent catheterization and experiences multiple episodes of incontinence between catheterizations. He experiences severe autonomic dysreflexia symptoms with indwelling urethral catheter. He has previously failed non operative management options of his bladder dysfunction. Our surgical technique utilizes 6 trocars, of note a 12mm assistant trocar is placed 1cm superior to the pubic symphysis, and this trocar is solely used to pass a laparoscopic stapler to facilitate the excision of the ileal segment and the enteric anastomosis. Surgical steps include: development of the space of Retzius/dropping the bladder; opening the bladder from the anterior to posterior bladder neck; excision of a segment of ileum; enteric anastomosis; detubularizing the ileal segment; suturing the ileal segment to the incised bladder edge.RESULTS:The surgery had no intraoperative complications. Operative time was 286 minutes (4.8 hours). Estimated blood loss was 50cc. Length of hospital stay was 8 days. He did experience a postoperative complication on hospital day 3 of hematemesis, which did not require blood transfusion. Cystometrogram at 22 days post operatively showed a maximum bladder capacity of 165cc with a Pdet at maximum capacity of 10cmH2O.CONCLUSIONS:As surgeon comfort and experience with robotic assisted surgery grows, robotic surgery can successfully be applied to less frequently performed procedures. In this case we successfully performed a robotic assisted laparoscopic augmentation ileocystoplasty displaying improvement in measurable functional outcomes.

ObjectivesTo compare optimum outcome achievement in open partial nephrectomy (OPN) with that in robot‐assisted partial nephrectomy (RAPN).Patients and methodsUsing our institutional partial nephrectomy (PN) database, we reviewed 605 cases performed for unifocal clinical T1 renal masses in non‐solitary kidneys between 2011 and 2015. Tetrafecta, which was defined as negative surgical margins, freedom from peri‐operative complications, ≥80% renal function preservation, and no chronic kidney disease upstaging, was chosen as the composite optimum outcome. Factors associated with tetrafecta achievement were assessed using multivariable logistic regression, with adjustment for age, gender, race, Charlson comorbidity score, body mass index, chronic kidney disease, tumour size, tumour complexity and approach.ResultsThe overall tetrafecta achievement rate was 38%. Negative margins, freedom from complications, and optimum functional preservation were achieved in 97.1%, 73.6% and 54.2% of cases, respectively. For T1a masses, the tetrafecta achievement rate was similar between approaches (P = 0.97), but for T1b masses, the robot‐assisted approach achieved significantly higher tetrafecta rates (43.0% vs 21.3%; P < 0.01). On multivariable analysis, the robot‐assisted approach had 2.6‐fold higher odds of tetrafecta achievement than the open approach, primarily because of lower peri‐operative morbidity, specifically related to wound complications. Positive surgical margin rates and renal function preservation were similar in the two approaches.ConclusionsOptimum outcomes are readily achieved regardless of PN approach. The robot‐assisted approach may facilitate optimum outcome achievement for 4–7‐cm masses by minimizing wound complications.

Background: The traditional treatment for a cT1b renal tumor has been radical nephrectomy. However, recent guidelines have shifted towards partial nephrectomy (PN) in selected patients with cT1b renal tumors. Furthermore, practitioners have extended the role of cryoablation (CA) to treat cT1b tumors in selected patients.Objective: To evaluate the efficacy of CA compared to PN for cT1b renal tumors.Design, setting, and participants: We performed a retrospective review of patients who underwent either renal CA (laparoscopic or percutaneous) or PN (robot-assisted) for a cT1b renal mass (>4 cm and <= 7 cm) between November 1999 and August 2014. To reduce the inherent biases of a retrospective study, CA and PN groups were matched on the basis of key variables: tumor size, Charlson comorbidity index (CCI), age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, preoperative serum creatinine, preoperative estimated glomerular filtration rate (eGFR), gender, and solitary kidney. The matching algorithm was 1:1 genetic matching with no replacement.Outcome measurements and statistical analysis: Survival analysis was performed only for patients diagnosed with renal cell carcinoma according to histopathologic evaluation of a tumor biopsy or resected tumor specimen. Recurrence-free, overall, and cancer-specific survival were analyzed using Kaplan-Meier survival curves. Survival outcomes were compared between groups using the log-rank test.Results and limitations: A total of 31 patients were treated using CA and 161 using PN during the study period. After matching, there was no significant difference between the PN and CA groups for tumor size (4.6 vs 4.3 cm; p = 0.076), CCI (6 vs 6; p = 0.3), RENAL score (9 vs 8; p = 0.1), age (68 vs 68 yr; p = 0.9), BMI (30 vs 31 kg/m(2); p = 0.2), ASA score (3 vs 3; p = 0.3), preoperative creatinine (1.2 vs 1.4mg/dl; p = 0.2), preoperative eGFR (63 vs 53 ml/min/1.73 m(2); p = 0.2), and proportion of patients with a solitary kidney (19% vs 32%; p = 0.4). The total postoperative complication rate was higher for PN than for CA (42% vs 23%; p = 0.10). There was no significant difference in percentage eGFR preservation between PN and CA (89% vs 93%; p = 0.5). The rate of local recurrence was significantly higher for CA than for PN (p = 0.019). There was no significant difference in cancer-specific mortality (p = 0.5) or overall mortality (p = 0.15) between the CA and PN groups.Conclusions: Patients treated with CA for cT1b renal tumors had a significantly higher rate of local cancer recurrence at 1 yr compared to those treated with PN. Until further studies are performed to clearly define the role of CA in cT1b renal tumors, CA should be reserved for patients with imperative indications for nephron-sparing surgery who cannot be subjected to the risks of more invasive PN.Patient summary: We evaluated the efficacy of renal cryoablation compared to partial nephrectomy for clinical T1b renal tumors. The cryoablation and partial nephrectomy groups were matched to provide a better comparison. We concluded that renal cryoablation had a higher rate of local cancer recurrence. (C) 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Background: Robotic single-site retroperitoneal renal surgery has the potential to minimize the morbidity of standard transperitoneal and multiport approaches. Traditionally, technological limitations of non-purpose-built robotic platforms have hindered the application of this approach.Objective: To assess the feasibility of retroperitoneal renal surgery using a new purposebuilt robotic single-port surgical system. Design, setting, and participants: This was a preclinical study using three male cadavers to assess the feasibility of the da Vinci SP1098 surgical system for robotic laparoendoscopic single-site (R-LESS) retroperitoneal renal surgery.Surgical procedure: We used the SP1098 to perform retroperitoneal R-LESS radical nephrectomy (n = 1) and bilateral partial nephrectomy (n = 4) on the anterior and posterior surfaces of the kidney. Improvements unique to this system include enhanced optics and intelligent instrument arm control. Access was obtained 2 cm anterior and inferior to the tip of the 12th rib using a novel 2.5-cm robotic single-port system that accommodates three double-jointed articulating robotic instruments, an articulating camera, and an assistant port.Measurements: The primary outcome was the technical feasibility of the procedures, as measured by the need for conversion to standard techniques, intraoperative complications, and operative times.Results and limitations: All caseswere completed without the need for conversion. There were no intraoperative complications. The operative time was 100 min for radical nephrectomy, and the mean operative time was 91.8 +/- 18.5 min for partial nephrectomy. Limitations include the preclinical model, the small sample size, and the lack of a control group.Conclusions: Single-site retroperitoneal renal surgery is feasible using the latest-generation SP1098 robotic platform. While the potential of the SP1098 appears promising, further study is needed for clinical evaluation of this investigational technology.Patient summary: In an experimental model, we used a new robotic system to successfully perform major surgery on the kidney through a single small incision without entering the abdomen. (C) 2016 Published by Elsevier B.V. on behalf of European Association of Urology.

PURPOSETo compare the oncological and functional outcomes of robotic partial nephrectomy (RPN) with radical nephrectomy (RN) in renal-cell carcinoma (RCC) cases with pT3a staging.PATIENTS AND METHODSA retrospective analysis of our IRB-approved nephrectomy database from 2005 to 2015 was performed. RPN and RN cases with confirmed RCC and pT3a staging were matched. Preoperative variables, functional, and oncological outcomes were compared between the groups, as well as Kaplan-Meier estimated overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS). A multivariable Cox proportional hazards regression model for overall mortality rate was generated to evaluate hazard ratios (HRs) of potential risk factors.RESULTSSeventy patients with pT3a tumors composed each group. Preoperative variables were comparable between groups. The median follow-up time for the cohort was 20 (9-38) months and the renal function preservation was higher in the RPN group (86% vs 70%; p < 0.001). The estimated 3 years of OS (90% vs 84%; p = 0.42), CSS (94% vs 95%; p = 0.78), and RFS (95% vs. 100%; p = 0.06) were similar between RPN and RN groups, respectively. On multivariable Cox regression model, the presence of ≥2 aggressive tumor features was the only factor associated with increased risk of overall mortality rate (HR 4.01 95% confidence interval [1.13, 14.27)]; p = 0.03).CONCLUSIONPatients with localized pT3a RCC treated with RPN had similar short-term oncological and better renal functional outcomes compared with similar cases treated by RN. In the minimally invasive robotic surgery era, renal masses suspicious for pathological T3a disease should not be a deterring factor for performing nephron-sparing surgery when technically feasible by skilled surgeons.

OBJECTIVE To describe our technique for robotic total pelvic exenteration with intracorporeal sigmoid conduit and colostomy using the da Vinci Si robot.METHODS Three 8-mm robotic ports and two 12-mm laparoscopic ports are placed in a "W" configuration, approximately 2-3 cm more cephalad than for radical prostatectomy (Fig. 1). The robot is docked between the legs with the patient in steep Trendelenburg. The ureters are dissected out from the iliac vessels to the rectovesical pouch, where they are clipped and transected. The sigmoid colon is stapled across at the rectosigmoid junction and reflected into the abdomen. A posterior plane is developed below the rectum (Fig. 2A), if space allows, or through the rectum. The endopelvic fascia is exposed and incised bilaterally. After sequentially controlling the bladder and prostatic pedicles (Fig. 2B) using the Harmonic scalpel, the urethra is transected at the prostatic apex, and the anterior rectal wall is incised (Fig. 2C). Any remaining attachments are divided, the rectal remnant is excised, and the specimen is bagged and extracted (Fig. 2D). Adjacent segments of left and sigmoid colon are harvested for the conduit and colostomy, avoiding a bowel anastomosis. The ureters are anastomosed to the conduit, maintaining separation between the gastrointestinal and the urinary systems. The conduit and left end colostomy are matured (Fig. 3). The technique is performed entirely intracorporeally with specimen extraction through the anus, avoiding a large open incision.RESULTS We present the case of a high-functioning (Eastern Cooperative Oncology Group performance status 1) 73-year-old man with metastatic castrate-resistant prostate cancer following failed primary brachytherapy. Despite a good systemic response to chemotherapy and complete androgen blockade, his prostate-specific antigen level continued to rise (to 33 ng/mL) because of an enlarging prostatic pelvic mass. He suffered from progressive local symptoms, including intractable pelvic pain, obstructive uropathy, and impending rectal obstruction. The indication for pelvic exenteration was local palliation. Total robotic time was 5.4 hours. The perioperative course was complicated by disseminated intravascular coagulation secondary to metastatic prostate cancer, which resulted in a transient ischemic attack. The disseminated intravascular coagulation resolved with blood product transfusion, and the patient recovered well without permanent disability. Inpatient length of stay was 8 days. Complete local palliation was achieved until the patient's death from prostate cancer 5 months later.CONCLUSION We demonstrate our step-by-step technique for robotic total pelvic exenteration with intracorporeal sigmoid conduit. (C) 2017 Elsevier Inc.

INTRODUCTIONWe sought to compare surgical outcomes between transperitoneal and retroperitoneal robotic partial nephrectomy (RPN) for posterior tumors.PATIENTS AND METHODSUsing our multi-institutional RPN database, we reviewed 610 consecutive cases for posterior renal masses treated between 2007 and 2015. Primary outcomes were complications, operative time, length of stay (LOS), surgical margin status, and estimated glomerular filtration rate (eGFR) preservation. Secondary outcomes were estimated blood loss, warm ischemia time (WIT), disease recurrence, and disease-specific mortality. Due to significant differences in treatment year and tumor size between approaches, retroperitoneal cases were matched 1:4 to transperitoneal cases based on propensity scores using the greedy algorithm. Outcomes were compared between approaches using the chi-square and Mann-Whitney U tests.RESULTSAfter matching, 296 transperitoneal and 74 retroperitoneal cases were available for analysis, and matched groups were well balanced in terms of treatment year, age, gender, race, American Society of Anesthesiologists physical status classification (ASA) score, body mass index, tumor laterality, tumor size, R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus, anterior/posterior, location relative to polar lines) score, and hilar location. Compared with transperitoneal, the retroperitoneal approach was associated with significantly shorter mean LOS (2.2 vs 2.6 days, p = 0.01), but longer mean WIT (21 vs 19 minutes, p = 0.01). Intraoperative (p = 0.35) and postoperative complications (p = 0.65), operative time (p = 0.93), positive margins (p = 1.0), and latest eGFR preservation (p = 0.25) were not significantly different between approaches. No differences were detected in the other outcomes.CONCLUSIONSAmong high-volume surgeons, transperitoneal and retroperitoneal RPN achieved similar outcomes for posterior renal masses, although with slight differences in LOS and WIT. Retroperitoneal RPN may be an effective option for the treatment of certain small posterior renal masses.