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OBJECTIVE: To describe the initial feasibility of fluorescence-enhanced robotic radical cystectomy (FERRC) using real-time cystoscopic injection of unconjugated indocyanine green (ICG) for tumor marking and identification of sentinel lymphatic drainage with additional intravenous injection for mesenteric angiography. METHODS: Ten patients with clinically localized high-grade bladder cancer underwent FERRC. Before robot docking, rigid cystoscopy was performed, during which a 2.5-mg/mL ICG solution was injected in the bladder submucosa and detrusor circumferentially around the tumor. After robot docking, parameters describing the time course of tissue fluorescence and pelvic lymphangiography were systematically recorded. Lymphatic packets containing fluorescent lymph nodes were considered the sentinel drainage. Eight patients underwent intracorporeal ileal conduit urinary diversion, during which an additional 2-mL ICG solution was given intravenously for mesenteric angiography, allowing maximal preservation of bowel vascularity to the conduit and remaining bowel segments. RESULTS: Bladder tumor marking and identification of sentinel drainage were achieved in 9 of 10 (90%) patients. The area of bladder tumor was identified at a median of 15 minutes after injection, whereas sentinel drainage was visualized at a median of 30 minutes. Mesenteric angiography was successful in 8 of 8 (100%) patients at a median time of <1 minutes after intravenous injection and enabled identification of bowel arcades before intracorporeal bowel stapling. CONCLUSION: FERRC using combined cystoscopic and intravenous injection of ICG is safe and feasible. FERRC allows for reliable bladder tumor marking, identification of sentinel lymphatic drainage, and identification of mesenteric vasculature in most patients.

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BACKGROUND: Pilot studies have demonstrated the utility of indocyanine green (ICG) sentinel lymphadenectomy for prostate cancer. Prior work has used ICG with radiocontrast agents injected at a separate procedure and relied on assistant-controlled fluorescence systems, making the technique costly and cumbersome. OBJECTIVE: To describe the initial optimization and feasibility of fluorescence-enhanced robotic radical prostatectomy (FERRP) using real-time injection of ICG for tissue marking and identification of sentinel lymphatic drainage visualized by a fully integrated surgeon-controlled system. DESIGN, SETTING, AND PARTICIPANTS: Patients with clinically localized prostate cancer at a tertiary referral center were offered FERRP. Ten patients participated in a pilot arm in which ICG dosing and injection technique were optimized. Fifty consecutive patients then underwent FERRP. SURGICAL PROCEDURE: After development of the space of Retzius, 0.4 ml of a 2.5 mg/ml ICG solution were injected into each lobe of the prostate using a robotically guided percutaneous needle. After ICG was allowed to travel through the pelvic lymphatics, lymphadenectomy was performed from the endopelvic fascia to the aortic bifurcation. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Parameters describing the time course of tissue fluorescence and pelvic lymphangiography were systematically recorded. Lymphatic packets containing fluorescent nodes were considered sentinel. RESULTS AND LIMITATIONS: Percutaneous, robotic-guided ICG injection proved superior to cystoscope or transrectal delivery. Tissue marking was achieved in all patients, positively identifying the prostate with uniform fluorescence relative to the obturator nerve, seminal vesicles, vas deferens, and neurovascular pedicles at a mean time of 10 min postinjection. Sentinel nodes were identified in 76% of patients at a mean time of 30 min postinjection and had 100% sensitivity, 75.4% specificity, 14.6% positive predictive value, and 100% negative predictive value for the detection of nodal metastasis. CONCLUSIONS: FERRP is safe, feasible, and allows for reliable prostate tissue marking and identification of sentinel lymphatic drainage in the majority of patients. ICG sentinel nodes are highly sensitive but relatively nonspecific for the detection of nodal metastasis.

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OBJECTIVE: To present the initial clinical experience with robot-assisted partial adrenalectomy using indocyanine green dye with near-infrared fluorescence (ICG-NIRF) imaging. METHODS: Three consecutive patients with solitary adrenal masses with worrisome features were referred for treatment. The preoperative workup included dedicated axial imaging and adrenal function studies. All patients underwent purely robotic partial adrenalectomy with ICG-NIRF guidance. Relevant steps of the technique included a transperitoneal approach, gross identification of the adrenal gland, administration of 5 mg intravenous ICG, and finally, mass resection guided by ICG-NIRF and white light visualization in an effort to completely excise the mass while sparing uninvolved adrenal tissue. RESULTS: Robotic partial adrenalectomy was successfully performed with negative margins in all patients. All masses were hypofluorescent relative to normal adrenal tissue with ICG-NIRF and included a pheochromocytoma, lipoadenoma, and follicular lymphoid hyperplasia. CONCLUSION: Robotic partial adrenalectomy with intraoperative ICG-NIRF is safe and feasible. The addition of ICG-NIRF may help mass identification, excision, and promote the use adrenal-sparing surgery.

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We present the fifth case in the world literature of a gas-containing urinary stone. Our patient is a 31-year-old woman referred for left flank pain and gross hematuria who was noted on imaging to have a 6.5 cm left renal pelvis stone containing gas. Cultures revealed Escherichia coli from the urine and stone material. Chemistry revealed underlying gouty diathesis. The stone was removed using robotic extended pyelolithotomy. Overall, renal function remained unchanged while drainage improved on nucleotide renography. Review of the world literature suggests that gas-containing renal stones are invariably associated with emphysematous pyelonephritis commonly caused by E. coli and Klebsiella. Contributing factors to gas-containing stone formation include urinary stasis, metabolic mineral derangement and, in a minority of the cases, diabetes.

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INTRODUCTION: Indocyanine green (ICG) is emerging as a potential adjunct to robot-assisted partial nephrectomy by its ability to aid in the real-time identification of renal vasculature, renal masses, and the renal mass-parenchymal margin. The fluorescence patterns of renal masses have not been adequately described according to histology, and it remains unknown if fluorescence pattern can reliably predict histology or malignancy. We therefore describe the ICG fluorescence pattern of our first 100 robot-assisted partial nephrectomies (RAPN) and correlate with histology. MATERIALS AND METHODS: We reviewed our prospective RAPN database and categorized fluorescence pattern as isofluorescent (same as surrounding parenchyma), hypofluorescent (less than surrounding parenchyma, but with uptake), or afluorescent (no visible uptake of dye). Descriptive statistics were applied. RESULTS: All 14 cystic lesions were afluorescent and comprised 9 malignant and 5 benign masses. Eighty-six lesions were solid, of which 3 were isofluorescent including two clear-cell and one translocation tumor. The remaining 83 solid lesions were hypofluorescent and included 65 malignant and 18 benign lesions. Clear-cell was the most common histology of which 96% were hypofluorescent and 4% isofluorescent. In determining malignant vs benign lesions, hypofluorescence had a positive predictive value of 87%, negative predictive value of 52%, sensitivity of 84%, and specificity of 57%. CONCLUSIONS: A three-grade classification of renal mass ICG fluorescence pattern is correlated with some histologic findings but unable to reliably predict malignant vs benign lesions.

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OBJECTIVE: To describe the clinical course, microbiology, and metabolic findings of 5 patients presenting to our institution with gas-containing renal stones. MATERIALS AND METHODS: During a 20-month period beginning in 2009, 5 patients were identified by computed tomography scanning to harbor gas-containing renal calculi. Despite similar imaging and referral practice patterns, no such cases had been seen at our institution in the preceding 20 years. The records of these patients were reviewed to better characterize this unique condition. RESULTS: All 5 subjects were premenopausal women. One patient presented with urosepsis and 4 presented with flank pain. All had urinary tract infections, and Escherichia coli was isolated from a voided urine specimen in 3. Stone culture was positive in 2 and was concordant with the voided specimen in 1. The stones were solitary in 4 and multiple in 1 patient. All the stones were composed of calcium phosphate. Of the 5 patients, 3 had pure calcium phosphate stones and 2 had stones with calcium oxalate monohydrate components. Also, 3 subjects had diabetes mellitus, 3 had hypertension, and 1 had a history of gout. Two subjects underwent 24-hour urine metabolic testing, and abnormalities were identified in both. All patients were rendered stone free: 4 with percutaneous nephrostolithotomy and 1 using robotic pyelolithotomy. CONCLUSION: Gas-containing renal stones are rare but might be increasing in prevalence. The pathophysiology is unknown but is most likely influenced by a combination of metabolic and infectious factors.

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INTRODUCTION: Subcutaneous penile injection of various oils for penile augmentation has been described among men in Laos. We have now treated three Laotian immigrants with penile disfigurement secondary to sclerosing lipogranulomas, also known as paraffinoma, induced by injection of a mineral oil compound marketed as "1Super Extenze," which they purchased in the United States. AIM: This series describes the clinical course and management of complications associated with the use of "1Super Extenze" in three Laotian men. METHODS: Surgeons excised all grossly affected tissue and performed reconstruction using skin grafting, Z-plasty, and tissue advancement, respectively. Tissue from the penile shaft of each patient and a local lymph node in one patient was examined microscopically. Mass spectroscopy was performed on an aliquot of "1Super Extenze." MAIN OUTCOME MEASURES: Urinary function, sexual function, and cosmesis of the three reported cases, chemical composition of "1Super Extenze," and microscopic analysis of penile and regional lymphatic tissue. RESULTS: Short-term cosmetic and functional outcomes were acceptable after surgical intervention. Histologic findings consistent with sclerosing lipogranulomas were seen in specimens from affected subcutaneous and lymphatic tissue. "1Super Extenze" proved to be composed of mineral oil with tocopherol acetate (vitamin E). CONCLUSION: Injection of "1Super Extenze" into the penile shaft results in sclerosing lipogranulomas, which can cause severe sexual and urinary complications. Surgical resection of all grossly involved tissue with appropriate reconstruction can mitigate these problems. This series supports previous recommendations in the literature that men should avoid the use of non-medical foreign bodies and fillers as means of penile augmentation.

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INTRODUCTION: To describe the incidence and outcomes of lower extremity neuropathies in a series of robot assisted laparoscopic radical prostatectomy (RALRP) and robot assisted laparoscopic radical cystectomy (RALRC) patients with 9 months follow up. Additionally, we compare this cohort to other published series of lithotomy based surgery and describe strategies for minimizing risk. MATERIALS AND METHODS: We performed a retrospective analysis of 179 consecutive patients who underwent either RALRP or RALRC at a single institution during a 17 month period. We included all patients who experienced bothersome lower extremity pain, weakness, or numbness at any time during their postoperative course. We further defined postoperative neuropathy as de-novo symptoms presenting in the first week postoperatively. Chart review and telephone survey were used to further characterize these patients. RESULTS: Six out of 179 patients complained of lower extremity neuropathic symptoms by 9 months of follow up. Probable injuries to the common peroneal, lateral femoral cutaneous, and obturator nerves were found. Three patients met our criteria for postop neuropathy making the incidence 1.68%. All patients remained ambulatory throughout their course. At 9 months follow up, only one patient, a man with metastatic bladder cancer, had activity limiting neuropathic symptoms. CONCLUSIONS: With routine use of common risk minimizing strategies, RALRP or RALRC may result in lower extremity europathy at rates similar to other lithotomy based procedures described in the literature.

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Renal cryoablation is a minimally invasive, nephron-sparing option that has shown promise in the treatment of patients with solitary small renal lesions suspicious for malignancy. Few large clinical studies have used this promising technology, although intermediate-term data are encouraging. We present a retrospective review and report the outcomes of a large cohort of patients who underwent renal cryotherapy. Patients who were candidates for partial nephrectomy with peripheral lesions < or = 5.0 cm in maximum diameter and no history of bleeding disorders were offered cryoablation as definitive therapy. Two freeze-thaw cycles were used for all lesions, and all were characterized by intraoperative ultrasound immediately before freezing. Data were collected as part of standard care, and chart review was performed only in cases of missing data. From February 2001 to March 2005, 85 consecutive patients with an average age of 67 years and a mean tumor size of 2.6 cm (range, 1.2-4.7 cm; median, 2.5 cm), underwent renal cryoablation; 70 procedures were performed laparoscopically. Mean estimated blood loss was 58 mL, with 2 patients requiring transfusion. Mean hospital stay was 3.0 days (range, 0-14 days; median, 2 days) for the entire cohort and 2.2 days (range, 0-7 days; median, 2 days) for the laparoscopic group. A total of 7 laparoscopic cases were converted to an open approach early in the experience, 2 of which were considered technical failures. Mean follow-up was 10 months (range, 3-36 months). Abnormal postoperative enhancement occurred in 2 patients at 3 months and 12 months. Radical nephrectomy in the first revealed no viable tumor; needle biopsy in the second revealed renal cell carcinoma, which prompted nephrectomy. Intraoperative needle biopsy yielded a 59% malignancy rate. We conclude that renal cryotherapy is a viable option for nephron-sparing surgery in small, peripheral renal lesions. The procedure is well tolerated, may be considered in patients who are not good candidates for open surgical approaches, results in minimal morbidity, and has shown encouraging treatment results. Close posttreatment surveillance is essential. Longer-term follow-up data will be necessary if the long-term durability of renal cryotherapy is to be established.

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