Scielo RSS <![CDATA[International braz j urol]]> vol. 40 num. 1 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[Editor Comment from the Video Section Editor]]> <![CDATA[A review of continuous vs intermittent androgen deprivation therapy: Redefining the gold standard in the treatment of advanced prostate cancer. Myths, facts and new data on a “perpetual dispute”]]> Objectives: To review the literature and present new data of continuous androgen deprivation therapy (ADT) vs intermittent androgen deprivation (IAD) as therapies for prostate cancer in terms of survival and quality of life and clarify practical issues in the use of IAD. Materials and Methods: We conducted a systematic search on Medline and Embase databases using “prostatic neoplasm” and “intermittent androgen deprivation” as search terms. We reviewed meta-analyses, randomised controlled trials, reviews, clinical trials and practise guidelines written in English from 2000 and onwards until 01/04/2013. Ten randomized controlled trials were identified. Seven of them published extensive data and results randomizing 4675 patients to IAD versus CAD. Data from the other three randomized trials were limited. Results: Over the last years studies confirmed that IAD is an effective alternative approach to hormonal deprivation providing simultaneously several potential benefits in terms of quality of life and cost effectiveness. Thus, in patients with non metastatic, advanced prostate cancer IAD could be used as standard treatment, while in metastatic prostate cancer IAD role still remains ambiguous. Conclusions: Nowadays, revaluation of the gold standard of ADT in advanced prostate cancer appears essential. Recent data established that IAD should no longer be considered as investigational, since its effectiveness has been proven, especially in patients suffering from non-metastatic advanced prostate cancer. <![CDATA[Transperineal versus transrectal prostate biopsy for predicting the final laterality of prostate cancer: are they reliable enough to select patients for focal therapy? Results from a multicenter international study]]> Objectives: To compare the concordance of prostate cancer (PCa) laterality between the extended transperineal (TP) or transrectal (TR) prostate biopsy (BP) and radical prostatectomy (RP) specimens. To identify predictors of laterality agreement between BP and RP. Materials and Methods: Data from 533 consecutive patients with PCa (278 TP and 255 TR-diagnosed) treated with RP were analyzed. A 12-core technique was used for both TP and TR biopsies. Additional cores were obtained when necessary. Results: Overall, the percentage of agreement of PCa laterality between BP and RP was 60% (K = 0.27, p &lt; 0.001). However, the RP confirmation of unilaterality at BP was obtained in just 33% of the cases. Considering the concordance on bilaterality as the “target” of our analysis, the sensitivity and specificity were 54.3% and 98.2%, respectively, with TP and 47.5% and 92.5%, respectively with TR. Focusing on patients with unilaterality at biopsy, none of the evaluated preoperative variables (biopsy technique, age, total positive biopsy cores, PSA, prostate volume, Gleason score on biopsy) were able to predict RP bilaterality in the multivariate analyses. Conclusions: Most of the patients with unilateral involvement at BP harbored bilateral PCa after RP. TR and TP biopsy showed no difference in their capacity to predict the concordance of tumor laterality at RP. None of the preoperative evaluated variables can predict the tumor laterality at RP. Using BP unilaterality to include patients in focal therapy (FT) protocols may hinder the oncologic efficacy of FT. <![CDATA[The S.T.O.N.E. Score: A new assessment tool to predict stone free rates in ureteroscopy from pre-operative radiological features]]> Objective: To develop a user friendly system (S.T.O.N.E. Score) to quantify and describe stone characteristics provided by computed axial tomography scan to predict ureteroscopy outcomes and to evaluate the characteristics that are thought to affect stone free rates. Materials and Methods: The S.T.O.N.E. score consists of 5 stone characteristics: (S)ize, (T)opography (location of stone), (O)bstruction, (N)umber of stones present, and (E)valuation of Hounsfield Units. Each component is scored on a 1-3 point scale. The S.T.O.N.E. Score was applied to 200 rigid and flexible ureteroscopies performed at our institution. A logistic model was applied to evaluate our data for stone free rates (SFR). Results: SFR were found to be correlated to S.T.O.N.E. Score. As S.T.O.N.E. Score increased, the SFR decreased with a logical regression trend (p &lt; 0.001). The logistic model found was SFR=1/(1+e <![CDATA[Effectiveness of tamsulosin in prevention of post-operative urinary retention: a randomized double-blind placebo-controlled study]]> Purpose: Urinary retention is one of the most common complications contributing to surgical procedures. Recent studies have shown the benefits of alpha-adrenergic blockers in preventing post-operative urinary retention (POUR). The aim of this prospective study was to compare the prophylactic effect of tamsulosin with placebo on postoperative urinary retention. Materials and Methods: In this randomized placebo controlled, clinical trial, 232 male patients aged 18 to 50 years old admitted to Razi University Hospital for varicocelectomy, inguinal herniorrhaphy, and scrotal surgery were randomly assigned to receive either three doses of 0.4mg tamsulosin (n = 118) or placebo (n = 114), 14 and 2 hours before, and 10 hours after surgery. Patients were closely monitored for the development of urinary retention 24 hours after surgical intervention. The primary endpoint was to investigate the effect of tamsulosin in prevention of post-operative urinary retention during the first 24 hours after surgical intervention. Collected data were analyzed using SPSS software version 18 and the P &lt; 0.05 was considered statistically significant. Results: One hundred and eighteen patients were included in tamsulosin arm and 114 in placebo arm. POUR in patients who received tamsulosin was significantly lower than placebo, as 5.9% of the patients treated with tamsulosin and 21.1% placebo group, reported urinary retention following surgery (P = 0.001). No serious adverse effects were seen in both groups. Conclusions: This study suggests that short perioperative treatment with tamsulosin can reduce the incidence of urinary retention and the need for catheterization after varicocelectomy, inguinal herniorrhaphy, and scrotal surgery. <![CDATA[Polyacrylamide Hydrogel (Bulkamid®) in Female Patients of 80 or More Years with Urinary Incontinence]]> Introduction: To assess the effectiveness of polyacrylamide hydrogel (Bulkamid ®) in injection therapy for urinary incontinence in women of 80 or more years. Materials and Methods: Twenty consecutive women mean age 84.5 (range 80-87) with stress or mixed urinary incontinence were enrolled in this prospective study. All subjects were evaluated at baseline and re-evaluated 7 days, 6,12,18 and 24 months after treatment. A detailed clinical evaluation, physical examination, daily pad count, urodynamic investigation and evaluation of urethral mobility by trans-labial ultrasound were performed. Results: A statistically significant decrease in the number of pads was observed in the follow-up (p = 0.0002 after 24 months). Physical examination showed a statistically significant lack or reduced lost of urine with stress test (p = 0.0163 after 24 months). Urodynamic findings showed an increase of Valsalva leak point pressure, maximum urethral closure pressure and functional length. Maximum flow and post void residual were respectively observed to be significantly reduced and increased only after 7 days from injection therapy. Quality of life (QoL) assessed with the Incontinence Impact questionnaire short form (IIQ-7) showed a statistically significant improvement (p = 0.0001 after 24 months). Patient satisfaction assessed with the Visual Analogue Scale and Patient Global Impression of Improvement questionnaire respectively produced evaluation of “satisfied” and “much improved” even after 24 months. Conclusions: Polyacrylamide hydrogel (Bulkamid®) is an effective treatment with low morbility in patients of 80 or more years. <![CDATA[Associated factors and prevalence of erectile dysfunction in hemodialysis patients]]> Purpose: The proposal of this study was to determine the prevalence and the associated factors of erectile dysfunction (ED) among hemodialysis (HD) patients. Materials and Methods: This was a cross-sectional study based on data collected from HD male patients. Clinical, demographic and laboratory data of all patients were collected in three HD clinics from December 2010 to June 2011. Patients answered questions of erectile function domain from International Index of Erectile Function. Data were evaluated by descriptive analysis and by univariate (ULRA) and multivariate logistic regression analysis (MLRA). Results: Three hundred and five patients participated of the study. The prevalence of ED was 68.19%. ED was associated with diabetes (DM), benign prostatic hyperplasia, glomerulonephritis as cause of chronic renal failure (CRF), smoking habits, lower creatinine levels (ULRA), use of calcium channel blocker (MLRA), aging, lower education level, alcohol consumption, DM (as cause of CRF) and coronary insufficiency (ULRA and MLRA). Conclusions: ED was highly prevalent in the HD men. It was independently associated with aging, current use of alcohol, long alcohol use (even for those who do not drink more), lower education level, diabetes as cause of CRF, coronary insufficiency and use of channel blockers calcium. <![CDATA[Sexual Function in Male Patients with Metabolic Syndrome and Effective Parameters on Erectile Dysfunction]]> Purpose: We aimed to investigate the relationship between metabolic syndrome and sexual function and effective parameters on erectile dysfunction (ED). Materials and Methods: A total of 1300 individuals were included in this study between January 2009 and July 2012. All of individuals were asked to fill in an International Index for Erectile Function (IIEF) questionnaire. The presence of metabolic syndrome was determined when any three or more of the five risk factors were present according to the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP)-III. Obese individuals were divided into six groups according to modified World Health Organization (WHO) definition. Effective parameters on erectile dysfunction were investigated in individuals with metabolic syndrome. Results: Metabolic syndrome was detected in 455 individuals (35%). Mean domain scores of IIEF for all parameters were higher in individuals without metabolic syndrome than individuals with metabolic syndrome (p &lt; 0.05). Mean domain scores of IIEF were lower in individuals with class 3 obesity than individuals with other obese groups (p &lt; 0.05) for erectile dysfunction. There was statistical difference in terms of mean score of IIEF-Erectile function between smoking and nonsmoking groups (p &lt; 0.05). Seventy percent of individuals with metabolic syndrome and 45% of individuals without metabolic syndrome had ED (p &lt; 0.001). Logistic regression analysis revealed that waist circumference (WC) was the most important criteria for ED (p &lt; 0.05). Conclusions: Metabolic syndrome, smoking and obesity seem to be potential risk factors for ED. We recommend individuals with metabolic syndrome, smoking and obesity should be questioned about ED. <![CDATA[Efficacy of spermatic vein ligation in patients affected by high grade left varicocele]]> Purpose: To study the effect of high grade varicocele treatment in infertile patients. Materials and Methods: Seventy-five patients were selected by the following criteria: infertility persisting for more than 1 year; abnormal semen parameters; no other infertility-related disease; no obvious causes of infertility in the subject’s partner; basal eco-color Doppler ultrasound demonstrating continuous reflux in the spermatic vein. All patients considered for the study had at least a six months period from the diagnosis to the surgery due to waiting list, choice of the patient or time needed to complete diagnostic evaluation of the couple. The surgical procedure was performed through an inguinal approach. All enrolled patients were counseled to have unprotected intercourse during the ovulation period in order to maximize the probability of pregnancy within the 6-month preoperative period. The achievement of pregnancy and semen parameters were recorded during the preoperative and postoperative period. Results: Two of the seventy-five patients were excluded because of persistent varicocele after surgery. The preoperative pregnancy rate was 1.3% (1 couple). The postoperative pregnancy rate was 42.5%. The stratification of pregnancies by semester showed a significantly higher rate in the first postoperative period (p = 0.0012). Mean time to conception was 13.5 months. Mean preoperative sperm count was 17.6x10 6 /mL compared to 19.7x10 6 /mL in the postoperative period (p &lt; 0.0001). Mean percentage of progressive sperm motility was 13.7%, compared to 17.6% in the postoperative period (p &lt; 0.0001). Mean percentage of normal sperm morphology was 7.6%, compared to 15.2% postoperatively (p &lt; 0.0001). Conclusion: Surgical treatment of high grade varicocele proved to effectively treat associated infertility by improving seminal parameters and pregnancy rate in our patient cohort. <![CDATA[Genital prevalence of HPV types and co-infection in men]]> Introduction: HPV infection is a highly prevalent sexually transmitted disease and there is evidence of the relationship of HPV infection and the development of genital warts, penile intraepitelial neoplasia, invasive penile carcinoma and cervical cancer. However, there is sparse data regarding the prevalence of HPV types and co-infection of different HPV types among men. Objectives: To assess the prevalence of HPV subtypes infections and rates of co-infection among men. Materials and Methods: 366 men were evaluated from March to October 2010. Men were referred to our institution for HPV diagnostic evaluation based on the following criteria: 1. presence of a genital wart; 2. presence of an atypical genital lesion; 3. absence of symptoms and a partner with a HPV diagnosis; 4. absence of symptoms and a desire to undergo a full STD diagnostic evaluation. Genital samples were collected from the urethra, penile shaft, scrotum and anus with Digene® collection and preservation kit and submitted to HPV genotype microarray detection (Papillocheck®). All men were tested for the low-risk HPV types 6-11-40-42-43-44 and for the high-risk HPV types 16-18-31-33-35-39-45-51-52-53-56-58-59-66-68-70-73-82. Results: Of the 366 men, 11 were tested inconclusive and were excluded from the analysis. 256 men (72.1% of the men from the cohort referred to our institution) tested positive with genotype micro-array detection and 99 tested negative. The most prevalent HPV-subtypes in the studied population were 6, 42, 51 and 16. Co-infection was found in 153 men. Of those, 70 (19.7%) had a co-infection by 2 types, 37 (10.4%) by 3 types; 33 men (9.2%) by 4 types; 8 men (2.2%) by 5 types; 1 man (0.3%) by 6 types; 1 man (0.3%) by 7 types; 2 men (0.6%) by 8 types and 1 man (0.3%) by 9 types. Conclusion: The most frequent HPV types were 6, 16, 42 and 51. Co-infection was found in 59% of our patients. This information is vital to drive future public health policies including massive public vaccination campaign. <![CDATA[Evaluation of the metabolism of glycosaminoglycans in patients with interstitial cystis]]> Introduction: Painful bladder syndrome/interstitial cystitis (PBS/IC) pathogenesis is not fully known, but evidence shows that glycosaminoglycans (GAG) of bladder urothelium can participate in its genesis. The loss of these compounds facilitates the contact of urine compounds with deeper portions of bladder wall triggering an inflammatory process. We investigated GAG in urine and tissue of PBS/IC and pure stress urinary incontinence (SUI) patients to better understand its metabolism. Materials and Methods: Tissue and urine of 11 patients with PBS/IC according to NIDDK criteria were compared to 11 SUI patients. Tissue samples were analyzed by histological, immunohistochemistry and immunofluorescence methods. Statistical analysis were performed using t Student test and Anova, considering significant when p &lt; 0.05. Results: PBS/IC patients had lower concentration of GAG in urine when compared to SUI (respectively 0.45 ± 0.11 x 0.62 ± 0.13 mg/mg creatinine, p &lt; 0.05). However, there was no reduction of the content of GAG in the urothelium of both groups. Immunofluorescence showed that PBS/IC patients had a stronger staining of TGF-beta, decorin (a proteoglycan of chondroitin/dermatan sulfate), fibronectin and hyaluronic acid. Conclusion: the results suggest that GAG may be related to the ongoing process of inflammation and remodeling of the dysfunctional urothelium that is present in the PBS/IC. <![CDATA[Long-term results of permanent memotherm urethral stent in the treatment of recurrent bulbar urethral strictures]]> Purpose: To evaluate the long term outcomes of permanent Memotherm urethral stent in the treatment of recurrent bulbar urethral stricture. Materials and Methods: Twenty patients who underwent permanent Memotherm urethral stent implantation due to recurrent bulbar urethral stricture following previous unsuccessful surgical procedure from 1996 to 2002 were included in the study. Long-term outcomes of the patients were evaluated. Results: The overall success rate was 87.5% at the end of the tenth year. There was discomfort in implantation area in eight patients about 1 month following the procedure. These patients were treated with alpha-blocker and anti-inflammatory drugs. Stone formation was observed at the urethral stent implantation area in two patients. Post-void dripping has been observed in 15 patients up to the postoperative 3rd month. Stress urinary incontinence was observed in a patient with a 1-year follow-up. Partial stent migration was observed in two patients. None of the patients experienced pain during erection. Conclusion: Memotherm urethral stent is a minimal invasive surgical procedure which can be safely and effectively used in patients with recurrent urethral stricture. <![CDATA[Validation of a novel non-biological bench model for the training of percutaneous renal access]]> Purpose: The percutaneous renal access (PRA) is the most critical step of percutaneous renal surgery (PRS). For the training of PRA in the lab, a novel non-biological bench model was developed and set for validation test. Materials and Methods: Experts in PRS (&gt; 60 cases) and novices were included to perform fluoroscopy guided PRA on the model. Overall time, X-ray exposure time and puncture attempts were recorded to establish construct validity. After accomplishment, the experts rated the model using a standardized questionnaire for face and content validity based on a 5-point Likert scale, with 1 denoting very bad and 5 as excellent. Baseline and post-training data of novices were analyzed for skill acquisition. Results: 9 experts and 30 novices were finally included. The overall appraisal was 4 by the experts, and consensus of all experts was reached for the model as an excellent training tool. Significant difference between experts and novices was detected with the experts using less total time 183.11 ± 29.40 vs. 278.00 ± 50.30 seconds (P &lt; 0.001), shorter X-ray exposure time 109.22 ± 19.93 vs. 183.13 ± 38.83 seconds (P &lt; 0.001), and fewer attempts 1.28 ± 0.44 vs. 2.35 ± 0.65 (P &lt; 0.001). After training, the novices demonstrated significant skill improvement in total and fluoroscopy time, and number of attempts (P &lt; 0.001). Conclusions: Our non-biological model provides a new method for PRA training. The face, content and construct validity were demonstrated. This model allows contact with PRA skills and could be applied to the first step in the learning curve. <![CDATA[Analysis of the effect of renal excretory system cooling during thermal radiofrequency ablation in an animal model]]> Objective: Analysis of renal excretory system integrity and efficacy of radiofrequency ablation with and without irrigation with saline at 2 o C (SF2). Materials and Methods: The median third of sixteen kidneys were submitted to radiofrequency (exposition of 1 cm) controlled by intra-surgical ultrasound, with eight minutes cycles and median temperature of 90 o C in eight female pigs. One excretory renal system was cooled with SF2, at a 30ml/min rate, and the other kidney was not. After 14 days of post-operatory, the biggest diameters of the lesions and the radiological aspects of the excretory system were compared by bilateral ascending pyelogram and the animals were sacrificed in order to perform histological analysis. Results: There were no significant differences between the diameters of the kidney lesions whether or not exposed to cooling of the excretory system. Median diameter of the cooled kidneys and not cooled kidneys were respectively (in mm): anteroposterior: 11.46 vs. 12.5 (p = 0.23); longitudinal: 17.94 vs. 18.84 (p = 0.62); depth: 11.38 vs. 12.25 (p = 0.47). There was no lesion of the excretory system or signs of leakage of contrast media or hydronephrosis at ascending pyelogram. Conclusion: Cooling of excretory system during radiofrequency ablation does not significantly alter generated coagulation necrosis or affect the integrity of the excretory system in the studied model. <![CDATA[The effect of Sertraline, Paroxetine, Fluoxetine and Escitalopram on testicular tissue and oxidative stress parameters in rats]]> Introduction: The aim of this study was to evaluate the effect of selective serotonin reuptake inhibitors (SSRIs) on testicular tissue and serum malondialdehyde (MDA) levels in rats. Materials and methods: A total of 40 male Wistar albino rats, 5.5-6 months old, were equally divided at random into five groups: group 1 was the control group, group 2 received sertraline 10mg/kg (p.o), group 3 was administered fluoxetine 10mg/kg (p.o), group 4 received escitalopram 10mg/kg (p.o), and group 5 (n = 8) was administered paroxetine 20mg/kg. Each dose was administered orally for two months. Johnsen’s criteria were used to categorize spermatogenesis. Johnsen’s method assigns a score of 1 to 10 to each tubule cross-section examined. In this system, a Johnsen score of 9 and 10 indicates normal histology. Serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone levels were evaluated. Serum MDA levels were also measured. Results: The mean Johnsen scores were 9.36 ± 0.33, 9.29 ± 0.32, 8.86 ± 0.48, 9.10 ± 0.56, and 8.33 ± 0.90 in control group, sertraline group, fluoxetine group, escitalopram group, and paroxetine group, respectively. The Johnsen score was significantly lower for paroxetine group compared with the control group (p &lt; 0.05). The mean FSH level increased only in the sertraline group. With the exception of the fluoxetine group, the testosterone levels were lower in all groups compared with the control group. The total testosterone level was significantly lower in the sertraline group compared with the control group [40.87 (22.37-46.8) vs. 15.87 (13.53-19.88), p &lt; 0.01]. There were no significant differences between the groups with respect to the MDA and LH levels (p = 0.090 and p = 0.092). Conclusion: These data suggest that SSRIs have a negative effect on testicular tissues. This negative impact is markedly greater in the paroxetine group. To determine the exact mechanism of action of these drugs on testicular tissue, well-designed randomized controlled clinical studies are needed on a larger population. <![CDATA[The effects of carvedilol on ischemia-reperfusion injury in the rat testis]]> Objective: To analyze the oxidative damage and histopathological alterations caused by ischemia-reperfusion (I/R) injury and ameliorative effects of carvedilol (CVD) in the rat testis. Materials and Methods: Twenty-one male rats were randomized into 3 groups as follows: Group I (n = 7); control (sham) group, Group II (n = 7); I/R group, in which I/R injury was performed by torsing the left testis 720º clockwise for 2 hours and detorsing for 2 hours. Group III (n = 7); CVD treatment group; in addition to I/R process, one-dose of CVD was administered (2mg/kg, i.p) 30 min. before detorsion. Levels of antioxidant enzymes, superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) and levels of malondialdehyde (MDA) and protein carbonyl (PC) were determined in testicular tissues and serum of rats. Testicular tissues were also examined histopathologically and Johnsen scores were determined. Results: Activities of SOD and GSH-Px in serum and testicular tissues were increased by I/R, but administration of CVD decreased these levels (p &lt; 0.001 and p = 0.001). Significantly increased MDA levels in serum and testicular tissues were decreased by CVD treatment (p &lt; 0.001 and p = 0.001). Concerning PC levels in serum and testicular tissues, there was no statistically significant difference between the groups (p = 0.989 and p = 0.428). There was not a statistically significant difference in terms of mean Johnsen scores between the groups (p = 0.161). Conclusions: Administration of CVD decreased oxidative damage biochemically in the rat testis caused by I/R injury, but histopathologically no change was observed between all of the groups. <![CDATA[The Occurrence of Primary Hepatic Adenoma in Deceased Donor Renal Transplant Recipient]]> Main findings: We reported a case of new-onset, multi-focal hepatic adenoma in an 18 year-old man with no classic risk factors occurring forty months after a renal transplant from a cadaver donor. Histopathology of the adenoma was examined and genotype and phenotype were also analyzed. Histopathologic examination of the adenoma showed no malignancy. Genotype and phenotype analysis revealed no HNF1α or β-catenin gene mutations and no inflammatory infiltration. The patient was well and disease-free postoperatively. Case hypothesis: Hepatic adenoma occurs mostly in those taking oral contraceptives or androgenic-anabolic steroids or in those with hereditary diseases. Hepatic adenoma in a renal transplant recipient is rare and has only been reported in one case with glycogen storage disease type Ia. Immunosuppressive treatment might have contributed to the development of the neoplasm. Promising future implications: Although malignant change occurs most often in β-catenin gene mutation hepatic adenoma, surgical resection of the adenoma in a patient under immunosuppressive therapy should be considered in order to avoid the possibility of malignant transformation or hemorrhagic rupture. <![CDATA[Retroperitoneoscopic pyelolithotomy: A minimally invasive alternative for the management of large renal pelvic stone]]> Introduction: Large stones in renal pelvis can be treated with percutaneous nephrolithotomy (PCNL) or pyelolithotomy (either by open or laparoscopic techniques). PCNL is difficult in undilated system. For pyelolithotomy, laparoscopy is more preferable over the open surgery. Surgeons are more familiar with the tansperitoneoscopic anatomy than retroperitoneoscopic one, but retroperitoneoscopic approach can be attempted if we anticipate the problems in the transperitoneal route. Case: A fifty years old gentleman presented to us with the complaint of dull aching right flank pain. On ultrasonographic examination, he was found to have a large stone in renal pelvis with minimal hydronephrosis and thickened omentum on right side. Xray KUB showed a large radio-opaque shadow in renal area. We did the CECT-Urogram of the patient to know the detailed anatomy, which showed a stone of 5.3 x 3.7 cm in right extra-rena pelvis without hydronephrosis and a large focal area of marked fat stranding in omentum on the right side in mid and lower abdomen with swirling of fat stranding on the superior aspect suggestive of omental infarction and torsion. Due to undilated caliceal system, we preferred laparoscopic surgery over the PCNL in this patient. As whole of the omental tissue was stuck on right side we decided to proceed with transperitoneoscopic route instead of retroperitoneoscopic one. The DJ stent was inserted preoperatively.The surgery was performed in the flank position with three ports, one 10mm port just antero-inferior to tip of 12th rib for camera and two 5mm working ports, one at anterior axillary line and other at renal angle. We created the retroperitoneal space with the customized balloon, made with the glove-fingure. Results: The operative time was 1 hour 40 minutes, and there were no intra or post-operative complications. The stone was removed in toto. Patient was orally allowed on first postoperative day and foleys was removed on second day. patient was discharged on day 2. DJ stent was removed after 15 days. At two months follow-up the patient was asymptomatic. Conclusion: The retroperitoneoscopic pyelolithotomy is a good alternative for removal of large stone in renal pelvis, with the added advantages of no peritoneal contamination and a quick recovery of bowel function. <![CDATA[Robotic nephrolithotomy and pyelolithotomy with utilization of the robotic ultrasound probe]]> Introduction: The treatment of large renal stones in children can be challenging often requiring combination therapy and multiple procedures. The purpose of this video is to describe our technique of robotic nephrolithotomy and pyelolithotomy for complex renal stone disease in children, and to demonstrate the utility of the robotic ultrasound probe to aid with stone localization. Materials and Methods: Robotic nephrolithotomy/pyelolithotomy was carried out in four consecutive patients. A robotic ultrasound probe (Hitachi-Aloka, Tokyo, Japan) under console surgeon control was used in all cases. Results: Two patients underwent robotic pyelolithotomy, one patient underwent robotic nephrolithotomy, whilst the fourth patient underwent robotic pyelolithotomy and nephrolithotomy along with Y-V pyeloplasty for concurrent ureteropelvic junction obstruction. Mean operative time, blood loss and hospital stay was 216 minutes, 37.5 mL and 2 days, respectively. The robotic ultrasound probe aided identification of calculi within the kidney in all cases. For nephrolithotomy it was helpful in planning the incision for nephrotomy. After nephrotomy or pyelotomy, stones were removed using a combination of robotic Maryland forceps, fenestrated grasper or Prograsp. Antegrade nephroscopy introduced through a laparoscopic port was used in all patients for confirmation of residual stone status. Two patients did not require a ureteral stent in the post-operative period. One patient had a minor complication (Clavien Grade 2 - dislodged malecot catheter). All patients were stone free at last follow-up. Conclusions: Robotic nephrolithotomy and pyelolithotomy with utilization of the robotic ultrasound probe offers a one-stop solution for complex renal stones with excellent stone-free rates. <![CDATA[Robotic Extramucosal Excision of Bladder Wall Leiomyoma]]> Introduction: Multiple case reports and reviews have been described in the literature for bladder wall leiomyoma resection via different approaches. The minimally invasive partial cystectomy remains the most widely accepted technique; however, case reports for enucleation of bladder wall leiomyoma have also been described. The purpose of this video is to demonstrate the robotic extramucosal excision of a bladder wall leiomyoma, without cystotomy, but with complete removal of the muscular layer. Materials and Methods: A 35-year old male present with lower urinary tract symptoms and imaging showed bladder wall mass with histopathology showed leiomyoma. The patient consented for mass excision with the possibility of a partial cystectomy. The patient was placed in the supine, 30-degree Trendelenburg position during the procedure. A total of 4 ports were inserted. A 3-arm da Vinci robotic surgical system was docked, and the arms were connected. Extramucosal excision was accomplished without cystotomy and muscle approximation was achieved by 2 0 Vicryle. Result: The operative time was 90 minutes, blood loss of approximately 50mL and the patient was discharged after 72 hours with no immediate complications and a 6 months follow-up showed no recurrence. Conclusion: Such a technique results in complete excision of the tumor, without cystotomy, and also maintains an intact mucosa. These steps, in addition to decreasing the risk of local recurrence, also shorten the period of postoperative catheterization and hospitalization.