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Objectives To identify retrospectively through chart analysis the biochemical recurrence frequency of localized prostate cancer at diagnosis of patients submitted to surgery or radiotherapy; to correlate diagnostic characteristics associated with higher risk of biochemical recurrence. Materials and Methods Retrospective analysis of 483 patients treated in a single center, from March 2000 to December 2009 in order to verify factors associated with biochemical recurrence. Results Biochemical recurrence was more frequent in patients with higher initial PSA levels and those with higher risk disease. Recurrence was more frequent in patients with high risk (25.9%) than those with intermediate risk (10.7%) and low risk (5.5%). There was no significant statistical difference of biochemical recurrence between patients submitted to radiotherapy or radical prostatectomy. Biochemical recurrence was diagnosed in only 11 of 73 patients (15%) submitted to conformal radiotherapy using tridimensional technique. Conclusion Radiotherapy and radical prostatectomy have similar treatment results. Tridimensional conformal radiotherapy used nowadays is more efficient than earlier forms of radiation therapy (cobalt therapy and bidimensional linear accelerator therapy).

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Objective Histological details of positive surgical margins in radical prostatectomy specimens have been related to outcome after surgery in rare studies recently published. Our objective is to assess whether the status of surgical margins, the extent and the Gleason score of positive margins, and the extent of the extraprostatic extension are predictive of biochemical recurrence post-radical prostatectomy. Materials and Methods Three hundred sixty-five radical prostatectomy specimens were analyzed. The length of the positive surgical margin and extraprostatic extension and the Gleason score of the margin were recorded. Statistical analyses examined the predictive value of these variables for biochemical recurrence. Results 236 patients were stage pT2R0, 58 pT2R1, 25 pT3R0 and 46 pT3R1. Biochemical recurrence occurred in 11%, 31%, 20% and 45.7% of pT2R0, pT2R1, pT3R0 and pT3R1, respectively. The extent of the positive surgical margins and the Gleason score of the positive surgical margins were not associated with biochemical recurrence in univariate analysis in a mean follow up period of 35.9 months. In multivariate analyses, only the status of the surgical margins and the global Gleason score were associated with biochemical recurrence, with a risk of recurrence of 3.1 for positive surgical margins and of 3.8 for a Gleason score > 7. Conclusion Positive surgical margin and the global Gleason score are significant risk factors for biochemical recurrence post-radical prostatectomy, regardless of the extent of the surgical margin, the extent of the extraprostatic extension, or the local Gleason score of the positive surgical margin or extraprostatic tissue. pT2R1 disease behaves as pT3R0 and should be treated similarly.

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Introduction and objective Active surveillance (AS) has become an accepted alternative for patients with low risk prostate cancer. The purpose of AS is to defer definitive therapy in these patients to avoid treatment-related complications. Our aim was to determine the pathological features of the surgical specimen from potential AS candidates that underwent radical prostatectomy (RP). Materials and Methods We retrospectively reviewed a group of patients submitted to RP who met criteria for AS: Gleason score (GS) ≤ 3+3 = 6, PSA ≤ 10ng/mL, T1c - T2a, < 1/3 of positive cores, < 50% of involvement in any core and PSA density < 0.15. We determined the concordance between GS in biopsy and RP specimen (RPS). Other pathological features of the RPS were also analyzed, including surgical margins, extracapsular extension, seminal vesicles and lymph node involvement. Results We identified 167 patients subjected to RP that met the criteria for AS. Fifty two patients (31.1%) had a GS > 6 in the RPS (GS 7 n = 49; GS 8 n = 3). Extracapsular extension, seminal vesicle and lymph node involvement was found in 6.1%, 3.1% and 1.2% of the specimens, respectively. Conclusion In this study a significant proportion of potential candidates for AS showed features of aggressive and/or high-risk tumors in the RPS. Therefore, before considering a patient for an AS protocol, a proper and strict selection must be performed, and informed consent is crucial for these patients.

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Purposes (a) To externally validate the Crippa and colleagues’ nomograms combining PSA, percentage of positive biopsy cores (PPBC) and biopsy Gleason score to predict organ-confined disease (OCD) in a contemporary sample of patients treated at a tertiary teaching institution. (b) To adjust such variables, resulting in predictive nomograms for OCD and seminal vesicle invasion (SVI): the USP nomograms. Materials and Methods The accuracy of Crippa and colleagues’ nomograms for OCD prediction was examined in 1002 men submitted to radical prostatectomy between 2005 and 2010 at the University of São Paulo (USP). ROC-derived area under the curve (AUC) and Brier scores were used to assess the discriminant properties of nomograms for OCD. Nomograms performance was explored graphically with LOESS smoothing plots. Furthermore, univariate analysis and logistic regression models targeted OCD and SVI. Variables consisted of PSA, PPBC, biopsy Gleason score and clinical stage. The resulted predictive nomograms for OCD and SVI were internally validated with bootstrapping and the same abovementioned procedures. Results Crippa and colleagues’ nomograms for OCD showed ROC AUC = 0.68 (CI: 0.65-0.70), Brier score = 0.17 and overestimation in LOESS plots. USP nomograms for OCD and SVI showed ROC AUC of 0.73 (CI: 0.70-0.76) and 0.77 (CI: 0.73-0.79), respectively, and Brier scores of 0.16 and 0.08, respectively. The LOESS plots showed excellent calibration for OCD and underestimation for SVI. Conclusions Crippa and colleagues’ nomograms showed moderate discrimination and considerable OCD overestimation. USP nomograms showed good discrimination for OCD and SVI, as well as excellent calibration for OCD and SVI underestimation.

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Introduction High-grade T1 (HGT1) bladder cancer represents a clinical challenge in that the urologist must balance the risk of disease progression against the morbidity and potential mortality of early radical cystectomy and urinary diversion. Using two non-muscle invasive bladder cancer (NMIBC) databases, we re-examined the rate of progression of HG T1 bladder cancer in our bladder cancer populations. Materials and Methods We queried the NMIBC databases that have been established independently at the Atlanta Veterans Affairs Medical Center (AVAMC) and the University of Pennsylvania to identify patients initially diagnosed with HGT1 bladder cancer. Demographic, clinical, and pathologic variables were examined as well as rates of recurrence and progression. Results A total of 222 patients were identified; 198 (89.1%) and 199 (89.6%) of whom were male and non-African American, respectively. Mean patient age was 66.5 years. 191 (86.0%) of the patients presented with isolated HG T1 disease while 31 (14.0%) patients presented with HGT1 disease and CIS. Induction BCG was utilized in 175 (78.8%) patients. Recurrence occurred in 112 (50.5%) patients with progression occurring in only 19 (8.6%) patients. At a mean follow-up of 51 months, overall survival was 76.6%. Fifty two patients died, of whom only 13 (25%) patient deaths were bladder cancer related. Conclusions In our large cohort of patients, we found that the risk of progression at approximately four years was only 8.6%. While limited by its retrospective nature, this study could potentially serve as a starting point in re-examining the treatment algorithm for patients with HG T1 bladder cancer.

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Objective The goal of this study was to utilize long-term patient follow-up to determine whether epithelial-to-mesenchymal transition (EMT)-related markers can predict bladder cancer patient survival and progression of disease. Materials and Methods This study included 121 patients with bladder cancer. Sixty-four of these patients presented with non-muscle invasive (NMI, stage T1) bladder cancer and 57 with muscle invasive (MI, stage T2, T3). The patients were diagnosed and treated between May 1998 and July 2012. The EMT markers E-cadherin, Twist, and Vimentin were detected via immunohistochemistry. Univariate and multivariate/Cox analyses were then utilized to determine whether these EMT markers could be useful prognostic markers for predicting bladder cancer patient outcomes. Results Analysis of the 121 bladder cancer patients in this study revealed that the frequency of E-cadherin expression was 59.5% (72/121), Twist was 54.5% (66/121), and Vimentin was 24.8% (30/121). Twist and Vimentin were found to have statistically significant correlations with grade, recurrence, and progression but not with stage, whereas E-cadherin was associated with stage but not with the other parameters. In the univariate analysis, grade (p = 0.02) was the only significant predictor for progression-free survival (PFS). Stage, grade, and expression of E-cadherin, Vimentin and Twist were included in the multivariate analysis of predicting PFS. In this analysis, grade (p = 0.01) and Vimentin expression (p = 0.001) were found to be significant prognostic factors in predicting PFS. Conclusions Grade and Vimentin are potential independent indicators in predicting bladder cancer progression and survival.

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Purpose To evaluate Lipiodol as a liquid, radio-opaque fiducial marker for image-guided radiation therapy (IGRT) for bladder cancer. Materials and Methods Between 2011 and 2012, 5 clinical T2a-T3b N0 M0 stage II-III bladder cancer patients were treated with maximal transurethral resection of a bladder tumor (TURBT) and image-guided radiation therapy (IGRT) to 64.8 Gy in 36 fractions ± concurrent weekly cisplatin-based or gemcitabine chemotherapy. Ten to 15mL Lipiodol, using 0.5mL per injection, was injected into bladder submucosa circumferentially around the entire periphery of the tumor bed immediately following maximal TURBT. The authors looked at inter-observer variability regarding the size and location of the tumor bed (CTVboost) on computed tomography scans with versus without Lipiodol. Results Median follow-up was 18 months. Lipiodol was visible on every orthogonal two-dimensional kV portal image throughout the entire, 7-week course of IGRT. There was a trend towards improved inter-observer agreement on the CTVboost with Lipiodol (p = 0.06). In 2 of 5 patients, the tumor bed based upon Lipiodol extended outside a planning target volume that would have been treated with a radiation boost based upon a cystoscopy report and an enhanced computed tomography (CT) scan for staging. There was no toxicity attributable to Lipiodol. Conclusions Lipiodol constitutes a safe and effective fiducial marker that an urologist can use to demarcate a tumor bed immediately following maximal TURBT. Lipiodol decreases inter-observer variability in the definition of the extent and location of a tumor bed on a treatment planning CT scan for a radiation boost.

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Purpose The incidence of lower urinary tract symptoms (LUTS) as the sole presenting symptom for bladder cancer has traditionally been reported to be low. The objective of this study was to evaluate the prevalence and clinical characteristics of newly diagnosed bladder cancer patients who presented with LUTS in the absence of gross or microscopic hematuria. Materials and Methods We queried our database of bladder cancer patients at the Atlanta Veteran’s Affairs Medical Center (AVAMC) to identify patients who presented solely with LUTS and were subsequently diagnosed with bladder cancer. Demographic, clinical, and pathologic variables were examined. Results 4.1% (14/340) of bladder cancer patients in our series presented solely with LUTS. Mean age and Charlson Co-morbidity Index of these patients was 66.4 years (range = 52-83) and 3 (range = 0-7), respectively. Of the 14 patients in our cohort presenting with LUTS, 9 (64.3%), 4 (28.6%), and 1 (7.1%) patients presented with clinical stage Ta, carcinoma in Situ (CIS), and T2 disease. At a median follow-up of 3.79 years, recurrence occurred in 7 (50.0%) patients with progression occurring in 1 (7.1%) patient. 11 (78.6%) patients were alive and currently disease free, and 3 (21.4%) patients had died, with only one (7.1%) death attributable to bladder cancer. Conclusions Our database shows a 4.1% incidence of LUTS as the sole presenting symptom in patients with newly diagnosed bladder cancer. This study suggests that urologists should have a low threshold for evaluating patients with unexplained LUTS for underlying bladder cancer.

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Introduction Tubeless PCNL has been utilized to shorten hospital stay and improve patient postoperative pain control. Prior studies have excluded those patients with significant bleeding or other complications. Our objective was to evaluate the utility of tubeless PCNL in all patients irrespective of intraoperative outcome. Materials and Methods A retrospective review of the charts of patients who underwent PCNL at our institute was performed. Patients were assigned to one endourologist who routinely performed tubeless PCNL and to a second endourologist who routinely left a small-bore pigtail nephrostomy. Preoperative demographics operative and postoperative outcomes were compared. Results Out of 159 patients included, 83 patients had tubeless PCNL while 76 patients had standard PCNL. There was no difference between groups regarding age, gender, ASA score, number, maximum diameter of stones, number of calyces involved, stone density (HU), laterality and use of preoperative narcotics. While staghorn stones were more common in patients who underwent standard PCNL (p = 0.008). Tubeless patients had less number of access tracts (p ≤ 0.001), shorter hospital stay (1.7 vs. 3.0 days, p = 0.001) when compared to standard PCNL group. Multivariable analysis controlling for confounding factors including staghorn calculi and number of accesses confirmed that tubeless PCNL was associated with shorter hospital stay and less postoperative pain. There was no significant difference in complication rates between the two groups. Conclusion Our report confirms the previous reports of shorter hospital stay, less pain and analgesia as compared to standard PCNL, and establishes its safety irrespective of bleeding, perforation, extravasation or other intraoperative issues that have previously been utilized as exclusionary criteria for this approach.

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Purpose We developed a stereotactic device to guide the puncture for percutaneous nephrolithotripsy, which uses the distance from the target calyx to its perpendicular point on skin (SCD) to calculate the needle´s entry angle. This study seeks to validate the use of measurements obtained by ultrasound (US) and computerized tomography (CT) for needle´s entry angle calculation and to study factors that may interfere in this procedure. Materials and Methods Height, weight, abdominal circumference, CT of the urinary tract in dorsal decubitus (DD) and ventral decubitus (VD), and US of the kidneys in VD were obtained from thirty-five renal calculi patients. SCD obtained were compared and correlated with body-mass index (BMI). Results BMI was 28.66 ± 4.6 Kg/m2. SCD on CT in DD was 8.40 ± 2.06cm, in VD was 8.32 ± 1.95cm, in US was 6.74 ± 1.68cm. SCD measured by US and CT were statistically different (p < 0.001), whereas between CT in DD and VD were not. SCD of the lower calyx presented moderate correlation with BMI. Conclusion SCD obtained by CT in ventral and dorsal decubitus may be used for calculation of the needle´s entry angle. SCD obtained by US cannot be used. A rule for the correlation between BMI and the SCD could not be determined.

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Objective To investigate the safety and feasibility of self-retaining bidirectional barbed absorbable suture application in retroperitoneoscopic partial nephrectomy. Materials and Methods From Sep 2011 and Aug 2012, 76 cases of retroperitoneoscopic partial nephrectomy were performed at our hospital. The patients were divided into two groups: self-retaining barbed suture (SRBS) group (n = 36) and non-SRBS group (n = 40). There was no significant difference in age, sex, tumor size and location between the two groups. Clinical data and outcomes were analyzed retrospectively. Results All 76 cases of retroperitoneoscopic partial nephrectomy were successfully performed, without conversion to open surgery or serious intraoperative complications. In the SRBS group, the suture time, warm ischemia time and operation blood loss were significantly shorter than that of non-SRBS group (p < 0.01), and operation time and hospital stay were shorter than that of non-SRBS group (p < 0.05). Conclusions The application of self-retaining bidirectional barbed absorbable suture in retroperitoneoscopic partial nephrectomy could shorten suture time and warm ischemia time, with good safety and feasibility, worthy of being used in clinic.

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Introduction The limitations of traditional ureteral stents in patients with deficiencies in ureteral drainage have resulted in frequent stent exchanges. The implementation of metallic stents was introduced to improve the patency rates of patients with chronic upper urinary tract obstruction, obviating the need for frequent stent exchanges. We report our clinical experiences with the use of metallic ureteral stents in the management of poor ureteral drainage. Materials and Methods Fifty patients underwent metallic ureteral stent placement from 2009 to 2012. Stent failure was defined as an unplanned stent exchange, need for nephrostomy tube placement, increasing hydronephrosis with stent in place, or an elevation in serum creatinine. Stent life was analyzed using the Kaplan-Meier methodology, as this was a time dependent continuous variable. A cost analysis was similarly conducted. Results A total of 97 metallic stents were placed among our cohort of patients: 63 in cases of malignant obstruction, 33 in the setting of cutaneous ureterostomies, and 1 in an ileal conduit urinary diversion. Overall, stent failure occurred in 8.2% of the stents placed. Median stent life was 288.4 days (95% CI: 277.4-321.2 days). The estimated annual cost for traditional polymer stents (exchanged every 90 days) was $9,648-$13,128, while the estimated cost for metallic stents was $4,211-$5,313. Conclusion Our results indicate that metallic ureteral stent placement is a technically feasible procedure with minimal complications and is well tolerated among patients. Metallic stents can be left in situ for longer durations and provide a significant financial benefit when compared to traditional polymer stents.

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Purpose We aimed to determine the differences of the urodynamic findings of mix urinary incontinence (MUI), urge urinary incontinence (UUI), and stress urinary incontinence (SUI), and to evaluate the urodynamic findings in different groups by using bladder sensitivity index (BSI). Materials and Methods The data of 99 patients who underwent urodynamic testing related to the suspicion of SUI, UUI or MUI were analysed. This analysis included a retrospective evaluation of patients’ cards, voiding diaries, and urodynamic reports. At filling cystometry, the parameters of first sensation of bladder filling (FSBF), first desire to void (FDV), strong desire to void (SDV), and bladder capacity (Vmax), which were related to the bladder sensation, were determined. Subsequently, uroflowmetric findings were recorded during bladder emptying. BSI was defined as the ratio of Vmax/FDV. These results were statistically compared among the goups. Results The sample included 35(35.5%) MUI, 33(33.3%) UUI and 31 (31.1%) SUI. The mean ages were similar in all groups (P = 0.868). The mean FSBF, FDV, SDV and Vmax values were significantly different among groups (p = 0.004, p < 0.001, p < 0.001, p < 0.001 respectively). Nevertheless, there was no statistically significant difference among the mean daily voiding accounts (P = 0.005). Although the mean maximum flow rate (Qmax) values were similar (P = 0.428), the mean maximum detrusor pressure (Pdetmax) values were significantly different (P = 0.021). The mean BSI values showed no significant differences (P = 0.097). Conclusions It was concluded that while the use of urodynamic testing could contribute to the management of urinary incontinence, the indexes including BSI requere more detailed and comprehensive studies.

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Purpose The effects of serum testosterone in the lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia (BPH) are not well established. The objective of the study is to evaluate the association of sex hormones with LUTS and control the results by patient weight. Materials and Methods The study comprised a cross-sectional analysis of 725 men included in a prostate cancer screening program at University of Sao Paulo Medical School. The serum concentrations of total testosterone (TT), free testosterone (FT) and sex hormone binding globulin (SHBG) were measured. Variables analyzed were age, American Urological Association (AUA) symptom score, storage symptoms, voiding symptoms, quality of life score, prostate specific antigen levels and prostate volume. Obesity was measured through the calculation of body mass index (BMI). A regression analysis model was performed. Results Median patient age was 65 years (48 to 94). A higher TT level was significantly associated with a severe AUA symptom score only among patients with a BMI ≥ 25. Median TT was 371, 370 and 427ng/dL (p = 0.017) in patients with mild, moderate and severe LUTS respectively. The multivariate regression analysis in patients with BMI ≥ 25 showed that only age, TT and sex score were related to LUTS. Conclusions A higher TT is associated with a severe AUA score symptom index only in obese patients. Further analysis are necessary to evaluate the mechanisms through which testosterone may influence LUTS in these patients.

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Purpose To investigate the relationship between human papillomavirus (HPV) infection and prostatitis-related symptoms. Materials and Methods All young heterosexual patients with prostatitis-related symptoms attending the same Center from January 2005 to December 2010 were eligible for this case-control study. Sexually active asymptomatic men were considered as the control group. All subjects underwent clinical examination, Meares-Stamey test and DNA-HPV test. Patients with prostatitis-related symptoms and asymptomatic men were compared in terms of HPV prevalence. Moreover, multivariable Cox proportional hazards regression analysis was performed to determine the association between HPV infection and prostatitis-related symptoms. Results Overall, 814 out of 2,938 patients (27.7%) and 292 out of 1,081 controls (27.0%) proved positive to HPV. The HPV genotype distribution was as follows: HR-HPV 478 (43.3%), PHR-HPV 77 (6.9%), LR-HPV 187 (16.9%) and PNG-HPV 364 (32.9%). The most common HPV genotypes were: 6, 11, 16, 26, 51, 53 and 81. No difference was found between the two groups in terms of HPV infection (OR 1.03; 95% CI 0.88-1.22; p = 0.66). We noted a statistically significant increase in HPV infection over the period 2005 to 2010 (p < 0.001) in both groups. Moreover, we found a statistically significant increase in HPV 16 frequency from 2005 to 2010 (p = 0.002). Conclusions This study highlights that prostatitis-like symptoms are unrelated to HPV infection. Secondary, we highlight the high prevalence of asymptomatic HPV infection among young heterosexual men.

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Purpose To evaluate the synthesis of type I (mature) and type III (immature) collagen in bladder suture of rats treated with a combination of tacrolimus and mycophenolate mofetil for 15 days. Materials and Methods Thirty rats were divided into 3 groups: the sham, control and experimental groups. All the animals underwent laparotomy, cystotomy and bladder suture in two planes with surgical PDS 5-0 thread. The sham group did not receive treatment. The control group received saline solution, and the experimental group received 0.1mg/kg/day of tacrolimus with 20mg/kg/day of mycophenolate mofetil, for 15 days. From then on, the tacrolimus was dosed. The surgical specimens of the bladder suture area were processed so that the total type I and type III collagen could be measured by the picrosirius red technique. Results There was a predominance of type I collagen production in the sham and control groups compared to the experimental group, in which type III collagen was predominant. The production of total collagen did not change. Conclusion The association of tacrolimus and mycophenolate mofetil in animals qualitatively changes the production of collagen after 15 days with a predominance of type III collagen.

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The surgical management with laparoscopic technique for renal cell carcinoma with inferior vena cava tumor thrombus (IVTT) remains challenging and technically demanding in urological oncology. We present two patients with level II IVTT that were managed with pure conventional laparoscopic radical nephrectomy and thrombectomy. Two patients were diagnosed with a renal tumor with level II IVTT from December 2011 to January 2012. They both underwent pure conventional laparoscopic radical nephrectomy with thrombectomy. During these operations, intraoperative laparoscopic ultrasonography was used to detect the thrombus and ensure complete removal. Two patients were operated through retroperitoneal approach for right renal tumor and transperitoneal approach for left renal tumor respectively. The demographics, perioperative and follow-up data were recorded for the study. Both operations were successfully performed without conversion. They both had no radiographic evidence of recurrence during follow-up. It is concluded that it is feasible to manage renal cell carcinoma with level II IVTT through pure conventional laparoscopic approach in carefully selected patients, which might expand the indication for laparoscopic surgery. The pure laparoscopic approach in the treatment of renal cell carcinoma with level II vena cava tumor thrombus is challenging and requires advanced laparoscopic skills. Multicenter prospective randomized control trials are needed to prove the benefits of this approach.

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Neither computed tomography (CT) nor intravenous pyelography (IVP) alone can diagnose tumors of renal pelvic diverticula, but magnetic resonance urography (MRU) can obtain accurate preoperative information.

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The Paraganglioma is the most common extra-adrenal pheochromocytoma arising from neural crest (1) (It will better to write: The paraganglioma is an extra-adrenal pheocromocytoma arising from the neural crest. 10% of pheocromocytomas are extra-adrenal and can arise form chromaffin tissue derived from primitive neuroectoderm). Minimally invasive techniques allow surgeons to perform the procedure without wide exposure and mobilization of intra abdominal organs. To our knowledge we present the third case of robotic excision of a retroperitoneal paraganglioma (2,3).