The benefits laparoscopic surgery brings to the table are well established in the literature. In our environment however, still most of the reconstructive/oncologic procedures are performed as open surgery. This can be explained by the multiple challenges this technique involves, as well as a demanding learning curve. Technology has provided means to improve precision and usefulness of laparoscopy, as well as broaden its use amongst the medical community by shortening its learning curve. Renal tumors have been managed by laparoscopic approach for the past 20 years. During this time, many studies appeared in the literature comparing this procedure with open surgery. In the vast majority, laparoscopic surgery has the upper hand in regards of Arch. Esp. Urol. 2013; 66 (1): 122-128perioperative events. A number of series are available regarding the feasibility of robotic radical nephrectomy, however there is no literature available that demonstrates better outcome of robotic radical nephrectomy compared to standard laparoscopy. Laparoscopic partial nephrectomy is technically difficult, which has prevented its massive spread through the urologist community, even amongst trained laparoscopists. Current reports are starting to favor robotic partial nephrectomy over standard laparoscopy regarding perioperative outcomes, with similar oncologic results. More studies have to be performed in order to elucidate the importance of NOTES and LESS in the treatment on localized renal cancer, but the use of the robot will lower their learning curve and probably make them attractive in the short term. Even though this technology has brought laparoscopy closer to a greater number of surgeons, physicians should become familiar and proficient in conventional laparoscopic procedures before embarking into robotics

Solid renal tumours with a diameter <4cm comprise up to half of all renal tumours coming for a therapeutic decision in tertiary care centres today. ~80% are renal cell cancers , and nephron-sparing excision is standard therapy. The approach has considerable morbidity , and as many of these tumours are diagnosed in elderly ,infirm patients less invasive focal ablation appears attractive . This is usually achieved with radiofrequency or cryoablation, either percutaneously under image guidance or by a laparoscopic approach. The quality of reports on the outcome with this treatment is moderate, with no prospective comparative studies, and in general short follow-up. Metanalyses suggest more reliable results with cyro- than with radiofrequency ablation . Morbidity is lower than with nephron-sparing surgery, but still substantial and almost entirely due to the perforating trauma at ablation. This would be avoided by energy ablation with high-intensity focused ultrasound from an extracorporeal energy source. Phase 1 clinical studies with several prototoypes have been disappointing, as multiple acoustic interphases and target mobility obviously render adequately precise focusing unreliable. New HIFU transducers that can be approximated directly to the tumour via a laparoscopic approach circumvent these problems. A phase 1 study with this technique in 31 patients demonstrates that complete ablation of tumours can be achieved in this manner, at least for tumours <3cm and in a peripheral position in the lower and middle third of the kidney. Perforating trauma to the kidney is avoided, and morbidity is minimized. Of course patients still need long – term follow-up with sequential imaging and even biopsies, and tumour control is most likely less reliable than with standard nephron- sparing surgery.

OBJECTIVES: To perform a bibliographic review of the laparoscopic approach for radiofrequency ablation of small renal masses. METHODS: For this review we used the Medline database. We reviewed the clinical guidelines of the American Urological Association, the European Association of Urology and other institutions. RESULTS: Radiofrequency ablation is a minimally invasive treatment in which a needle is introduced in the tumor once it is identified, and it produces an increase of temperature high enough to destroy tumor cells. This technique may be used by percutaneous approach, or during a laparoscopic approach. The choice of one technique or another depends on tumor site, closeness to the bowels or other organs and patient conditions. It would be indicated in patients with small tumors or important comorbidity who are not candidates for surgery. There are not randomized studies comparing these ablation techniques with the surgical techniques. There is no randomized study comparing the efficacy of percutaneous and laparoscopic techniques either but a metanalysis comparing them has been performed. CONCLUSIONS: The treatment of small renal masses keeps being surgical excision. Radiofrequency ablationrepresents an alternative for carefully selected patients due to its low morbidity and few complications. There are not long term efficacy studies to date. Laparoscopic radiofrequency ablation would be indicated in cases in which the percutaneous approach is complicated due to tumor site.

Renal cell adenocarcinoma requires different therapeutic pathways because it is one of the most therapy-resistant tumors, on the other hand it is biologically one of the most attractive tumors. Its pathological classification has a genetic base. There is an anomaly of the Von Hippel Lindau gene in 80% of adenocarcinomas, being this fact determinant to know the biological characteristics of tumor initiation and development, as well as the identification of factors susceptible to be used as therapeutic targets. Since 2005 a group of molecules have been used in the treatment of metastatic adenocarcinomas and, even though therapeutic results are significant but not clinically relevant yet, we are sure they are a key way for more efficient future developments.The present study tries to make a tour on the research of the biological anomaliesin renal adenocarcinoma with special emphasis in the Von HippelLindau gene.

Acute kidney injury (AKI) can occur spontaneously or iatrogenically, and rates of AKI continue to rise over the last two decades despite improvements in clinical care and development of preventive strategies. Serum creatinine (sCr) is the current gold standard for measuring changes in kidney function and identifying AKI. Detection of AKI by sCr, however, is delayed and small rises connote significantly increased morbidity and mortality. Diagnosis of AKI by sCr is therefore likely too late to prevent some of the early structural changes that characterize renal injury. Several urinary biomarkers including neutrophil gelatinase-associated lipocalin (NGAL), N-acetyl-β-D-glucosaminidase (NAG), Interleukin-18 (IL-18), kidney injury molecule-1 (KIM-1), liver fatty-acid-binding protein (L-FABP), and cystatin-C, have shown an ability to predict AKI days before an elevation in sCr, and a few even seem to predict AKI-related morbidity and mortality better than sCr alone. A review of the current literature regarding these biomarkers reveals that they individually have unique strengths and weaknesses that can provide different types of information about patients. Currently, NGAL is the urine biomarker with the most promise as an individual marker. However, combining multiple markers to form a ‘biomarker panel’ along with sCr is an improvement over current clinical risk prediction models alone, and may be able to provide more individualized detail about the type and location of renal injury.

The objective of this paper is to discuss the role of open partial nephrectomy (OPN) for complex renal tumours and large renal tumours > 4 cm in the minimally invasive era. The current status of OPN, laparoscopic partial nephrectomy (LPN) and robotic PN are reviewed. The literature search is done using the National Library of Medicine database (PubMed).The indication of OPN has been extended to T1b tumours (4-7 cm). PN and radical nephrectomy (RN) provide equivalent oncological outcomes for these tumours. In addition, there is a growing application of OPN for complex tumours (centrally located, hilar, multifocal). Despite the more challenging cohort of patients, thereArch. Esp. Urol. 2013; 66 (1): 129-138is no increase in the overall morbidity of OPN. In contemporary cohorts there is an increase in overweight patients and a higher incidence of central tumours treated with OPN. LPN has been extended to select patients with larger renal masses (4–7 cm) and centrally located tumours. LPN for tumours > 4 cm was in the early phase associated with increased complication rate and prolonged warm ischemia time (WIT). Complication rates decreased with improvement of surgical technique and expertise. Early experience with robotic PN is promising and perioperative outcomes are at least comparable to LPN. LPN and robotic PN have to compete with the functional and oncological results of OPN.In the era of nephron-sparing surgery (NSS), OPN remains the established standard for the management of T1 renal tumours in centres without advanced laparoscopic expertise. Complex scenarios with centrally located tumours, tumours in a solitary kidney, and multifocal lesions probably are best managed with OPN. LPN is feasible in numerous clinical scenarios in centres with advanced laparoscopic expertise but remains a challenging operation. Long-term studies are needed to further define the role of the robotic approach for PN.

The present study does not establish comparisons of the different techniques (open, laparoscopic and robotic surgery); rather, it analyzes the how, when and why of each of them from a historical perspective.This historical analysis begins in the late XIX century and extends up to the present time.The study examines the principles, the uncertainties regarding the feasibility of the techniques, the failures, the complications, the doubts about whether the right thing is being done, and the success of a surgical treatment which is presently beyond question. The historical account is summarized, since it covers a period of over one hundred years.It is the history written by innovating and inspired men and women who changed the course of the treatment of renal neoplastic disease.

OBJECTIVES: To examine the role of laparoscopic partial nephrectomy in the management of small renal masses. METHODS: We searched MEDLINE (through March 2012) using PubMed, the Cochrane Central Search Library (though March 2012), and Web of Science (through March 2012). We retrieved citations using the text terms “small renal mass,” “laparoscopic,” “partial nephrectomy,” and “radical nephrectomy.” We limited the search to articles in the English language, to T1a renal tumors, and expanded the search using the related articles function. We also performed hand searches of references identified in electronically abstracted articles.RESULTS: There is a paucity of well conducted clinical trials to elucidate laparoscopic partial nephrectomy’s role.A number of assumptions had to be made to complete the review. Other than possibly less operative blood loss, less operative time, less inpatient stay time, and less cost, there was insufficient evidence to support laparoscopic partial nephrectomy over other modalities. Laparoscopic partial nephrectomy appears to have a higher rate of radical nephrectomy conversion.CONCLUSION: There is insufficient evidence to clearly state that laparoscopic partial nephrectomy is the gold standard in the management of small renal masses. If this skill is part of a surgeon’s armamentarium, it is certainly not inferior to other modalities, and may offer some benefit to patients.

We present our experience with surgical training programs development for basic and advanced laparoscopic urological surgery. Both training programs consist of 21 and 28 hours respectively. Basic surgical programs start with general knowledge of ergonomics and instrumentation, there after, attendants acquire basic skills on physical simulator. Posteriorly, techniques on animal model are undertaken, always assisted by an expert. Advanced activities start with surgical tasks on physical simulator. Posteriorly, reconstructive urological surgical techniques are undertaken on animal model, focused on partial nephrectomy, and always assisted by an expert tutor. We present our results on exophytic renal tumour model creation based chromatic Alginate

OBJECTIVES: Laparoscopic radical nephrectomy is considered to be the technique of choice in the management of stage T1 and T2 renal cancer, through increased expertise in this alternative type of surgery has served to expand its indications. In any case, these procedures have a series of limitations which are tied to the intrinsic characteristics of laparoscopic surgery, and associated with patient and tumor characteristics, and surgeon`s expertise.METHODS: We performed a bibliographic review through Pub Med database.RESULTS: The present study discusses the different indications and establishes the current limits of laparoscopic surgery applied to the management of renal tumors (including T3 and T4). Its role in cell-reducing therapy for metastatic disease, and the available methods to reduce tumor implantation in the surgical ports are also commented.CONCLUSIONS: Radical laparoscopic surgery is the technique of choice for the treatment of renal tumors in stage T1 and T2. There are not significant differences among the different approaches, and it haslower incision-related morbidity compared to traditional surgery, a shorter period of convalescence and the same oncological efficacy.

OBJECTIVES: The diagnosis of low clinical stage renal cancer has risen up during the last years thanks to the advances on radiological imaging tools. As a result, several minimally invasive techniques have appearedwhich offer the same oncological results than conventional/laparoscopic surgery withouttheir morbidity. One of these techniques is percutaneous radiofrequency (RF). In this paper we expose the oncological and functional outcomes of percutaneous RF after a review of the literature.METHODS: We made a search using the principal medical libraries as theCochrane Central of clinical controlled trials, Medline and the ExcerptaMedica database.We used the following terms: “renal radiofrequency ablation US guided”, “renal radiofrequency ablation CT guided “, “renal radiofrequency ablation MR guided”,” renal radiofrequency ablation “,” renal radiofrequency ablation image guided”. A methodological and clinical expert analyzed each abstract.All studies where renal cancer or small renal masses were treated were included. We excluded series with hereditary renal cancer only or metastatic cancer, technical series and those where tumor recurrence or other oncological criteria were not evaluated. Data collection included patient age, tumor size, follow up and oncological data. The oncological data evaluated included: tumor local recurrence (radiological or pathologic evidence of residual disease after initial treatment, independently of time to recurrence, accordingly to the recommendations of the Working group on image guided tumor ablation) or distant metastasesRESULTS: There were a total of 1621 papers. Only 24 met the inclusion criteria, and we only found 1 controlled trial, and several retrospective studies and series of cases. A total of 11, 10 y 3 for US, CT and MR guided RF, respectively, with a follow up of 1-57 months, with a total of 1764 tumors in 1524 patients. Tumor size was 1 to 8.9cm and local recurrence between0%-15.06%CONCLUSIONS: Surgical treatment remains the “gold standard” for clinical stage I renal cancer because we do not have enough long term scientific information to be sure that percutaneous renal RF offersthe same oncological results than surgery, but percutaneous renal RF is an option for those patients that are not candidates to surgery.

OBJECTIVES: Early diagnosis of renal masses has resulted in most of them being smaller than in the past, so that up to 61% of masses diagnosed are ≤ 4 cm. Due to this fact the term small renal mass (SRM) has been forged, and there is a search to determine their biology. The objective of this article is to detail the possible help of pathology in this task.METHODS: We performed a PubMed review ofthe bibliography from January 2000 to march 2012.RESULTS: Preoperative CT scan evaluation of the size of the renal masses correlates well with specimen measures(It only exceeds 3.1 mm).Size and growing speed do not allow recognizing benign masses, although it is true that the smaller the mass and the slower the growing speed the less aggressive the biology. Biopsy of the mass is the best method to determine the biology; it usually obtains valid material in 80.6% of the cases, and among them histologic subtype is determined in 88% to 93% of the cases and grade from 63.5% to 68%, with good reproducibility between observers (kappa from 0.010 to 0.830).This diagnostic capacity may increase joining biopsy and FNAC (reaching up to 96.5%) or determining some immunohistochemical markers (increase from 9% to 18%) or using some FISH (7% increase) or molecular methods (11.7% increase).CONCLUSION: The biopsy of SRMs is useful and may answer the new demands to determine their nature and help therapeutic indications both surgical and with new drugs.

OBJECTIVE: The purpose of this review isto provide an overview of the possibilities and drawbac-ks of the various possibilities of renal parenchymalcooling during laparoscopic partial nephrectomy andalso give an outlook into future developments.METHODS: In January 2012 a PubMed Search usingthe search terms “partial nephrectomy, cooling,” followedby a systematic and critical review was performed.CONCLUSION: Renal cooling during laparoscopicpartial nephrectomy is a feasible, safe and effective pro-cedure to expand ischemia time up to over 60 minutes,without risking significant and long lasting deteriorationof renal function. It can be of value in patients with animperative indication for partial nephrectomy, like solita-ry kidneys, synchronous bilateral tumors or renal failurein the opposite kidney as well as for patients at risk fordeterioration of renal function and in any situation, whe-re you think to yourself that 20 minutes will be maybenot enough to finish the job technically. Renal arterialperfusion provides the clinically best-studied option inthis situation followed by ice-cold saline irrigation. Othersurface coolants look promising, but still lack clinicaldata

Renal graft neoplasias are a rarecomplication,possibly due to the immunosuppressive therapyitself and increased susceptibility to potentially oncoge-nic viruses. Few case series have been reported in theliterature on the treatment of such tumors, so far there isno clear consensus on how to deal with them. We con-ducted an exhaustive review of the literature to examinethe treatmentperformed by different authors

OBJECTIVES: To analize the current role of target therapies in the treatment of small renal masses.METHODS: We performed a bibliographic review on the effect of target therapies on primary renal tumor, including our initial experience with two cases of small renal tumor in single kidneys treated with sunitinib.RESULTS: There is very limited experience with target therapies, being possible to use them, as the reviewed literature shows, to increase safety in nephron sparing surgery or tissue ablation technique, or as the treatment for small renal tumors in patients with single kidney in whom nephron sparing surgery is not feasible. Of our two cases with small renal tumors in patients with single kidney, the first case has had complete response to sunitinib after 21 months of follow up, and the second has had tumor stabilization after 33 months of follow up, shifting from sunitinib to pazopanib due to intolerance.CONCLUSIONS: The indication of target therapies in the treatment of metastatic renal cancer could be expanded. These therapies could be useful in localized small renal cancer and, although experience with this indication is limited, results are promising

OBJECTIVES: We aim to analyse the role of new technologies in management of small renal cancer.METHODS: We perform a non-systematic review of the literature in Medline, Cochrane Database of Systematic Reviews between period 2000-2012, using following mesh terms: partial nephrectomy, renal ablative technologies, and renal cancer.RESULTS: We don’t review in this article ablative technologies such as cryotherapy, radiofrequency, as they are the subject of others manuscripts within this monographic issue. We focus on high intensity ultrasounds (HIFU) microwaves therapy, radiosurgery, laser and water jet dissection. CONCLUSIONS: New technologies in partial nephrectomy are under constant and vertiginous evolution. Although efficacy has been demonstrated in short term and isolated studies, more studies, better designed, with bigger sample size and longer follow up are needed.

Over the last 20 years surgery has suffered a dramatic change. We saw how open surgery was almost replaced by laparoscopic surgery and this latter has evolved to minimally invasive surgical techniques such as LaparoEndoscopic Single-site Surgery (LESS) and NOTES ((Natural Orifice Transluminal Endoscopic These minimally invasive operations try to maximally reduce the size and number of abdominal scars in order to minimize morbidity, reducing surgical aggression and therefore the need for analgesia during the postoperative period, and they offer excellent cosmetic results. LESS surgery implies the performance of intra-abdominal surgery through a single 3-4 cm incision, through which laparoscopic instruments are introduced. This may be considered the next step in the evolution of laparoscopic surgery advancing to the ideal of scarless surgery. This modality is having great acceptance, since it allows the insertion of an extra trocar at any time transforming it in conventional laparoscopic surgery. Furthermore, when performing the incision within the umbilical scar, it enables concealing the incision in it at the end of the operation, achieving very good cosmetic results. NOTES surgery would be another step forward. Pure NOTES techniques in the field of Urology are very complex to perform today with the available equipment. Hybrid NOTES and assisted NOTES are variations described which have demonstrated they are viable and offer very good cosmetic results and lower morbidity. Regarding this, the vaginal approach offers a good working channel that can also be used for specimen extraction. Recent published studies confirm the feasibility and reproducibility of both techniques in urologic surgery, specifically in the treatment of renal cancer, with comparable results to conventional laparoscopic surgery.

The warm ischaemia time appears the most prominent modifiable risk factor for the development of renal impairment following laparoscopic partial nephrectomy. Historically, hilar clamping was the ‘gold standard’ technique, but now we are pushing our techniques to achieve the ultimate: ‘zero ischaemia’ approach. Results from ‘early unclamping’ techniques reinforced the importance of ‘every minute counts’ (28). Subsequent techniques in non-hilar clamping demonstrated that this approach was indeed feasible, but at the expense of higher bleeding, positive margins, and collecting system breach rates. With the advancement of technology, through the use of robotic assistance, improved haemostatic agents, as well as various imaging modalities (laparoscopic ultrasound, CT angiography), the surgeon can now potentially perform Nephron Sparing Surgery (NSS) in a more precise manner. Specifically, with the use of superselective clamping of the feeding vessel(s) to the tumour, the remaining healthy renal parenchyma should be less compromised, with associated low bleeding rates. NSS in the form of laparoscopic partial nephrectomy is clearly evolving, with increasing demands on the surgeon, requiring more expertise and experience, with the added assistance from other specialties (anaesthetists, radiologists etc). To be able to regularly perform Laparoscopic Partial Nephrectomy (LPN) without ischaemia safely, the laparoscopist must develop his / her experience in a stepwise fashion, perhaps commencing with artery-only clamping, leading on to early declamping, and then ‘on demand’ clamping. When moving on to LPN without ischaemia, patient selection is paramount. The ideal patient would harbour a single small, polar, exophytic renal mass with a normal functioning contralateral kidney. Although currently the techniques and outcomes laparoscopic partial nephrectomy without ischaemia published are limited to a few authors, with no current long term results to prove its full worth and reproducibility, early results are very encouraging. The pursuit of acquiring ‘zero ischaemia’ is clearly worthwhile, but needs to be measured against the potential risks of increased morbidity and positive margin rates.

Over the last decade the widespread use of abdominal axial imaging has led to a significant rise in the number of incidentally discovered renal cortical neoplasms. Among the available treatment options for ablative therapies cryoablation (CA) and radiofrequency ablation (RFA) has established themselves as feasible and viable alternatives to partial nephrectomy (open/laparoscopic/robotic).The purpose of this manuscript is to compare RFA and CA. In order to do so, it is paramount to fully understand the small renal mass dilemma and to have a working knowledge as to how these technologies achieve cellular destruction.

OBJECTIVES: To provide an up-to-date review of the available literature on laparoscopic cryotherapy for small renal masses (SRMs) including technique description, indications and outcomes.METHODS: A systematic literature search was conducted in March 2012, using MEDLINE and EMBASE via Ovid databases, to identify studies on laparoscopic cryotherapy for SRMs published during the last 10 years. Only English-language and human-based full manuscripts reporting case series studies with >20 participants, patient characteristics, efficacy and safety data were included.RESULTS:No randomised controlled trials (RCTs) were identified. In total, 27 full reports addressing laparoscopic cryoablation (LCA) for SRMs were selected. The number of patients per study ranged from 20 to 144. Mean age of treated patients across the series ranged from 62 to 73 years. Mean size of renal tumors ranged from 2.7 to 4 cm, being in most cases <3 cm. The number of cryoprobes used for cryoablation ranged from 1 to 6, and only 10 series described the use of 17-gauge (1.47 mm) third-generation needles. Overall, more than 55% of all ablated lesions were pathologically confirmed RCC.Mean follow-up ranged from 9 to 93 months. Only 7 series presented a long-term follow-up of more than 36 months. Most studies were limited by a relatively short follow-up. At least four urologic groups reported intermediate- and long-term outcomes. Persistence rates ranged from 0% to 17% and recurrence rates ranged from 0% to 14%. Overall complication rates ranged from 0% to 40%.CONCLUSIONS: Retrospective observational data and a few prospective series on LCA of SRMs show acceptable oncological 3- to 5-year outcomes with a low recurrence rate. It has proven to be a safe procedure with an overall low complication rate. It is mainly indicated for SRMs in elderly patients affected by co-morbidity and high surgical risk bearing tumours in the anterior valve of the kidney or in contact with the ureter or neighbouring organs.