[in Japanese]

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  Increased use of cross-sectional imaging has led to an increase in the diagnosis of small renal masses （≤ 4cm）. Percutaneous renal cryoablation allows for a minimally invasive treatment option for select lesions and for the high risk surgical patient. Contemporary series suggest that renal cryoablation maintains good intermediate oncologic outcomes while minimizing patient morbidity. Over time, percutaneous renal cryoablation will play a central role in the management of patients with small renal masses, especially in elderly or comorbid patients.

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  In the last 2 decades, the number of incidentally discovered renal cortical neoplasms（RCN）has significantly risen. In response, treatment options have also evolved. The purpose of this paper is to review the details of cryoablation and RFA including patient selection, indications and contraindications, the mechanism of action, and a brief literature review. Additionally, our technique for both laparoscopic cryoablation（LCA）and percutaneous cryoablation（PCA）including management of complications and follow-up protocols will be detailed. A literature search was performed of MEDLINE using PubMed and relevant articles were included in the review. Correct application of either technology requires that the surgeon understands the technology, the mechanism of action, and incorporates the evolving concepts of these young therapeutic options. Emerging data suggests that both RFA and cryoablation are excellent alternatives to extirpative therapy.

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[in Japanese]

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  RFA is an optional modality in the focal therapy of the adrenal tumor. Percutaneous RFA under local anesthesia is a feasible, safe, and effective alternative treatment of the functioning adrenal tumor for the patients having refused the surgery due to high surgical risk, high age and the cosmetic viewpoint. And also percutaneous RFA may keep better QOL for patients with metastatic adrenal tumor who cannot expect convalescence compared with surgery or no treatment. The issues in focal therapy of adrenal tumor are the incomplete excision or destruction of lesions and recurrences of the tumors within normal adrenal. Percutaneous RFA is an easy repeatable procedure for the residual or the recurrent tumor. Percutaneous RFA is a promising treatment method superior in local control of the adrenal tumor.

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  Focal therapy is emerging as an alternative to active surveillance for the management of low-risk prostate cancer in carefully selected patients. The ideal patient group and an accurate method to localize cancer in the prostate is yet to be agreed upon the optimal ablative technique unknown. HIFU have enabled precision ablation to be delivered to almost millimeter accuracy. Early studies evaluating focal therapy have found a lower morbidity with acceptable short- to medium-term cancer control rates. More data from large trials on the safety and efficacy of focal therapy are required before this approach can be recommended in men with prostate cancer. Focal therapy appears to be a logical alternative to radical treatment and active surveillance, potentially combining cancer control and minimal morbidity.

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[in Japanese]

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[in Japanese]

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[in Japanese]

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  118 cases of laparoscopic partial nephrectomy were examined. No recurrent and death case due to renal cell cancer were experienced during 65 months. The renal function a month after the surgery was dependent on age, pre-operative renal function, renal ischemic time, heparin and manitol injection. The renal function twelve months after the surgery was dependent on age, renal ischemic time and pre-operative renal function. The difference between the effect of renal surface cooling and trans-ureteral cooling on the renal function was not defined. The average bleeding volume was 276±373ml, and the renal ischemic time was 44.4±15.9min. 2 cases of peri-renal bleeding after leaving hospital, and the same 2 cases just after the surgery were experienced. All of the cases were cured with non-surgical treatment. There were not critical complications, for example, injury of other organ, ileus, deep venous thrombosis, pneumonia, nephrectomy due to serious bleeding.

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[in Japanese]

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[in Japanese]

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  We have started using laparo-endoscopic single-site surgery（LESS）in urologic surgery, although its use has not gained momentum due to its level of difficulty. We here report our initial experience with transumbilical LESS for adrenal tumor by using a single port with a multichannel cannula（SILS port）and bent laparoscopic instrumentation. The intraperitoneal space was approached through the umbilicus. The SILS port was placed through a 2 cm incision at the inner edge of the umbilicus. A 5 mm flexible laparoscope was introduced to keep the laparoscope outside, and surgical specimens were extracted using an Endocatch bag. The transumbilical approach in LESS for adrenalectomy is safe and feasible and also improves cosmetic outcome as a scarless surgery compared with standard laparoscopic procedures. Improvements in surgical devices may aid the further development of this approach.

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  We present here the initial 6 patients undergoing laparo-endoscopic single site（LESS）live donor nephrectomy（LESS-DN）in Japan. Three trocars were inserted into the abdominal cavity through a 4-cm periumbilical longitudinal incision without special devices, such as R-Port. No extra skin incisions and trocar placement were made. Donor kidney was placed into the extraction bag and was retrieved through para-umbilical incision without any extra skin incision and transferred for bench preparation. Following case 3, pararectal incision was made and Rap Disk system was used. LESS-DN was successful in all 6 patients. Mean operative time was 299.3 minutes, blood loss was 228.3 ml, warm ischemia time was 5.9 minutes and hospital stay was 14 days. There were no intraoperative and postoperative complications. Each allograft functioned immediately on transplantation except for one case of hyperacute rejection and mean recipient serum creatinine levels were 1.14mg/dl at 1 month and 1.15 mg/dl at 3 months, respectively. LESS-DN could be carried out safely using standard instruments without complications in this initial series. Although LESS-DN had longer warm ischemia time comparing previous reports on standard laparoscopic living DN（LLDN）, early allograft function was comparable. LESS-DN has the potential to become a standard in the continuing evolution of minimally invasive surgery and should be evaluated in further randomized studies.

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  Introduction and objectives：To examine the safety and feasibility of laparoscopic radical nephrectomy in ESRD patients requiring hemodialysis with renal cell carcinoma.
  Materials and methods：One hundred and seventeen HD patients who underwent radical nephrectomy for renal cell carcinoma were the subjects of this study. One hundred and thirty nine laparoscopic radical nephrectomies were performed on 95 patients with unilateral RCC and 22 patients with bilateral RCC.
  Results：The transperitoneal and retroperitoneal approaches were selected in 10（7%）and 129（93%）, respectively. Eleven of 139 cases（8%）had perioperative and postoperative complications including A-V thrombotic occlusion in 2, intestinal damage in 2, local recurrence at removed kidney site in 2 and acute myocardial infarction, leakage of lympho fluid, hypercarcemia, angiocholitis, and pancreatitis each in 1. Ten cases（7%）were converted to open surgery.
  Conclusions：HD patients sometimes suffer unexpected complications as they often present with multiple comorbidities. It is necessary to examine these patients closely during the perioperative period.

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  Laparoscopic nephroureterectomy has been used to treat upper urinary tract urothelial cell carcinoma（UUT-UC）with reduced morbidity. We started retroperitoneal laparoscopic nephroureterectomy（RNU）using hand-assisted technique on December 2002. We performed a retrospective review of data from patients who underwent open nephroureterectomy（ONU）and RNU for UUT-UC from December 1990 to November 2010 at our institution. Overall, 57 patients underwent ONU and 56 underwent RNU. Patients and histological characteristics were similar between the two groups. Mean operating time was 289 mins for RNU and 240 mins for ONU（p=0.005）. The bladder recurrence rate, distant metastases, and cancer specific survival did not differ significantly between the two groups. RNU does not negatively affect long-term oncologic control and can be considered an alternative modality. However, long-term follow-up is necessary to recommend RNU for highly invasive or high grade tumors.

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  Long-term result of laparoscopic pyeloplasty （LPP）for ureteropelvic junction obstruction（UPJO）was investigated. Until March 2006, we performed LPP on 50 ureters in 47 patients with hydronephrosis due to UPJO. All procedures were performed transperitoneally, including Anderson-Hynes pyeloplasty, Fenger plasty, Y-V plasty and slit incisiton for 37, 10, 2 and one ureters, respectively. Seven postoperative minor complications were observed（14.6%）. During a median follow-up period of 91（58-146）months, re-stricture was observed in one ureter, which developed immediately after the stent removal. In addition, obstruction was not dissolved in two ureters. Remaining 47 ureters（94%）were regarded as success by improving symptoms and decreasing pelvic capacity associated with a patency of UPJ. Efficacy of LPP seems to be settled for long-term and, thus, LPP can be a powerful and less invasive alternative for surgical treatment of UPJO.

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  It is unknown whether there is clinical relevance between the skills of laparoscopic surgery and the experience of transurethral and open surgery.
  We assessed the results of various tasks performed using a laparoscopic virtual reality training system （LapVR^Ⓡ）for urological surgeons. Fourteen urological surgeons performed tasks using the LapVR^Ⓡ. The relation between the results of the tasks and the number of experiences of surgery was investigated. Statistically significant inverse correlations were observed between the ratio of right to left hand length of movement and the number of radical cystectomies conducted. This inverse correlation disappeared later in training.
  The experience of urological surgery may have a good influence on the results of some tasks of the LapVR^Ⓡ. This implies that all urological surgeries and experiences promote laparoscopic surgery skills.

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  Adrenalectomy was analyzed based on the data compiled between July and December each year by the DPC Research Group from 2006 to 2008, which is funded by the Ministry of Health, Labour and Welfare, Japan.
  In Japan, 75% of adrenalectomy have been managed in urology. In adrenalectomy cases done in urology, Laparoscopic procedure was chosen for 80% of the cases. Removal of adenal gland for benign adrenal tumor with laparotomy seemed to be more often in general surgery. In laparoscopic cases against benign adrenal tumor, the rate of blood transfusion was 3.3%, the length of stay was 14.5 days, the average duration of anesthesia was 201 min, and no related death was reported. Laparoscopic adrenalectomy seemed to lead better result in these parameters of surgical outcome than laparotomy.
  The analysis from DPC data unveiled that laparoscopic procedure becomes main stream in the choice of surgical treatment for adrenal tumor, regardless of surgeon's department.

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  Patients with pheochromocytoma are likely to be hypotensive and need vasopressor agents after tumor resection, even if hypotension has been treated with aggressive volume expansion. Our aim was to identify the clinical factors that influence post-resection hypotension and postoperative catecholamine support in patients with pheochromocytoma. The records of 44 patients who had undergone unilateral adrenalectomy for pheochromocytoma were surveyed retrospectively. The patients were divided into two groups according to whether catecholamine support was necessary or not postoperatively. Preoperative and intraoperative data, including clinical and biochemical variables, were evaluated. After surgery, 63.6% of the patients continued to require catecholamine support to keep blood pressure normal. Multivariate logistic regression analysis showed that patients who had had post-resection hypotension were significantly more likely to have a higher concentration of serum adrenaline preoperatively and greater catecholamine index intraoperatively. No variables were significantly correlated with the duration of postoperative catecholamine support.

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  Objectives：Between January 2005 and January 2010, 6 patients underwent transurethral uretroscopic incision of a ureteropelvic junction obstruction and ureteral stricture with flexible scissors at our hospital （Group S）. We reviewed the operative records, complications and outcomes and compared them with those who underwent a conventional laser incision（Group L）.
  Results：In Group L, the average preoperative stricture length was 8 mm（5-30）and the average incision length was 37 mm（15-100）, while in Group S, they were 7 mm（5-15）and 32 mm（15-60）, respectively. In Group S, the urinary flow improved in all patients（6/6 cases）, while in Group L, it improved in 15 out of 23 patients （65%）（P = 0.37）.
  Conclusion：In this study, there was a relatively small number of cases using flexible scissors compared to those in which a holmium YAG laser was used. The observed differences were not statistically significant because of the limited scale of the study. However, the outcomes of the uteroscopic endopyelotomies and endoureterotomies using flexible scissors were so encouraging that we believe flexible scissors could also be an effective option for treating uteropelvic junction obstruction and ureteral stricture.

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  Purpose：We evaluated the efficacy and clinical outcome of transurethral lithotripsy（TUL）for upper urinary tract stones.
  Materials and Methods：Between April 2002 and March 2010, we performed TUL in 229 patients（156 males 73 females）. The mean patient age was 57.2 years （range 21-88）. Lithotripsy was performed with a rigid ureteroscope and Lithoclast^Ⓡ for ureteral stones, and with a flexible ureteroscope and holmium-YAG（Ho-YAG）laser for renal stones. Effective treatment was defined as the patient becoming stone-free or having fragments less than 4 mm one month after TUL.
  Result：The overall effective rate was 83.4%（193/229）. The effective rate according to stone location was as followed：29.4% for stones in the renal pelvis and calix（R2）, 69.0% for those in the ureteropelvic junction（R3）, 84.8% for those in the upper ureter（U1）, 94.1% for those in the middle ureter（U2）, and 98.6% for those in the distal ureter（U3）.
  Conclusion：TUL is an effective and safe method of managing ureteral stones, but for renal stones more than 20 mm, TUL is not effective.

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  Objective：We describe our technique and experience of TAP（TUL-assisted PNL）in the modified Valdivia position.
  Patients and methods：From November 2007 to March 2011, 59 patients with complicated upper urinary tract stone disease were treated with TAP in the modified Valdivia position. Double continuous irrigation system was used to stretch the urinary tract, improve vision and wash out fragments.
  Results：All patients had only one percutaneous access tract achieved by combined ultrasonographic, fluoroscopic and endoscopic guidance. Stone-free rates were 77.6%. Blood transfusion was not administered, and fever＞38.5℃ occurred in 13.3% of patients.
  Conclusions：With a high success rate and a low major complication rate, TAP in the modified Valdivia position is efficient, safe without intraoperative re-positioning. We are sure that this method of intervention would be a standard and minimally invasive technique of endourological combined therapy for refractory upper urinary tract stone disease.

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  Purpose：We evaluated the efficacy of flexible transurethral ureterolithotripsy（TUL）for renal stones larger than 2 cm.
  Methods：We retrospectively identified patients who underwent TUL, extracorporeal shock wave lithotripsy（SWL）, and percutaneous nephrolithotomy（PNL）from January 2005 to July 2011 for renal stones larger than 2 cm.
  Results：A total of 25, 42, and 11 patients underwent TUL, SWL, and PNL, respectively. In the TUL group, the mean number of procedures was 1.5, stone-free rate was 88.0%, and complication rate was 28.0%. In the SWL group, the mean number of procedures was 4.5, stone-free rate was 35.7%, and complication rate was 35.7%. In the PNL group, the mean number of procedures was 1.4, stone-free rate was 45.5%, and complication rate was 45.5%.
  Conclusion：TUL is a reasonable option for renal stones larger than 2 cm.

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  A total of 110 men with BPH were treated with the TUEB procedure. In TUEB, incomplete enucleation is performed with a TUEB detaching blade, and this is followed by removal of the prostatic tissue by TURP. Median patient follow-up was 12 months（maximum 36 months）. The mean weight of removed prostate tissue was 26.9 g. The mean duration of surgery was 60 min. The mean decrease in hemoglobin level was 0.3 g/dl. Significant improvements in all voiding parameters were observed after surgery. There was a significant reduction in prostatic volume（preoperative, 53.2 ml； postoperative, 12.1 ml）, and there was a significant reduction in PSA level（preoperative, 6.7 ng/ml； postoperative, 1.5 ng/ml）. Complications included urethral stricture in 10.9% and bladder neck contracture in 1.8%. No patients developed transurethral resection syndrome or required blood transfusion.
  The long-term outcomes showed that TUEB was a minimally invasive and effective treatment for patients with BPH.

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  Of 135 patients for whom HoLEP（holmium laser enucleation of the prostate）was performed in this department between June 2009 and January 2011, 105 underwent enucleation with anteroposterior dissection HoLEP. This technique is relatively simple, capable of facilitating the completion of surgery regardless of the size of the adenoma, and expected to decrease the risk of stress urinary incontinence（SUI）, one of the post-operative complications. In order to normalize “ablation of the lateral lobes of the prostate at the 12-o’clock position”, we evaluated this procedure, technically the most difficult part of anteroposterior dissection HoLEP. As a result, it was possible to reach the ablation surface from the 12-o’clock position in all patients, and, hence, it was considered that this procedure can be normalized. In addition, this technique was thought to possibly decrease the early post-operative risk of SUI, because there was a significant decrease in SUI one month postoperatively.

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  Between September 2004 and December 2009, we reviewed 165 patients retrospectively who had undergone holmium laser enucleation of the prostate（HoLEP）at Kyoto university hospital, and investigated the incidence, prognostic factors, and clinical details of prostate and bladder cancer before and after the surgery. 14 （8.5%）and 5（3.0%）patients were diagnosed as prostate and bladder cancer, respectively. Prostate volume and enucleation weight were larger, and operation time was longer in patients with bladder cancer compared with in those without bladder cancer. However, patients with bladder cancer and those with prostate cancer had lower the International Prostate Symptom Score. In 2 cases, gross hematuria appeared and multiple superficial bladder cancers were diagnosed 5 and 9 months after the surgery, respectively. Even though preoperative prostate biopsies revealed no malignancy or we found no tumors during HoLEP, we should be aware of the probability of prostate and bladder cancer after surgery.

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  We evaluated operative results and perioperative complications after laparoscopic radical prostatectomy（LRP）based on 101 patients from January 2007 to December 2010. No open conversion was necessary in all cases. The mean operating time was 215 minutes and the estimated blood loss averaged 459ml. Both of them were significantly decreased by the surgical experience. There were 7（6.9%）intraoperative complications, including two rectal injuries（2.0%）. These injuries could be diagnosed intraoperatively and closed laparoscopically in two layers without subsequent complications. Although there were 18（17.8%）early complications, reoperation was not necessary in any case. The overall positive surgical margin rate was 31.7%（32 patients）. At 3 years, PSA failure had occurred in 19 patients and a Kaplan-Meier analysis estimated that PSA progression free survival rates was 74.4% at 3 years. Multivariate analysis revealed that positive surgical margins were independent predictors of PSA failure. A total of 96.4% of patients were continent 12 months after LRP. Thus, we concluded that LRP offered the benefits of minimally invasive surgery and did not compromise clinical or pathological outcomues.

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  We evaluated the impact of serum cytokine levels and genetic polymorphisms on surgical invasiveness in prostate cancer who underwent radical prostatectomy（RP）. We compared surgical invasiveness of open and laparoscopic by measuring the cytokine levels. One-hundred sixty-five patients were enrolled. Patient sera were obtained at three time points（pre-OP, post-OP, and POD1）, and six cytokine levels were measured using a multiplex bead array. Post-operative serum IL-6 levels were significantly associated with operative duration and estimated blood loss. Significant difference was observed in serum IL-10, IL-6, and IL-1β levels in patients who underwent laparoscopic and open RP. The mean post-OP serum IL-6 levels in patients with the CC genotype of the IL-6 receptor rs8192284 were significantly lower than in those with AA and AC genotypes. rs8192284 polymorphism influenced post-OP serum IL-6 levels. From the cytokine production standpoint, our data support the hypothesis that laparoscopic RP is less invasive than open RP.

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  Purpose：To evaluate the effectiveness of Sacral Surface Therapeutic Electrical Stimulation（ssTES）for recovery of urinary continence following laparoscopic radical prostatectomy（LRP）.
  Methods：Between July 2008 and June 2009, thirty-six patients with prostate cancer underwent LRP and were randomly assigned to two treatment groups for urinary continence. One group performed pelvic floor exercise alone beginning soon after LRP, while the other group was performed pelvic floor exercise and also received ssTES beginning soon after LRP. Urinary continence was defined as not requiring a pad to keep their clothing dry and continence was serially evaluated in each of these two groups 1, 3, 6 and 12 months postoperatively.
  Results：At 6 and 12 months postoperatively, recovery rate of urinary continence in the combined therapy group was significantly higher than that in the group performing pelvic floor exercise alone. On multivariable analysis, the addition of ssTES was significantly associated with recovery of urinary continence at 6 and 12 months postoperatively.
  Conclusions：The addition of ssTES effectively contributed to the recovery of urinary continence especially at 6 and 12 months postoperatively.

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  Introduction：We evaluated the accuracy of pathological diagnoses by percutaneous renal biopsy specimens after radiofrequency ablation（RFA）or transcatheter arterial embolization（TAE）.
  Materials and methods：Between July 2002 and February 2010, a total of 28 cases, which consisted of 17 cases with biopsies after RFA and 11 cases with biopsies after TAE, were enrolled.
  Results：The final pathological results of the diagnosed malignant tumors were 15 clear cell carcinomas and 2 chromophobes in the RFA group and 11 clear cell carcinomas in the TAE group. The rate of disrupted architecture in the RFA group was significantly higher than that in the TAE group（P＜0.005）.
  The accuracy of classification with the Fuhrman nuclear grade in the RFA group was significantly lower than that in the TAE group（P＜0.0001）.
  Conclusion：The diagnostic accuracy of the Fuhrman nuclear grade was relatively low in RFA cases.

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