Introduction: Metallothioneins (MTs) are a group of low-molecular weight, cysteine-rich proteins. In general, MT is known to modulate three fundamental processes: (1) the release of gaseous mediators such as hydroxyl radical or nitric oxide, (2) apoptosis and (3) the binding and exchange of heavy metals such as zinc, cadmium or copper. Previous studies have shown a positive correlation between the expression of MT with invasion, metastasis and poor prognosis in various cancers. Most of the previous studies primarily used immunohistochemistry to analyze localization of MT in renal cell carcinoma (RCC). No information is available on the gene expression of MT2A isoform in different types and grades of RCC. Materials and Methods: In the present study, total RNA was isolated from 38 histopathologically confirmed cases of RCC of different types and grades. Corresponding adjacent normal renal parenchyma was taken as control. Real-time polymerase chain reaction (RT PCR) analysis was done for the MT2A gene expression using b-actin as an internal control. All statistical calculations were performed using SPSS software. Results: The MT2A gene expression was found to be significantly increased (P < 0.01) in clear cell RCC in comparison with the adjacent normal renal parenchyma. The expression of MT2A was two to three-fold higher in sarcomatoid RCC, whereas there was no change in papillary and collecting duct RCC. MT2A gene expression was significantly higher in lower grade (grades I and II, P < 0.05), while no change was observed in high-grade tumor (grade III and IV) in comparison to adjacent normal renal tissue. Conclusion: The first report of the expression of MT2A in different types and grades of RCC and also these data further support the role of MT2A in tumorigenesis.

Introduction: Shortening of telomere is associated with cellular senescence and cancer. This study aims to investigate the relationship between tumor grade and recurrence in relation to telomere length (TL), telomerase activity (TA) and telomere-binding proteins expression (TBPs) in patients with non-muscle invasive bladder cancer (NMIBC). Materials and Methods: Tumor/healthy tissues were collected from 58 patients (35 with and 23 without NMIBC). Cystoscopy was performed at 3, 6 and 12 months to determine recurrence. Tumor grades and recurrence were correlated with TL, TA and TBPs using the Kruskal-Wallis non-parametric test. Results were considered significant at P < 0.05. Results: Histological evaluation indicated 15 patients (42.9%) with high-grade (HG) and 20 patients (57.1%) with low-grade (LG) NMIBC. TL, TA and TBPs were found to be significantly different in tumors as compared with controls. A significant (p < 0.05) difference in the expression of TBPs was observed in the disease-free mucosa of cancer patients as compared with HG and LG tumors. In the follow-up, a total of 11 tumor recurrences were observed; among these eight recurrences were observed in patients with HG tumors and three in patients with LG tumors. TL,  Human telomerase reverse transcriptase (hTERT) (that represents TA) and poly (ADP-ribose) polymerase 1 (PARP-1) in tumor samples and telomeric repeat binding factors TRF1, TRF2 and tankyrase (TANK) in normal mucosa obtained from the tumor group were respectively found to exhibit a positive and negative association with the risk of recurrence. Conclusions: Our study demonstrates that TL, TA and TBPs are altered in tumors and non-cancerous mucosa in patients with papillary urothelial NMIBC. Further studies are warranted to identify their suitability as a potential biomarker.

Introduction: The international prostate symptom score (IPSS) is commonly used in the evaluation of the severity of symptoms of patients with prostatic enlargement. It is a self-administered questionnaire. It has not been validated in any Indian language and an English version is used which can be difficult to interpret by our patients who do not have English as their primary language. In this study, we evaluate the patient's ability to understand the IPSS by comparing the scores when the IPSS questionnaire was self-administered versus when it was administered using the assistance of a clinician. Materials and Methods: Patients who presented with lower urinary tract symptoms suggestive of benign prostatic hyperplasia, who had passed at least twelfth grade of school and had a reasonable command over English were included in the study. They were allowed to self-administer the IPSS questionnaire following which a clinician, blinded to these scores, assisted the patient in filling the questionnaire. For each question, the score in both the questionnaires was noted and kappa agreement statistical test was used to assess the agreement between the two scores. Results: A total of 87 patients were included in the study. It was found that none of the questions had a perfect agreement of scores in the self-administered and the assisted administration. Conclusion: Our results show that our patients misinterpret the IPSS questionnaire. This problem can lead to significant errors in interpretation of the symptom severity.

Introduction: Although laparoscopic donor nephrectomy (LDN) is being performed at many centers, there are reservations on the routine use of laparoscopy for harvesting the right kidney due to a perception of technical complexity and increased incidence of allograft failure, renal vein thrombosis and the need for more back-table reconstruction along with increased operative time. Materials and Methods: We performed a prospective non-randomized comparison of transperitoneal laparoscopic left donor nephrectomy (LLDN) with laparoscopic right donor nephrectomy (RLDN) from August 2008 to May 2013. The operative time, warm ischemia time, intraoperative events, blood loss and post-operative parameters were recorded. The renal recipient parameters, including post-operative creatinine, episodes of acute tubular necrosis (ATN)  and delayed graft function were also recorded. Results: A total of 188 LDN were performed between August 2008 and May 2013, including 164 LLDN and 24 RLDN. The demographic characteristics between the two groups were comparable. The operative duration was in favor of the right donor group, while warm ischemia time, estimated blood loss and mean length of hospital stay were similar between the two groups. Overall renal functional outcomes were comparable between the two donor groups, while the recipient outcomes including creatinine at discharge were also comparable. Conclusions: RLDN has a safety profile comparable with LLDN, even in those with complex vascular anatomy, and can be successfully performed by the transperitoneal route with no added morbidity. RLDN requires lesser operative time with comparable morbidity.

Objective: This prospective randomized study was designed to evaluate the feasibility and outcome of transmesocolic laparoscopic pyeloplasty (TMP) and compare it with retrocolic laparoscopic pyeloplasty (RLP) in pediatric and adolescent patients. Materials and Methods: Between September 2006 to May 2012, data of pediatric and adolescent patients undergoing laparoscopic pyeloplasty were recorded in a prospective manner. Data included age, pelvic volume, presence of stones, aberrant vessels, operative time, analgesics requirement and time to accept oral feeds and drain removal. Patients with left side pelviureteric junction obstruction with any size of pelvic volume, with or without renal stones and aberrant vessels were included in the study. Patients were assigned into two groups by simple randomization technique. A total of 38 TMP and 41 left sided RLP were performed. Median follow-up period for transmesocolic group was 12.5 months (9.5-62 months) and 14 months (8-66 months) for retro colic group. Outcome for this study was adequate drainage on renal scan, improvement in symptom and or resolution of hydronephrosis on ultrasound. Statistical analysis was performed using the Mann-Whitney test. Results: The mean patient age was 8.73 years in RLP and 7.73 years in TMP. In RLP group the mean operative time was 75.84 min (time from port insertion to pyeloplasty) and 135.4 min (total operative time) while it was 44.82 min and 104.82 min respectively in TMP group. Compared with classic RLP, TMP cases showed a significant reduction in operative time. Conclusions: The transmesocolic approach for left sided pyeloplasty enables a shorter operative time even in the presence of large pelvis, aberrant vessel and stones without increasing morbidity in comparison to RLP approach.

Introduction: The objective of this study is to compare intrafascial nerve-sparing (NS), interfascial NS and non-NS prostatecomy specimens to assess the feasibility of NS technique in Robot-assisted radical prostatectomies (RARP). Materials and Methods: The records of the first 43 consecutive patients (86 prostatic sides (lobe) who underwent NS RARP (6 intrafascial NS, 46 interfacial NS, 34 non-NS) were reviewed and histopathological examinations were performed. The presence and distribution of periprostatic neurovascular structures were histologically evaluated using mid-gland section of each prostate lobe in the prostatectomy specimen and it was immunostained with the S-100 antibody for quantitative analysis of nerves. Results: The average number of nerve fibers per prostatic half was 37.2 ± 20.6. The number of resected peri-prostatic nerves counted was 13.7 ± 13.5, 30.5 ± 15.0 and 50.4 ± 20.4 in intrafascial NS, interfascial NS and non-NS specimens, respectively. The difference in the number of nerve bundle counts in the three groups was statistically significant (P < 0.05). Patients with urinary continence at 6 months after surgery had significantly less number of nerve fibers resected with the prostate than the incontinence group (P = 0.013) and the number of nerve fi bers resected in the potent group were lower than in the impotent group but did not reach statistical significance (P = 0.057). Conclusions: Our study showed that NS RARP could be performed according to surgeons' intention (intrafascial, interfascial or non-NS) and urinary continence significantly correlated to the number of nerve fibers resected with the prostate.

There have been a number of advances in robotic partial nephrectomy (RPN) for renal masses. We reviewed these advances with emphasis on the evolution of technique and outcomes as well as the expanding indications for RPN. Literature in the English language was reviewed using the National Library of Medicine database. Relevant articles were extracted, and their citations were utilized to broaden our search. The identified articles were reviewed and summarized with a focus on novel developments. RPN is an evolving procedure and is an emerging viable alternative to laparoscopic partial nephrectomy and open partial nephrectomy with favorable outcomes. The contemporary techniques used for RPN demonstrate excellent perioperative outcomes. The short-term oncologic outcomes are comparable to those of laparoscopic and open surgical approaches. Further studies are needed to assess long-term oncologic control.

Robotic surgery has been applied to increasingly complex urologic procedures since its initial widespread adoption for prostatectomy. While laparoscopic nephrectomy was initially reported over 2 decades ago, renal tumors involving the inferior vena cava (IVC) appeared to be a limitation to the application of laparoscopy. Laparoscopic management had only been reported in a limited fashion for short tumor thrombi not requiring cross-clamping of the IVC. The first robotic nephrectomy for renal cancer with IVC tumor thrombus was performed in 2008 with the first series reported in 2011, including for larger tumor thrombi requiring IVC cross-clamping for thrombus extraction. Since then, several surgeons at various institutions have adopted robotic surgery for these complex procedures. With experience and meticulous surgical technique, the procedure can be reproduced in properly selected cases. Further adoption and reports of multi-institutional experiences are necessary to validate this still relatively new procedure, and such work is already underway.

Kidney transplantation is the standard of care for patients with end stage renal disease. While open surgery remains the gold standard, minimally invasive surgery has recently been introduced for the recipient undergoing kidney transplantation. We review the evolution of techniques of minimally invasive surgery for kidney transplantation with specific emphasis on technical aspects of robotic assisted kidney transplantation.

Introduction and Objectives: The benefits of robotic surgery when compared to standard laparoscopy have been well established, especially when it comes to reconstructive procedures. The application of robotic technology to laparoscopic pyeloplasty has reduced the steep learning curve associated with the procedure. Consequently, this has allowed surgeons who are less experienced with laparoscopy to offer this treatment to their patients, instead of referring them to "centers of excellence". Robotic pyeloplasty has also proved useful for repairing secondary UPJO, a procedure which is considered extremely difficult using a conventional laparoscopic approach. Finally, the pursuit of "scarless" surgery has seen the development of laparoendoscopic single site (LESS) procedures. The application of robotics to LESS (R-LESS) has also reduced the difficulty in performing conventional LESS pyeloplasty. Herein we present a literature review with regards to robotic-assisted laparoscopic pyeloplasty. We also discuss the benefits of robotic surgery with regards to reconstruction of the lower urinary tract. Materials and Methods: A systematic literature review was performed using PubMed to identify relevant studies. There were no time restrictions applied to the search, but only studies in English were included. We utilized the following search terms: Ureteropelvic junction obstruction and laparoscopy; laparoscopic pyeloplasty; robotic pyeloplasty; robotic ureteric reimplantation; robotic ureteroneocystostomy; robotic boari flap; robotic psoas hitch. Results: There has been considerable experience in the literature with robotic pyeloplasty. Unfortunately, no prospective randomized studies have been conducted, however there are a number of meta analyses and systematic reviews. While there are no clear benefits when it comes to surgical and functional outcomes when compared to standard laparoscopic pyeloplasty, it is clear that robotics makes the operation easier to perform. There is also a benefit to the robotic approach when performing a redo-pyeloplasty. Robotic pyeloplasty has also been applied to the pediatric population, and there may be a benefit in older children while in very young patients, retroperitoneal open pyeloplasty is still the gold standard. In the field of single incision surgery R-LESS is technically easier to perform than conventional LESS. However, the design of the current robotic platform is not completely suited for this application, limiting its utility and often requiring a larger incision. Optimized R-LESS specific technology is awaited. What is clear, from a number of analyses, is that robotic pyeloplasty is considerably more expensive than the laparoscopic approach, largely due to costs of instrumentation and the capital expense of the robot. Until cheaper robotic technology is available, this technique will continue to be expensive, and a cost-benefit analysis must be undertaken by each hospital planning to undertake this surgery. Finally, the benefits of upper tract reconstruction apply equally to the lower tract although there is considerably less experience. However, there have been a number of studies demonstrating the technical feasibility of ureteral reimplantation. Conclusions: Robotic-assisted laparoscopic pyeloplasty is gaining popularity, likely due to the shorter learning curve, greater surgeon comfort, and easier intracorporeal suturing. This has allowed more surgeons to perform the procedure, improving accessibility. Robotic technology is also beneficial in the field of LESS. Nevertheless, the procedure still is not as cost-effective as the conventional laparoscopic approach, and until more affordable robotic technology is available, it will not be universally offered.

Introduction: Radical cystectomy is the gold-standard treatment for muscle-invasive and refractory nonmuscle-invasive bladder cancer. We describe our technique for robotic radical cystectomy (RRC) and intracorporeal urinary diversion (ICUD), that replicates open surgical principles, and present our preliminary results. Materials and Methods: Specific descriptions for preoperative planning, surgical technique, and postoperative care are provided. Demographics, perioperative and 30-day complications data were collected prospectively and retrospectively analyzed. Learning curve trends were analyzed individually for ileal conduits (IC) and neobladders (NB). SAS ^® Software Version 9.3 was used for statistical analyses with statistical significance set at P < 0.05. Results: Between July 2010 and September 2013, RRC and lymph node dissection with ICUD were performed in 103 consecutive patients (orthotopic NB=46, IC 57). All procedures were completed robotically replicating the open surgical principles. The learning curve trends showed a significant reduction in hospital stay for both IC (11 vs. 6-day, P < 0.01) and orthotopic NB (13 vs. 7.5-day, P < 0.01) when comparing the first third of the cohort with the rest of the group. Overall median (range) operative time and estimated blood loss was 7 h (4.8-13) and 200 mL (50-1200), respectively. Within 30-day postoperatively, complications occurred in 61 (59%) patients, with the majority being low grade (n = 43), and no patient died. Median (range) nodes yield was 36 (0-106) and 4 (3.9%) specimens had positive surgical margins. Conclusions: Robotic radical cystectomy with totally ICUD is safe and feasible. It can be performed using the established open surgical principles with encouraging perioperative outcomes.

Introduction: The aim of this report is to describe our surgical technique of totally intracorporeal robotic assisted radical cystectomy (RARC) with neobladder formation. Materials and Methods: Between December 2003 and March 2013, a total of 147 patients (118 male, 29 female) underwent totally intracorporeal RARC for urinary bladder cancer. We also performed a systematic search of Medline, Embase and PubMed databases using the terms RARC, robotic cystectomy, robot-assisted, totally intracorporeal RARC, intracorporeal neobladder, intracorporeal urinary diversion, oncological outcomes, functional outcomes, and complication rates. Results: The mean age of our patients was 64 years (range 37-87). On surgical pathology 47% had pT1 or less disease, 27% had pT2, 16% had pT3 and 10% had pT4. The mean number of lymph nodes removed was 21 (range 0-60). 24% of patients had lymph node positive dAQ1isease. Positive surgical margins occurred in 6 cases (4%). Mean follow-up was 31 months (range 4-115 months). Two patients (1.4%) died within 90 days of their operation. Using Kaplan-Meier analysis, overall survival and cancer specific survival at 60 months was 68% and 69.6%, respectively. 80 patients (54%) received a continent diversion with totally intracorporeal neobladder formation. In the neobladder subgroup median total operating time was 420 minutes (range 265-760). Daytime continence and satisfactory sexual function or potency at 12 months ranged between 70-90% in both men and women. Conclusions: Our experience with totally intracorporeal RARC demonstrates acceptable oncological and functional outcomes that suggest this is a viable alternative to open radical cystectomy.

Robot-assisted radical cystectomy (RARC) is an emerging operative alternative to open surgery for the management of invasive bladder cancer. Studies from single institutions provide limited data due to the small number of patients. In order to better understand the related outcomes, a world-wide consortium was established in 2006 of patients undergoing RARC, called the International Robotic Cystectomy Consortium (IRCC). Thus far, the IRCC has reported its findings on various areas of operative interest and continues to expand its capacity to include other operative modalities and transform it into the International Radical Cystectomy Consortium. This article summarizes the findings of the IRCC and highlights the future direction of the consortium.

Pelvic organ prolapse (POP) is a prevalent condition with 1 in 9 women seeking surgical treatment by the age of 80 years. Goals of treatment are relief and prevention of symptoms, and restoration of pelvic floor support. The gold standard for surgical treatment of POP has been abdominal sacrocolpopexy (ASC). However, emerging technologies have allowed for more minimally invasive approach including the use of laparoscopic assisted sacrocolpopexy and robotic assisted sacrocolpopexy (RASC). We performed a PubMed literature search for sacrocolpopexy, "robotic sacrocolpopexy" and "RASC" and reviewed all retrospective, prospective and randomized controlled trials. The techniques, objective and subjective outcomes and complications are discussed. The most frequent technique involves a polypropylene Y mesh attached to the anterior and posterior walls of the vagina with the single arm attached to the sacrum. Multiple concomitant procedures have been described including hysterectomy, anti-incontinence procedures and concomitant vaginal prolapse repairs. There are few studies comparing RASC to ASC, with the longest follow-up data showing no difference in subjective and objective outcomes. Anatomic success rates have been reported at 79-100% with up to 9% of patients requiring successive surgery for recurrence. Subjective success is poorly defi ned, but has been reported at 88-97%. Most common complications are urinary retention, urinary tract infection, bladder injury and vaginal mucosal injury. Mesh exposure is reported in up to 10% of patients. RASC allows for a minimally invasive approach to treatment of POP with comparable outcomes and low complication rates.

Introduction and Objectives: It has been established that robotic-assisted laparoscopic surgery has several advantages when compared with standard laparoscopic surgery. Optics, ergonomics, dexterity and precision are all enhanced with the use of a robotic platform. For these reasons, it was postulated that the application of robotics to laparoendoscopic single-site surgery (LESS) could overcome some of the constraints seen with the conventional laparoscopic approach. Issues such as instrument clashing, inability to achieve effective triangulation for dissection and difficulties with intracorporeal suturing have limited the widespread adoption of conventional LESS. The application of robotics has eliminated many of the constraints experienced with conventional LESS; however, challenges still remain. Materials and Methods: A systematic literature review was performed using PubMed to identify relevant studies. There were no time restrictions applied to the search, but only studies in English were included. We used the following search terms: Robotic single site surgery, robotic single port surgery, robotic single incision surgery and robotic laparoendoscopic single site surgery. Results: A number of centers have published their experience with robotic-laparoendoscopic single-site surgery (R-LESS); however, no prospective studies exist. What is clear is that R-LESS minimizes several of the difficulties experienced with conventional LESS, including intracorporeal suturing and triangulation during dissection. Outcomes are comparable to standard robotic surgery, with a trend toward improved cosmesis and reduced pain. However, a significant advantage with regard to these two factors has yet to be demonstrated. Conclusions: R-LESS is technically feasible and the benefits of robotic surgery eliminate many of the challenges seen with conventional LESS. However, despite the advantages of the robotic platform, R-LESS is not free of challenges. Instrument clashing remains an issue due to the bulky profile of the current robotic system. Other issues include lack of space for the assistant at the bedside, inability to incorporate the 4 ^th robotic arm for retraction and difficulties with triangulation. Although solutions for some of these issues are currently under development, R-LESS is still very much in its infancy.

Objectives: The objectives of this review are to summarize the current training modalities and assessment tools used in urological robotic surgery and to propose principles to guide the formation of a comprehensive robotics curriculum. Materials and Methods: The PUBMED database was systematically searched for relevant articles and their citations utilized to broaden our search. These articles were reviewed and summarized with a focus on novel developments. Results: A multitude of training modalities including didactic, dry lab, wet lab, and virtual reality have been developed. The use of these modalities can be divided into basic skills-based exercises and more advanced procedure-based exercises. Clinical training has largely followed traditional methods of surgical teaching with the exception of the unique development of tele-mentoring for the da Vinci interface. Tools to assess both real-life and simulator performance have been developed, including adaptions from Fundamentals of Laparoscopic Surgery and Objective Structured Assessment of Technical Skill, and novel tools such as Global Evaluative Assessment of Robotic Skills. Conclusions: The use of these different entities to create a standardized curriculum for robotic surgery remains elusive. Selection of training modalities and assessment tools should be based upon performance data-based validity and practical feasibility. Comparative assessment of different modalities (cross-modality validity) can help strengthen the development of common skill sets. Constant data collection must occur to guide continuing curriculum improvement.

Adrenocortical carcinoma (ACC) co-secreting aldosterone and cortisol is extremely rare. We report the case of a 37-yearold female who presented with paresis and facial puffiness. Evaluation revealed hypertension, hyperglycemia, severe hypokalemia and hyperaldosteronemia with elevated plasma aldosterone to renin ratio (ARR). Urinary free cortisol estimation showed elevated levels. Computed tomography scan revealed a right adrenal mass. Radical adrenalectomy specimen revealed ACC (T3N1). Post-operatively, the patient became normotensive and euglycemic with normalization of urinary cortisol and ARR. This case highlights the need for a complete evaluation in patients of hyperaldosteronism if overlapping symptoms of hypercortisolism are encountered, to avoid post-operative adrenal crisis.

Adrenocortical carcinoma is a rare disease. Additionally, in the case of coexisting pregnancy, there are diagnostic difficulties due to associated physiological hormonal changes as well as imaging limitations. Cushing's syndrome and virilization during pregnancy is a rare entity with few cases reported in the literature. Misdiagnosis is common as the syndrome may be easily confused with preeclampsia or gestational diabetes. We present the case of a 31-year-old pregnant woman with rapidly developing symptoms related to hormonally active adrenocortical cancer.

Penile hair tourniquet (PHT) is a painless form of penile ischemia, typically seen in toddlers with long-haired mothers, caused by entanglement of hair on the balano-prepucial sulcus, normally associated with circumcision. Its association with hypospadias has been reported only once. A school-aged boy admitted for surgery to treat hypospadias failure was incidentally detected to have PHT and severe hourglass deformity of the penis. Urethral anastomosis and glanuloplasty were done after removal of the constricting ring, without complications. Normal erections were reported during follow up. Treatment may involve urethral reconstruction and penile reimplantation in extreme cases.

Venous air embolism during percutaneous nephrolithotomy (PCNL) following air pyelogram or saline irrigation has been occasionally reported. We present a case of suspected venous air embolism during air pyelogram in a patient undergoing PCNL. The clinical diagnosis of air embolism was made by fall in end tidal carbon dioxide, blood pressure and Oxygen saturation and was conservatively managed. Early diagnosis with rapid resuscitation is the key to management of a patient with air embolism.

A lady of 52 years with painful bladder syndrome/interstitial cystitis (PBS/IC) presented with chronic pelvic pain, irritative voiding with sphincter dominance on urodynamics. 3 yrs of oral analgesics, antispasmodics and intravesical therapy was ineffective. We surmised her pain, and irritative voiding to be secondary to constant straining against a dysfunctional pelvic floor. We treated PBS/IC as a neuropathic phenomenon with a combination of neuromodulator medications and continuous caudal epidural analgesia to reduce the pain induced peripheral and central sensitisation. Botulinum toxin type A injection into pelvic floor muscles appeared to address their dysfuction. Clinical and urodynamics response was encouraging.

Xanthogranulomatous pyelonephritis (XGP) is an uncommon form of chronic pyelonephritis and a well recognized entity. It is rarely seen in children and neonates. The preoperative diagnosis is difficult and the etiology is still obscure. The condition is mostly diagnosed on nephrectomy specimen. The focal form mimicking neoplastic condition is rare. A case of XGP is reported here in an 8 month old child in which case nephrectomy was done with the clinical diagnosis of malignant renal tumor. Various modalities of preoperative diagnosis of this entity with conservative approach are also discussed.

A young lady presented with complaints of right flank pain and a palpable mass. On contrast-enhanced tomography (CECT), a renal mass with extension into the inferior vena cava (IVC) - suggestive of renal cell carcinoma - was diagnosed and she underwent radical nephrectomy with en bloc excision of the IVC thrombus. Histopathology revealed a benign arteriovenous malformation that had extended into the IVC. Arteriovenous malformation should therefore be kept in the list of differentials for a renal mass with IVC extension.