We demonstrate that single-stage URS/holmium laser lithotripsy is effective for management of renal stones that measure 2 to 3 cm through intermediate follow-up. Staged procedures can be used selectively for technical reasons or disease factors. Although PCNL achieves superior stone clearance overall, URS/laser lithotripsy is a viable treatment option for selected patients.

The adrenal gland is a potential site of metastasis for various malignancies. Metastases to the adrenal gland are the second most common type of adrenal mass lesion after adenomas. Differentiation of a metastatic lesion from a primary adrenal lesion can be challenging and requires the selective use of radiologic imaging, serologic testing, and adrenal biopsy. In patients who present with an isolated adrenal metastasis, adrenalectomy is often considered to aid in cancer control. Numerous studies have reported improved survival with resection of solitary adrenal metastases for various types of primary tumors. Traditionally, open adrenalectomy was the preferred option for these patients. More recently, laparoscopic adrenalectomy has offered a minimally invasive approach, with its resultant advantages of improved perioperative parameters. Proper patient selection for the laparoscopic versus open approach remains paramount in deciding the best treatment for the individual patient.

Purpose To investigate the differential impact of straddles (Ans and Bns) and noseless two–cheek seats (Antcs and Bntcs) on penile hemodynamics and perineal compressive forces in subjects who cycle in a stationary bicycle. Materials and Methods Subjects underwent cavernosal artery peak systolic velocity (CAPSV) measurements after intracavernosal injection of vasoactive agents while supine, sitting upright on an examination table, straddling a saddle, sitting on a seat, and again supine. Mean perineal compression pressures recorded while straddling the saddles were compared with those while sitting upright. Results No differences were found in right and left CAPSV values while supine, sitting upright on an examination table, sitting on a seat, and supine again. Right/left CAPSV (cm/second) values straddling Ans and saddle Bns (0.7 ± 2.9/1.5 ± 6.2 and 0/0, respectively) were significantly lower than values obtained while sitting on Antcs and Bntcs (25.6 ± 13.4/23.8 ± 12.0 and 17.3 ± 6.4/18.3 ± 6.5, respectively) (P < 0.001). Mean perineal compression pressures (mm Hg) on Ans and saddle Bns (315.2 ± 39 and 387.9 ± 64.3, respectively) were significantly higher than values obtained while sitting upright on an examination table (47.6 ± 5.2 and 46.0 ± 8.1, respectively) (P < 0.001). Conclusions We have identified an objective test to assess if an individual bicycle rider, sitting on a certain shape of bicycle saddle or seat generates sufficient compressive forces at the perineal–saddle interface to obstruct cavernosal arterial inflow. This study also demonstrated that straddling bicycle saddles with nose extensions is associated with perineum–saddle interface compressive pressures that exceed systolic perfusion pressures, significantly diminishing penile hemodynamics.

BACKGROUND Pelvi‐ureteric junction (PUJ) obstruction is characterized by a functionally significant impairment of urinary transport caused by intrinsic or extrinsic obstruction in the area where the ureter joins the renal pelvis. The majority of cases are congenital in origin; however, acquired conditions at the level of the ureteropelvic junction may also present with symptoms and signs of obstruction. Historically, open pyeloplasty and endoscopic techniques have been the main surgical options with the intent of complete excision or incision of the obstruction. The advent of laparoscopy and robotic‐assisted applications has allowed for minimally invasive reconstructive surgery that mirrors open surgical techniques. AIMS We review the current status of robotic‐assisted laparoscopic pyeloplasty and report on the result, continuing evolution, and potential role for this surgical procedure. MATERIALS AND METHODS A review of the recent literature encompassing laparoscopic and robotic‐assisted pyeloplasty was conducted with particular attention to operative techniques, surgical outcomes, and complication rates. RESULTS Laparoscopic and robotic‐assisted approaches are able to duplicate the open technique, and not surprisingly, are now being shown to be as efficacious as the gold standard open approach. The laparoscopic remains technically challenging due to the high proficiency level required for intracorporeal suturing, although added experience has resulted in shorter operative times. The advent of robotics has further expanded the breadth of this reconstructive procedure while preserving the benefits of decreased pain, shorter hospitalization, rapid convalescence, and an improved cosmetic result. DISCUSSION The introduction of robotics to the field of minimally invasive surgery facilitates this procedure and may allow for more widespread implementation by surgeons of varying skill levels. These benefits must be balanced against the increased costs of the robotic platform. CONCLUSION Clinical reports have demonstrated that robotic‐assisted pyeloplasty is a safe, feasible, and effective technique for treating ureteropelvic junction obstruction in short term studies. Additional studies with prolonged follow‐up will ultimately provide valuable information as to the long‐term efficacy of robotic‐assisted laparoscopic pyeloplasty.

For midureteral and distal-ureteral tumors not amenable to endoscopic resection, distal ureterectomy with ureteral reimplantation is a treatment option. When ureteral length is insufficient for direct reimplantation, additional length can be gained with either a psoas hitch or a Boari flap. We describe our technique for robot-assisted laparoscopic distal ureterectomy and ureteral reimplantation with psoas hitch.