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A potassium-titanyl-phosphate (KTP) laser through robotic endo-wrist instrument has been evaluated as an ablative and hemostatic tool in robotic assisted laparoscopic partial nephrectomy (RALPN). Ten RALPN were performed in five domestic female pigs. The partial nephrectomies were performed with bulldog clamping of the pedicle. Flexible glass fiber carrying 532-nm green light laser was used through a robotic endowrist instrument in two cases. Power usage from 4 to 10 W was tested. The laser probe was explored both as a cutting knife and for hemostasis. The pelvicalyceal system was closed with a running suture. Partial nephrectomies using KTP laser were performed without complications. Mean operative times and warm ischemia times for laser cases were 96 and 18 min, respectively. Mean estimated blood loss was 60 ml compared with 50 ml for non-laser cases. Complete hemostasis with the laser alone could be achieved with a power of 4 W and was found to be effective. In our hands the laser fiber powered up to 10 W was not effective as a quick cutting agent. Histopathologic analysis of the renal remnant revealed a cauterized surface effect with average laser penetration depth less than 1 mm and minimal surrounding cellular injury. The new robotic endowrist instrument carrying flexible glass fiber transmitting 532-nm green light laser is a useful addition to the armamentarium of the robotic urologic setup. Its control by the console surgeon enables quicker and more complete hemostasis of the cut surface in renal sparing surgery using a porcine model. Histologically proven lased depth of less than 1 mm suggests minimal parenchyma damage in an acute setting. Laser application as a cutting agent, however, requires further investigation with interval power settings beyond the limits of this preliminary study. We estimate that effective cutting should be possible with a setting lower than traditionally recommended for solid organs.

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The current NCCN guideline for management of atypical ductal hyperplasia (ADH) diagnosed on a breast core needle biopsy (CNB) includes surgical excision, frequent follow-up with mammograms, and chemoprevention with selective estrogen receptor modulator (SERM). Studies have shown that histological differentiation between ADH and usual ductal hyperplasia (UDH) on a CNB can sometimes be challenging. In our institution, "abnormal epithelial proliferation" (AEP) is a term coined to identify a pathologically worrisome entity on CNB that falls short of a diagnosis of ADH, but warrants surgical excision for further analysis. The objective of this study was to compare the follow-up surgical excision diagnosed as AEP or ADH on CNB. Retrospective review of the institutional pathology database between January 2011 and December 2012 identified 82 cases of AEP and 60 cases of ADH diagnosed on breast CNB and surgically excised at our institution. Pathology reports of both CNB and excisional biopsy were reviewed. An upgrade was defined as a change to DCIS or invasive carcinoma. A downgrade was defined when benign lesions such as UDH were reported. Patients with AEP and ADH had a similar upgrade rate (24% vs 28%, P > .05), while downgrading rate was significantly higher in the AEP group (44% vs 2%, P < .001). If this were to be a single cohort, wherein all of these cases carried a diagnosis of ADH on CNB (AEP + ADH = ADH), 25% of these patients would have a diagnosis downgraded to benign. By using AEP terminology, we do not lose our ability to diagnose a higher-grade lesion in the final excision. Meanwhile, by deferring the definitive diagnosis of ADH to excisional biopsy in appropriate situations, a subset of patients (25% in our study) were spared from SERM treatment and possible associated side effects, and the lifelong mental anxiety of being labeled as "high risk."