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PD37-12 DAILY TADALAFIL DOES NOT INCREASE PRIAPISM RATES IN AN INTRACAVERNOSAL INJECTION (ICI) REHABILITATION PROGRAM, AFTER RADICAL PROSTATECTOMY (RP)
THE JOURNAL OF UROLOGYâ
e774
PD37-10 ERECTILE FUNCTION AFTER RADICAL PROSTATECTOMY e DO PATIENTS RETURN TO BASELINE? Mikkel Fode*, Roskilde and Herlev, Denmark; Anders Frey, Henrik Jakobsen, Jens Sønksen, Herlev, Denmark INTRODUCTION AND OBJECTIVES: Variations in study methodology have resulted in controversy regarding the incidence of erectile dysfunction (ED) after radical prostatectomy (RP). The most commonly utilized questionnaire is the International Index of Erectile Function (IIEF). However, this questionnaire has not been validated specifically for the situation. The purpose of this study was to assess post-RP ED as assessed by the IIEF-5 questionnaire and by subjective patient perception. METHODS: This is a sub-analysis from a cross-sectional questionnaire study in patients following RP (Frey et al, J. Sex. Med, 2014). Preoperative erectile function was evaluated using the IIEF-5. Disease characteristics and information regarding the surgeries were retrieved from a prospectively collected database. A questionnaire designed to capture information on demographics, co-morbidity, and sexual function was mailed to the participants. The questionnaire included the IIEF-5 and the question “Is your erectile function as good as before the surgery (yes/ no)”. The validity of this question was confirmed by a test-retest analysis. We included men who had undergone RP at our center between 1 and 3 years before the study and who had been sexually active prior to their surgery. Descriptive statistics were performed and a multiple regression analysis controlling for nervesparing, age, time since surgery, D’Amico classification and co-morbidities was used to identify predictors of a subjective return to baseline erectile function. RESULTS: A total of 210 participants fulfilled the inclusion criteria. The mean age was 65 years and the mean time since surgery was 23 months. Mean preoperative IIEF-5 score was 21.7 [95% CI 20.6e 22.9]. At the time of the study it had dropped to 9.9 [95% CI 8.6 e 11.3]. Of 189 patients who did not use erectile aids preoperatively, 58 patients had started using a PDE5-Inhibitors, 17 used injection therapy, 5 used MUSE, 1 used a VED and 2 had received a penile implant. Forty-nine patients (23.3%, [95% CI 18.9%e 28.5%]), who did not report use of erectile aids, showed no decline in IIEF-5 score. However, only 14 patients (6.7%, [95% CI 4.4%e 10.1%]) reported that their erections were as good as before the surgery. Bilateral nervesparing (p¼ 0.003) and the absence of cardiovascular disease (p¼ 0.04) were the only significant predictors of a subjective return to baseline erectile function. CONCLUSIONS: Return to baseline erectile function following radical prostatectomy is a rare event. The IIEF5 questionnaire may not adequately reflect patients’ experience. Source of Funding: None
PD37-11 STATIN THERAPY MAY IMPROVE LONG-TERM SEXUAL FUNCTION AFTER RADICAL PROSTATECTOMY Alon Mass*, Vinay Prabhu, Darren Bryk, New York, NY; Herbert Lepor, New York, NC; Lee Zhao, New York, NY INTRODUCTION AND OBJECTIVES: Statin therapy (ST) is associated with improvement of erectile function in otherwise healthy patients with erectile dysfunction refractory to oral phosphodiesterase-5 inhibitors, due to preservation of vascular endothelium though antioxidant and anti-inflammatory mediators and by a direct increase of endothelial nitric oxide synthase. We investigated the influence of ST on return of sexual function in cohort of men following radical prostatectomy (RP). METHODS: 1,192 men participating in a prospective longitudinal outcomes study of open bilateral nerve sparing RP by a single experienced surgeon met inclusion criteria. Cases were stratified into three tertile groups according to baseline UCLA-Prostate Cancer Index sexual function (UCLA-PCI-SF) scores, and the sexual function was compared between statin versus non-statin users at 3, 6, 12, 24 and 96 months following RP.
Vol. 193, No. 4S, Supplement, Monday, May 18, 2015
RESULTS: 30.4% of men were on ST at the time of RP. Statin users were similar to non-statin users in all pre-operative clinicopathological characteristics. Statin and non-statin users had statistically similar sexual function scores within each tertile at any follow-up period. Follow-up data at 8 years was available for 125 statin users and 298 non-statin users. All tertile groups demonstrated a dramatic decline of sexual function immediately following radical prostatectomy, with a gradual and significant improvement seen steadily at each subsequent follow-up period. Statin users had higher UCLA-PCI-SF scores as compared to non-statin users at any subsequent follow-up period, and within every tertile, but this finding did not reach statistical significance. CONCLUSIONS: ST may have a beneficial effect on sexual function in patients who have undergone RP. Future investigation with a prospective randomized trial of statin use (with or without concomitant PDE5I) in patients after RP is warranted.
Source of Funding: None.
PD37-12 DAILY TADALAFIL DOES NOT INCREASE PRIAPISM RATES IN AN INTRACAVERNOSAL INJECTION (ICI) REHABILITATION PROGRAM, AFTER RADICAL PROSTATECTOMY (RP) Eduardo Miranda*, Sao Paulo, Brazil; Serkan Deveci, Lawrence Jenkins, Joseph Narus, John Mulhall, New York, NY INTRODUCTION AND OBJECTIVES: PDE5 inhibitor (PDE5i) labeling states that these agents should not be used in conjunction with other erectogenic medications for fear of priapism occurring. Tadalafil 5mg daily reaches a peak serum level of approximately 8mg after 5 days and remains at erectogenic serum levels at all times. We explored the risk of priapism in men in our post-radical prostatectomy (RP) penile injection program who were using regular PDE5i as part of their rehabilitation program. METHODS: Study cohort included men on penile injection therapy who (i) were taking tadalafil 5mg daily or taking sildenafil 25mg on non-injection days (ii) had a RP (iii) were using their respective PDE5i regularly at the time of penile injection training and (iv) complied with the program instructions regarding penile injection use. Demographics, comorbidity details, PDE5i dose and utilization as well as injection dose and utilization data were collected. All patients underwent in-office injection training and used trimix (papaverine/phentolamine/ PGE1) as the intracavernosal medication. Priapism was defined as a patient self-reported penetration hardness erection 4 hours in duration, while prolonged erection was defined as a penetration hardness erection lasting 2 hours. RESULTS: 112 tadalafil (T) users and 364 sildenafil (S) users were compared. Mean age and duration post-RP were 6214 years and 5.212 months respectively, no difference between T and S groups. Mean trimix dose was: T 2424 units; S 3137 units, p<0.05. Priapism occurred in: T 2/112 (1.7%); S 5/364 (1.4%), p¼0.47. Excluding those men experiencing priapism on any occasion, those with any reported penetration hardness erection lasting 2 hours: T 7/ 110 (6.3%); S 12/359 (3.3%), p<0.01. 53% of these prolonged erections occurred within the first 6 injections at home (no difference between T and S groups).
THE JOURNAL OF UROLOGYâ
Vol. 193, No. 4S, Supplement, Monday, May 18, 2015
CONCLUSIONS: No difference in priapism event rates existed between T and S users in this analysis. However, the mean trimix dose was higher for men using T and the proportion of men using T who experienced a prolonged erection not requiring an emergency room visit was also higher. While both strategies (T and S) appear safe in the penile injection population, excellent patient counseling is required especially for men using T. Source of Funding: None
Robotics e Renal Video 9 Monday, May 18, 2015
8:00 AM-10:00 AM
V9-01 ROBOTIC PARTIAL NEPHRECTOMY FOR MULTIPLE RENAL TUMORS Deepansh Dalela*, Ravi Barod, Detroit, MI; Craig Rogers, Plymouth, MI INTRODUCTION AND OBJECTIVES: Robotic partial nephrectomy (RPN) in the setting of multiple renal tumors presents unique challenges. While previous reports have documented its feasibility, loner median operative times and length of stay have also been noted. In this video, we present key steps of performing robotic partial nephrectomy in multiple renal tumors. METHODS: In this video, we show footage from different cases to highlight the four key areas in RPN for multiple renal tumors. First, we show the use of 4th arm for kidney retraction, allowing two-handed renal hilar dissection, followed by adequate kidney mobilization for providing optimal tumor exposure. Next, intraoperative ultrasound may be used for accurate anatomical identification of margins. Finally, we show techniques of on-demand ischemia, selective clamping, early unclamping, and cooling the kidney using ice to minimize ischemic damage to the kidney. RESULTS: From 2008 to 2014, 30 patients underwent RPN for multiple renal tumors at our institution (Table 1). The mean size of the index tumor was 2.8 cm, and the RENAL nephrometry score was 8. Acceptable operating and warm ischemia times and estimated blood loss were achieved. There were two episodes of intraoperative bleeding. Focal positive surgical margins were seen in two patients who underwent tumor enucleation, one for hereditary papillary renal cell carcinoma (RCC) and the other for sporadic RCC. Both the patients were free of recurrence at two years follow-up CONCLUSIONS: We present one of the largest single-center case series for multiple renal tumors exclusively undergoing RPN. Judicious use of the 4th arm, greater mobilization of the kidney for tumor exposure, use of the intraoperative ultrasound, and clamping modifications to reduce ischemic damage to the kidney may facilitate RPN in the setting of multiple tumors. Variables (n¼30) Age; mean (SD)
Result 60.8 (7.2)
Index tumor diameter (cm); mean (SD)
2.8 (1)
Nephrometry score (index tumor); median (IQR)
8 (7-9)
OR time (min); median (IQR)
234 (211-272)
Estimated blood loss (ml); median (IQR)
100 (93-212)
Warm ischemia time (min); median (IQR)
22 (19-27)
Intra-operative complications; n (%)
2 (6.7)
Post-operative complications; n (%)
7 (24.1)
Length of stay (days); median (IQR)
3 (2-3)
Positive surgical margins (focal); n (%)
2 (6.7)
Source of Funding: None
e775
V9-02 SELECTIVE CLAMPING OF THE SEGMENTARY ARTERY IN ROBOTIC PARTIAL NEPHRECTOMY OPERATION Omer Aytaç, Hasan Tavukçu, Haluk Kulaksizoglu, Fatih Atug*, Istanbul, Turkey INTRODUCTION AND OBJECTIVES: A close relationship exists between the duration of partial ischemia and loss of renal function. Clamping the main artery of the kidney results in ischemia in the whole renal parachymal tissue. Selective clamping of the segmentary artery prevents global ischemia in the kidney and preserves renal functions. The aim of this video is to present a robotic partial nephrectomy operation with selective clamping of the segmentary artery. METHODS: A 45 years old male patient was diagnosed with an incidental 3 cm mass located in the upper pole of the right kidney. A robotic right partial nephrectomy operation was planned. The colon was medialized after an incision on the toldt line and retroperitoneal space was entered. The hilum of the right kidney was exposed. The renal artery and vein were dissected separately. The branch of segmental artery supplying the tumour was dissected and suspended with a vessel tape. The margins of the tumour was scored with monopolar cautery and excision line was marked. Than segmental artery was clamped with a bulldog clamp. The tumour was excised by cold scissors without using cautery in order to achieve safe surgical margins. The tumour bed was sutured with 3/0 v-lock suture. Renography was performed with sliding-weck clip technique by 2/0 vicryl. The duration of ischemia was 13 min, operative time was 105 min and blood loss was 20 cc. No postoperative complications occured and the surgical drain was removed at postoperative day 1. Patient was discharged at postoperative 48th hour. RESULTS: The pathologic examination was reported clear cell renal carcinoma with negative surgical margins. CONCLUSIONS: The selective clamping of the segmentary artery in robotic partial nephrectomy operation is an important and feasible technic in decreasing the ischemic trauma and the associated functional deterioration of the kidney. Source of Funding: none
V9-03 ROBOTIC ENUCLEO-RESECTION OF SMALL RENAL MASSES: A SAFE AND ONCOLOGICALLY SOUND ALTERNATIVE TO TRADITIONAL PARTIAL NEPHRECTOMY Robert Blackwell*, Gopal Gupta, Maywood, IL INTRODUCTION AND OBJECTIVES: Nephron-sparing surgery is the standard of care for treatment of renal masses when technically feasible. Renal masses develop a fibrous pseudocapsule around themselves, leaving a plane that can be exploited. Enucleation techniques have previously been described via open techniques to maximally preserve normal renal parenchyma. Our objective is to describe a robotic-assisted laparoscopic enucleoresection (RALER) technique for the treatment of small renal masses. METHODS: Between 3/2012 and 1/2014, 42 RALER procedures were performed on patients with small renal masses. All patients had a mass radiologically suspicious for malignant neoplasm. Pre- and post-operative imaging and serum creatinine levels were obtained. Positioning and port placement arranged as for traditional partial nephrectomy. After achieving renal vascular control, the renal capsule is incised and the plane between the renal parenchyma and tumor pseudocapsule developed. As demonstrated in the figure, a) The tumor is identified (white asterisk) and the margin closest to the camera delineated for the initial incision (white dotted line). b) Following incision
e774
PD37-10 ERECTILE FUNCTION AFTER RADICAL PROSTATECTOMY e DO PATIENTS RETURN TO BASELINE? Mikkel Fode*, Roskilde and Herlev, Denmark; Anders Frey, Henrik Jakobsen, Jens Sønksen, Herlev, Denmark INTRODUCTION AND OBJECTIVES: Variations in study methodology have resulted in controversy regarding the incidence of erectile dysfunction (ED) after radical prostatectomy (RP). The most commonly utilized questionnaire is the International Index of Erectile Function (IIEF). However, this questionnaire has not been validated specifically for the situation. The purpose of this study was to assess post-RP ED as assessed by the IIEF-5 questionnaire and by subjective patient perception. METHODS: This is a sub-analysis from a cross-sectional questionnaire study in patients following RP (Frey et al, J. Sex. Med, 2014). Preoperative erectile function was evaluated using the IIEF-5. Disease characteristics and information regarding the surgeries were retrieved from a prospectively collected database. A questionnaire designed to capture information on demographics, co-morbidity, and sexual function was mailed to the participants. The questionnaire included the IIEF-5 and the question “Is your erectile function as good as before the surgery (yes/ no)”. The validity of this question was confirmed by a test-retest analysis. We included men who had undergone RP at our center between 1 and 3 years before the study and who had been sexually active prior to their surgery. Descriptive statistics were performed and a multiple regression analysis controlling for nervesparing, age, time since surgery, D’Amico classification and co-morbidities was used to identify predictors of a subjective return to baseline erectile function. RESULTS: A total of 210 participants fulfilled the inclusion criteria. The mean age was 65 years and the mean time since surgery was 23 months. Mean preoperative IIEF-5 score was 21.7 [95% CI 20.6e 22.9]. At the time of the study it had dropped to 9.9 [95% CI 8.6 e 11.3]. Of 189 patients who did not use erectile aids preoperatively, 58 patients had started using a PDE5-Inhibitors, 17 used injection therapy, 5 used MUSE, 1 used a VED and 2 had received a penile implant. Forty-nine patients (23.3%, [95% CI 18.9%e 28.5%]), who did not report use of erectile aids, showed no decline in IIEF-5 score. However, only 14 patients (6.7%, [95% CI 4.4%e 10.1%]) reported that their erections were as good as before the surgery. Bilateral nervesparing (p¼ 0.003) and the absence of cardiovascular disease (p¼ 0.04) were the only significant predictors of a subjective return to baseline erectile function. CONCLUSIONS: Return to baseline erectile function following radical prostatectomy is a rare event. The IIEF5 questionnaire may not adequately reflect patients’ experience. Source of Funding: None
PD37-11 STATIN THERAPY MAY IMPROVE LONG-TERM SEXUAL FUNCTION AFTER RADICAL PROSTATECTOMY Alon Mass*, Vinay Prabhu, Darren Bryk, New York, NY; Herbert Lepor, New York, NC; Lee Zhao, New York, NY INTRODUCTION AND OBJECTIVES: Statin therapy (ST) is associated with improvement of erectile function in otherwise healthy patients with erectile dysfunction refractory to oral phosphodiesterase-5 inhibitors, due to preservation of vascular endothelium though antioxidant and anti-inflammatory mediators and by a direct increase of endothelial nitric oxide synthase. We investigated the influence of ST on return of sexual function in cohort of men following radical prostatectomy (RP). METHODS: 1,192 men participating in a prospective longitudinal outcomes study of open bilateral nerve sparing RP by a single experienced surgeon met inclusion criteria. Cases were stratified into three tertile groups according to baseline UCLA-Prostate Cancer Index sexual function (UCLA-PCI-SF) scores, and the sexual function was compared between statin versus non-statin users at 3, 6, 12, 24 and 96 months following RP.
Vol. 193, No. 4S, Supplement, Monday, May 18, 2015
RESULTS: 30.4% of men were on ST at the time of RP. Statin users were similar to non-statin users in all pre-operative clinicopathological characteristics. Statin and non-statin users had statistically similar sexual function scores within each tertile at any follow-up period. Follow-up data at 8 years was available for 125 statin users and 298 non-statin users. All tertile groups demonstrated a dramatic decline of sexual function immediately following radical prostatectomy, with a gradual and significant improvement seen steadily at each subsequent follow-up period. Statin users had higher UCLA-PCI-SF scores as compared to non-statin users at any subsequent follow-up period, and within every tertile, but this finding did not reach statistical significance. CONCLUSIONS: ST may have a beneficial effect on sexual function in patients who have undergone RP. Future investigation with a prospective randomized trial of statin use (with or without concomitant PDE5I) in patients after RP is warranted.
Source of Funding: None.
PD37-12 DAILY TADALAFIL DOES NOT INCREASE PRIAPISM RATES IN AN INTRACAVERNOSAL INJECTION (ICI) REHABILITATION PROGRAM, AFTER RADICAL PROSTATECTOMY (RP) Eduardo Miranda*, Sao Paulo, Brazil; Serkan Deveci, Lawrence Jenkins, Joseph Narus, John Mulhall, New York, NY INTRODUCTION AND OBJECTIVES: PDE5 inhibitor (PDE5i) labeling states that these agents should not be used in conjunction with other erectogenic medications for fear of priapism occurring. Tadalafil 5mg daily reaches a peak serum level of approximately 8mg after 5 days and remains at erectogenic serum levels at all times. We explored the risk of priapism in men in our post-radical prostatectomy (RP) penile injection program who were using regular PDE5i as part of their rehabilitation program. METHODS: Study cohort included men on penile injection therapy who (i) were taking tadalafil 5mg daily or taking sildenafil 25mg on non-injection days (ii) had a RP (iii) were using their respective PDE5i regularly at the time of penile injection training and (iv) complied with the program instructions regarding penile injection use. Demographics, comorbidity details, PDE5i dose and utilization as well as injection dose and utilization data were collected. All patients underwent in-office injection training and used trimix (papaverine/phentolamine/ PGE1) as the intracavernosal medication. Priapism was defined as a patient self-reported penetration hardness erection 4 hours in duration, while prolonged erection was defined as a penetration hardness erection lasting 2 hours. RESULTS: 112 tadalafil (T) users and 364 sildenafil (S) users were compared. Mean age and duration post-RP were 6214 years and 5.212 months respectively, no difference between T and S groups. Mean trimix dose was: T 2424 units; S 3137 units, p<0.05. Priapism occurred in: T 2/112 (1.7%); S 5/364 (1.4%), p¼0.47. Excluding those men experiencing priapism on any occasion, those with any reported penetration hardness erection lasting 2 hours: T 7/ 110 (6.3%); S 12/359 (3.3%), p<0.01. 53% of these prolonged erections occurred within the first 6 injections at home (no difference between T and S groups).
THE JOURNAL OF UROLOGYâ
Vol. 193, No. 4S, Supplement, Monday, May 18, 2015
CONCLUSIONS: No difference in priapism event rates existed between T and S users in this analysis. However, the mean trimix dose was higher for men using T and the proportion of men using T who experienced a prolonged erection not requiring an emergency room visit was also higher. While both strategies (T and S) appear safe in the penile injection population, excellent patient counseling is required especially for men using T. Source of Funding: None
Robotics e Renal Video 9 Monday, May 18, 2015
8:00 AM-10:00 AM
V9-01 ROBOTIC PARTIAL NEPHRECTOMY FOR MULTIPLE RENAL TUMORS Deepansh Dalela*, Ravi Barod, Detroit, MI; Craig Rogers, Plymouth, MI INTRODUCTION AND OBJECTIVES: Robotic partial nephrectomy (RPN) in the setting of multiple renal tumors presents unique challenges. While previous reports have documented its feasibility, loner median operative times and length of stay have also been noted. In this video, we present key steps of performing robotic partial nephrectomy in multiple renal tumors. METHODS: In this video, we show footage from different cases to highlight the four key areas in RPN for multiple renal tumors. First, we show the use of 4th arm for kidney retraction, allowing two-handed renal hilar dissection, followed by adequate kidney mobilization for providing optimal tumor exposure. Next, intraoperative ultrasound may be used for accurate anatomical identification of margins. Finally, we show techniques of on-demand ischemia, selective clamping, early unclamping, and cooling the kidney using ice to minimize ischemic damage to the kidney. RESULTS: From 2008 to 2014, 30 patients underwent RPN for multiple renal tumors at our institution (Table 1). The mean size of the index tumor was 2.8 cm, and the RENAL nephrometry score was 8. Acceptable operating and warm ischemia times and estimated blood loss were achieved. There were two episodes of intraoperative bleeding. Focal positive surgical margins were seen in two patients who underwent tumor enucleation, one for hereditary papillary renal cell carcinoma (RCC) and the other for sporadic RCC. Both the patients were free of recurrence at two years follow-up CONCLUSIONS: We present one of the largest single-center case series for multiple renal tumors exclusively undergoing RPN. Judicious use of the 4th arm, greater mobilization of the kidney for tumor exposure, use of the intraoperative ultrasound, and clamping modifications to reduce ischemic damage to the kidney may facilitate RPN in the setting of multiple tumors. Variables (n¼30) Age; mean (SD)
Result 60.8 (7.2)
Index tumor diameter (cm); mean (SD)
2.8 (1)
Nephrometry score (index tumor); median (IQR)
8 (7-9)
OR time (min); median (IQR)
234 (211-272)
Estimated blood loss (ml); median (IQR)
100 (93-212)
Warm ischemia time (min); median (IQR)
22 (19-27)
Intra-operative complications; n (%)
2 (6.7)
Post-operative complications; n (%)
7 (24.1)
Length of stay (days); median (IQR)
3 (2-3)
Positive surgical margins (focal); n (%)
2 (6.7)
Source of Funding: None
e775
V9-02 SELECTIVE CLAMPING OF THE SEGMENTARY ARTERY IN ROBOTIC PARTIAL NEPHRECTOMY OPERATION Omer Aytaç, Hasan Tavukçu, Haluk Kulaksizoglu, Fatih Atug*, Istanbul, Turkey INTRODUCTION AND OBJECTIVES: A close relationship exists between the duration of partial ischemia and loss of renal function. Clamping the main artery of the kidney results in ischemia in the whole renal parachymal tissue. Selective clamping of the segmentary artery prevents global ischemia in the kidney and preserves renal functions. The aim of this video is to present a robotic partial nephrectomy operation with selective clamping of the segmentary artery. METHODS: A 45 years old male patient was diagnosed with an incidental 3 cm mass located in the upper pole of the right kidney. A robotic right partial nephrectomy operation was planned. The colon was medialized after an incision on the toldt line and retroperitoneal space was entered. The hilum of the right kidney was exposed. The renal artery and vein were dissected separately. The branch of segmental artery supplying the tumour was dissected and suspended with a vessel tape. The margins of the tumour was scored with monopolar cautery and excision line was marked. Than segmental artery was clamped with a bulldog clamp. The tumour was excised by cold scissors without using cautery in order to achieve safe surgical margins. The tumour bed was sutured with 3/0 v-lock suture. Renography was performed with sliding-weck clip technique by 2/0 vicryl. The duration of ischemia was 13 min, operative time was 105 min and blood loss was 20 cc. No postoperative complications occured and the surgical drain was removed at postoperative day 1. Patient was discharged at postoperative 48th hour. RESULTS: The pathologic examination was reported clear cell renal carcinoma with negative surgical margins. CONCLUSIONS: The selective clamping of the segmentary artery in robotic partial nephrectomy operation is an important and feasible technic in decreasing the ischemic trauma and the associated functional deterioration of the kidney. Source of Funding: none
V9-03 ROBOTIC ENUCLEO-RESECTION OF SMALL RENAL MASSES: A SAFE AND ONCOLOGICALLY SOUND ALTERNATIVE TO TRADITIONAL PARTIAL NEPHRECTOMY Robert Blackwell*, Gopal Gupta, Maywood, IL INTRODUCTION AND OBJECTIVES: Nephron-sparing surgery is the standard of care for treatment of renal masses when technically feasible. Renal masses develop a fibrous pseudocapsule around themselves, leaving a plane that can be exploited. Enucleation techniques have previously been described via open techniques to maximally preserve normal renal parenchyma. Our objective is to describe a robotic-assisted laparoscopic enucleoresection (RALER) technique for the treatment of small renal masses. METHODS: Between 3/2012 and 1/2014, 42 RALER procedures were performed on patients with small renal masses. All patients had a mass radiologically suspicious for malignant neoplasm. Pre- and post-operative imaging and serum creatinine levels were obtained. Positioning and port placement arranged as for traditional partial nephrectomy. After achieving renal vascular control, the renal capsule is incised and the plane between the renal parenchyma and tumor pseudocapsule developed. As demonstrated in the figure, a) The tumor is identified (white asterisk) and the margin closest to the camera delineated for the initial incision (white dotted line). b) Following incision