Electroacupuncture decreases the urinary bladder pressure in patients with acute gastrointestinal injury

The present study investigates the effects of electroacupuncture (EA) on urinary bladder pressure (UBP) in patients with acute gastrointestinal injury (AGI). Twenty patients with AGI admitted to the First Hospital of Jiaxing intensive care unit from December 2011 to June 2013 were evaluated. Conventional group patients (n = 10) were administered moderate enteral nutritional support, and electroacupuncture group patients (n = 10) were administered enteral nutritional support followed by EA at bilateral Zusanli (ST-36), Shangjuxu (ST-37), Hegu (LI-4), and QuChi (LI-11) acupoints. UBP was then measured every 6 h and the serum creatinine once daily for 7 days. There were no statistically significant patient demographic differences in the study groups (P > 0.05). The initial UBP of both patient groups was ≥12 mmHg. On days 6 and 7, the UBP significantly decreased in the EA group compared to the conventional group (P < 0.05). The serum creatinine concentration on day 7 was significantly lower in the EA group than in the conventional group (P < 0.05). Based on these results, electroacupuncture contributed to gastrointestinal motility recovery in patients with AGI. This procedure may reduce UBP and provide organ-protective effects in AGI patients.

Rapid-onset antidepressant action of ketamine: potential revolution in understanding and future pharmacologic treatment of depression

WHAT IS KNOWN AND OBJECTIVE

The current pharmacotherapeutic treatment of major depressive disorder (MDD) generally takes weeks to be effective. As the molecular action of these drugs is immediate, the mechanistic basis for this lag is unclear. A drug that has a more rapid onset of action would be a major therapeutic advance and also be a useful comparator to provide valuable mechanistic insight into the disorder and its treatment.

COMMENT

Recent evidence suggests that ketamine produces rapid-onset antidepressant action. Important questions are as follows: is it specific or coincidental to other effects; is there a dose-response relationship; and is the mechanism related to that of current antidepressants. NMDA receptor antagonism is unlikely the explanation for ketamine's antidepressant action.

WHAT IS NEW AND CONCLUSION

It is not an exaggeration to state that the new findings, if validated, might produce a revolution in understanding and treating depressive disorders.

The prevalence and the risk factors of testosterone deficiency in newly diagnosed and previously known type 2 diabetic men

INTRODUCTION

While the epidemiology of testosterone deficiency has been well described in men with previously known type 2 diabetes mellitus (T2DM), it was less reported in those with untreated, newly diagnosed T2DM.

AIM

The aim of this study was to investigate the prevalence and the risk factors of testosterone deficiency of men with newly diagnosed T2DM.

METHODS

The cross-sectional study included 105 men (mean age: 61.2 ± 6.8 years) with previously known T2DM and another 81 (57.8 ± 8.8 years) with newly diagnosed T2DM. All received health checkup and sex hormone measurement at our institute in 2009.

MAIN OUTCOME MEASURES

We calculated the prevalence and explored the risk factors of low total (<300 ng/dL) and free (<6 ng/dL) testosterone in men with newly diagnosed and previously known T2DM.

RESULTS

Men with previously known T2DM were older and had higher diastolic pressure and greater fasting glucose. There was no significant difference in total (358.0 [155.0] ng/dL vs. 363.0 [154.0] ng/dL, P=0.68) and free (7.2 [2.5] ng/dL vs. 7.4 [2.4]ng/dL, P=0.84) testosterone and sex-hormone binding globulin (SHBG) (27.3 [22.3]nmol/L vs. 28.7 [14.9]nmol/L, P=0.46). The prevalence of low total and free testosterone was 28.4% and 21.0%, respectively, in men with newly diagnosed T2DM, and was 26.7% and 19.0% in those with previously known T2DM. In men with previously known T2DM, better glycemic control (HbA1c <7%) was associated with a higher level of total testosterone and a lower risk of low total testosterone. Men with newly diagnosed and previously known T2DM shared similar risk factors of low total testosterone, including high HbA1c (≥ 7%), low SHBG (<20 nmol/L), obesity, hyperuricemia, hypertriglycemia, and metabolic syndrome. Elevated prostate-specific antigen was a protective factor of low total testosterone. However, none of these factors was associated with low free testosterone.

CONCLUSIONS

The prevalence and the risk factors of testosterone deficiency are similar between newly diagnosed and previously known type 2 diabetic men.

CTC1 increases the radioresistance of human melanoma cells by inhibiting telomere shortening and apoptosis

Melanoma has traditionally been viewed as a radioresistant cancer. However, recent studies suggest that under certain clinical circumstances, radiotherapy may play a significant role in the treatment of melanoma. Previous studies have demonstrated that telomere length is a hallmark of radiosensitivity. The newly discovered mammalian CTC1-STN1-TEN1 (CST) complex has been demonstrated to be an important telomere maintenance factor. In this study, by establishing a radiosensitive/radioresistant human melanoma cell model, MDA-MB-435/MDA-MB-435R, we aimed to investigate the association of CTC1 expression with radiosensitivity in human melanoma cell lines, and to elucidate the possible underlying mechanisms. We found that CTC1 mRNA and protein levels were markedly increased in the MDA-MB-435R cells compared with the MDA-MB-435 cells. Moreover, the downregulation of CTC1 enhanced radiosensitivity, induced DNA damage and promoted telomere shortening and apoptosis in both cell lines. Taken together, our findings suggest that CTC1 increases the radioresistance of human melanoma cells by inhibiting telomere shortening and apoptosis. Thus, CTC1 may be an attractive target gene for the treatment of human melanoma.

Laparoendoscopic single-site (LESS) retroperitoneal partial adrenalectomy using a custom-made single-access platform and standard laparoscopic instruments: technical considerations and surgical outcomes

BACKGROUND

We previously reported our initial experience with laparoendoscopic single-site (LESS) retroperitoneal partial adrenalectomy using a custom-made single-port device and conventional straight laparoscopic instruments.

METHODS

Between December 2010 and February 2012, LESS retroperitoneal partial adrenalectomies were performed in 11 patients. Six patients had aldosterone-producing adenomas (APAs) and five patients had nonfunctioning tumors. A single-port access was created with an Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) through an incision of 2-3 cm beneath the tip of the 12th rib. All procedures were performed with straight laparoscopic instruments.

RESULTS

All LESS procedures were successfully completed without conversion to traditional laparoscopic conversion. The tumors ranged from 1 cm to 4.7 cm (mean, 2.3 cm). The operative time was 71-257 minutes (mean, 121 minutes). Most patients (n = 8) had minimal blood loss; the other three patients had a blood loss of 150 mL, 100 mL, and 100 mL. The mean hospital stay was 3 days (range, 1-6 days). There were no perioperative or postoperative complications. Pathological examinations revealed negative surgical margins in all specimens. All patients with Conn's syndrome had an improvement in blood pressure and normalization of plasma renin activity and serum aldosterone levels; all patients were free of potassium supplementation.

CONCLUSION

Our results clearly demonstrate that LESS retroperitoneal partial adrenalectomy can be performed safely and effectively using a custom-made single-access platform and standard laparoscopic instruments.

Lipomembranous changes associated with systemic lupus erythematosus

Lipomembranous changes are distinctive histopathological findings, which include the presence of cystic cavities lined by crenulated, hyaline membranes in adipose tissue. It is likely that ischaemia is fundamental to the development of these lesions, and that lipomembranes are formed from the products of degenerating fat cell membranes by some unknown mechanism. Such changes may be seen, although rarely, in many types of subcutaneous inflammatory processes. However, an association with systemic lupus erythematosus (SLE) is rare. We report a patient with SLE who had the histological features of lipomembranous changes associated with vasculopathy.

Hyposensitivity of C-fiber afferents at the distal extremities as an indicator of early stages diabetic bladder dysfunction in type 2 diabetic women

Purpose

To investigate the relationship between distal symmetric peripheral neuropathy and early stages of autonomic bladder dysfunction in type 2 diabetic women.

Materials and Methods

A total of 137 diabetic women with minimal coexisting confounders of voiding dysfunction followed at a diabetes clinic were subject to the following evaluations: current perception threshold (CPT) tests on myelinated and unmyelinated nerves at the big toe for peroneal nerve and middle finger for median nerve, uroflowmetry, post-void residual urine volume, and overactive bladder (OAB) symptom score questionnaire. Patients presenting with voiding difficulty also underwent urodynamic studies and intravesical CPT tests.

Results

Based on the OAB symptom score and urodynamic studies, 19% of diabetic women had the OAB syndrome while 24.8% had unrecognized urodynamic bladder dysfunction (UBD). The OAB group had a significantly greater mean 5 Hz CPT test value at the big toe by comparison to those without OAB. When compared to diabetic women without UBD, those with UBD showed greater mean 5 Hz CPT test values at the middle finger and big toe. The diabetic women categorized as C-fiber hyposensitivity at the middle finger or big toe by using CPT test also had higher odds ratios of UBD. Among diabetic women with UBD, the 5 Hz CPT test values at the big toe and middle finger were significantly associated with intravesical 5 Hz CPT test values.

Conclusions

Using electrophysiological evidence, our study revealed that hyposensitivity of unmyelinated C fiber afferents at the distal extremities is an indicator of early stages diabetic bladder dysfunction in type 2 diabetic women. The C fiber dysfunction at the distal extremities seems concurrent with vesical C-fiber neuropathy and may be a sentinel for developing early diabetic bladder dysfunction among female patients.

Laparoscopic radical prostatectomy monotherapy, a more aggressive yet less invasive option, is oncologically effective in selected men with high-risk prostate cancer having only one D'Amico risk factor: experience from an Asian tertiary referral center

PURPOSE

To present oncologic results of laparoscopic radical prostatectomy (LRP) monotherapy for men with high-risk, localized prostate cancer, and to find factors associated with a good prognosis via surgery alone.

PATIENTS AND METHODS

Between 2002 and 2009, 241 men underwent LRP at an Asian tertiary referral center. Among them, we retrospectively identified 85 (35.3%) men who met the D'Amico's high-risk criteria: Prostate-specific antigen level >20 ng/mL, Gleason score of 8 to 10, or clinical stage ≥T2c. Perioperative parameters were analyzed against biochemical recurrence (BCR)-free survival.

RESULTS

At a median follow-up of 54 months, BCR developed in 28 (34.1%), with an actuarial BCR-free survival rate of 63.3% at 5 years. Pathologically, 37.6% of the men had organ-confined (OC) disease. Positive surgical margins (PSM) were identified in 49.4% of the patients. A favorable pathologic outcome, defined as OC(+)PSM(-), was observed in 24 patients and associated with a 5-year BCR-free survival rate of 87.0%, compared with 100%, 54.0%, and 46.4% in men with OC(+)PSM(+), OC(-)PSM(-) and OC(-)PSM(+) disease (log-rank, P=0.008). The overall positive lymph node rate was 14.1%. Men (65.9%) with only one D'Amico risk factor had a 5-year BCR-free survival rate of 76.9%, compared with 34.6% in men (34.1%) with ≥2 risk factors (log-rank, P<0.001).

CONCLUSIONS

Radical prostatectomy monotherapy performed laparoscopically or robotically appears to be an option for high-risk prostate cancer, especially in men with a single D'Amico risk factor. Men with ≥2 risk factors are more prone for BCR to develop after surgery and may need second-line therapy.

Association between schizophrenia and urinary calculi: a population-based case-control study

Background

People with schizophrenia have been demonstrated to have higher overall morbidity and all-cause mortality rates from general medical conditions. However, little attention has been given to the urinary system of people with schizophrenia. As no direct evidence has been reported demonstrating a link between schizophrenia and urinary calculi, this study utilized a population-based case-control study design to investigate the possibility of an association between schizophrenia and the occurrence of urinary calculi.

Method

This study used data from the Taiwan Longitudinal Health Insurance Database. Cases consisted of 53,965 urinary calculi patients newly diagnosed between 2002 and 2008. In total, 269,825 controls were randomly selected and matched with the cases in terms of age and sex. Each person was traced to discern whether he had previously received a diagnosis of schizophrenia. Conditional logistic regression models were performed for the analysis.

Results

A total of 3,119 (1.0%) subjects had been diagnosed with schizophrenia prior to the index date. This included 0.7% of the patients with urinary calculi, and 1.0% of the controls. A prior diagnosis of schizophrenia was independently associated with a 30% decrease (95% CI = 0.62–0.76) in the occurrence of urinary calculi. The reduction was even more remarkable in males (38%, 95% CI = 0.55–0.71) and in elder individuals independent of gender (48% in those aged >69, 95% CI = 0.36–0.77).

Conclusion

Our findings suggest that there is an inverse association between schizophrenia and urinary calculi. Future studies are needed to elucidate the mechanisms by which schizophrenia negatively associates with urinary calculi.

Alterations in peripheral purinergic and muscarinic signaling of rat bladder after long-term fructose-induced metabolic syndrome

PURPOSE

We explored the pathophysiologic mechanisms of long-term fructose-induced lower urinary tract symptoms (LUTS) in rats.

METHODS

Male Wistar rats were fed with fructose for 3 or 6 months. Biochemical and transcystometric parameters were compared between fructose-fed and age-matched normal-diet rats. Pelvic nerve and external urethral sphincter-electromyogram activity recordings were performed to investigate fructose effects on neural control of bladders. Mitochondrial structure, ATP and acetylcholine content and purinergic and muscarinic cholinergic receptors were examined. Cytosolic cytochrome C staining by Western blot and immunocytochemistry for mitochondrial injury and PGP 9.5 stain for nerve density were also determined.

RESULTS

The fructose-fed rats with higher plasma triglyceride, LDL and fasting glucose levels displayed LUTS with increased frequency and suppressed voiding contractile amplitude in phase 1 and phase 2 duration versus normal-diet control. Fructose feeding altered the firing types in pelvic afferent and efferent nerves and external urethral sphincter-electromyogram activity. Increased mast cell number, disrupted and swollen mitochondria, increased cytosolic cytochrome C stain and expression and decreased nerve density in bladder smooth muscle layers appeared in the fructose-fed rats. Fructose feeding also significantly reduced ATP and acetylcholine content and enhanced protein expression of postsynaptic P(2)X(1), P(2)X(2) and P(2)X(3) purinergic receptors and M(2) and M(3) muscarinic cholinergic receptors expression in the smooth muscles of urinary bladder.

CONCLUSION

Long-term fructose feeding induced neuropathy and myopathy in the urinary bladders. Impaired mitochondrial integrity, reduced nerve density, ATP and acetylcholine content and upregulation of purinergic and muscarinic cholinergic receptors expression may contribute to the bladder dysfunction of fructose-fed animals.

Advances in understanding of mammalian penile evolution, human penile anatomy and human erection physiology: clinical implications for physicians and surgeons

Recent studies substantiate a model of the tunica albuginea of the corpora cavernosa as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat spanning from the bulbospongiosus and ischiocavernosus proximally and extending continuously into the distal ligament within the glans penis. The anatomical location and histology of the distal ligament invites convincing parallels with the quadrupedal os penis and therefore constitutes potential evidence of the evolutionary process. In the corpora cavernosa, a chamber design is responsible for facilitating rigid erections. For investigating its venous factors exclusively, hemodynamic studies have been performed on both fresh and defrosted human male cadavers. In each case, a rigid erection was unequivocally attainable following venous removal. This clearly has significant ramifications in relation to penile venous surgery and its role in treating impotent patients. One deep dorsal vein, 2 cavernosal veins and 2 pairs of para-arterial veins (as opposed to 1 single vein) are situated between Buck’s fascia and the tunica albuginea. These newfound insights into penile tunical, venous anatomy and erection physiology were inspired by and, in turn, enhance clinical applications routinely encountered by physicians and surgeons, such as penile morphological reconstruction, penile implantation and penile venous surgery.

Clear cell carcinoma of female urethral diverticulum--a case report

Primary malignancies of female urethral diverticulum are rare. A well-documented female patient with primary clear cell carcinoma of the urethral diverticulum is presented here. A 65-year-old woman presented with frequency and voiding difficulty for 2 months. Physical examination showed a 4-cm mass protruding from anterior vaginal wall. Intravenous urography, magnetic resonance imaging, and cystoscopy showed a polypoid mass in urethral diverticulum. She then underwent anterior exenteration with ileal conduit diversion and urethrectomy. Pathology confirmed the diagnosis of clear cell adenocarcinoma with bladder neck invasion. She had no disease recurrence at 2-year follow-up. Careful clinical examination and image studies are helpful in making the preoperative diagnosis for the rare disease. Early radical surgery can achieve better survival.

Penile veins are the principal component in erectile rigidity: a study of penile venous stripping on defrosted human cadavers

The human erectile mechanism is an intricate interplay of hormonal, vascular, neurological, sinusoidal, pharmacological, and psychological factors. However, the relative influence of each respective component remains somewhat unclear, and merits further study. We investigated the role of venous outflow in an attempt to isolate the key determinant of erectile function. Dynamic infusion cavernosometry and cavernosography was conducted on 15 defrosted human cadavers, both before and after the systematic removal and ligation of erection-related penile veins. Preoperatively, an infusion rate of more than 28.1 mL/min (from more than 14.0 to 85.0 mL/min) was required to induce a rigid erection (defined as intracavernosal pressure [ICP] exceeding 90 mmHg). Following surgery, we were able to obtain the same result at a rate of 7.3 mL/min (from 3.1 to 13.5 mL/min) across the entire sample. Thus, we witnessed statistically significant postoperative differences (all P ≤ .01), consistently elevated ICP, lower perfusion volumes, and a general reduction in time taken to attain rigidity. The cavernosograms provided further evidence substantiating the critical role played by erection-related veins, whereas histological samples confirmed the postoperative integrity of the corpora cavernosa. Given that our use of cadavers eliminated the influence of hormonal, arterial, neurological, sinusoidal, pharmacological, and psychological factors, we believe that our study demonstrates that the human erection is fundamentally a mechanical event contingent on venous competence.

Testosterone and sex hormone-binding globulin have significant association with metabolic syndrome in Taiwanese men

OBJECTIVES

To investigate the relationship between sex hormones and metabolic syndrome (MS) in an Asian population.

METHODS

A cross-sectional study was conducted in 237 men aged 20-88 years (mean age 52 years). Serum lipids, glucose, insulin, total testosterone (TT), estradiol (E2), sex hormone-binding globulin (SHBG), and dehydroepiandosterone sulfate (DHEA-S) were measured along with body height, weight, waist circumference, and blood pressure. Free testosterone (FT) and bioavailable testosterone (BT) were calculated. Correlations were determined using univariate and multivariate regression analyses.

RESULTS

Men with MS had lower levels of TT, BT, FT, SHBG and DHEA-S than men without MS. Multivariate analysis, after adjusting for age and smoking status, indicated that TT (OR: 0.909, 95% CI: 0.836-0.988, p = 0.003) and SHBG (OR: 0.948, 95% CI: 0.913-0.985, p = 0.006) were significantly associated with MS (R(2) = 0.314). TT was associated with waist circumference (p = 0.008) and abnormal triglycerides level (p = 0.006); SHBG was associated with blood pressure (p = 0.003), blood glucose (p = 0.043) and abnormal triglycerides (p = 0.048). A significant trend was observed between decreasing levels of TT, BT, FT, and SHBG and increasing numbers of MS components.

CONCLUSION

Results show that serum testosterone and SHBG levels inversely correlate with MS in an Asian population applying the Asian MS definition.

Significant association between serum dihydrotestosterone level and prostate volume among Taiwanese men aged 40-79 years

INTRODUCTION

We evaluated the association between serum sex hormone levels and prostate volume in Taiwanese men.

METHODS

A cross-sectional study was conducted in 505 men (aged 40-79 years, mean age 58 years). Serum total testosterone (TT), free testosterone (FT), dihydrotestosterone (DHT) and estradiol (E2) levels were measured. Total prostate volume (TPV) and transition zone volume (TZV) were measured by transrectal ultrasonography. Body mass index (BMI), DHT/TT and E2/TT were calculated. Correlations were determined using univariate and multivariate regression analyses.

RESULTS

Apart from DHT, an age-dependent change of sex hormone levels were observed. On univariate analyses, age, BMI, serum DHT level and DHT/TT ratio, as well as serum E2 level and E2/TT ratio, but not serum TT and FT levels showed a significant association with prostate volume. On multivariate analysis, however, only serum DHT level and DHT/TT ratio remained significant. Logistic regression analysis showed that the odds ratios (95% confidence interval) of the second, third, and fourth quartiles of serum DHT levels for benign prostatic hyperplasia (defined as TPV ≥ 20 ml) risk were 2.06 (1.21-3.51), 2.66(1.56-4.53) and 7.15(4.0-12.6), respectively (p < 0.001).

CONCLUSIONS

Higher serum DHT level and DHT/TT ratio were associated with larger prostate volume and higher prevalence of BPH in Taiwanese men.

Long-term oncologic outcomes of hand-assisted retroperitoneoscopic radical nephrectomy to treat clinically localized renal cell carcinoma

BACKGROUND/PURPOSE

To evaluate the long-term oncological outcomes of hand-assisted retroperitoneoscopic radical nephrectomy (HARRN) for treating clinically localized renal cell carcinoma.

METHODS

We retrospectively collected and analyzed the data and clinical outcomes of 46 patients who underwent HARRN and 50 patients who underwent conventional open radical nephrectomy (ORN) at our institution for clinical localized renal cell carcinoma (RCC).

RESULTS

The median follow-up period of the HARRN group was 56.5 months (range: 14.6-78.7 months); for the ORN group, the median follow-up period was 110.8 months (range: 15.5-123 months). Patient age, sex, body mass index, pathologic parameters, and classification based on the guidelines of the American Society of Anesthesiologists were not significantly different between the two groups. The HARRN group had a significantly longer operative time (218 minutes vs. 178 minutes, p = 0.003) and less blood loss (203 mL vs. 670 mL, p < 0.001). The complication rates of the ORN and HARRN groups were similar (8% and 4.3%, respectively, p = 0.46). No conversions to an open procedure or intraoperative mortality occurred in the HARRN group. The disease-free and disease-specific survival rates were comparable between the two groups.

CONCLUSION

The results of our study indicate that HARRN is a feasible, minimally invasive treatment for managing clinically organ-confined RCC with a good long-term oncological outcome.

Low serum sex hormone-binding globulin: marker of inflammation?

BACKGROUND

Low sex hormone-binding globulin (SHBG) is associated with metabolic syndrome (MetS), but its relationship with inflammation is unclear.

METHODS

This cross-sectional study included 696 subjects (255 men, 235 pre-menopausal women, and 206 postmenopausal women). Body mass index, waist circumference, blood pressure, lipid profiles, plasma glucose, insulin, FSH, LH, total testosterone (TT), estradiol, SHBG, dehydroepiandrosterone sulfate (DHEA-S), and hs-CRP concentrations were measured. MetS was defined according to the updated National Cholesterol Education Program criteria with modification of waist circumference for Asians.

RESULTS

Serum hs-CRP and SHBG were negatively correlated in men (r=-0.29, p<0.001), pre-menopausal women (r=-0.38, p<0.001), and postmenopausal women (r=-0.27, p<0.001). In men, TT and hs-CRP showed a negative association (r=-0.25, p<0.001), but the association was attenuated after adjusting for SHBG (r=-0.14, p=0.039). Multivariate regression models showed that SHBG was independently associated with hs-CRP in men (r=-0.18, p=0.009), pre-menopausal women (r=-0.15, p=0.025), and postmenopausal women (r=-0.21, p=0.005), adjusted for age, MetS components, insulin resistance, low-density lipoprotein-cholesterol, and serum sex hormone levels.

CONCLUSIONS

Serum SHBG and hs-CRP concentrations were inversely correlated in men, pre-menoposal, and post-menopausal women independently.

Laparoscopic resection of gastric gastrointestinal stromal tumors presenting as left adrenal tumors

Gastrointestinal stromal tumors (GISTs) are rare gastrointestinal malignancies. They are rarely seen near the urinary tract. In a literature review, only one case of GIST presenting as a left adrenal tumor was reported. We report two documented cases of gastric GISTs mimicking left adrenal tumors which were successfully treated with pure laparoscopic adrenalectomy and wedge resection of the stomach by excising the tumor from the stomach with serial firing of endoscopic gastrointestinal staplers. The surgical margins were clear, and the patients recovered smoothly. No adjuvant therapy with imatinib was prescribed. During the surveillance for 9 mo and 44 mo respectively, no tumor recurrence and metastasis were documented. Laparoscopic tumor excision, when adhering to the principles of surgical oncology, seems feasible and the prognosis is favorable for such tumors.

Retroperitoneoscopic laparo-endoscopic single-site radical nephrectomy (RLESS-RN): initial experience with a homemade port

We successfully performed 6 LESS radical nephrectomy via the retroperitoneal approach (RLESS) using the Alexis wound retractor as a single access with conventional laparoscopic instruments. The results demonstrated that our RLESS technique of radical nephrectomy is a safe and feasible procedure for management of localized renal cancer.