Rapid communication: transvaginal single-port NOTES nephrectomy: initial laboratory experience

BACKGROUND AND PURPOSE: Natural orifice translumenal endoscopic surgery (NOTES) using purpose-built equipment has never been applied to urologic surgery. Herein, we present our initial experience with a trans-vaginal single-port NOTES nephrectomy. METHODS AND RESULTS: An acute experiment was performed in a female farm pig. A single 12-mm trocar was placed in the midline and the TransPort Multi-Lumen Operating Platform (USGI Medical, San Clemente, CA) was passed transvaginally. This flexible device has four working channels and can be locked into position, thereby creating a rigid multitasking platform that allows two-handed tissue manipulation. Dissection was performed using an endoscopic needle knife and a tissue grasper for retraction. Via the 12-mm port, the renal artery and vein were taken separately with a vascular EndoGIA and standard laparoscopic titanium clips, respectively. The kidney was placed in a 10-mm EndoPouch retriever and removed intact via the vagina. The total operative time was 300 minutes. Conclusion: Transvaginal NOTES nephrectomy can be accomplished in a porcine model. Additional testing on survival animals is necessary to validate this approach.     

Rapid communication: robot-assisted anterior exenteration: technique and initial series

BACKGROUND AND PURPOSE: The feasibility of robot-assisted anterior exenteration (RAAE) in women has been reported but not well established. We report our experience with seven patients, providing perioperative data, hospital course, and immediate oncologic outcomes. PATIENTS AND METHODS: From November 2005 to June 2006, seven consecutive patients with a mean age of 70 years (range 59-82 years) underwent RAAE for bladder cancer. Urinary diversion consisted of an ileal conduit in six patients and neobladder in one. The mean body mass index and ASA scores were 25 (range 20-36) and 2 (range 2-3), respectively. Data were collected prospectively on intraoperative performance, oncologic status, and postoperative outcomes. RESULTS: The mean operative times for RAAE, pelvic lymph-node dissection, and ileal-conduit creation were 227 minutes (range 142-350 minutes), 48 minutes (range 35-80 minutes), and 132 minutes (range 80-255 minutes), respectively. The time needed for neobladder formation was 3 hours. The time required for anastomosis between the neobladder and the urethra with robotic assistance was 1 hour and 43 minutes, including time for closure of the mini-incision, redocking, and port placement. No case was converted to open surgery. All the surgical specimens were removed vaginally. There were no intraoperative complications or need for intraoperative blood transfusions. The only postoperative complication was an episode of pyelonephritis, which was managed successfully with antibiotics. The average times to return to normal and strenuous activity were 3.7 and 7.3 weeks, respectively. Final pathology examination revealed T(0)N(0), TisN(0), T(1)N(0), T(2b)N(0), T(3a)N(0), T(3a)N(1), and T(4)N(3) disease. Six patients had negative surgical margins, whereas the patient with T(4)N(3) disease had positive vaginal margins. CONCLUSION: Robot-assisted anterior exenteration can be offered safely to women. The long-term oncologic outcomes and experience of others will define its place in urologic oncology.     

Off-clamp robot-assisted partial nephrectomy: initial washington university experience

Abstract Background and Purpose: Because of the impact warm ischemia time may have on renal function, various surgical techniques have been proposed to minimize or eliminate warm ischemia. The purpose of this study is to evaluate our initial renal functional outcomes of off-clamp robot-assisted partial nephrectomy (RAPN), while assessing the safety profile of this unconventional surgical approach. Patients and Methods: We performed a retrospective review of our off-clamp RAPN experience between August 2007 and January 2012. All patients with baseline and postoperative serum creatinine determinations were included. Patient demographics, operative information, perioperative outcomes, and renal functional outcomes were evaluated for this cohort. Results: Forty-two patients with a mean age of 59.9 years (standard deviation [SD]=12) had a median follow-up of 100 days (range 1-1007 days). In all cases, warm ischemia time was 0 minutes. Mean operative time was 143 minutes (SD=59), and median estimated blood loss was 138?mL (range 50-1500?mL). No intraoperative complications were encountered, and all surgical margins were negative. Our postoperative complication rate was 14.3%. At the most recent follow-up, the mean estimated glomerular filtration rate (eGFR) was 76.2?mL/min/1.73?m(2) (SD=27.6), compared with 78.5?mL/min/1.73?m(2) (SD=28.9) preoperatively (P=0.11). Therefore, the mean eGFR decline of 2.3?mL/min/1.73?m(2) (SD=9.1) was not significant. Conclusions: Off-clamp RAPN is associated with minimal morbidity and minimal decline in renal function on short-term follow-up. Further studies and continued monitoring of renal function are needed to determine if off-clamp RAPN provides any advantage in renal function preservation relative to the traditional RAPN with vascular clamping.     

Laparoscopic nephrectomy: initial case report

A tumor-bearing right kidney was completely excised from an 85-year-old woman using a laparoscopic approach. A newly devised method for intra-abdominal organ entrapment and a recently developed laparoscopic tissue morcellator made it possible to deliver the 190 gm. kidney through an 11 mm. incision.     

Rapid communication: pure robot-assisted laparoscopic ureteral reimplantation for ureteral stricture disease: case report

BACKGROUND AND PURPOSE: The role of the da Vinci robot is slowly being defined in minimally invasive urologic surgery. We report its use in the management of ureteral stricture disease. CASE REPORT: A 42-year-old man with recurrent kidney stone disease was found to have a left distal-ureteral stricture. After failure of endoscopic treatment, a robot-assisted laparoscopic ureteral reimplantation was performed. The total operative time was 210 minutes. The estimated blood loss was <50 mL. There were no intraoperative or postoperative complications. Total analgesic use was 30 mg of morphine. The hospital stay was 5 days. CONCLUSION: Pure robot-assisted laparoscopic ureteral reimplantation is a safe and feasible approach to the management of ureteral stricture disease.     

Tumor enucleoresection in robot-assisted partial nephrectomy

The objective of this study is to describe our technique and results of the enucleoresection technique in robot-assisted partial nephrectomy. The patient is positioned in full flank position. Three robotic arms of a da Vinci system and an assistant’s port are used. The renal hilus is freed, the kidney mobilized and the site of the partial excision prepared. The vessels are clamped with a bulldog. The capsula of the kidney is incised circular about 5 mm around the tumor. A pseudocapsula of compressed healthy tissue around the tumor is found and mainly blunt dissection is done with the cold scissors. At the base of the dissection, the resection is completed sharply. Possible calyceal defects and major vessels are stitched. Fibrinogen coagulation enhancer and cellulose coagulation sponge are used to lessen the gap and the renal defect is closed with absorbable suture. The kidney is re-perfused and observed for bleeding. We have performed 17 cases with warm ischemia time 16–35 min (mean 24 min) and tumor size 2.2–5.3 cm (mean 3.8 cm). All surgical margins were tumor free. No postoperative complications were identified except one clot retention. Robot-assisted enucleoresection of kidney tumors is a feasible and very promising technique that needs to be further evaluated for results.     

Laparoscopic robot-assisted appendicovesicostomy: an initial experience

PURPOSE: To describe our initial experience with laparoscopic robot-assisted appendicovesicostomy (LRAA). MATERIALS AND METHODS: We have performed the LRAA in three patients, aged 9, 17, and 45 years. The underlying medical conditions were myelomeningocele, prune-belly syndrome, and multiple sclerosis. Adjuvant procedures consisted of extensive lysis of adhesions and a bladder-neck fascial sling. RESULTS: All procedures were completed intracorporeally. The mean blood loss was 50 mL. The mean operative time was 301 minutes (range 203-362 minutes). The mean hospital stay was 3 days (range 2-4 days). Follow-up ranges from 1 to 8 months. All patients currently catheterize without difficulty and are continent. CONCLUSIONS: In our initial experience, LRAA is a safe and effective option for creating a continent catheterizable channel into the urinary bladder.     

Rapid communication: chronic renal insufficiency after laparoscopic partial nephrectomy and radical nephrectomy for pathologic t1a lesions

PURPOSE: To report the prevalence of new-onset renal insufficiency in patients undergoing laparoscopic partial nephrectomy (LPN) as compared to laparoscopic radical nephrectomy (LRN) for pathologic T1a lesions. PATIENTS AND METHODS: Forty-eight patients and 37 patients with a normal contralateral kidney, preoperative creatinine (Cr) concentration <2 mg/dL, and tumors <4 cm in size underwent LPN and LRN, respectively. Glomerular filtration rate (GFR) was estimated using an abbreviated Modification of Diet in Renal Disease (MDRD) equation. Cr concentrations and GFR values were analyzed in patients undergoing LPN or LRN. Statistical analysis was performed with two-tailed t-test assuming unequal variances, to establish significance by P < 0.05. RESULTS: Preoperative Cr and GFR was equivalent in the LPN and LRN groups (0.9 mg/dL and 90 mL/min). At last follow-up (mean 205 and 233 days in the LPN and LRN groups, respectively) mean creatinine was 1.03 +/- 0.3 mg/dL v 1.4 mg/dL +/- 0.3 (P = 0.0002). Estimated GFR was 79 +/- 22 mL/min per 1.73 m2 v 55 +/- 14 mL/min per 1.73 m2 (range 31-91 mL/min per 1.73 m2; P < .0001) in the LPN and LRN groups, respectively. One patient in the LPN group and three patients in the LRN group had clinical renal insufficiency as defined by Cr > 2.0 mg/dL. Subclinical renal insufficiency (Cr < 2.0, but calculated GFR <60 mL/min per 1.73 m2) was present in 57% of the LRN patients v 15% of the LPN patients. CONCLUSIONS: LPN preserves renal function more effectively than LRN for pathologic T1a lesions. Subclinical renal insufficiency (GFR <60 mL/min per 1.73 m2) was present in the majority of patients undergoing radical nephrectomy in our series. Importantly, this series included the use of warm ischemia in all cases.     

Off-clamp robot-assisted partial nephrectomy for complex renal tumors

Abstract Background and Purpose: Considering the potential impact of warm ischemia time (WIT) on renal functional outcomes after robot-assisted partial nephrectomy (RAPN), many techniques that reduce or eliminate WIT have been studied. We present our institutional experience and progression using one such technique-off-clamp RAPN-as well as the results of this technique in the management of complex cases. Patients and Methods: A retrospective chart review of 65 patients undergoing off-clamp RAPN was performed, 15 of whom underwent off-clamp RAPN for 26 complex tumors. Complex features included hilar location, completely endophytic growth, and ipsilateral multifocality. In all cases, hilar vessels were dissected but not clamped. Results: Mean tumor size was 2.5?cm (standard deviation; [SD]=1.4), while mean nephrometry score was 8.7 (SD=1.5). One (7%) intraoperative complication occurred. Mean estimated blood loss was 403?mL (SD=381), mean operative time was 190 minutes (SD=68), and WIT was 0 minutes in all cases. Mean length of stay was 1.8 days (SD=0.9), with one patient needing a postoperative blood transfusion (Clavien II complication). Final pathology results demonstrated clear-cell carcinoma (n=16), papillary carcinoma (n=4), angiomyolipoma (n=1), oncocytoma (n=2), and cystic nephroma (n=3). Margins were negative for tumor for 96% (25/26) of resected masses. Estimated glomerular filtration rate (eGFR) decreased by an average of 3.1?mL/min/1.73m(2) (SD=9.8, P=0.24), at a mean follow-up of 177 days (SD=296). Five patients with radiographic follow-up of at least 6 months have no evidence of disease recurrence. Conclusions: Off-clamp RAPN can be safely and effectively performed even in the case of complex tumors, but occurs with higher estimated blood loss. Minimal changes in eGFR were experienced by patients undergoing off-clamp RAPN at an average follow-up of roughly 6 months. Longer follow-up and direct comparison with conventional clamped RAPN technique are needed to establish the efficacy of off-clamp RAPN in complex cases.     

Laparo-endoscopic single-site (LESS) radical nephrectomy with renal vein thrombectomy: initial report

Background

The aim of the following study is to evaluate the advancement of incidentally diagnosed prostate cancer in specimen after cystoprostatectomies caused by muscle-invasive bladder cancer. Secondly we assessed the survival in patients after radical cystoprostatectomy whose postoperative specimen was characterized by the presence of co-existing prostate cancer or prostate infiltration by urothelial bladder cancer.

Methods

Between 1993 and 2009 a total of 320 patients with muscle-invasive bladder cancer underwent cystoprostatectomy. The first analyzed group consisted of 52 patients with bladder cancer infiltrating prostate, while the second group consisted of 21 patients with co-existing prostate cancer. In all patients cancer specific survival and progression were analyzed. Average follow up was 75.2 months (range: 0 - 181).

Results

Cancer-specific survival was significantly shorter in group I (p = 0.03). Neoplastic progression in patients from group I was observed in 42.2% of patients, while in patients from group II in 23.6% of patients (p = 0.04). No statistical difference was observed in the percentage of positive lymph nodes between the groups (p = 0.22). The median Gleason score in patients with co-existing prostate cancer was equal to 5. The stage of prostate cancer pT₂/pT₃ was equal to 20 (96%)/1 (4%) patients. 12 (57%) prostate cancers were clinically insignificant. Biochemical recurrence occurred in 2 (9%) patients.

Conclusions

1. Incidentally diagnosed prostate cancer in specimen after cystoprostatectomies is frequently clinically insignificant and characterized by low progression.
2. Patients with bladder cancer infiltrating prostate are characterized by higher percentage of progression and death in comparison with patients with co-existing prostate cancer.