Aly M. Abdel-Karim

Urological laparoendoscopic single site surgery: Multi-institutional analysis of risk factors for conversion and postoperative complications

PURPOSE We analyzed the incidence of and risk factors for complications and conversions in a large contemporary series of patients treated with urological laparoendoscopic single site surgery. MATERIALS AND METHODS The study cohort consisted of consecutive patients treated with laparoendoscopic single site surgery between August 2007 and December 2010 at a total of 21 institutions. A logistic regression model was used to analyze the risks of conversion, and of any grade and only high grade postoperative complications. RESULTS Included in analysis were 1,163 cases. Intraoperatively complications occurred in 3.3% of cases. The overall conversion rate was 19.6% with 14.6%, 4% and 1.1% of procedures converted to reduced port laparoscopy, conventional laparoscopic/robotic surgery and open surgery, respectively. On multivariable analysis the factors significantly associated with the risk of conversion were oncological surgical indication (p=0.02), pelvic surgery (p<0.001), robotic approach (p<0.001), high difficulty score (p=0.004), extended operative time (p=0.03) and an intraoperative complication (p=0.001). A total of 120 postoperative complications occurred in 109 patients (9.4%) with major complications in only 2.4% of the entire cohort. Reconstructive procedure (p=0.03), high difficulty score (p=0.002) and extended operative time (p=0.02) predicted high grade complications. CONCLUSIONS Urological laparoendoscopic single site surgery can be done with a low complication rate, resembling that in laparoscopic series. The conversion rate suggests that early adopters of the technique have adhered to the principles of careful patient selection and safety. Besides facilitating future comparisons across institutions, this analysis can be useful to counsel patients on the current risks of urological laparoendoscopic single site surgery.

Laparoendoscopic Single-site Surgery Extravesical Repair of Vesicovaginal Fistula: Early Experience

OBJECTIVE To describe for the first time the technique of laparoendoscopic single-site surgery (LESS) for repair of vesicovaginal fistula (VVF). LESS has recently been described as an alternative to conventional laparoscopy for the treatment of various urologic pathologic features. METHODS The present study included 5 female patients with supratrigonal VVF who presented with urinary leakage per vagina after obstetric and gynecologic procedures. Extravesical LESS repair of VVF was done using the TriPort and prebent instruments. The fistulas tracts were identified and excised extravesically using sharp dissection. The edge of the bladder was trimmed at the site of fistula tract. The vagina was closed in 1 layer with continuous 3-0 Vicryl sutures, and the urinary bladder was closed in 2 layers using 3-0 Vicryl sutures. An additional 5-mm extraport was added at suturing to allow triangulation and hand-free extracorporeal suturing. An omental flap was interposed between the bladder and vagina. The urinary bladder was drained by an indwelling urethral catheter for 3 weeks. RESULTS The operative time was 198±27.7 minutes. The blood loss was 90±25 mL. No intraoperative or postoperative complications developed. No conversion to conventional laparoscopy or open surgery was necessary. The postoperative hospital stay was 2 days. No postoperative urinary leakage occurred. The follow-up examination at 8±3.2 months showed complete continence and no recurrence of VVF. CONCLUSION LESS extravesical repair of VVF is a technically feasible and effective procedure that adheres to the principles of transabdominal open surgical repair. The technique has significant low morbidity; however, it requires advanced laparoscopic skills.

Laparoendoscopic single-site pyeloplasty: Outcomes of an international multi-institutional study of 140 patients

OBJECTIVE To report an international, multi-institutional series of laparoendoscopic single-site pyeloplasty (LESS-P) with analysis of functional outcomes. MATERIALS AND METHODS LESS-P cases performed between October 2007 and June 2012 at 7 institutions worldwide per individual institutional protocols, entry criteria, and techniques were included. Patient characteristics, operative indications, perioperative outcomes, and postoperative follow-up were retrospectively collected and analyzed. RESULTS The study included 140 adult patients (age 39.9 ± 15.7 years; body mass index 24.8 ± 4.2 kg/m(2); 15% with previous abdominal surgery) who underwent unilateral LESS-P, most of whom (94.3%) had dismembered reconstructions. Mean operative time was 202.1 ± 47 minutes with an estimated blood loss of 61.2 ± 44.6 mL. Robotic laparoendoscopic single-site surgery was applied in 31 patients (22.1%). A single 2-3 mm accessory port was used in 44 patients (31.4%) and a single 5-12 mm accessory port was added in 9 patients (6.4%), whereas 10 patients (7.1%) were converted to conventional multiport laparoscopy. No patients required conversion to open surgery, nor were any intraoperative complications reported. Length of hospitalization was 2.4 ± 1.6 days. The overall 90-day postoperative complication rate was 18.6%, mostly low-grade complications (Clavien I-II). With a mean follow-up of 14.0 ± 10.8 months, 93.4% had resolution of symptoms and 94.4% had radiographic evidence demonstrating resolution of ureteropelvic junction obstruction. Assessment of drainage with diuretic nuclear renal scan provided evidence of improvement in 86.5% of patients on their first postoperative renal scan. CONCLUSION This study highlights the most comprehensive experience with LESS-P reported to date. Outcome measures parallel those of large published series of conventional laparoscopic pyeloplasty. Despite these encouraging findings, longer follow-up is needed to determine the efficacy and durability of this approach for the treatment of ureteropelvic junction obstruction.

Laparoendoscopic single-site nephroureterectomy for upper urinary tract urothelial carcinoma: outcomes of an international multi-institutional study of 101 patients

LESS‐NU may be an alternative minimally‐invasive treatment option for patients eligible to undergo laparoscopic surgery for upper urinary tract urothelial carcinoma. The true benefits of LESS‐NU remain to be determined and require randomized control trials in the future. Despite encouraging early findings, clinical trials still are warranted before this procedure is adopted widely, and longer follow‐up is needed to determine its oncological durability.

Laparoendoscopic single-site surgery (LESS) for the treatment of different urologic pathologies in pediatrics: Single- center single-surgeon experience

INTRODUCTION Recently LESS has been reported as a valid minimally option for treatment of some urologic pathologies in pediatrics. However, the initial reports of pediatric LESS are still limited to case reports and initial case series. This may be due to the inherent technical difficulty of LESS and the currently available LESS instruments. In this report, we present the largest case series of pediatric LESS for treatment of different urologic pathologies in pediatrics. MATERIALS AND METHODS Included in this study are children who had LESS during the period of January 2011 to June 2013. Both Olympus TriPort (Olympus, New York, USA and Advance Surgical Concept, Wicklow, Ireland) and Covedien SILS access port (Covedien, Chicopec, Massachusetts, USA) were used and were inserted through the umbilicus. Exclusion criteria included children less than 3 years old, history of previous transperitoneal abdominal surgery, malignant indications, and complex urogenital congenital anomalies. All LESS procedures were done by a single experienced laparoscopist and data were reviewed retrospectively. RESULTS Twenty-two children had 39 LESS procedures without conversion to conventional laparoscopy or open surgery. No intraoperative or postoperative complications were reported and no extra-port was added in any of the patients. The following table shows the mean age, operative time, hospital stay, VAS as well as the overall mean of different LESS procedures. In all patients the umbilical scar was invisible and all patients and their parents had high wound satisfaction. At a mean follow up of 18.6 ± 6.4 months, all patients with UPJO had successful repair. DISCUSSION Our study included 13 boys with undescended testis who were managed in different ways according to the length of spermatic vessels and the size of the testis. One of the arguments against LESS management of undescended testis is that it requires a 2.5-cm incision, which is collectively larger than a 5-mm camera and two 3-mm working ports of conventional laparoscopy. However, the Triport access can be inserted through a 12-15-mm single umbilical incision without any additional openings in the abdomen as required with conventional laparoscopy which may increase the risk of internal organ injury and other port-related complications. Our results of five LESS varicocelectomies correlate with reports in the literature; regarding the operative time and hospital stay. LESS pediatric nephrectomy has been reported by many authors and our results correlates with that have been published. Compared with conventional laparoscopic nephrectomy, LESS nephrectomy seems to have shorter operative time and hospital stay. Although both cases of LESS nephrectomy were on the right side, we did not add any extra-ports which could be related to technical modifications during the surgery as well as the experience of the surgeon. To date, few data are available about LESS pyeloplasty in pediatrics. Our study included three patients who had left LESS pyeloplasties. In these patients, no extra-port was added. Despite of the technical difficulty of intracorporeal suturing during LESS, LESS pyeloplasty seems to be feasible with adequate training. Our patients had short hospital stay, low VAS at discharge, received a low dose of NSAID as postoperative analgesic and in all cases there was high wound satisfaction. One of the limitations of the current study could be the selection criteria of the patients, with children younger than 3 years and children who may be more technically difficult, being excluded. Furthermore, the number of patients in some indications is small and more patients are required to give solid conclusions and detect possible complications. CONCLUSIONS Our study demonstrates the technical feasibility and safety of LESS for both ablative and reconstructive pathologies in pediatrics. However, more applications including a larger scale of pediatric patients as well as prospective comparative studies with conventional laparoscopy, are necessary.

Laparoendoscopic single-site surgery in urology: Evaluation of complications.

Abstract Objective: To comprehensively review current reports on the complications of laparoendoscopic single-site surgery (LESS), introduced recently into urology as an option for treating various urological pathologies. Methods: We reviewed previous reports to August 2011 using Medline, focusing on LESS in urology, with special interest in the complications, evaluating those during and after surgery, as well as conversions to reduced-port laparoscopy, conventional laparoscopy and open surgery. Results: There are increasing reports of LESS in urology, with expanding indications. Complication rates both during and after surgery are low and related mostly to the technical difficulty and dexterity with the currently available instruments. Overall, intraoperative complications were reported by 11 published studies, while postoperative complications were reported by 15. Although the overall conversion rates to open surgery and conventional laparoscopy were low, the incidence of reduced-port laparoscopy was significantly higher. Conclusions: Although there are expanding indications for LESS in urology, the risk of complications is low. This might be related to the fact that LESS is still restricted to experienced laparoscopic surgeons, and to the criteria for selecting patients.

Laparoendoscopic single-site surgery for the treatment of different urological pathologies: Defining the learning curve of an experienced laparoscopist

Abstract Objectives: To define the learning curve of laparoendoscopic single-site surgery (LESS) of an experienced laparoscopist. Patients and methods: Patients who had LESS, since its implementation in December 2009 until December 2014, were retrospectively analysed. Procedures were divided into groups of 10 and scored according to the European Scoring System for Laparoscopic Operations in Urology. Different LESS indications were done by one experienced laparoscopist. Technical feasibility, surgical safety, outcome, as well as the number of patients required to achieve professional competence were assessed. Results: In all, 179 patients were included, with mean (SD) age of 36.3 (17.5) years and 25.4% of the patients had had previous surgeries. Upper urinary tract procedures were done in 65.9% of patients and 54.7% of the procedures were extirpative. Both transperitoneal and retroperitoneal LESS were performed in 92.8% and 7.2% of the patients, respectively. The intraoperative and postoperative complication rates were 2.2% and 5.6% (Clavien–Dindo Grade II 3.9% and IIIa 1.7%), respectively. In all, 75% of intraoperative complications and all conversions were reported during the first 30 LESS procedures; despite the significantly higher difficulty score in the subsequent LESS procedures. One 5-mm extra port, conversion to conventional laparoscopy and open surgery was reported in 14%, 1.7%, and 1.1% of the cases, respectively. At mean (SD) follow-up of 39.7 (11.4) months, all the patients that underwent reconstructive LESS procedures but one were successful. Conclusion: In experienced hands, at least 30 LESS procedures are required to achieve professional competence. Although difficult, both conversion and complication rates of LESS are low in experienced hands.

Laparoscopic Single Site Surgery for Repair of Retrocaval Ureter in a Morbidly Obese Patient.

This is to describe a case of a morbidly obese (BMI = 40) female with retrocaval ureter treated with laparoendoscopic single-site surgery. A JJ stent was positioned. A 2 cm umbilical access was created. A single port platform was positioned. The entire ureter was mobilized posterior to the vena cava and transected where the dilated portion ended. The distal ureter was repositioned lateral to the inferior vena cava. Anastomosis was done. A 3 mm trocar was used to assist suturing. At 4-month follow-up, CT revealed no evidence of obstruction of the right kidney and the patient was symptomless. Although challenging, in a morbidly obese patient, LESS repair for retrocaval ureter is feasible.

MP23-16 EVALUATION OF THE ROLE OF LAPAROENDOSCOPIC SINGLE-SITE SURGERY VERSUS MINILAPAROSCOPY FOR TREATMENT OF DIFFERENT UPPER URINARY TRACT PATHOLOGIES: PROSPECTIVE RANDOMIZED COMPARATIVE STUDY

Objectives: To present the first prospective randomized comparison between laparoendoscopic single-site surgery (LESS) and minilaparoscopy (ML) for treatment of upper urinary tract pathologies. Patients and methods: Between January 2013 and June 2015, patients with different upper urinary pathologies were blindly randomized to both LESS and ML. All procedures were done by single experienced surgeon. Both cohorts were compared regarding demographic data, peri and postoperative characteristics and visual analogue pain scale (VAS). Cosmetic outcome was assessed after 12 months using patient scar assessment scale (PSAS) and observer scar assessment scale (OSAS). Results: Sixty patients were randomized into 2 equal groups with comparable demographic and preoperative characteristics. Indications included nephrectomy, pyeloplasty, cyst marsupialization, adrenalectomy and repair of retrocaval ureter. Operative time was 167 ±24 and 145±39 minutes in LESS and ML groups, respectively (P=0.09). Estimated blood loss w...