Anja Dietel

Technique of Laparoscopic-Endoscopic Single-Site Surgery Radical Nephrectomy

BACKGROUND Laparoscopic-endoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery. OBJECTIVE To assess the feasibility of LESS radical nephrectomy (LESS-RN). DESIGN, SETTING, AND PARTICIPANTS Ten patients with body mass index (BMI) < or = 30 underwent LESS-RN for renal tumour by two experienced laparoscopists. SURGICAL PROCEDURE TriPort (Olympus Winter & Ibe, Hamburg, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and flexible grasper and scissors was used. A 5-mm 30 degrees camera was also used. The standard laparoscopic transperitoneal nephrectomy technique was performed. MEASUREMENTS Patient demographics, operative details, and final pathology were prospectively recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. RESULTS AND LIMITATIONS Ten cases were successfully accomplished (two right-sided tumours and eight left-sided tumours; tumour diameter ranges: 4-8 cm). The mean patient age was 63.5 yr (22-77 yr), and median BMI was 23.56 (18.2-26.6). The mean operative time was 146.4 min (120-180 min), and the mean blood loss was 202 ml (50-900 ml). Pathological examination observed organ-confined T1 renal cell carcinoma in nine cases and pT3b tumour in one case. One bleeding complication occurred. Limitations regarding the intraoperative instrument ergonomics and the requirement for ambidexterity of the surgeon were noted. CONCLUSIONS LESS-RN proved to be safe and feasible. Further clinical investigation in comparison to the established techniques should take place to evaluate the outcome of LESS-RN.

Endoscopic Extraperitoneal Radical Prostatectomy: Evolution of the Technique and Experience with 2400 Cases

OBJECTIVES We report the outcome of 2400 endoscopic extraperitoneal radical prostatectomy (EERPE) cases performed in three institutions, with emphasis on the evolution of the EERPE technique. METHODS In total, 2400 EERPE procedures were performed in three institutions. Several surgeons performed the operations. The presented cases also include the learning curve of the surgeons. EERPE was performed in all cases of localized prostate cancer with the same indications to open and transperitoneal laparoscopic radical prostatectomy. RESULTS Average patient age was 63.3 years (range 41-81 years), and mean preoperative prostate specific antigen (PSA) level was 9.8 ng/mL (range 0.08-93 ng/mL); 857 (38%) patients had previously undergone abdominal or pelvic surgery, while 143 (5.8%) patients had prior prostatic treatment. Pelvic lymph node dissection took place in 1219 (50.8%) patients. Bilateral nerve sparing was performed in 672 patients and unilateral in 284 patients; 100 patients underwent intraoperative hernia repair with mesh placement (82 unilateral and 18 bilateral). Mean operative time was 150.7 minutes (range 50-340 minutes). Conversion to open surgery was never deemed necessary. Fifteen patients received transfusion (0.7%). The mean catheterization time was 6.19 days (range 3-40 days). Overall, 71.7% and 94.7% of the patients were continent at 3 and 12 months, respectively. Totally, 956 patients were treated with nerve-sparing procedure either interfascial or intrafascial; 672 patients underwent bilateral neurovascular bundle preservation, and 284, unilateral. Younger patients tend to have better postoperative potency. Bilateral nerve-sparing EERPE in patients younger than 55 years results in potency rate of 32.4%, 75.3%, and 84.9% at 3, 6, and 12 months postoperatively. CONCLUSIONS The functional and oncological outcome of EERPE is comparable to other approaches for radical prostatectomy. Continuous refinements contribute to the improving outcome of the procedure. Long-term results especially in terms of oncological efficacy are expected.

Comparative assessment of laparoscopic single-site surgery instruments to conventional laparoscopic in laboratory setting.

INTRODUCTION Laparoendoscopic single-site surgery (LESS) represents the latest innovation in laparoscopic surgery. We compare in dry and animal laboratory the efficacy of recently introduced pre-bent instruments with conventional laparoscopic and flexible instruments in terms of time requirement, maneuverability, and ease of handling. MATERIALS AND METHODS Participants of varying laparoscopic experience were included in the study and divided in groups according to their experience. The participants performed predetermined tasks in dry laboratory using all sets of instruments. An experienced laparoscopic surgeon performed 24 nephrectomies in 12 pigs using all sets of instruments. Single port was used for all instrument sets except for the conventional instruments, which were inserted through three ports. The time required for the performance of dry laboratory tasks and the porcine nephrectomies was recorded. Errors in the performance of dry laboratory tasks of each instrument type were also recorded. RESULTS Pre-bent instruments had a significant advantage over flexible instruments in terms of time requirement to accomplish tasks and procedures as well as maneuverability. Flexible instruments were more time consuming in comparison to the conventional laparoscopic instruments during the performance of the tasks. There were no significant differences in the time required for the accomplishment of dry laboratory tasks or steps of nephrectomy using conventional instruments through appropriate number of ports in comparison to pre-bent instruments through single port. DISCUSSION Pre-bent instruments were less time consuming and with better maneuverability in comparison to flexible instruments in experimental single-port access surgery. Further clinical investigations would elucidate the efficacy of pre-bent instruments.

A Comparison of Outcomes for Interfascial and Intrafascial Nerve-sparing Radical Prostatectomy

OBJECTIVE To compare the outcome of intrafascial nerve-sparing endoscopic extraperitoneal radical prostatectomy (nsEERPE) with interfascial (standard) nsEERPE. METHODS Four-hundred patients underwent nsEERPE; 200 patients underwent bilateral intrafascial nsEERPE (group A) and 200 bilateral standard nsEERPE (group B). Tumor stages of T1 and T2a, prostate-specific antigen level <10 ng/mL, maximal Gleason score 3+4 (not 4+3) and preoperative potency were considered as candidates for nsEERPE. Patients were randomized to the aforementioned groups. Perioperative data, and functional and oncological outcome were reviewed. Patients not requiring any pads or requiring 1 pad for safety were defined as continent. Patients responding positively to sexual encounter profile diary question numbers 2, 3, and 5 were considered as potent. RESULTS Perioperative data were similar between groups. At 3 months, 74% of group A and and 63% of group B were continent. At 6 months, the respective figures were 87.9% and 76.2%, respectively (A, B). At 12 months, 93.2% of group A and 90.7% of group B were continent. Potency rates of group A were 93.5% (<55 years), 83.3% (55-65 years), and 60% (>65 years) at 12 months. The respective figures for Group B were 77.1%, 50%, and 40%. Positive surgical margins were detected in 9% and 9.5% of groups A and B, respectively. CONCLUSIONS Intrafascial nsEERPE provides significantly better potency in patients <55 years of age at 12 months and in patients 55-65 years of age at 6 and 12 months, with probably limited effect on the oncological outcome. Significantly improved continence was observed at 3 and 6 months in favor of intrafascial nsEEPRE.

Serum levels of fibroblast growth factor-21 are increased in chronic and acute renal dysfunction

Fibroblast growth factor (FGF)‐21 has recently been introduced as a circulating adipokine which reverses insulin resistance and obesity in rodents. In this study, regulation of FGF‐21 in renal dysfunction was elucidated in both chronic kidney disease (CKD) and acute kidney dysfunction (AKD).

Laparoendoscopic Single-Site Surgery: Early Experience with Tumor Nephrectomy

BACKGROUND AND PURPOSE Laparoendoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery. We performed LESS for renal tumor nephrectomy in eight patients to assess feasibility and perioperative outcome. PATIENTS AND METHODS Eight patients with a body mass index (BMI) <or=30 underwent single-port nephrectomy for renal tumor by an experienced laparoscopic surgeon. Tri-Ports were used through a transumbilical incision in all cases. A flexible grasper and a 5-mm 30-degree high-definition camera were used in addition to standard laparoscopic equipment. Patient demographics; operative details, including procedure duration, blood loss, and complications; and final pathology results were prospectively recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. RESULTS All LESS nephrectomy operations were successfully accomplished without the need to convert to conventional laparoscopy. The median patient age was 60.75 years (range 22-76 years) and median BMI was 22.95 (range 18.2-26.1). The median operative duration was 141 minutes (range 120-180 min), and the median blood loss was 103 mL (range 50-150 mL). Histologic evaluation confirmed complete excision of an intact specimen. All cases revealed organ-confined T(1) renal-cell carcinoma (two right-sided and six left-sided, tumor diameter range 4-8 cm). A tumor with an adjacent simple renal cyst was excised in one patient. No intraoperative or postoperative complications occurred. CONCLUSIONS LESS was a feasible and safe approach in a selected group of patients (low BMI and stage tumor). LESS nephrectomy was made possible with the use of multi-instrument port and flexible instruments. The oncologic outcome was not compromised. Further evaluation of LESS surgery needs prospective, randomized studies.

Pure single-port laparoscopic surgery or mix of techniques?

PurposeLaparoendoscopic single-site surgery (LESS) has emerged in the recent years as an alternative approach to conventional laparoscopic surgery which is accompanied by additional advantages over laparoscopy. In this work we attempt to review the current literature and to investigate the possible combination of LESS to other currently available approaches such as natural orifice transluminal endoscopic surgery (NOTES), needlescopic and robotic laparoscopic surgery.MethodsExtensive literature search on the topics of LESS, hybrid and pure NOTES, Needlescopic-assisted LESS and “Robot-assisted LESS” took place. Additionally, the accumulated experience from 118 LESSs performed in our departments is presented in an attempt to provide evidence regarding the mix of technique in LESS in urology.ResultsThe challenging nature of LESS limits the broader application and acceptance. Expanding experience in single-site surgery has currently provided tools such as transvaginal access, needlescopic instruments and robot assistance that can aid LESS and enhance its efficiency without compromising any of its advantages. A mix of these techniques with LESS could ease the stiff learning curve of the second and benefit not only its performance but also the adaptation of LESS as a standard practice.ConclusionPure LESS although feasible, remains a technical challenge for the surgeon, preventing the widespread application of the technique. The goal of urologists on LESS surgery should not be the purity of LESS approach, but the superiority against already established techniques. A mix of techniques could be a key for the documentation of the advantages of LESS over conventional laparoscopy.

Hernia repair during endoscopic (laparoscopic) radical prostatectomy.

We retrospectively reviewed our experience in performing endoscopic extraperitoneal radical prostatectomy (EERPE) and totally extraperitoneal (TEP) hernia repair in one procedure to evaluate its feasibility and safety. Based on our experience of 70 laparoscopic radical prostatectomies, a total of 60 patients underwent EERPE. Eight of these had 10 hernias repaired with Prolene mesh. The median total operating time for EERPE was 165 minutes. Mesh placement required an additional 15 minutes for a unilateral hernia and 25 minutes for bilateral hernias. The conversion rate and the reoperation rate were 0%. The median duration of vesical catheterization was 8.3 days. One patient required a blood transfusion. The most common minor complications, occurring in eight patients, were edema and hematoma of the penis. No wound infection occurred. The only major complication was a deep venous thrombosis in one patient. No additional complications developed in the hernioplasty group. We conclude that the extraperitoneal approach for radical prostatectomy allows concomitant inguinal hernia repair with a low morbidity rate and within an acceptable operating time.

Effect of bladder neck preservation during endoscopic extraperitoneal radical prostatectomy on urinary continence.

Objective: The current study investigates the effect of bladder neck (BN) preservation on postoperative continence and positive surgical margins (+SMs). Patients and Methods: 150 patients (group 1) who underwent BN-sparing endoscopic extraperitoneal radical prostatectomy (EERPE) and 90 patients treated with EERPE and BN resection (group 2) were retrospectively evaluated. Results: Both groups were similar for age, prostate-specific antigen and prostate size. There was no significant difference in operative time, mean blood loss or transfusion rate. Mean catheterization time was similar. The overall +SM rates were very similar at 10.7% for group 1 and 10.0% for group 2 (group 1, pT2 = 5.1% and pT3 = 30.3%; group 2, pT2 = 2.9% and pT3 = 33.3%). One of 16 patients in group 1 and 1 of 9 in group 2 had a +SM at BN. Statistically significant differences in continence were observed 24 h after catheter removal and 3 months postoperatively between both groups. Conclusion: BN preservation proved to have an impact on postoperative early continence of patients undergoing EERPE. Continence of patients who underwent BN preservation was improved after catheter removal and at the 3-month follow-up in comparison to those without BN preservation, but +SMs were not affected by the BN-sparing surgery.

Prevention and management of perioperative complications in laparoscopic and endoscopic radical prostatectomy

IntroductionLaparoscopic transperitoneal radical prostatectomy (LRP) and endoscopic extraperitoneal radical prostatectomy (EERPE) are established techniques for the management of localized prostate cancer in numerous specialized urologic centers worldwide.ResultsThe complication rates of LRP and EERPE are ranging between 2 and 17%. Rare but possible complications are vascular injuries, bowel injury, lymphocele formation, port-site hernia, anastomotic leakage, gas embolism and catheter obstruction and other rare events.ConclusionPrevention and management of complications requires high surgical expertise and adequate standardization of the technique.Materials and methodsWe herein review our experience with the endoscopic extraperitoneal radical prostatectomy in a series of 1,800 consecutive patients regarding the appearance of complications and their management.