Enrique Ian S. Lorenzo

Initial experience with 50 laparoendoscopic single site surgeries using a homemade, single port device at a single center.

PURPOSE We report our technique of and initial experience with 50 patients who underwent laparoendoscopic single site surgery using a homemade single port device at a single institution. MATERIALS AND METHODS Between December 2008 and August 2009 we performed 50 laparoendoscopic single site surgeries using the Alexis wound retractor, which was inserted at the umbilical incision. A homemade single port device was made by fixing a size 7 1/2 surgical glove to the retractor outer ring and securing the glove fingers to the end of 3 or 4 trocars with a tie and a rubber band. A prospective study was performed in 50 patients to evaluate outcomes. RESULTS Of 50 patients 34 underwent conventional laparoendoscopic single site surgery, including radical and simple nephrectomy, and cyst decortication in 8 each, nephroureterectomy in 3, partial nephrectomy and adrenalectomy in 2 each, and partial cystectomy, ureterectomy and ureterolithotomy in 1 each, while 16 underwent robotic laparoendoscopic single site surgery, including partial nephrectomy in 11, nephroureterectomy in 3, and simple and radical nephrectomy in 1 each. Mean patient age was 52 years, mean body mass index was 23.4 kg/m(2), mean operative time was 201 minutes and mean estimated blood loss was 201 ml. Four intraoperative complications occurred, including 2 bowel serosal tears, diaphragm partial tearing and conversion to open radical nephrectomy. One case of postoperative bleeding was managed by transfusion. Surgical margins were negative in the 13 patients who underwent partial nephrectomy. Mean hospital stay was 4.5 days (range 1 to 16). CONCLUSIONS Our homemade single port device is cost-effective, provides adequate range of motion and is more flexible in port placement for laparoendoscopic single site surgery than the current multichannel port.

Robot-assisted Laparoendoscopic Single-site Surgery: Partial Nephrectomy for Renal Malignancy

OBJECTIVES To describe our experience with robot-assisted laparoendoscopic single-site surgery (LESS) to perform partial nephrectomy and evaluate a hybrid homemade port system as an effective access technique. METHODS From December 2008 to September 2009, robot-assisted LESS to perform partial nephrectomy through a hybrid homemade port was performed to treat 14 cases of renal cell carcinoma. The data, including patient characteristics, operative records, complications, and pathologic results, were analyzed. RESULTS The mean tumor size was 3.2 cm, the mean ischemic time was 30 minutes, and the mean operative time was 233 minutes. We used the hybrid homemade port technique in 10 cases. All surgical margins after partial nephrectomy were negative for malignancy. No port-related complications were reported. Two cases required conversion to mini-incisional partial nephrectomy. CONCLUSIONS Robot-assisted LESS for performing partial nephrectomy using a hybrid homemade port system is a safe and feasible treatment technique. It provided access for meticulous suturing on the renal parenchyma using articulating robot arms and ready access to the surgical field for the assistant.

Laparoscopic Partial Nephrectomy Versus Robot-Assisted Laparoscopic Partial Nephrectomy

PURPOSE Laparoscopic partial nephrectomy (LPN) is an alternative treatment modality for small-sized renal tumors. Robot-assisted LPN (RLPN) has also been performed with an advantage in repairing the defect after a resection of the tumor. We compared the perioperative data of patients treated with LPN with patients who underwent RLPN. MATERIALS AND METHODS From September 2006 to April 2008, 26 patients were treated with LPN and 31 with RLPN. Three arms were used for RLPN; camera was inserted through the 12 mm umbilical trocar port. Laparoscopic Bulldog clamps were used for clamping the renal hilum. We retrospectively compared each group on tumor size, operative time, estimated blood loss, warm ischemic time, and hospital stay. RESULT Operative time of LPN was shorter than that of RLPN (p = 0.034). Tumor size, estimated blood loss, and hospital stay were not significantly different in each group. No case was converted to open surgery. One patient in the RLPN group, however, was converted to robot-assisted radical nephrectomy because of severe bleeding. CONCLUSION RLPN is safe and feasible for small-sized renal tumors. Warm ischemic time is within reasonable limits. Associated morbidity is also low.

Robotic Palpation-Based Mechanical Property Mapping for Diagnosis of Prostate Cancer

PURPOSE The aim of this study was to estimate the mechanical properties (elasticity) of normal and cancer prostate tissues and to develop a tissue elasticity map for the diagnosis and localization of prostate cancer. MATERIALS AND METHODS A total of 735 sites from 35 radical prostatectomy specimens were used in the experiments using a robotic palpation system, and the elasticities of the specimens were estimated by a tissue characterization algorithm. The estimated elasticities from 21 regions were separated into normal and cancer tissues using the pathological information, and a tissue elasticity map was developed using numerical functions and a nonlinear surface-fitting method. RESULTS The mean elastic moduli of the normal and cancer tissues were 15.25 ± 5.88 and 28.80 ± 11.20 kPa, respectively. The base region had the highest elasticity, followed by the medial and apex regions. These results demonstrated the ability to separate the cancer tissue from the normal tissue based on its elastic modulus. The tissue elasticity mapping was carried out using the estimated elasticity and nonlinear surface fitting. The proposed map showed the elasticity and was used to estimate the elastic modulus of the prostate at any given region. CONCLUSION Tissue elasticity may be an important indicator of prostate cancer because the pathologic changes alter the tissue properties, including cell integrity and intercellular matrix. This work provides quantitative and objective information for the diagnosis of prostate cancer. In addition, these results may have implications for the localization of prostate cancers.

Robotics applied in laparoscopic kidney surgery: the Yonsei University experience of 127 cases.

OBJECTIVE We report our experience on 127 kidney surgeries with the da Vinci surgical system and show the feasibility of a robotics application in a variety of kidney surgeries by both a laparoscopically-trained and a laparoscopically-naïve surgeon. METHODS Clinical data of patients who underwent kidney surgery with the da Vinci surgical system from September 2006 to April 2009 were reviewed. Data acquired from medical records included patient demographics, operative time, estimated blood loss (EBL), incidence of intraoperative complication, duration of hospital stay, blood transfusion rate, oncological outcomes, and follow-up results. RESULT One-hundred twenty-seven kidney surgeries have been conducted with the da Vinci surgical system at our institution. Three urologists--1 with formal endourology training, 1 with laparoscopic experience, and 1 laparoscopically naïve--have used it for a variety of procedures involving the kidney. The cases include 65 partial nephrectomies (RPN), 38 radical nephrectomies (RRN), and 24 nephroureterectomies with bladder cuff (RNU). Results on operative time, EBL, incidence of intraoperative injury, duration of hospital stay, and blood transfusion rate are comparable with contemporary studies. CONCLUSIONS Robotics application in kidney surgery is a viable option for various procedures. Our experience shows it can be safely and effectively conducted by both laparoscopically-trained and laparoscopically-naïve surgeons once they are accustomed to the robotics system.

Iliac Vein Injury Due to a Damaged Hot Shears™ Tip Cover During Robot Assisted Radical Prostatectomy

We report a rare case of vascular injury secondary to a damaged Hot Shears™ tip cover. Two 1 mm holes in the tip cover resulted in perforations in the obturator and external iliac veins during pelvic node dissection. Bleeding was controlled with bipolar coagulation and a 5 mm metal clip in the obturator and iliac vein, respectively. The rest of the procedure was completed uneventfully. Frequent integrity assessment of this accessory is necessary. Its function is important in order to carry out safe dissection in proximity to delicate structures. When injuries arise from areas not directly involved in the dissection, immediate inspection of the instruments should be mandatory.

Palpation device for the identification of kidney and bladder cancer: a pilot study.

Purpose To determine the ability of a novel palpation device to differentiate between benign and malignant tissues of the kidney and bladder by measuring tissue elasticity. Materials and Methods A novel palpation device was developed, mainly composed of a micromotor, a linear position sensor, a force transducer, and a hemisphere tip and cylindrical body probe. Motion calibration as well as performance validation was done. The tissue elasticity of both benign and malignant tissues of the kidney and bladder was measured using this device. A single investigator performed the ex-vivo palpation experiment in twelve kidneys and four bladder specimens. Malignant tissues were made available from partial nephrectomy specimens and radical cystectomy specimens. Palpations for benign renal parenchyma tissue were carried out on nephroureterectomy specimens while non-involved areas in the radical cystectomy specimens were used for benign bladder samples. Elastic modulus (Youngs modulus) of tissues was estimated using the Hertz-Sneddon equation from the experimental results. These were then compared using a t-test for independent samples. Results Renal cell carcinoma tissues appear to be softer than normal kidney tissues, whereas tissues from urothelial carcinoma of the bladder appear to be harder than normal bladder tissues. The results from renal cell carcinoma differed significantly from those of normal kidney tissues (p=0.002), as did urothelial carcinoma of the bladder from normal bladder tissues (p=0.003). Conclusion Our novel palpation device can potentially differentiate between malignant and benign kidney and bladder tissues. Further studies are necessary to verify our results and define its true clinical utility.

Robotic palpation system for prostate cancer detection

Medical robotic system enable precise and safe treatment for patients, especially in the area of urology. In this paper, we propose a robotic palpation system to detect prostate cancers. These cancers usually arise in the posterior of the prostate and as they are firmer than normal tissues, can be detected by digital rectal examination (DRE). This system is designed to induce a controllable deformation to tissues as well as to measure the force response of tissues. To validate the system performance, ex vivo experiments on human organs were conducted to determine the differences between the mechanical properties of normal and cancerous tissues. The tissue properties were characterized using experimental results. In addition, we propose the numerical maps expected to be used to diagnose prostate cancer by using the obtained elastic moduli of normal and cancer tissues. The results indicate that this system could detect differences of mechanical properties between normal and cancerous prostrate tissues.

Double primary tumor of the stomach and the prostate managed robotically simultaneously

The occurrence of multiple primary tumors is rare. Here we present a case of a 65-year-old male with a longstanding cardiac condition who presented with synchronous adenocarinoma of the stomach and prostate. Both cancers were managed simultaneously using robot-assisted laparoscopy techniques. Subtotal gastrectomy with gastro-jejunostomy and nerve-sparing radical prostatectomy were performed successfully. Post-operative course was likewise uneventful. Operative and oncologic outcomes were excellent with the patient cancer-free after one year of follow up. We believe the robotic system enabled us to manage this case simultaneously with excellent results.