George-Pascal Haber

Single-Port Laparoscopic Radical Prostatectomy

OBJECTIVES To present the initial experience in laparoscopic radical prostatectomy performed exclusively through an umbilical incision using a single three-channel port and specially designed flexible laparoscopic instrumentation. METHODS Since November 26, 2007, we have performed single-port laparoscopic radical prostatectomy in 4 patients diagnosed with prostate cancer. Patients with early-stage prostate cancer (T1c), no previous pelvic surgery, and a body mass index <or=35 kg/m(2) were selected for single-port laparoscopic radical prostatectomy. A multichannel port was inserted transperitoneally through a 1.8-cm umbilical incision. No additional extraumbilical instruments or ports were inserted. Urethrovesical anastomosis was performed using free-hand interrupted suturing and extracorporeal knot tying. Data were collected prospectively into our institutional review board-approved data registry. RESULTS All cases were completed successfully, without conversion to a standard laparoscopic approach. The total operative time was 285 +/- 30 minutes, with a mean operative time for prostate excision and urethrovesical anastomosis of 3.25 hours and 1.1 hours, respectively. The mean blood loss was 288 +/- 131 mL, and no patient required a blood transfusion. The hospital stay was 2.5 +/- 0.6 days. The Foley catheter was removed 2 weeks (range 1-3) after surgery. No intraoperative complications occurred; however, 1 patient developed a rectourethral fistula that was noted 2 months after surgery. At 18 weeks of follow-up, 3 patients used 1 or 0 pads for continence daily, 2 patients had positive margins noted at the site of extracapsular extension, and all patients had an undetectable prostate-specific antigen level. CONCLUSIONS Single-port laparoscopic radical prostatectomy is feasible. Additional investigation is needed to evaluate the safety and oncologic adequacy of this new approach.

Urine leak in minimally invasive partial nephrectomy: analysis of risk factors and role of intraoperative ureteral catheterization

PURPOSE To investigate risk factors for urine leak in patients undergoing minimally invasive partial nephrectomy (MIPN) and to determine the role of intraoperative ureteral catheterization in preventing this postoperative complication. MATERIALS AND METHODS MIPN procedures done from September 1999 to July 2012 at our Center were reviewed from our IRB-approved database. Patient and tumor characteristics, operative techniques and outcomes were analyzed. Patients with evidence of urine leak were identified. Outcomes were compared between patients with preoperative ureteral catheterization (C-group) and those without (NC-group). Univariable and multivariable analyses were performed to identify factors predicting postoperative urine leak. RESULTS A total of 1,019 cases were included (452 robotic partial nephrectomy cases and 567 laparoscopic partial nephrectomy cases). Five hundred twenty eight patients (51.8%) were in the C-group, whereas 491 of them (48.2%) in the NC-group. Urine leak occurred in 31(3%) cases, 4.6% in the C-group and 1.4% in the NC-group (p<0.001). Tumors in NC-group had significantly higher RENAL score, shorter operative and warm ischemic times. On multivariable analysis, tumor proximity to collecting system (OR=9.2; p<0.01), surgeons early operative experience (OR=7.8; p<0.01) and preoperative moderate to severe CKD (OR=3.1; p<0.01) significantly increased the odds of the occurrence of a postoperative urine leak. CONCLUSION Clinically significant urine leak after MIPN in a high volume institution setting is uncommon. This event is more likely to occur in cases of renal masses that are close to the collecting system, in patients with preoperative CKD and when operating surgeon is still in the learning curve for the procedure. Our findings suggest that routine intraoperative ureteral catheterization during MIPN does not reduce the probability of postoperative urine leak. In addition, it adds to the overall operative time.

Robotic Partial Nephrectomy in the Treatment of Renal Angiomyolipoma

PURPOSE To present the experience and efficacy of Robotic Partial Nephrectomy (RPN) for the management of renal angiomyolipomas (AMLs) with regard to renal function preservation and perioperative outcomes. PATIENTS AND METHODS We retrospectively searched our RPN database for pathologically confirmed renal AML patients between 2006 and 2014. Clinical presentation, perioperative complications, and postoperative outcomes of the patients were analyzed. Preoperative imaging findings were reviewed to examine their ability to predict pathology of AML. RESULTS From 1005 RPN performed in our center during the study period, 53 patients met our inclusion criteria. The mean age at presentation was 54.1 (± 13) years, and 42 (79.2%) patients were female. Median tumor size was 2.8 (interquartile range [IQR], 1.8-4.6) cm. The indication for RPN was suspicious radiologic features for malignancy in 42 (79.2%) patients and acute retroperitoneal hemorrhage risk and pain in 11 (20.8%) patients who were found to have AML according to preoperative imaging. Mean estimated blood loss was 198 (± 194) mL, and 5 (9.4%) patients required blood transfusion. Postoperative complications occurred in 8 (15%) patients. Median estimated glomerular filtration rate within the latest follow-up was 86.9 (IQR, 69.7-100.1) mL/minute/1.73 m(2) with a median of 91% (IQR, 80.4-103) preservation. None of patients developed urinary fistula or pseudoaneurysm requiring second intervention. No local recurrences occurred with a median follow-up of 7 (IQR, 1-17) months. CONCLUSION Given the low complication rate and preservation of renal function after RPN for AML, it can be considered a reliable method for AML treatment. The majority of AMLs were not suspected based on preoperative imaging. Further diagnostic methods are needed to differentiate benign from malignant lesions.

Robotic Partial Nephrectomy for Caliceal Diverticulum: A Single-Center Case Series

The aim of this study is to examine the role of robotic partial nephrectomy (RPN) in the management of caliceal diverticula by assessing our single-center outcomes. Between July 2007 and July 2013, 7 of 670 patients underwent RPN procedures as a reason of caliceal diverticula. The indications for RPN in all cases were recurrent urinary tract infection and pain attributed to the diverticulum in addition to failed management by endourologic or extracorporeal shockwave lithotripsy (SWL) treatments. One patient with a calcified diverticulum and another with an unsuccessful SWL treatment underwent RPN without further endourologic intervention. The other five patients had a history of unsuccessful percutaneous nephrolithotomy (one case), ureteroscopy (URS) (two cases), and a combination of SWL+URS (two cases). No intraoperative or postoperative complications were observed. No patient was readmitted postoperatively. Unique features of the robotic platform facilitate the excision of diverticulum and subsequent kidney reconstruction for this benign, but complex pathology.