Jeffrey A. Cadeddu

Single-Incision, Umbilical Laparoscopic versus Conventional Laparoscopic Nephrectomy: A Comparison of Perioperative Outcomes and Short-Term Measures of Convalescence

BACKGROUND Recent reports have suggested that single-port or single-incision laparoscopic surgery (SILS) is technically feasible. OBJECTIVE To present a comparison between SILS and conventional laparoscopic nephrectomy with respect to perioperative outcomes and short-term measures of convalescence. DESIGN, SETTING, AND PARTICIPANTS This was a case-control study comparing 11 SILS nephrectomies (cases) and 22 conventional laparoscopic nephrectomies (controls) performed from September 2004 to April 2008. The control group was matched in a 2:1 ratio to SILS cases with respect to patient age, surgical indication, and tumor size. INTERVENTION A single surgeon performed all SILS nephrectomy cases using three adjacent 5-mm trocars inserted through a single 2.5-cm periumbilical incision. MEASUREMENTS Demographics, operative time, blood loss, perioperative complications, transfusion requirement, decrease in serum hemoglobin, analgesic requirement, length of stay, and final pathology were compared. RESULTS AND LIMITATIONS Mean patient age was 53 yr for both groups, with more females in the SILS cohort (82% vs 41%). Nephrectomy was performed for benign disease in 45% of the cases. Median tumor size was 5.5 cm for both groups, and all but one suspected malignancy was renal cell carcinoma on final pathology. There was no difference between SILS and conventional laparoscopy cases in median operative time (122 min vs 125 min, p=0.78), percent decrease from preoperative hemoglobin (14.1% vs 15.8%, p=0.52), analgesic use (8 morphine equivalents vs 15 morphine equivalents, p=0.69), length of stay (49 h vs. 53 h, p=0.44), or complication rate (0% for both). The SILS group did have a lower recorded median estimated blood loss (20 ml vs 100ml, p=0.001). This study is retrospective and is susceptible to all limitations and biases inherent in such a design. CONCLUSIONS SILS nephrectomy is feasible with perioperative outcomes and short-term measures of convalescence comparable to conventional laparoscopic nephrectomy. Although SILS may offer a subjective cosmetic advantage, prospective comparison is needed to more clearly define its role.

Laparoscopic nephrectomy for renal cell cancer: evaluation of efficacy and safety: a multicenter experience

OBJECTIVES Although laparoscopic radical nephrectomy is a safe and minimally invasive alternative to open surgery, the long-term disease-free outcome of this procedure has not been reported. We evaluated our experience with the laparoscopic management of renal cell carcinoma to assess the clinical efficacy of this surgical modality. METHODS Between February 1991 and June 1997, 157 patients at five institutions were retrospectively identified who had clinically localized, pathologically confirmed, renal cell carcinoma and had undergone laparoscopic radical nephrectomy. Operative and clinical records were reviewed to determine morbidity, disease-free status, and cancer-specific survival. Of the patients followed up for at least 12 months (n = 101), 75% had an abdominal computed tomography scan at their last visit. RESULTS The mean age at surgery was 61 years (range 27 to 92) and all patients were clinical Stage T1-2,NO,MO. Fifteen patients (9.6%) had perioperative complications. During a mean follow-up of 19.2 months (range 1 to 72; 51 patients with 2 years or more of follow-up), no patient developed a laparoscopic port site or renal fossa tumor recurrence. Four patients developed metastatic disease, and 1 patient developed a local recurrence. The 5-year actuarial disease-free rate was 91%+/-4.8 (SE). At last follow-up, there were no cancer-specific mortalities. CONCLUSIONS The laparoscopic surgical management of localized renal cell carcinoma is feasible. Short-term results indicate that laparoscopic radical nephrectomy is not associated with an increased risk of port site or retroperitoneal recurrence. Longer follow-up is necessary to compare long-term survival and disease-free rates with those of open surgery.

Laparoscopic radical nephrectomy: cancer control for renal cell carcinoma.

PURPOSE We evaluated the clinical efficacy of laparoscopic versus open radical nephrectomy in patients with clinically localized renal cell carcinoma. MATERIALS AND METHODS Between 1991 and 1999, 67 laparoscopic radical nephrectomies were performed for clinically localized, stages cT1/2 NXMX, pathologically confirmed renal cell carcinoma. During this period 54 patients who underwent open radical nephrectomy with pathologically confirmed stages pT1/2 NXMX disease were also identified. Medical and operative records were retrospectively reviewed and telephone followup was done to assess patient status. RESULTS In the laparoscopic and open groups average tumor size was 5.1 (range 1 to 13) and 5.4 cm. (range 0.2 to 18), respectively, which was not statistically significant. No patient had laparoscopic port site, wound or renal fossa tumor recurrence in either group. All patients were followed at least 12 months. In the laparoscopic group 2 cancer specific deaths occurred at a mean followup of 35.6 months. In the open group there were 2 cancer specific deaths and 3 cases of disease progression at a mean followup of 44 months. Kaplan-Meier disease-free survival and actuarial survival analysis revealed no significant differences in the laparoscopic and open radical nephrectomy groups. Also, no differences were noted in the complication rate. CONCLUSIONS Laparoscopic radical nephrectomy is an effective alternative for localized renal cell carcinoma when the principles of surgical oncology are maintained. Initial data show shorter patient hospitalization and effective cancer control with no significant difference in survival compared with open radical nephrectomy.

Transvaginal laparoscopic nephrectomy: Development and feasibility in the porcine model

OBJECTIVES To assess feasibility of laparoscopic nephrectomy completed entirely by way of the vagina in the porcine model. METHODS Six transvaginal laparoscopic nephrectomies were performed in female farm pigs. Two acute and two 1-week survival animals were used for the study. Before killing the survival animals, a second transvaginal laparoscopic nephrectomy was performed on the remaining renal unit. For one renal unit, the laparoscopic nephrectomy was completed entirely by way of the vagina. In five renal units, a single, 5-mm transabdominal trocar for the laparoscope was required to facilitate visualization. RESULTS The operative time for the procedure completed entirely by way of the vagina was 360 minutes, and the mean operative time for the procedures requiring placement of a single 5-mm transabdominal trocar was 210 minutes. In 5 cases, dissection, control of the renal pedicle, and extraction of the kidney were successfully completed using a transvaginal approach. In 1 acute case, an uncontrollable vascular injury occurred during placement of the Endo-GIA stapler, resulting in exsanguination. In all other cases, the mean blood loss was less than 30 mL, and no significant perioperative complications were noted. Both survival pigs had normal bowel and bladder function before being killed. CONCLUSIONS Complete transvaginal laparoscopic dissection and nephrectomy is feasible in the porcine model using a single, 5-mm abdominal trocar for visualization. A completely transvaginal laparoscopic nephrectomy was performed once, but limitations imposed by the porcine anatomy and by the currently available instrumentation made the procedure very cumbersome. Additional development of this technique in animal models and improved instrumentation is needed before clinical assessment is warranted.

Laparoendoscopic Single-site Surgery in Urology: Worldwide Multi-institutional Analysis of 1076 Cases

BACKGROUND Laparoendoscopic single-site surgery (LESS) has gained popularity in urology over the last few years. OBJECTIVE To report a large multi-institutional worldwide series of LESS in urology. DESIGN, SETTING, AND PARTICIPANTS Consecutive cases of LESS done between August 2007 and November 2010 at 18 participating institutions were included in this retrospective analysis. INTERVENTION Each group performed a variety of LESS procedures according to its own protocols, entry criteria, and techniques. MEASUREMENTS Demographic data, main perioperative outcome parameters, and information related to the surgical technique were gathered and analyzed. Conversions to reduced-port laparoscopy, conventional laparoscopy, or open surgery were evaluated, as were intraoperative and postoperative complications. RESULTS AND LIMITATIONS Overall, 1076 patients were included in the analysis. The most common procedures were extirpative or ablative operations in the upper urinary tract. The da Vinci robot was used to operate on 143 patients (13%). A single-port technique was most commonly used and the umbilicus represented the most common access site. Overall, operative time was 160±93 min and estimated blood loss was 148±234 ml. Skin incision length at closure was 3.5±1.5 cm. Mean hospital stay was 3.6±2.7 d with a visual analog pain score at discharge of 1.5±1.4. An additional port was used in 23% of cases. The overall conversion rate was 20.8%; 15.8% of patients were converted to reduced-port laparoscopy, 4% to conventional laparoscopy/robotic surgery, and 1% to open surgery. The intraoperative complication rate was 3.3%. Postoperative complications, mostly low grade, were encountered in 9.5% of cases. CONCLUSIONS This study provides a global view of the evolution of LESS in the field of minimally invasive urologic surgery. A broad range of procedures have been effectively performed, primarily in the academic setting, within diverse health care systems around the world. Since LESS is performed by experienced laparoscopic surgeons, the risk of complications remains low when stringent patient-selection criteria are applied.

Laparoendoscopic Single-site and Natural Orifice Transluminal Endoscopic Surgery in Urology: A Critical Analysis of the Literature ☆

CONTEXT Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been developed to benefit patients by enabling surgeons to perform scarless surgery. OBJECTIVE To summarize and critically analyze the available evidence on the current status and future perspectives of LESS and NOTES in urology. EVIDENCE ACQUISITION A comprehensive electronic literature search was conducted in June 2010 using the Medline database to identify all publications relating to NOTES and LESS in urology. EVIDENCE SYNTHESIS In urology, NOTES has been completed experimentally via transgastric, transvaginal, transcolonic, and transvesical routes. Initial clinical experience has shown that NOTES urologic surgery using currently available instruments is indeed possible. Nevertheless, because of the immaturity of the instrumentation, early cases have demanded high technical virtuosity. LESS can safely and effectively be performed in a variety of urologic settings. As clinical experience increases, expanding indications are expected to be documented and the efficacy of the procedure to improve. So far, the quality of evidence of all available studies remains low, mostly being small case series or case-control studies from selected centers. Thus, the only objective benefit of LESS remains the improved cosmetic outcome. Prospective, randomized studies are largely awaited to determine which LESS procedures will be established and which are unlikely to stand the test of time. Technology advances hold promise to minimize the challenging technical nature of scarless surgery. In this respect, robotics is likely to drive a major paradigm shift in the development of LESS and NOTES. CONCLUSIONS NOTES is still an investigational approach in urology. LESS has proven to be immediately applicable in the clinical field, being safe and feasible in the hands of experienced laparoscopic surgeons. Development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery.

The "mini-perc" technique: a less invasive alternative to percutaneous nephrolithotomy.

Abstract The disadvantages of standard percutaneous nephrolithotomy (PCNL) as compared with ureteroscopy or extracorporeal shock-wave lithotripsy include increased blood loss, greater pain, and longer hospital stay. A 13-Fr “mini-perc” technique using a ureteroscopy sheath for PCNL was developed in an attempt to address these drawbacks. Nine “mini-percs” have been performed in patients aged 40–73 years with stone burdens of ≤ 2 cm2. On average, patients had 1.4 stones with a cross-sectional area of 1.5 cm2. The mean total procedure time, estimated blood loss, and hematocrit decrease were 176 min, 83 ml, and 6.6%, respectively. On average, patients used 14 mg of parenteral morphine and stayed 1.7 days in the hospital. There was no procedure-related complication or transfusion. Eight of nine kidneys (89%) were stone-free on early follow-up at a mean of 3.8 weeks. As compared with standard PCNL, the “mini-perc” technique has similar early success rates in selected patients and may offer advantages with respect to hemorrhage, postoperative pain, and shortened hospital stays.

LONG-TERM RESULTS OF RADIATION THERAPY FOR PROSTATE CANCER RECURRENCE FOLLOWING RADICAL PROSTATECTOMY

PURPOSE Following radical prostatectomy, radiation therapy may be beneficial in select patients with isolated local recurrence. Pathological stage, Gleason score and the timing of prostate specific antigen (PSA) elevation are useful in distinguishing men with local recurrence from those with distant metastases. We test the ability of these criteria to predict long-term suppression of PSA recurrence following post-prostatectomy radiation therapy. MATERIALS AND METHODS Of 1,699 men treated with radical prostatectomy from 1982 to 1995, 82 with an isolated PSA elevation or local recurrence following surgery underwent radiation therapy to the prostatic bed and were followed for at least 2 years. No patient had evidence of metastases at the time of radiation. RESULTS Of the men 17 (21%) had an undetectable PSA (less than 0.2 ng./ml.) for 2 or greater years following radiation. The 5-year actuarial PSA recurrence-free rate after radiation was 10%. PSA remained at undetectable levels for 2 or greater years in no patients with Gleason score 8 or greater (12 cases), positive seminal vesicles (12) or positive lymph nodes (3), and in only 1 of 16 men (6%) who had a PSA recurrence within 1 year of prostatectomy. As the interval to PSA recurrence increased, the likelihood of responding to radiotherapy increased to 44% if initial disease detection occurred 5 or more years after prostatectomy. There was no demonstrated advantage to radiating men with an isolated PSA elevation before a documented local recurrence. CONCLUSIONS Patients with Gleason score 8 or greater, positive seminal vesicles or lymph nodes, or a PSA recurrence within the first year following surgery rarely benefit from radiation therapy. As the interval to PSA recurrence increases, the likelihood of responding to radiation therapy increases substantially. These parameters are useful in the selection of patients with prostate cancer recurrences who are likely to benefit from radiation to the prostatic bed.

Cost Comparison of Robotic, Laparoscopic, and Open Radical Prostatectomy for Prostate Cancer

BACKGROUND Demand and utilization of minimally invasive approaches to radical prostatectomy have increased in recent years, but comparative studies on cost are lacking. OBJECTIVE To compare costs associated with robotic-assisted laparoscopic radical prostatectomy (RALP), laparoscopic radical prostatectomy (LRP), and open retropubic radical prostatectomy (RRP). DESIGN, SETTING, AND PARTICIPANTS The study included 643 consecutive patients who underwent radical prostatectomy (262 RALP, 220 LRP, and 161 RRP) between September 2003 and April 2008. MEASUREMENTS Direct and component costs were compared. Costs were adjusted for changes over the time of the study. RESULTS AND LIMITATIONS Disease characteristics (body mass index, preoperative prostate-specific antigen, prostate size, and Gleason sum score 8-10) were similar in the three groups. Nerve sparing was performed in 85% of RALP procedures, 96% of LRP procedures, and 90% of RRP procedures (p<0.001). Lymphadenectomy was more commonly performed in RRP (100%) compared to LRP (22%) and RALP (11%) (p<0.001). Mean length of hospital stay was higher for RRP than for LRP and RALP. The median direct cost was higher for RALP compared to LRP or RRP (RALP:

Laparoendoscopic single-site surgery in urology: where have we been and where are we heading?

6752 [interquartile range (IQR):