Kyung Hwa Choi

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.

Laparoendoscopic Single-Site Surgeries: A Single-Center Experience of 171 Consecutive Cases

Purpose We report our experience to date with 171 patients who underwent laparoendoscopic single-site surgery for diverse urologic diseases in a single institution. Materials and Methods Between December 2008 and August 2010, we performed 171 consecutive laparoendoscopic single-site surgeries. These included simple nephrectomy (n=18; robotic surgeries, n=1), radical nephrectomy (n=26; robotic surgeries, n=2), partial nephrectomy (n=59; robotic surgeries, n=56), nephroureterectomy (n=20; robotic surgeries, n=12), pyeloplasty (n=4), renal cyst decortications (n=22), adrenalectomy (n=4; robotic surgeries, n=2), ureterolithotomy (n=10), partial cystectomy (n=3), ureterectomy (n=1), urachal mass excision (n=1), orchiectomy (n=1), seminal vesiculectomy (n=1), and retroperitoneal mass excision (n=1). All procedures were performed by use of a homemade single-port device with a wound retractor and surgical gloves. A prospective study was performed to evaluate outcomes in 171 cases. Results Of the 171 patients, 98 underwent conventional laparoendoscopic single-site surgery and 73 underwent robotic laparoendoscopic single-site surgery. Mean patient age was 53 years, mean operative time was 190.8 minutes, and mean estimated blood loss was 204 ml. Intraoperative complications occurred in seven cases (4.1%), and postoperative complications in nine cases (5.3%). There were no complications classified as Grade IIIb or higher (Clavien-Dindo classification for surgical complications). Conversion to mini-incision open surgery occurred in seven (4.1%) cases. Regarding oncologic outcomes, no cancer-related events occurred during follow-up other than one aggressive progression of Ewing sarcoma. Conclusions Laparoendoscopic single-site surgery is technically feasible and safe for various urologic diseases; however, surgical experience and long-term follow-up are needed to test the superiority of laparoendoscopic single-site surgery.

Urologic Robot-Assisted Laparoendoscopic Single-Site Surgery Using a Homemade Single-Port Device: A Single-Center Experience of 68 Cases

PURPOSE To describe our experience with robot-assisted laparoendoscopic single-site (R-LESS) surgeries and evaluate a homemade port system as an effective access technique. PATIENTS AND METHODS Between May 2009 and April 2010, 68 consecutive R- LESS urologic operations were performed in our institution. A 4 to 5 cm long incision was made over the umbilicus. After the inner ring of the Alexis wound retractor was placed into the peritoneum, a common size 7 surgical glove was then applied over the external side of the wound retractor. A homemade single port was established by inserting two 12-mm trocars and two 8-mm trocars through fingers of a surgical glove and securing it to the port. RESULTS Sixty-eight patients underwent R-LESS, including partial nephrectomy in 51, nephroureterectomy in 12, radical nephrectomy and adrenalectomy in 2 each, and simple nephrectomy in 1. Mean patient age was 56 years (range 16-81 y). Mean body mass index was 23.9 kg/m(2) (range 17.2-32.9 kg/m(2)). The mean operative time was 219 minutes (range 109-382 min). Mean estimated blood loss 319 mL (range 50-1550 mL), and change in hematocrit was 5.2 % (range 0.0-14.8%). At a mean follow-up of 8 months, there were no port-related complications, and cosmesis was excellent. CONCLUSIONS R-LESS is feasible and can be safely applied to a variety of urologic operations, considering the low intraoperative complication rate. Our homemade single-port device provides adequate range of motion and is more flexible in port placement for R-LESS than the current multichannel port.

Laparoendoscopic Single-site Surgery for Ureterolithotomy: Focus on Intracorporeal Stenting and Suturing

OBJECTIVES To describe a technique of laparoendoscopic single-site surgery (LESS) for ureterolithotomy, focusing on intracorporeal stenting and suturing. METHODS From August 2009 to May 2010, 8 cases of LESS ureterolithotomy were performed by a single, experienced laparoscopic surgeon. The indications for LESS ureterolithotomy were a stone size of ≥15 mm, an impacted stone, intractable pain, or failure of previous treatment. All procedures were done using a platform homemade port device that was inserted through a 20-30-mm umbilical incision. We developed our own percutaneous stenting method and intracorporeal suture technique to suit the single port procedure. Additional ports and a stone retrieval bag were not needed. RESULTS All LESS ureterolithotomies were performed successfully without any complications. The mean stone size was 17.4 mm (range 11-24), and the stones were located in the upper ureter in all 8 patients. The mean operative time was 155.3 minutes (range 102-227), and the estimated blood loss was 37.5 mL (range <10-150). The mean postoperative time to stent removal was 3.4 weeks (range 1-4). CONCLUSIONS LESS ureterolithotomy using our technique was safe and effective, and the ureteral stenting and suturing techniques were a feasible alternative to those currently used for LESS.

Differential diagnosis of complex renal cysts based on lesion size along with the Bosniak renal cyst classification.

Purpose To identify size criteria for complex cystic renal masses that can distinguish renal cell carcinoma from benign cysts supplementing the Bosniak classification. Materials and Methods We reviewed the records of 97 patients who underwent surgery for complex cystic renal masses from January 2001 to April 2010. The pathological results were compared with the lesion sizes measured by preoperative computed tomography and other radiological features (contrast enhancement, irregularities of cyst walls and septa, and calcification) were also obtained for categorization according to the Bosniak renal cyst classification. Results Malignancy was significantly associated with cyst size (>2 cm), male gender, and younger patient age (<50 years). According to the Bosniak classification, there was no category I cyst, and all 8 category II cysts were benign. However, 3 of 18 (17%) category IIF cysts, 21 of 39 (54%) category III cysts, and 29 of 32 (90%) category IV cysts were malignant. All category IIF cysts were benign in patients older than 50 years of age. Conclusion Many complex cystic renal masses smaller than 2 cm were benign. We suggest that lesion size should be taken into account when formulating treatment plans for complex cystic renal masses.

The Learning Curve for Flank Percutaneous Nephrolithotomy for Kidney Calculi: A Single Surgeon's Experience

Purpose Percutaneous nephrolithotomy (PCNL) is conventionally conducted in the prone position. However, the prone position increases anesthesia-related morbidity and position changes lengthen the operation time. We report perioperative outcomes and the learning curve for flank PCNL on the basis of a single surgeons experience. Materials and Methods This study investigated 53 cases of flank PCNL performed for renal stones at our institution from April 2008 to September 2010. We compared mean operative time, stone-free rate, drop in hemoglobin level, length of hospital stay, complications, and need for additional procedures after the surgery. The 53 cases were divided into three groups by case number to compare therapeutic effect, stability, and the learning curve for flank position PCNL. Results The mean operation time for the 53 patients was 97.3±43.1 minutes. The mean operation time gradually decreased as the surgeon accumulated experience. From the 36th case, the mean operation time showed a statistically significant decrease to 72.2±24.1 minutes (p=0.003). The overall stone-free rate was 64.2% for all procedures (range, 61.1-76.5%). There were no significant differences in the drop in hemoglobin level, stone-free rate, re-treatment, hospital stay, or complication rate. There was no injury to the bowel or renal vessels, and no other major complications occurred. Conclusions Flank PCNL can be used to remove renal stones effectively while overcoming the disadvantages of the existing prone position PCNL. After 36 cases, the learning curve showed acquisition of surgical competence. The clinical experience reported here suggests that flank PCNL is a safe and feasible technique.

Renal Cell Carcinoma in Kidney Transplant Recipients and Dialysis Patients

Purpose In a group of surgery patients diagnosed with renal cell cancer, those who underwent dialysis were compared with those who received a kidney transplant. Materials and Methods The 43 subjects included in this study were patients who had been undergoing dialysis because of end-stage renal disease or had undergone kidney transplantation. The patients were diagnosed with renal cell carcinoma (RCC) during follow-up and underwent radical nephrectomy from May 1996 to December 2010. Their medical records were retrospectively analyzed as part of the study. Results In the transplantation group, the renal replacement therapy period averaged 54 months, and the period from transplantation to RCC averaged 119 months (range, 0 to 264 months). In the dialysis group, RCC was observed after an average of 124 months (range, 2 to 228 months) of dialysis, and nephrectomy was then conducted. Acquired cystic kidney disease (ACKD) was found more frequently in the dialysis group, and it had a statistically relevant effect on the occurrence of RCC by comparison with the transplantation group (p<0.01). Conclusions Although the incidence rate of ACKD was significantly higher in the dialysis group among patients undergoing surgery for RCC, cancer was found even without ACKD development in some transplant recipients. Considering that the transplant recipients also underwent dialysis, an informative prospective study will be necessary to determine whether other immunosuppressive agents besides ACKD may function as a cancer risk factor.

Preconditioning Strategies for Kidney Ischemia Reperfusion Injury: Implications of the “Time-Window” in Remote Ischemic Preconditioning

Remote ischemic preconditioning (IP) is a potential renoprotective strategy. However, there has been no demonstrated result in large animals and the role of time window in remote IP remains to be defined. Using a single-kidney porcine model, we evaluated organ protective function of remote IP in renal ischemia reperfusion injury. Fifteen Yorkshire pigs, 20 weeks old and weighing 35–38 kg were used. One week after left nephrectomy, we performed remote IP (clamping right external iliac artery, 2 cycles of 10 minutes) and right renal artery clamping (warm ischemia; 90 minutes). The animals were randomly divided into three groups: control group, warm ischemia without IP; group 1 (remote IP with early window [IP-E]), IP followed by warm ischemia with a 10-minute time window; and group 2 (remote IP with late window [IP-L]), IP followed by warm ischemia after a 24-hour time window. There were no differences in serum creatinine changes between groups. The IP-L group had lower urinary neutrophil gelatinase-associated lipocalin than control and IP-E at 72 hours post-ischemia. At 72 hours post-ischemia, the urinary kidney injury molecule-1 (KIM-1) was lower in the IP-L group than in the control and IP-E groups, and the IP-L group KIM-1 was near pre-ischemic levels, whereas the control and IP-E group KIM-1 levels were rising. Microalbumin also tended to be lower in the IP-L group. Taken together, remote IP showed a significant reduction in renal injury biomarkers from ischemia reperfusion injury. To effectively provide kidney protection, remote IP might require a considerable, rather than short, time window of ischemia.

Standardized video‐assisted retroperitoneal minilaparotomy surgery for 615 living donor nephrectomies

To increase the rate of living kidney donation, the long‐term safety of nephrectomy must be demonstrated to potential donors. We analyzed long‐term donor outcomes and evaluated the standardization of surgical technique. We evaluated 615 donors who underwent Video‐assisted minilaparotomy living donor nephrectomy (VLDN) at Yonsei Severance Hospital between 2003 and 2009. Perioperative data and predictors of outcomes were prospectively analyzed. The mean operative time and mean warm ischemia time were 192.7 and 2.2 min, respectively. Mean estimated blood loss was 195.3 ml. The mean post‐transplant serum creatinine levels and Modification of Diet in Renal Disease study equation for estimating glomerular filtration rate were 1.1 mg/dl and 68 ml/min/1.73 m2, respectively at 5 years after VLDN. The intra‐operative and postoperative complication rate were 3.1% and 6.3%, respectively. Delayed renal function, 5‐year graft survival, and complication rates of recipients were 1.1%, 98.4%, and 0.4%, respectively. Predictors of operative time were medical history, vessel anomaly, and surgeon experience (>50 cases). The single predictor of intra‐operative complications was vessel anomaly. Standardized VLDN is feasible and safe. Our data on long‐term outcomes can assist in demonstrating the long‐term safety of donor nephrectomy to potential donors. To compare VLDN to other types of donor nephrectomy, a prospective multicenter study must be performed.

Retroperitoneal Giant Liposarcoma

Retroperitoneal liposarcoma is an infrequent, locally aggressive malignancy. We report two cases of huge retroperitoneal liposarcomas. The presence of a palpable abdominal mass was a common symptom of the two patients. Preoperative imaging study showed huge retroperitoneal tumors. Both patients underwent complete surgical resections, and a negative microscopic margin was achieved in both cases. The histopathologic diagnosis was a well-differentiated retroperitoneal liposarcoma. Neither of the two patients developed a recurring tumor during the 1.5 years of follow-up.