Michael A. White

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

BACKGROUNDnLaparoendoscopic single-site surgery (LESS) has gained popularity in urology over the last few years.nnnOBJECTIVEnTo report a large multi-institutional worldwide series of LESS in urology.nnnDESIGN, SETTING, AND PARTICIPANTSnConsecutive cases of LESS done between August 2007 and November 2010 at 18 participating institutions were included in this retrospective analysis.nnnINTERVENTIONnEach group performed a variety of LESS procedures according to its own protocols, entry criteria, and techniques.nnnMEASUREMENTSnDemographic 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.nnnRESULTS AND LIMITATIONSnOverall, 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.nnnCONCLUSIONSnThis 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.

Novel Robotic da Vinci Instruments for Laparoendoscopic Single-site Surgery

OBJECTIVESnTo describe novel robotic laparoendoscopic single-site surgery (R-LESS) instruments, and present the initial laboratory experience in urology.nnnMETHODSnThe VeSPA surgical instruments (Intuitive Surgical, Sunnyvale, CA) were designed to be used with the DaVinci Si surgical system. A multichannel port and curved cannulae were inserted through a single 3.5-cm umbilical incision. The port allowed 1 scope, 2 robotic instruments, and a 5- to 12-mm assistant instrument. Four pyeloplasties (right 2, left 2), 4 partial nephrectomies (right 2, left 2), and 8 nephrectomies (right 4, left 4) were performed in 4 female farm pigs (mean weight, 34.5 kg). Technical feasibility and efficiency were assessed in addition to perioperative outcomes.nnnRESULTSnAll 16 R-LESS procedures were performed successfully without the addition of laparoscopic ports or open conversion. Mean total operative time was 110 minutes (range, 82-127), and mean blood loss was 20 mL (range, 10-100). Mean warm ischemia time for partial nephrectomy was 14.8 minutes (range, 12-20). There were no intraoperative complications. No robotic system failures occurred, and robotic instrument clashing was found to be minimal. One needle driver malfunctioned and assistant movement was limited.nnnCONCLUSIONSnR-LESS kidney surgery using the VeSPA instruments is feasible and efficient in the porcine model. The system offers a wide range of motion, instrument and scope stability, improved ergonomics, and minimal instrument clashing. Although preliminary experience is encouraging, further refinements are expected to optimize urological applications of this robotic technology.

Robotic Versus Laparoscopic Partial Nephrectomy: Single-surgeon Matched Cohort Study of 150 Patients

OBJECTIVESnTo present comparative outcomes among matched patients who underwent robotic partial nephrectomy (RPN) or laparoscopic partial nephrectomy (LPN) by a single surgeon at a single institution.nnnMETHODSnBetween March 2002 and August 2009, a retrospective review of 261 consecutive patients who underwent LPN (n = 186) or RPN (n = 75) by a single surgeon was performed. Patients were matched for age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and tumor size, side, and location. Perioperative outcomes were compared.nnnRESULTSnA matched cohort of 150 patients who underwent RPN (n = 75) or LPN (n = 75) were compared. There was no significant difference between the 2 cohorts with respect to patient age (P = .17), BMI (P = .68), ASA score (P = .96), preoperative estimated glomerulofiltration rate (eGFR; P = .54), or tumor size (P = .17). Mean operative time for RPN was 200 vs 197 minutes for LPN (P = .75). Mean estimated blood loss (EBL) was higher in the RPN cohort (323 vs 222 mL, P = .01). There was no significant difference with respect to warm ischemia time (18.2 minutes vs 20.3 minutes, P = .27), length of hospitalization (P = .84), percent change in eGFR (P = .80), or adverse events (P = .52). All surgical margins were negative.nnnCONCLUSIONSnAlthough initial surgical experience with RPN was included in this study and compared with a vast experience in LPN by the same surgeon, RPN offers at least comparable outcomes to LPN.

Robotic Laparoendoscopic Single-Site Radical Prostatectomy: Technique and Early Outcomes

BACKGROUNDnLaparoendoscopic single-site (LESS) surgery is challenging. To help overcome current technical and ergonomic limitations, the da Vinci robotic platform can be applied to LESS.nnnOBJECTIVESnOur aim was to describe the surgical technique and to report the early outcomes of robotic LESS (R-LESS) radical prostatectomy (RP).nnnDESIGN, SETTING, AND PARTICIPANTSnA retrospective review of prospectively captured R-LESS RP data was performed between May 2008 and May 2010. A total of 20 procedures were scheduled (12 with and 8 without pelvic lymph node dissection).nnnSURGICAL PROCEDUREnR-LESS prostatectomy was performed using the methods outlined in the paper and in the supplemental video material.nnnINTERVENTIONSnAll patients underwent R-LESS RP by one high-volume surgeon. Single-port access was achieved via a commercially available multichannel port. The da Vinci S and da Vinci Si surgical platform was used with pediatric and standard instruments.nnnMEASUREMENTSnPreoperative, perioperative, pathologic, and functional outcomes data were analyzed.nnnRESULTS AND LIMITATIONSnThe mean age was 60.4 yr; body mass index was 25.4 kg/m(2). The mean operative time was 189.5 min; estimated blood loss was 142.0 ml. The average length of stay was 2.7 d, and the visual analog pain score at discharge was 1.4 of 10. Four focal positive margins were encountered, with two occurring during the first three cases. Pathology revealed a Gleason score of 3+3 in 3 patients, 3+4 in 11 patients, 4+3 in 4 patients, and 4+4 in 2 patients. There were a total of four complications according to the Clavien system including one grade 1, two grade 2, and one grade 4. The median follow-up has been 4 mo (range: 1-24 mo). Study limitations include the small sample size, the short follow-up, and the lack of comparative cohort.nnnCONCLUSIONSnThe R-LESS RP is technically feasible and reduces some of the difficulties encountered with conventional LESS RP.

Outcomes of Robotic Partial Nephrectomy for Renal Masses With Nephrometry Score of ≥7

OBJECTIVESnTo evaluate the safety and feasibility of robotic partial nephrectomy for patients with complex renal masses.nnnMETHODSnWe reviewed the data for 164 consecutive patients who had undergone transperitoneal robotic partial nephrectomy at a tertiary care center from February 2007 to June 2010. Of the 112 patients who had available imaging studies to review, 67 were identified and classified as having a moderately or highly complex renal mass according to the R.E.N.A.L. nephrometry score (≥7) (tumor size-[R]adius, location and depth-[E]xophytic or endophytic; nearness to the renal sinus fat or collecting system [N]; anterior or posterior position [A], and polar vs non-polar location [L]). The preoperative, perioperative, pathologic, and functional outcomes data were analyzed.nnnRESULTSnThe median body mass index was 29.6 kg/m(2) (range 19.9-44.8). Of the 67 patients, 32 were men and 35 were women, with 32 right-sided masses and 35 left-sided masses. The median tumor size was 3.7 cm (range 1.2-11), and the median operative time was 180 minutes (range 150-180). The median estimated blood loss was 200 mL (range 100-375), and the warm ischemia time was 19.0 minutes (range 15-26). The median hospital stay was 3.0 days (range 3-4). The estimated glomerular filtration rate was calculated at a median decrease of 11.1 mL/min/1.73 m(2) (range 9-1.3). According to the Clavien-Dindo classification of surgical complications, 2 grade 1, 12 grade 2, and 1 grade 3 complication occurred. All margins were pathologically negative, except for 1, and, after a mean follow-up of 10 months, no recurrences had developed.nnnCONCLUSIONSnRobotic partial nephrectomy is a safe and feasible option for moderately or highly complex renal masses determined by the R.E.N.A.L. nephrometry score. The warm ischemia time, blood loss, and complications were increased with highly complex masses.

Robotic Laparoendoscopic Single-Site Radical Nephrectomy: Surgical Technique and Comparative Outcomes

BACKGROUNDnRecent reports have suggested that robotic laparoendoscopic single-site surgery (R-LESS) is feasible, yet comparative studies to conventional laparoscopy are lacking.nnnOBJECTIVEnTo report our early experience with R-LESS radical nephrectomy (RN).nnnDESIGN, SETTING, AND PARTICIPANTSnA retrospective review of R-LESS RN data was performed between May 2008 and November 2010. A total of 10 procedures were performed and subsequently matched to 10 conventional laparoscopic RN procedures (controls). The control group was matched with respect to patient age, body mass index (BMI), American Society of Anesthesiologists score, surgical indication, and tumor size.nnnSURGICAL PROCEDUREnR-LESS RN was performed using methods outlined in the manuscript and supplemental video material. All patients underwent R-LESS RN by a single surgeon. Single-port access was achieved via two commercially available multichannel ports, and robotic trocars were inserted either through separate fascial stabs or through the port, depending on the type used. The da Vinci S and da Vinci-Si Surgical Systems (Intuitive Surgical, Sunnyvale, CA, USA) with pediatric and standard instruments were used.nnnMEASUREMENTSnPreoperative, perioperative, pathologic, and functional outcomes data were analyzed.nnnRESULTS AND LIMITATIONSnThe mean patient age was 64.0 yr of age for both groups, and BMI was 29.2 kg/m(2). There was no difference between R-LESS and conventional laparoscopy cases in median operative time, estimated blood loss, visual analogue scale, or complication rate. The R-LESS group had a lower median narcotic requirement during hospital admission (25.3 morphine equivalents vs 37.5 morphine equivalents; p=0.049) and a shorter length of stay (2.5 d vs 3.0 d; p=0.03). Study limitations include the small sample size, short follow-up period, and all the inherent biases introduced by a retrospective study design.nnnCONCLUSIONSnR-LESS RN offers comparable perioperative outcomes to conventional laparoscopic RN. Prospective comparison is needed to definitively establish the position of R-LESS in minimally invasive urologic surgery.

252 Robotic Partial Nephrectomies: Evolving Renorrhaphy Technique and Surgical Outcomes at a Single Institution

OBJECTIVEnTo describe the evolution of robotic partial nephrectomy (PN) technique and to analyze the surgical outcomes in a large single institution experience.nnnMATERIALS AND METHODSnRetrospective review of our institutional review board-approved, prospectively maintained, minimally invasive PN database yielded 252 robotic partial nephrectomy (RPN) procedures from June 2007 to October 2010. Our initial experience, adopted from our laparoscopic PN approach included a standard interrupted bolstered renorrhaphy, whereas our contemporary experience included a nonbolstered continuous horizontal mattress stitch for the capsular closure. Perioperative results were evaluated depending on renorrhaphy technique, length of warm ischemia time, and nephrometry scores.nnnRESULTSnOverall, mean tumor size was 3.1 ± 1.6 cm, operative time 190 ± 56 minutes, warm ischemia time 18.2 ± 9.4 minutes, and estimated blood loss 267 ± 275 mL. Significantly better outcomes were noted in the contemporary experience in terms of transfusion rate (8.2% vs 21.9%, P <.001), operative time (181 vs 219 minutes, P <.001), hospital stay (3.6 vs 4.3 days, P = .02), and complication rate (14.4% vs 33.8%, P <.01). Increasing tumor complexity based on RENAL score predicted longer operative time (P <.0001), warm ischemia time (P <.0001), and hospital stay (P <.04), and a greater risk of postoperative complications (P = .003). Of the series, only 2 patients had hemorrhagic complications (0.8%) requiring angioembolization, 4 patients developed urine leaks (1.5%), and 2 positive margins (0.8%) were noted.nnnCONCLUSIONnWe report the largest single-institution study with RPN to date. Despite it being a relatively nascent procedure, initial results suggest that RPN is an effective approach for minimally invasive nephron-sparing surgery. As experience is gained and the technique for RPN evolves, further improvement in outcomes will be noted.

Current status and future perspectives in laparoendoscopic single-site and natural orifice transluminal endoscopic urological surgery.

Objective of this study is to provide an evidence‐based analysis of the current status and future perspectives of scarless urological surgery. A PubMed search has been performed for all relevant urological literature regarding natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single‐site surgery (LESS). In addition, experience with LESS and NOTES at our own institution has been considered. All clinical and investigative reports for LESS and NOTES procedures in the urological literature have been considered. A wide variety of clinical procedures in urology have been succesfully completed by using LESS techniques. Thus far, experience with NOTES has largely been investigational, although early clinical reports are emerging. Further development of instrumentation and platforms is necessary for both techniques to become more widely adopted throughout the urological community.

SPIDER Surgical System for Urologic Procedures With Laparoendoscopic Single-Site Surgery: From Initial Laboratory Experience to First Clinical Application

This case study describes our initial laboratory experience using the SPIDER surgical system (TransEnterix, Morrisville, NC, USA) for laparoendoscopic single-site surgery (LESS) urologic procedures and reports its first clinical application. The SPIDER system was tested in a laboratory setting and used for a clinical case of renal cyst decortication. Three tasks were performed during the dry lab session, and different urologic procedures were conducted in a porcine model. The time to complete the tasks and penalties were registered during the dry lab session. Perioperative outcomes and subjective assessment by the surgeons were registered. The surgeons had a positive experience with the SPIDER system, with a mean overall score of 3.6 (on a scale of 1-5). The surgeons were able to gain proficiency in performing tasks regardless of their level of expertise. The highest scores recorded were for ease of device insertion, instrument insertion and exchange, and triangulation. The lowest scores were for retraction. During the clinical case, the platform provided good triangulation without instrument clashing. However, retraction was challenging because of the lack of strength and precise maneuverability with the tip of the instruments fully deployed. The SPIDER system offers intuitive instrument maneuverability and restored triangulation without external instrument clashing. Further refinements are awaited to define its role in the urologic LESS armamentarium.

Robotic Laparoendoscopic Single Site Urological Surgery: Analysis of 50 Consecutive Cases

PURPOSEnWe present our cumulative experience with robotic laparoendoscopic single site urological surgery at a single institution.nnnMATERIALS AND METHODSnMedical records of patients undergoing robotic laparoendoscopic single site procedures between May 2008 and December 2010 were analyzed. The da Vinci® S or Si systems and 3 different multichannel single port devices were used. Demographic, intraoperative and postoperative data were assessed.nnnRESULTSnOverall, 50 patients were scheduled to undergo robotic laparoendoscopic single site urological surgery during the study period, representing 36% of the total patients undergoing laparoendoscopic single site surgery at our institution. Mean ± SD patient age was 60.2 ± 13.6 years. Mean body mass index was 27.0 ± 4.5 kg/m(2). Specifically, 24 patients underwent robotic laparoendoscopic single site renal surgery and the same method was used in 26 patients undergoing pelvic surgery. Mean operative time was 207 ± 74 minutes and mean estimated blood loss was 140 ± 111 ml. Four cases were converted to laparoscopy (2 standard, 2 robotic assisted) and 6 cases required at least 1 additional trocar outside of the single site incision. A rectal injury occurred during radical cystectomy, which was recognized intraoperatively and closed primarily without sequelae. Postoperative complications occurred in 8 cases and 1 was Clavien grade IV. Mean length of hospital stay was 2.9 ± 1.7 days.nnnCONCLUSIONSnOur preliminary experience with robotic laparoendoscopic single site surgery has demonstrated feasibility and safety in the realm of urological surgery. Widespread adoption of this new approach will likely require redesign of the robotic system or development of a task specific robotic platform, and should be limited to centers with significant robotic, laparoscopic and laparoendoscopic single site surgery experience.