Oswaldo Carmona

Single-port transvesical simple prostatectomy: initial clinical report.

INTRODUCTION To present the initial report of single-port transvesical enucleation of the prostate in 3 patients with large-volume benign prostatic hyperplasia. METHODS Single-port transvesical enucleation of the prostate was performed in 3 patients with large-volume (187, 93, and 92 g) benign prostatic hyperplasia. A novel single-port device (r-Port) was introduced percutaneously into the bladder through a 2.5-cm incision under cystoscopic guidance. After establishing pneumovesicum, the adenoma was enucleated in its entirety transvesically under laparoscopic visualization using standard and articulating laparoscopic instrumentation. The adenoma was extracted through the solitary skin and bladder incision after bivalving the prostate lobes within the bladder. RESULTS Single-port transvesical enucleation of the prostate was technically feasible in all 3 cases. The operative time was 6, 1.5, and 2.5 hours, and the blood loss was 900, 250, and 350 mL. In patient 1, who had previously undergone open suprapubic surgery, a bowel injury occurred during r-Port insertion; the injury was recognized and repaired intraoperatively without sequelae. The urethral Foley catheter was removed on day 4, and all patients were voiding spontaneously with a minimal postvoid residual volume and full continence. CONCLUSIONS Transvesical single-port laparoscopic simple prostatectomy is technically feasible. Additional experience at our and other institutions is necessary to determine its role in the surgical management of large-volume symptomatic benign prostatic hyperplasia.

Robotic Simple Prostatectomy

PURPOSE Minimally invasive approaches for large, symptomatic benign prostatic hyperplasia are replacing the gold standard open surgical approach, duplicating its results with lower morbidity. We describe our initial experience with robotic simple prostatectomy. MATERIALS AND METHODS Since January 2007, robotic simple prostatectomy was performed via a transperitoneal approach in 7 patients with symptomatic significant prostatomegaly on transrectal ultrasound (mean 77.66 gm). Demographic, perioperative and outcome data were recorded and all procedures were performed by the same surgeon. RESULTS Average patient age was 63.2 years (range 56 to 72) and estimated blood loss was 298 ml (range 60 to 800). Average operative time was 205 minutes (range 120 to 300). Average hospital stay was 1.4 days (range 1 to 2), average Foley catheter duration was 7 days (range 6 to 9) and drains were removed after an average of 3.75 days (range 3 to 4). Mean specimen weight on pathological examination was 50.48 gm (range 40 to 64.5). Transfusion was necessary in 1 patient. No complications were documented. Considerable improvement from baseline was noted in International Prostate Symptom Score (preoperative vs postoperative 22 vs 7.25) and maximum urine flow (preoperative vs postoperative 17.75 vs 55.5 ml per minute). Four patients were in acute urinary retention preoperatively. CONCLUSIONS Robotic simple prostatectomy is a feasible, reproducible procedure. Further publications are expected with larger series and larger prostatic adenomas.

NOTES Hybrid Transvaginal Radical Nephrectomy for Tumor: Stepwise Progression Toward a First Successful Clinical Case

BACKGROUND Natural orifice translumenal endoscopic surgery (NOTES) has been used to perform nephrectomy in the laboratory; however, clinical reports to date have used multiple abdominal trocars to assist the transvaginal procedure. OBJECTIVE To present our stepwise technique development and the first successful clinical case of NOTES transvaginal radical nephrectomy for tumor with umbilical assistance without extraumbilical skin incisions. DESIGN, SETTING, AND PARTICIPANTS The four transvaginal NOTES procedures were performed at two institutions after obtaining institutional review board approval. Various operative steps were developed experimentally in three clinical cases, and on March 7, 2009, we performed the first successful case of NOTES hybrid transvaginal radical nephrectomy without any extraumbilical skin incisions. Using one multichannel access port in the vagina and one in the umbilicus, laparoscopic visualization, intraoperative tissue dissection, and hilar control were performed transvaginally and transumbilically. The intact specimen was extracted transvaginally. MEASUREMENTS All perioperative data were accrued prospectively. A stepwise progression to the successful completion of the fourth case is systematically presented. RESULTS AND LIMITATIONS Intraoperatively, at incrementally more advanced stages of the procedure, the first three NOTES clinical cases were electively converted to standard laparoscopy because of rectal injury during vaginal entry, of failure to progress, and of gradual bleeding during upper-pole dissection after transvaginal hilar control, respectively. The fourth case was successfully completed via transvaginal and umbilical access without conversion to standard laparoscopy. Operative time was 3.7 h, estimated blood loss was 150 cm(3), and hospital stay was 1 d. Final pathology confirmed a 220-g, pT1b, 7-cm, grade 2, clear-cell renal cell carcinoma with negative margins. The patient was readmitted for an intraabdominal collection that responded to drainage and antibiotics. CONCLUSIONS We report our stepwise progression and the initial successful clinical case of NOTES hybrid transvaginal radical nephrectomy for tumor, assisted with only one umbilical trocar. Although transvaginal nephrectomy is feasible in the highly selected patient with favorable intraoperative circumstances, considerable refinements in technique and technology are necessary if this approach is to advance beyond mere anecdote.

Laparoendoscopic Single-site Surgery Simple Prostatectomy: Initial Report

OBJECTIVES To report the first case and detailed technique of laparoendoscopic single-site (LESS) surgery simple prostatectomy for benign hypertrophy. METHODS A 67-year-old man presented with acute urinary retention requiring catheterization. Serum prostate-specific antigen level was 5 ng/mL, and a biopsy revealed benign hypertrophy with a transrectal ultrasound volume estimation of 110 mL. LESS simple prostatectomy was performed using a single multilumen port inserted through a solitary 2.5-cm intraumbilical incision. Standard laparoscopic ultrasonic shears and needle drivers, articulating scissors, and specifically designed bent grasping instruments facilitated dissection and suturing. RESULTS An R-port was placed intraperitoneally through a 2.5-cm intraumbilical incision. No extraumbilical skin incisions were made. Total operative time was 120 minutes and estimated blood loss was 200 mL. A closed suction drain was externalized through the umbilical incision. No intraoperative or postoperative complications occurred. Hospital stay was 2 days, the retropubic drain was removed at 3 days, and the catheter removed at 1 week. Specimen weight was 95 g and final pathology revealed benign prostatic hyperplasia. At 3 months follow-up, the patient was completely continent and voiding spontaneously with a Q(max.) of 85 mL/s. CONCLUSIONS We demonstrate technical feasibility and describe the detailed surgical technique of LESS simple prostatectomy. Our initial experience suggests that this technique may be an alternative for large-volume benign prostatic hyperplasia in lieu of open surgery. Comparative studies with other surgical techniques will determine its place in the surgical armamentarium of benign prostatic hyperplasia.

Robotic Repair of Rectovesical Fistula Resulting From Open Radical Prostatectomy

OBJECTIVES Rectovesical fistula (RVF) is a rare complication of radical prostatectomy. A 57-year-old man underwent open radical prostatectomy with recognized rectal injury, primary closure of the rectal wall, and loop colostomy. The patient developed urine leakage per rectum after colostomy closure. We diverted the fecal stream with end colostomy and placed a suprapubic tube. An open transsacral (Kraske) repair failed 1 month later. We have previously described the laparoscopic approach, and report the technique and results of our first robotic assisted operation. METHODS The operative steps were as follows: (1) cystoscopy, (2) RVF catheterization (3) five-port transperitoneal laparoscopic initial dissection (4) mobilization of omental pedicle flap, (4) cystotomy extending toward the fistulous tract, (5) robot docking (6) dissection of the rectovesical plane, (7) interrupted rectal closure, (8) omental interposition, (9) bladder closure, and (10) drain placement. RESULTS Operative time was 180 minutes. Hospital stay was 1 day. The suprapubic tube was removed at 2 months after normal cystography. Bowel continuity was restored at 4 months, with no fistula recurrence at 1-month follow-up. CONCLUSIONS We await longer follow-up and experience in larger series. For now, robotic repair of rectovesical fistula appears feasible and represents an attractive alternative to open and laparoscopic approaches.

Robot-Assisted Intrafascial Simple Prostatectomy: Novel Technique

PURPOSE We describe our initial experience with intrafascial robot-assisted simple prostatectomy (IF-RSP). Potential advantages include reduced blood loss, elimination of the need for postoperative bladder irrigation, and elimination of the risk of residual or future prostate cancer, without interrupting potency or continence. PATIENTS AND METHODS From June 2011 to March 2012, 10 patients with symptomatic prostatomegaly on transrectal ultrasonography (TRUS) (mean 81 g) underwent IF-RSP. Three patients had acute urinary retention. Demographic perioperative and outcome data were recorded up to 1 month follow-up. RESULTS Average age was 71.7 years (range 60-79 years), estimated blood loss was 375 mL (range 150-900 mL), operative time was 106 minutes (range 60-180 min), hospital stay was 1 day (range 0-3 days), and Foley catheter duration was 8.9 days (range 6-14 days). The drain was removed at a mean 2.8 days (range 0-8 days). Mean prostate volume on preoperative TRUS was 81 cc (range 47-153 cc). Mean specimen weight was 81 g (range 50-150 g). Improvement was noted in the International Prostate Symptom Score (preoperative vs postoperative 18.8 vs 1.7) and peak flow rate (12.4 vs 33.49 mL/min). Sexual Health Inventory for Men score ranged from 12 to 24. All patients were completely continent within 1 month postoperatively, and sexual function was preserved. One patient had urinary tract infection and one patient needed blood transfusion postoperatively. CONCLUSIONS IF-RSP appears to be a feasible procedure in large-volume prostatomegaly. The entire prostate tissue is removed without compromising continence and potency. Larger series and longer-term follow-up are needed to evaluate the proper place of this approach.

Laparoscopic augmentation enterocystoplasty through a single trocar.

OBJECTIVES To report on the initial case and surgical technique of laparoendoscopic, single-site, subtotal cystectomy and augmentation enterocystoplasty performed through a single multichannel transumbilical port in a patient with neurogenic bladder. METHODS Laparoendoscopic, single-site, subtotal cystectomy and augmentation enterocystoplasty was performed in a 20-year-old woman with neurogenic bladder secondary to congenital sacral lipoma that had been operated on at 2 years of age. The patient had a long history of urinary incontinence and frequent and urgent urination. The imaging and urodynamic studies revealed a 100-mL bladder capacity with thickened walls, countless diverticula, and low compliance. The procedure was performed exclusively using a novel multichannel access port. Additional instruments included the 5-mm video laparoscope, SonoSurge, and flexible scissors. Subtotal cystectomy was initially performed by resecting 70% of the bladder. The ileal loop was exteriorized through the single port by detaching the valve, and the ileal pouch and bowel continuity were restored extracorporeally. The vesicoileal anastomosis was performed laparoscopically. RESULTS The operating time was 300 minutes, and the blood loss was <100 mL. No intraoperative or postoperative complications developed. The hospital stay was 6 days. The drain and Foley catheter were removed at 7 and 21 days postoperatively, respectively. Postoperative cystography confirmed a watertight anastomosis and increased bladder capacity. At last follow-up, the patient was performing intermittent self-catheterization to complete emptying. CONCLUSIONS Our initial experience with laparoendoscopic, single-site, subtotal cystectomy and enterocystoplasty through a single port was encouraging. The use of the larger diameter port significantly facilitated extracorporeal bowel reconstruction and can be used for various minimally invasive surgical procedures.

Laparo-endoscopia por acceso único: experiencia inicial

Resumen Objetivo Presentar nuestra experiencia inicial en LESS Surgery (Laparo-Endoscopic Single Site Surgery/Cirugia laparoendoscopica por acceso unico), mediante uso de dispositivo multicanal, instrumentos estandar, articulables y otros adaptados para la consecucion de los procedimientos. Materiales y metodos Entre febrero y septiembre del 2008 se realizaron 28 procedimientos quirurgicos LESS con puerto multicanal: prostatectomia simple transumbilical (PSTU) y transvesical (PSTV), nefrectomia simple (NS), enterocistoplastia de aumento (ECA) e histerectomia simple (HS). Los datos clinicos fueron recopilados de manera prospectiva y analizados retrospectivamente. Se utilizo dispositivo de acceso multicanal (R-Port). Los procedimientos fueron realizados en un centro por un solo cirujano (RS). La tecnica quirurgica empleada correspondio a la misma utilizada por via laparoscopica convencional. Resultados Se realizaron 28 intervenciones quirurgicas: PSTU(01), PSTV(20), NS(01), ECA(01), HS(05). La incision de acceso fue realizada a nivel umbilical o infraumbilical. Solo un caso (nefrectomia) amerito uso de trocar adicional de 2 mm. La edad media en anos por procedimiento fue: PSTU, 67; PSTV, 68 (57–89); NS, 12; ECA, 20; HS, 46.4 (41–54). El tiempo quirurgico medio en minutos fue: PSTU, 120; PSTV, 91 (45–210); NS, 120; ECA, 300; HS, 112 (90–160). El sangrado operatorio fue: PSTU, 200cc; PSTV, 337 cc (50-1500); NS, 100cc; EAC, 100cc; HS, 118cc. (100–160). La complicacion observada fue hematuria profusa en dos casos de PSTV, ambos pacientes requirieron exploracion postoperatoria con evolucion satisfactoria. Conclusiones LESS es una alternativa factible y reproducible en patologia uroginecologica de resolucion quirurgica. Mayores estudios, experiencias y seguimiento permitiran la evaluacion objetiva de esta tecnica.

Robotic bilateral inguinal lymphadenectomy in penile cancer, development of a technique without robot repositioning: a case report

Introduction Inguinal lymphadenectomy is the treatment of choice for patients with penile cancer and inguinal lymph node metastases. We describe the performance of the robotic bilateral inguinal lymphadenectomy technique without repositioning the robot in a patient with penile carcinoma and high risk for nodal metastases and no palpable lymph nodes. Materials and methods A 64-year-old male patient was diagnosed with penile cancer (TNM: T3 N 0 M 0) and underwent a total penectomy with perineal urethrostomy. We performed a robotic bilateral inguinal lymphadenectomy four weeks after the penectomy. Results The entire procedure was performed with the robot-assisted technique. The operative time, median estimated blood loss, and hospital stay was 360 min, 100 ml (50 ml in the right side and 150 ml in the left side), and three days, respectively. Metastatic nodes were present in both inguinal regions, with a yield of 19 lymph nodes on the right and 14 on the left. The patient presented with a left-side lymphocele that was drained at follow-up. No other complications were reported. Conclusion Robotic bilateral inguinal lymphadenectomy secondary to penile cancer is feasible, safe, and provides a good performance. Prospective studies are required to include a larger number of patients and long-term monitoring to assess the results of this procedure in comparison with open and laparoscopic techniques.

Robotic repair of vesicovaginal fistulae with the transperitoneal-transvaginal approach: A case series

OBJECTIVE To describe a novel technique of repairing the VVF using the transperitoneal-transvaginal approach. MATERIALS AND METHODS From June 2011 to October 2013, four patients with symptoms of urine leakage in the vagina underwent robotic repair of VVF with the transperitoneal-transvaginal approach. Cystoscopy revealed the fistula opening on the bladder. A ureteral stent was placed through the fistulous tract. After trocar placement, the omental flap was prepared and mobilized robotically. The vagina was identified and incised. The fistulous tract was excised. Cystorrhaphy was performed in two layers in an interrupted fashion. The vaginal opening was closed with running stitches. The omentum was interposed and anchored between the bladder and vagina. Finally, the ureteral catheters were removed in case they have been placed, and an 18 Fr urethral catheter was removed on the 14th postoperative day. RESULTS The mean age was 46 years (range: 41 to 52 years). The mean fistula diameter was 1.5 cm (range 0.3 to 2 cm). The mean operative time was 117.5 min (range: 100 to 150 min). The estimated blood loss was 100 mL (range: 50 to 150 mL). The mean hospital stay was 1.75 days (range: 1 to 3 days). The mean Foley catheter duration was 15.75 days (range: 10 to 25 days). There was no evidence of recurrence in any of the cases. CONCLUSIONS The robot-assisted laparoscopic transperitoneal transvaginal approach for VVF is a feasible procedure when the fistula tract is identified by first intentionally opening the vagina, thereby minimizing the bladder incision and with low morbidity.