Rakesh Khanna

Novel Robotic da Vinci Instruments for Laparoendoscopic Single-site Surgery

OBJECTIVES To describe novel robotic laparoendoscopic single-site surgery (R-LESS) instruments, and present the initial laboratory experience in urology. METHODS The 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. RESULTS All 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. CONCLUSIONS R-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 Laparoendoscopic Single-Site Radical Prostatectomy: Technique and Early Outcomes

BACKGROUND Laparoendoscopic single-site (LESS) surgery is challenging. To help overcome current technical and ergonomic limitations, the da Vinci robotic platform can be applied to LESS. OBJECTIVES Our aim was to describe the surgical technique and to report the early outcomes of robotic LESS (R-LESS) radical prostatectomy (RP). DESIGN, SETTING, AND PARTICIPANTS A 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). SURGICAL PROCEDURE R-LESS prostatectomy was performed using the methods outlined in the paper and in the supplemental video material. INTERVENTIONS All 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. MEASUREMENTS Preoperative, perioperative, pathologic, and functional outcomes data were analyzed. RESULTS AND LIMITATIONS The 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. CONCLUSIONS The R-LESS RP is technically feasible and reduces some of the difficulties encountered with conventional LESS RP.

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

BACKGROUND Recent reports have suggested that robotic laparoendoscopic single-site surgery (R-LESS) is feasible, yet comparative studies to conventional laparoscopy are lacking. OBJECTIVE To report our early experience with R-LESS radical nephrectomy (RN). DESIGN, SETTING, AND PARTICIPANTS A 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. SURGICAL PROCEDURE R-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. MEASUREMENTS Preoperative, perioperative, pathologic, and functional outcomes data were analyzed. RESULTS AND LIMITATIONS The 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. CONCLUSIONS R-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

OBJECTIVE To describe the evolution of robotic partial nephrectomy (PN) technique and to analyze the surgical outcomes in a large single institution experience. MATERIALS AND METHODS Retrospective 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. RESULTS Overall, 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. CONCLUSION We 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.

Image Guided Percutaneous Probe Ablation for Renal Tumors in 65 Solitary Kidneys: Functional and Oncological Outcomes

PURPOSE We evaluated the oncological and functional outcomes of computerized tomography guided percutaneous cryotherapy or radio frequency ablation of kidney tumors in patients with a solitary kidney. MATERIALS AND METHODS We reviewed the medical charts of patients with a solitary kidney who underwent percutaneous probe ablation for renal masses at our institution from April 2002 through March 2010. Followup consisted of computerized tomography or magnetic resonance imaging 1 day postoperatively, at 3, 6 and 12 months, and annually thereafter. Serum creatinine and estimated glomerular filtration rate were used to measure renal function. The cryotherapy and radio frequency ablation groups were compared for demographics, the 2-year actuarial survival rate and renal function. RESULTS Overall 65 patients were included in this retrospective analysis, of whom 29 (44.6%) underwent cryotherapy and 36 (55.4%) underwent radio frequency ablation. Median followup was 15.1 (IQR 4.4 to 32.9) and 38.8 months (13.8 to 50.7), respectively. The 2 groups were comparable in median age, body mass index, American Society of Anesthesiologists score, tumor size and preoperative estimated glomerular filtration rate. The 3 primary treatment failures, including 1 after cryotherapy and 2 after radio frequency ablation, were successfully re-treated with thermal ablation. There were 14 recurrences after radio frequency ablation and 3 after cryotherapy. Two-year actuarial overall, cancer specific, recurrence-free and metastasis-free survival rates for cryotherapy vs radio frequency ablation were 89% vs 93%, 100% vs 96%, 69% vs 58% and 86% vs 91%, respectively. For each group no significant decrease in renal functional parameters was found at the latest followup visit. CONCLUSIONS Computerized tomography guided percutaneous probe ablation represents a safe treatment option in surgical patients at high risk with a solitary kidney. It provides low morbidity, acceptable short-term cancer control and minimal clinical impact on postoperative renal function.

Pure and hybrid natural orifice transluminal endoscopic surgery (NOTES): current clinical experience in urology

An exciting era of discovery in the field of scarless urological surgery has just begun. Hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy has been reported by a few groups in the last two years. Recently, our group at the Cleveland Clinic was able to demonstrate the feasibility of a transvaginal pure NOTES nephrectomy. During this pioneering period, a critical appraisal of results and a scrupulous determination of benefits are of utmost importance. Further studies are awaited to define the actual role of NOTES in the management of urological diseases.

Robotic laparoendoscopic single-site surgery

Laparoscopic surgery is frequently used in urology and the introduction of the da Vinci surgical system has served to further increase the demand for these procedures. Yet, laparoscopy is not without its drawbacks including port site complications, such as bleeding, hernia, internal organ damage and scarring. To further decrease morbidity of standard laparoscopy, newer techniques such as laparoendoscopic single‐site surgery (LESS) are currently being investigated. LESS is technically challenging and reduces instrument triangulation and robust retraction, and is associated with a steep learning curve. To help overcome current limitations we have introduced the da Vinci surgical system to LESS and report our experience with robotic laparoendoscopic single‐site surgery.

Probe ablation as salvage therapy for renal tumors in von Hippel-Lindau patients: The Cleveland Clinic experience with 3 years follow-up

BACKGROUND To evaluate the efficacy and safety of probe ablative therapy as salvage treatment for renal tumor in von Hippel-Lindau (VHL) patients after previous partial nephrectomy (PN). METHODS Medical records of VHL patients undergoing probe ablative treatment for renal tumors from March 2003 to January 2010 at our institution were retrospectively analyzed. RESULTS Fourteen VHL patients who were submitted to salvage probe ablative therapy were included in the analysis. Twelve patients (85%) had a solitary kidney. Overall, 33 tumors were ablated by either percutaneous cryoablation (P-Cryo) (n of procedures = 13), radiofrequency ablation (RFA) (n = 14), and laparoscopic cryoablation (L-Cryo) (n = 3). Average maximal renal tumor diameter was 2.6 ± 1 cm. Average ablation time was 18.3 ± 2.1 minutes for P-Cryo, 36.7 ± 17 minutes for RFA, and 17.3 ± 4 minutes for L-Cryo. All procedures were successfully completed without transfusions and intraoperative complications. No early postoperative complications were recorded. Postoperative decline in renal function was minimal and not clinically significant. With a mean follow-up of 37.6 months (range 12-82), 4 patients had a suspicious recurrence on computed tomography/magnetic resonance imaging (CT/MRI) scan and in 3 of them a re-ablation was performed. Actuarial overall and cancer-specific survivals were 92% and 100%, respectively. CONCLUSIONS Probe ablative therapy seems to represent a suitable treatment option for VHL patients with a previous history of PN as it offers a repeatable operation, with a high technical success rate and causing minor changes in renal function.