Ricardo Brandina

Laparoendoscopic Single-site Surgery: Initial Hundred Patients

OBJECTIVES To report our initial experience with laparoendoscopic single-site (LESS) surgery in 100 patients in urology. METHODS Between October 2007 and December 2008, we performed LESS urologic procedures in 100 patients for various indications. These included nephrectomy (N = 34; simple 14, radical 3, donor 17), nephroureterectomy (N = 2), partial nephrectomy (N = 6), pyeloplasty (N = 17), transvesical simple prostatectomy (N = 32), and others (N = 9). Data were prospectively collected in a database approved by the Institutional Review Board. All procedures were performed using a novel single-port device (r-Port) and a varying combination of standard and specialized bent/articulating laparoscopic instruments. Robotic assistance was used to perform LESS pyeloplasty (N = 2) and simple prostatectomy (N = 1). In addition to standard perioperative data, we obtained data on postdischarge analgesia requirements, time to complete convalescence, and time to return to work. RESULTS In the study period, LESS procedures accounted for 15% of all laparoscopic cases by the authors for similar indications. Conversion to standard multiport laparoscopy was necessary in 3 cases, addition of a single 5-mm port was necessary in 3 cases, and conversion to open surgery was necessary in 4 cases. On death occurred following simple prostatectomy in a Jehovahs Witness due to patient refusal to accept transfusion following hemorrhage. Intra- and postoperative complications occurred in 5 and 9 cases, respectively. Mean operative time was 145, 230, 236, and 113 minutes and hospital stay was 2, 2.9, 2, and 3 days for simple nephrectomy, donor nephrectomy, pyeloplasty, and simple prostatectomy, respectively. CONCLUSIONS The LESS surgery is technically feasible for a variety of ablative and reconstructive applications in urology. With proper patient selection, conversion and complications rates are low. Improvement in instrumentation and technology is likely to expand the role of LESS in minimally invasive urology.

Laparoscopic Radical Nephrectomy for Renal Cell Carcinoma: Oncological Outcomes at 10 Years or More

PURPOSE We present oncological outcomes at a followup of 10 years or greater after laparoscopic radical nephrectomy for cancer. MATERIALS AND METHODS Between February 1994 and March 1999 a total of 73 laparoscopic radical nephrectomies were performed by 2 surgeons for pathologically confirmed renal cell carcinoma. Data were obtained from patient charts, radiographic reports, telephone followup and a check of the Social Security Death Index. RESULTS Mean followup was 11.2 years (range 10 to 15). Each patient completed a minimum 10-year followup. Mean patient age at surgery was 60 years. Mean tumor size on computerized tomography was 5 cm (range 1.7 to 13). Pathological stage was pT1a in 41% of cases, pT1b in 30%, pT2 in 15%, pT3a in 10%, pT3b in 3% and pT4 in 1%. High grade tumors (Fuhrman 3 or greater) were present in 18 cases (28%). A positive surgical margin occurred in 1 case. Actual 10-year overall, cancer specific and recurrence-free survival rates were 65%, 92% and 86%, respectively. Overall, cancer specific and recurrence-free survival rates at 12 years were 35%, 78% and 77%, respectively. At a mean of 67 months 10 patients (14%) had metastatic disease, of whom 8 (11%) died. CONCLUSIONS Long-term oncological outcomes after laparoscopic radical nephrectomy for renal cell carcinoma are excellent and appear comparable to those of open surgery.

Laparoendoscopic single‐site pyeloplasty: a comparison with the standard laparoscopic technique

Study Type – Therapy (case series)

Robotic and Laparoscopic High Extended Pelvic Lymph Node Dissection During Radical Cystectomy: Technique and Outcomes

BACKGROUND With the increasing use of laparoscopic and robotic radical cystectomy (RC), there are perceived concerns about the adequacy of lymph node dissection (LND). OBJECTIVE Describe the robotic and laparoscopic technique and the short-term outcomes of high extended pelvic LND (PLND) up to the inferior mesenteric artery (IMA) during RC. DESIGN, SETTING, AND PARTICIPANTS From January 2007 through September 2009, we performed high extended PLND with proximal extent up to the IMA (n=10) or aortic bifurcation (n=5) in 15 patients undergoing robotic RC (n=4) or laparoscopic RC (n=11) at two institutions. SURGICAL PROCEDURE We performed robotic extended PLND with the proximal extent up to the IMA or aortic bifurcation. The LND was performed starting from the right external iliac, obturator, internal iliac, common iliac, preaortic and para-aortic, precaval, and presacral and then proceeding to the left side. The accompanying video highlights our detailed technique. MEASUREMENTS Median age was 69 yr, body mass index was 26, and American Society of Anesthesiologists class ≥ 3 was present in 40% of patients. All urinary diversions, including orthotopic neobladder (n=5) and ileal conduit (n=10), were performed extracorporeally. RESULTS AND LIMITATIONS All 15 procedures were technically successful without need for conversion to open surgery. Median operative time was 6.7h, estimated blood loss was 500 ml, and three patients (21%) required blood transfusion. Median nodal yield in the entire cohort was 31 (range: 15-78). The IMA group had more nodes retrieved (median: 42.5) compared with the aortic bifurcation group (median: 20.5). Histopathology confirmed nodal metastases in four patients (27%), including three patients in the IMA group and one patient in the aortic bifurcation group. Perioperative complications were recorded in six cases (40%). During a median follow-up of 13 mo, no patient developed local or systemic recurrence. Limitations of the study include its retrospective design and small cohort of patients. CONCLUSIONS High extended PLND during laparoscopic or robotic RC is technically feasible. Longer survival data in a larger cohort of patients are necessary to determine the proper place for robotic and laparoscopic surgery in patients undergoing RC for high-risk bladder cancer.

Transvaginal nephrectomy with a multichannel laparoscopic port: a cadaver study.

To determine whether a novel port (QuadPort, Advanced Surgical Concepts, Wicklow, Ireland) can facilitate transvaginal nephrectomy (TN), a natural orifice transluminal surgery (NOTES) procedure, using standard and articulating laparoscopic instruments.

Surgical management of bilateral synchronous kidney tumors: Functional and oncological outcomes

PURPOSE We evaluated renal functional and oncological outcomes after sequential partial nephrectomy and radical nephrectomy in patients with bilateral synchronous kidney tumors. MATERIALS AND METHODS A total of 220 patients treated from June 1994 to July 2008 were included in the study. Estimated glomerular filtration rate, and overall, cancer specific and recurrence-free survival were assessed. RESULTS Patients underwent sequential partial nephrectomy (134), partial nephrectomy followed by radical nephrectomy (60) or radical nephrectomy followed by partial nephrectomy (26). Final estimated glomerular filtration rate after bilateral surgery was 59, 36 and 35 ml/minute/1.73 m(2) in these 3 groups, respectively (p <0.001). The order in which partial nephrectomy and radical nephrectomy were conducted did not affect functional outcomes. Overall survival of patients with bilateral cancer was 86% at 5 years and 71% at 10 years, cancer specific survival was 96% at 5 and 10 years, and recurrence-free survival was 73% at 5 years and 44% at 10 years. Overall survival was decreased in patients with tumors larger than 7 cm (p = 0.003). Patients with postoperative stage III or greater chronic kidney disease had decreased overall survival due to noncancer causes (p = 0.007). CONCLUSIONS Patients treated with sequential surgery for bilateral synchronous kidney tumors have 5 and 10-year oncological outcomes comparable to those of patients with unilateral kidney cancer. Decreased overall survival was significantly associated with tumor size larger than 7 cm and postoperative stage III or greater chronic kidney disease. Nephron sparing surgery should be conducted for all amenable bilateral kidney masses given the negative impact of renal functional decline on overall survival.

Current status of laparoscopic partial nephrectomy.

Purpose of review As familiarity with laparoscopic partial nephrectomy (LPN) has grown, application has expanded into increasingly complex cases. In this review, we present a recent series describing use of LPN in specific clinical scenarios and describe common technical modifications commonly employed in each case. In addition, we discuss modifications to standardly performed maneuvers. Recent findings Partial nephrectomy was originally reserved for absolute indications and small peripheral masses. However, well tolerated utilization of LPN in larger and more complex tumors including those in hilar or central locations, in kidneys with multiple masses, and in patients with previous renal surgery have been described. Additionally, patients with comorbidities such as obesity, and anatomic variations including multiple renal vessels and solitary kidneys have also undergone LPN with success. Furthermore, modifications to standard techniques have helped improve perioperative characteristics, such as warm ischemia time, to levels comparable to open surgery. Although many of the LPN series are small, they represent the most recent novel applications of the technique. Summary LPN is a continuously evolving technique, and with case specific modifications can be safely performed in a wide range of clinical scenarios by sufficiently experienced hands.

Critical appraisal of robotic-assisted radical prostatectomy.

Purpose of review To perform a contemporary critical appraisal of robotic-assisted radical prostatectomy (RaRP) through a review of the recent literature. Recent findings Most studies of RaRP are observational and report perioperative, functional and short-term oncological outcomes. RaRP is associated with less blood loss and blood transfusion than open radical prostatectomy (ORP), has a positive margin rate of 9.4–20.9%, potency rate of 79.2–80.4% at 1 year and a continence rate of 90.2–97% at 1 year. Costs of the da Vinci system remain a limitation of this technique. Summary RaRP has shown rapid dissemination over the past few years in the US urological community. However, prospective randomized clinical trials with long-term follow-up of RaRP, ORP and laparoscopic radical prostatectomy are still necessary.

Robotic Partial Nephrectomy: New Beginnings

When faced with a small renal mass ( 4 cm, cT1), the contemporary urologist must recognize that renal functional outcomes assume equal importance with oncologic outcomes [1]. As such, in the vast majority of cases, nephron-sparing strategies constitute optimal management. The desirability of nephron sparing is fundamental; the technical approach utilized to achieve it is secondary. Various options are available today, requiring judicious, individualized decision making [2]. The historical nephronsparing reference standard, open partial nephrectomy (OPN), is now joined by laparoscopic partial nephrectomy (LPN) as a fully equivalent option, readily available at tertiary centers with expertise. Despite increasing tumor complexity, three key outcomes of contemporary LPN have improved significantly, including ischemia time (mean: 14.4 min), hemorrhagic complications (2%), and superior renal function [3]. In 2010, it is fair to say that OPN and LPN are now technically, functionally, and oncologically equivalent over the short and long terms [4]. Undeniably, LPN results in faster and superior patient recovery compared to OPN. Today, only two questions have relevance for LPN: (1) Can it reliably address complex tumors? (2) Do all centers have the requisite expertise? Our responses: (1) Absolutely (2) No. So, enter robotics! Look at what robotics has done in the United States. Hard data notwithstanding, robotics has changed the landscape for prostate cancer surgery: >70% of radical prostatectomies today are robotic compared with <5% amere 5 yr ago—not a statistic to be trifledwith. As one has learned (far slower than one would have liked), robotics is a potent and powerful technique, with market appeal for urologist and patient alike. Certainly, the da Vinci platform allows for precision surgery, but at least as important, it

Laparoscopic partial nephrectomy: advances since 2005.

Purpose of review Laparoscopic partial nephrectomy (LPN) technique has continually evolved over the last decade, resulting in better outcomes and increased popularity within the urological community. In this article, we provide an overview of the contemporary literature on LPN. Recent findings The technique of LPN has evolved over the last 5 years with a nearly 50% reduction of warm ischemia time in experienced hands. Complication rates have also declined such that morbidity and oncological outcomes are comparable to open partial nephrectomy, the gold standard. LPN is now an established procedure for the treatment of T1a renal tumors. It can also be safely performed for favorably located T1b tumors and more complex tumors, including hilar tumors, central tumors or tumors in solitary kidneys with good oncological and functional outcomes. Summary For renal tumors less than 4–7 cm (T1 lesions), partial nephrectomy is the treatment of choice. Contemporary LPN is a sophisticated procedure, and in expert hands, offers perioperative, functional and oncologic outcomes comparable to open partial nephrectomy, even for complex tumors.