Sebastien Crouzet

Single-port Urological Surgery: Single-center Experience With the First 100 Cases

OBJECTIVES To present perioperative outcomes in an observational cohort of patients who underwent LaparoEndoscopic Single Site (LESS) surgery at a single academic center. METHODS A prospective study was performed to evaluate patient outcomes after LESS urologic surgery. Demographic data including age, body mass index, operative time, estimated blood loss, operative indications, complications, and postoperative Visual Analog Pain Scale scores were accrued. Patients were followed postoperatively for evidence of adverse events. RESULTS Between September 2007 and February 2009, 100 patients underwent LESS urologic surgery. Specifically, 74 patients underwent LESS renal surgery (cryoablation, 8; partial nephrectomy, 15; metastectomy, 1; renal biopsy, 1; simple nephrectomy, 7; radical nephrectomy, 6; cyst decortication, 2; nephroureterectomy, 7; donor nephrectomy, 19; and dismembered pyeloplasty, 8) and 26 patients underwent LESS pelvic surgery (varicocelectomy, 3; radical prostatectomy, 6; radical cystectomy, 3; sacral colpopexy, 13; and ureteral reimplant, 1). Mean patient age was 54 years. Mean body mass index was 26.2 kg/m(2). Mean operative time was 199 minutes. Mean estimated blood loss was 136 mL. No intraoperative complications occurred. Six patients required conversion to standard laparoscopy. Mean length of hospitalization was 3 days. Mean Visual Analog Pain Scale score at discharge was 1.5/10. At a mean follow-up of 11 months, 9 Clavien Grade II (transfusion, 7; urinary tract infection, 1; deep vein thrombosis, 1) and 2 Clavien Grade IIIb (recto-urethral fistula, 1; angioembolization, 1) surgical complications occurred. CONCLUSIONS In our experience, LESS urologic surgery is feasible, offers improved cosmesis, and may offer decreased pain. Complications are consistent with the published data. Whether LESS urologic surgery is superior in comparison with standard laparoscopy is currently speculative.

Robotic single‐port transumbilical surgery in humans: initial report

To describe our initial clinical experience of robotic single‐port (RSP) surgery.

Dynamic contrast-enhanced-magnetic resonance imaging evaluation of intraprostatic prostate cancer: correlation with radical prostatectomy specimens.

OBJECTIVES To determine the diagnostic performance of dynamic contrast-enhanced-magnetic resonance imaging (DCE-MRI) in the identification of intraprostatic cancer foci related to cancer volume at histopathology, in patients with clinically localized cancer treated by radical prostatectomy, with whole-mount histopathologic sections as the reference standard. METHODS Eighty-three consecutive radical prostatectomy specimens from patients referred for a prostate-specific antigen elevation were correlated with prebiopsy MRI. MRI results ranked on a 5-point scale were correlated with the findings of histopathology maps in 8 prostate sectors, including volume, largest surface area, and percentage of Gleason grade 4/5. The area under the receiver operating characteristic curve was used. RESULTS Median prostate-specific antigen was 8.15 ng/mL. DCE-MRI was suspicious in 55 (66%) out of 83 patients. A separate cancer foci (mean 2.55 per patient) was present in 212 (34%) of 664 octants and DCE-MRI was suspicious in 68 of 212. Sensitivity and specificity of DCE-MRI at score 3.4 or 5 for identification of cancer foci at any volume was 32% and 95%, respectively. For identification of cancer foci > 0.5 mL, the sensitivity and specificity were 86% and 94%, respectively, with the under the receiver operating characteristic curve of 0.874. Mean volume of DCE-MRI detected and missed cancers were 2.44 mL (0.02-14.5) and 0.16 mL (0.005-2.4), respectively. Sensitivity and specificity of DCE-MRI for identification of > 10% of Gleason grade 4/5 were 81% and 82%, respectively. CONCLUSIONS DCE-MRI can accurately identify intraprostatic cancer foci. Possible applications are guidance for biopsies, selection of patients for watchful waiting, and focal treatment planning.

Single-Port Laparoscopic Radical Prostatectomy

OBJECTIVES To present the initial experience in laparoscopic radical prostatectomy performed exclusively through an umbilical incision using a single three-channel port and specially designed flexible laparoscopic instrumentation. METHODS Since November 26, 2007, we have performed single-port laparoscopic radical prostatectomy in 4 patients diagnosed with prostate cancer. Patients with early-stage prostate cancer (T1c), no previous pelvic surgery, and a body mass index <or=35 kg/m(2) were selected for single-port laparoscopic radical prostatectomy. A multichannel port was inserted transperitoneally through a 1.8-cm umbilical incision. No additional extraumbilical instruments or ports were inserted. Urethrovesical anastomosis was performed using free-hand interrupted suturing and extracorporeal knot tying. Data were collected prospectively into our institutional review board-approved data registry. RESULTS All cases were completed successfully, without conversion to a standard laparoscopic approach. The total operative time was 285 +/- 30 minutes, with a mean operative time for prostate excision and urethrovesical anastomosis of 3.25 hours and 1.1 hours, respectively. The mean blood loss was 288 +/- 131 mL, and no patient required a blood transfusion. The hospital stay was 2.5 +/- 0.6 days. The Foley catheter was removed 2 weeks (range 1-3) after surgery. No intraoperative complications occurred; however, 1 patient developed a rectourethral fistula that was noted 2 months after surgery. At 18 weeks of follow-up, 3 patients used 1 or 0 pads for continence daily, 2 patients had positive margins noted at the site of extracapsular extension, and all patients had an undetectable prostate-specific antigen level. CONCLUSIONS Single-port laparoscopic radical prostatectomy is feasible. Additional investigation is needed to evaluate the safety and oncologic adequacy of this new approach.

Laparoscopic and Robotic Assisted Radical Cystectomy for Bladder Cancer: A Critical Analysis

CONTEXT AND OBJECTIVES Interest in laparoscopic assisted radical cystectomy (LRC) and robotic assisted radical cystectomy (RRC) is increasing at select centers worldwide. In this update we present the recent worldwide experience and critically evaluate the role of minimally invasive radical surgery for patients with bladder cancer. EVIDENCE ACQUISITION English-language literature between 1992 and 2007 was reviewed using the National Library of Medicine database and the following key words: laparoscopic, laparoscopic-assisted, robotic, robotic-assisted, and radical cystectomy. Over 102 papers were identified, 48 of which were selected for this review on the basis of their contribution to advancing the field with regard to three criteria: (1) evolution of concepts, (2) development and refinement of techniques, and (3) intermediate- and long-term clinical outcomes. These were evaluated with respect to current techniques and perioperative, functional, and oncological outcomes. Our initial experience is also reported. EVIDENCE SYNTHESIS Minimally invasive techniques can adequately achieve the extirpative aspects of LRC and extended template lymphadenectomy. At most institutions the reconstructive urinary diversion is now typically being performed extracorporeally through a minilaparotomy. Perioperative data indicate that minimally invasive techniques are associated with reduced blood loss, slightly increased operating time, and shorter hospital stay without any significant difference in postoperative complications compared with open surgery. Intermediate-term oncological outcomes appear to be comparable with the open approach. Worldwide experience continues to increase; >700 surgeries have already been performed. CONCLUSION LRC or RRC with extracorporeally constructed urinary diversion is a safe and effective operation for appropriate patients with bladder cancer. Perioperative and functional outcomes are comparable with open surgery. More focus on extended lymphadenectomy is necessary to routinely achieve higher node yields. Surrogate and intermediate oncological outcomes are encouraging, and long-term assessment is ongoing.

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

OBJECTIVES To 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. METHODS Between 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. RESULTS A 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. CONCLUSIONS Although 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.

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 NOTES (Natural Orifice Translumenal Endoscopic Surgery) in Reconstructive Urology: Initial Laboratory Experience

OBJECTIVES To present an initial experience with robotic natural orifice translumenal surgery (R-NOTES) in reconstructive urology using the da Vinci surgical system. METHODS In 10 female farm pigs (mean weight, 34.5 kg), 10 pyeloplasties (right 5, left 5), 10 partial nephrectomies (right 5, left 5), and 10 radical nephrectomies (right 5, left 5) were performed. The robot telescope and the first robotic arm were placed through a single 2-cm umbilical incision, and the second robotic arm was placed through the vagina. RESULTS All 30 R-NOTES procedures were performed successfully without any addition of laparoscopic port or open conversion. Mean length of the umbilical incision was 2.6 cm. Mean operative time was 154 minutes, and mean estimated total blood loss was 72 mL. Mean warm ischemia time in the partial nephrectomy group was 25.4 minutes. There were no intraoperative complications. There were no robotic system failures during the entire experiment. We did not find any significant difference when comparing right-side and left-side procedures. When analyzing the learning curve, only robot preparation time reached a statistically significant inverse correlation with increasing number of cases (r = -0.72, P = .018). CONCLUSIONS Robotic NOTES pyeloplasty, partial nephrectomy, and radical nephrectomy are feasible and safe in the porcine model. This approach has the potential for a less morbid and scarless outcome. Intracorporeal suturing is significantly enhanced using the robot, especially through the challenging translumenal natural orifice approach. Further development of robots adaptive to NOTES would boost efforts toward clinical NOTES applications.

Focal Therapy in Prostate Cancer: International Multidisciplinary Consensus on Trial Design

BACKGROUND Focal therapy has been introduced for the treatment of localised prostate cancer (PCa). To provide the necessary data for consistent assessment, all focal therapy trials should be performed according to uniform, systematic pre- and post-treatment evaluation with well-defined end points and strict inclusion and exclusion criteria. OBJECTIVE To obtain consensus on trial design for focal therapy in PCa. DESIGN, SETTING, AND PARTICIPANTS A four-staged consensus project based on a modified Delphi process was conducted in which 48 experts in focal therapy of PCa participated. According to this formal consensus-building method, participants were asked to fill out an iterative sequence of questionnaires to collect data on trial design. Subsequently, a consensus meeting was held in which 13 panellists discussed acquired data, clarified the results, and defined the conclusions. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS A multidisciplinary board from oncologic centres worldwide reached consensus on patient selection, pretreatment assessment, evaluation of outcome, and follow-up. RESULTS AND LIMITATIONS Inclusion criteria for candidates in focal therapy trials are patients with prostate-specific antigen <15 ng/ml, clinical stage T1c-T2a, Gleason score 3+3 or 3+4, life expectancy of >10 yr, and any prostate volume. The optimal biopsy strategy includes transrectal ultrasound-guided biopsies to be taken between 6 mo and 12 mo after treatment. The primary objective should be focal ablation of clinically significant disease with negative biopsies at 12 mo after treatment as the primary end point. CONCLUSIONS This consensus report provides a standard for designing a feasible focal therapy trial. PATIENT SUMMARY A variety of ablative technologies have been introduced and applied in a focal manner for the treatment of prostate cancer (PCa). In this consensus report, an international panel of experts in the field of PCa determined pre- and post-treatment work-up for focal therapy research.

Pure Natural Orifice Translumenal Endoscopic Surgery (NOTES) Transvaginal Nephrectomy

Natural orifice translumenal endoscopic surgery (NOTES) within urology has largely been limited to experimental animal studies and diagnostic procedures in humans. Attempts to complete a pure NOTES transvaginal nephrectomy have thus far been unsuccessful. We report the first clinical experience with pure NOTES transvaginal nephrectomy. A 58-year-old woman presented with recurrent urinary tract infections and an atrophic right kidney. Transvaginal access was obtained through a 3-cm posterior colpotomy. The right kidney was mobilized, the renal hilum was divided, and the specimen was removed through the vaginal incision. Operative time was 420 min. Estimated blood loss was 50 ml. There were no perioperative complications.