Wesley M. White

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

OBJECTIVESnTo present perioperative outcomes in an observational cohort of patients who underwent LaparoEndoscopic Single Site (LESS) surgery at a single academic center.nnnMETHODSnA 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.nnnRESULTSnBetween 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.nnnCONCLUSIONSnIn 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 Laparoendoscopic Single-Site Surgery Using GelPort as the Access Platform

BACKGROUNDnLaparoendoscopic single-site surgery (LESS) allows for the performance of major urologic procedures with a single small incision and minimal scarring. The da Vinci Surgical System provides advantages of easy articulation and improved ergonomics; however, an ideal platform for these procedures has not been identified.nnnOBJECTIVEnTo evaluate the GelPort laparoscopic system as an access platform for robotic LESS (R-LESS) procedures.nnnDESIGN, SETTING, AND PARTICIPANTSnSince April 2008, 11 R-LESS procedures have been completed successfully in a single institutional referral center. For the last four consecutive cases, the GelPort has been used as an access platform through a 2.5-5-cm umbilical incision.nnnINTERVENTIONnR-LESS cases performed with the GelPort included pyeloplasty (n=2), radical nephrectomy (n=1), and partial nephrectomy (n=1).nnnMEASUREMENTSnPerioperative data were obtained for all patients including demographic data, operative indications, operative records, length of stay, complications, and pathologic analysis.nnnRESULTS AND LIMITATIONSnFor both pyeloplasty cases, average operative time (OR time) was 235 min and estimated blood loss (EBL) was 38 cm(3). For the patient undergoing radical nephrectomy for a 5.1-cm renal tumor, OR time was 200 min and EBL was 250 cm(3). The final patient underwent partial nephrectomy without renal hilar clamping for an 11-cm angiomyolipoma with OR time of 180 min and EBL of 600 cm(3). All R-LESS procedures attempted with the GelPort were completed successfully and without complication. Average length of hospital stay was 1.75 d (range: 1-2). The partial nephrectomy patient required transfusion of 1 U of packed red blood cells.nnnCONCLUSIONSnUse of the GelPort as an access platform for R-LESS procedures provides adequate spacing and flexibility of port placement and acceptable access to the surgical field for the assistant, especially during procedures that require a specimen extraction incision. Additional platform and instrumentation development will likely simplify R-LESS procedures further as experience grows.

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.

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.

NOTES Transvaginal Nephrectomy: First Human Experience

OBJECTIVESnTo present the operative outcomes of the first natural orifice translumenal endoscopic surgery (NOTES) transvaginal nephrectomy.nnnMETHODSnA 57-year-old woman with hypertension, right-sided flank pain, and radiographic evidence of an atrophic right kidney consented for NOTES transvaginal nephrectomy. Pneumoperitoneum was achieved with a Veress needle inserted deep in the umbilicus. Under direct vision, a colpotomy was made and a transvaginal port positioned. Using standard and articulating operating instruments inserted transvaginally, the kidney was mobilized and the renal hilum was controlled with an endovascular stapler. The kidney was placed in a laparoscopic retrieval bag and extracted through the vaginal incision. Salient demographic and operative data were obtained.nnnRESULTSnNOTES transvaginal nephrectomy was successfully completed, with all the operative steps performed transvaginally. Dense pelvic adhesions from a prior hysterectomy necessitated the use of a 5-mm umbilical port during vaginal port placement and for retraction of the ascending colon during division of the renal hilum. No intraoperative complications occurred. Operative time was 307 minutes, with 124 minutes dedicated to vaginal port placement and 183 minutes dedicated to adhesiolysis and nephrectomy. The duration of hospitalization was 23 hours. The visual analog pain scale score was 1 of 10 on postoperative day 2.nnnCONCLUSIONSnOur experience shows that NOTES transvaginal nephrectomy is technically feasible. Access to the peritoneal cavity should be performed under visual guidance and after insufflation through the umbilicus. Additional experience is needed to better define patient selection criteria and indications for NOTES transvaginal urologic surgery.

Single-port Laparoscopic Retroperitoneal Surgery: Initial Operative Experience and Comparative Outcomes

OBJECTIVESnTo present the initial operative outcomes and comparative data among patients undergoing single-port laparoscopic retroperitoneal surgery (SPLRS).nnnMETHODSnA prospective, observational study of all patients who underwent SPLRS was performed. The salient demographic and operative data, including age, body mass index, operative indications, operative time, estimated blood loss, complications, and postoperative visual analog pain scale scores were recorded. Patients who underwent cryoablation were then retrospectively compared to a contemporary, matched cohort of patients undergoing traditional laparoscopic retroperitoneal cryosurgery. Statistical analyses were performed.nnnRESULTSnFrom September 25, 2007 to July 15, 2008, 8 patients underwent SPLRS. Five patients underwent SPLR cryoablation and 1 underwent SPLR partial nephrectomy for radiographic evidence of an enhancing renal mass. One patient underwent SPLR metastectomy for isolated recurrence of renal cell carcinoma. The remaining patient underwent SPLR cyst decortication for unrelenting pain. The mean patient age was 63.5 years. The mean body mass index was 28.9 kg/m(2). The mean operative time and estimated blood loss was 165 +/- 23 minutes and 134 +/- 152 mL, respectively. No intraoperative or postoperative complications were noted. The mean hospitalization was 1.4 days. The mean visual analog pain scale score at discharge was 0.4 of 10 (range 0-2). No significant difference was noted between the single-port and standard retroperitoneal cryotherapy cohorts with respect to age, body mass index, estimated blood loss, and length of hospitalization (P > .05). Patients who underwent SPLR cryoablation reported lower visual analog pain scale scores (P = .023).nnnCONCLUSIONSnThe results of our study have shown that SPLRS is feasible and offers comparable surgical outcomes and superior cosmesis and pain control compared with traditional retroperitoneoscopy.

Robotic partial nephrectomy without renal hilar occlusion

Study Type – Therapy (case series)u2028Level of Evidenceu20034

Laparoendoscopic Single-site Radical Cystectomy and Pelvic Lymph Node Dissection: Initial Experience and 2-Year Follow-up

OBJECTIVEnTo report the first series of laparoendoscopic single-site surgery for radical cystectomy and bilateral pelvic lymph node dissection. The development of laparoendoscopic single-site surgery and its application to urothelial malignancy has not been previously evaluated.nnnMETHODSnA novel, single multichannel port and flexible laparoscopic instruments and laparoscope were used for all procedures. The eligible patients had transitional cell carcinoma that was muscle invasive or refractory to intravesical therapy. Locally advanced disease, previous abdominal or pelvic surgery or radiotherapy, or those desiring orthotopic reconstruction were excluded. No additional ports were needed, and lymphadenectomy was performed using an extended template up to the aortic bifurcation.nnnRESULTSnA total of 3 patients (2 men and 1 woman) underwent radical cystectomy with bilateral pelvic lymph node dissection. All the procedures were completed successfully. All patients underwent extracorporeal urinary diversion by way of extension of the umbilical port site. The operative time was 315 ± 40 minutes, and the blood loss was minimal (217 ± 29 mL). The pathologic evaluation revealed negative margins and negative lymph node involvement (mean number of nodes 16 ± 3). All patients were discharged within 1 week (6 ± 1 days) with minimal postoperative pain according to the visual analog pain scale (0-1 of 10). At a minimum of 2 years of follow-up (range 24-26 months), no evidence of recurrent or metastatic disease was detected.nnnCONCLUSIONSnLaparoendoscopic single-site surgery for radical cystectomy and bilateral pelvic lymph node dissection is feasible and safe for select patients. Adequate lymph node dissection was possible through a single multichannel port. The long-term oncologic evaluation of these patients awaits; however, the preliminary outcomes have been promising.

Single-port Laparoscopic Abdominal Sacral Colpopexy: Initial Experience and Comparative Outcomes

OBJECTIVESnTo determine the efficacy and safety of single-port laparoscopic abdominal sacral colpopexy (ASC) for the treatment of female pelvic organ prolapse (POP).nnnMETHODSnA retrospective cohort study was performed to assess perioperative outcomes among women who were treated for symptomatic POP with laparoscopic, robotic, or single-port laparoscopic ASC. All patients underwent preoperative history and physical examination including POP quantification (POP-Q) staging and urodynamics. ASC with or without anti-incontinence surgery was performed via the aforementioned approaches. Demographic and perioperative data were obtained. Patients were followed up postoperatively at 3 and 6 months with POP-Q evaluation. Statistical analysis was performed.nnnRESULTSnFrom October 2005 to July 2008, 30 female patients with symptomatic Stage II (6 patients), Stage III (23 patients), or Stage IV (1 patient) POP were treated with laparoscopic (10), robotic (10), or single-port laparoscopic (10) ASC. Mean age of the entire cohort was 61.1 years. Mean body mass index was 26.7 kg/m(2). Seventeen patients demonstrated stress urinary incontinence and underwent concomitant sling placement. No intraoperative complications were encountered. No significant difference was noted in the 3 cohorts with respect to operative time, blood loss, mean visual analog pain score at discharge, or duration of hospitalization. At 6 months following surgery, 27 patients underwent follow-up POP-Q, with all patients demonstrating excellent apical support and prolapse reduction.nnnCONCLUSIONSnSingle-port laparoscopic ASC offers comparable efficacy and superior cosmesis compared to alternative approaches. Long-term follow-up is needed to confirm durability of repair.

Robotic single port suprapubic transvesical enucleation of the prostate (R‐STEP): initial experience

Study Type – Therapy (case series)