Won Sik Ham

Initial experience with 50 laparoendoscopic single site surgeries using a homemade, single port device at a single center.

PURPOSE We report our technique of and initial experience with 50 patients who underwent laparoendoscopic single site surgery using a homemade single port device at a single institution. MATERIALS AND METHODS Between December 2008 and August 2009 we performed 50 laparoendoscopic single site surgeries using the Alexis wound retractor, which was inserted at the umbilical incision. A homemade single port device was made by fixing a size 7 1/2 surgical glove to the retractor outer ring and securing the glove fingers to the end of 3 or 4 trocars with a tie and a rubber band. A prospective study was performed in 50 patients to evaluate outcomes. RESULTS Of 50 patients 34 underwent conventional laparoendoscopic single site surgery, including radical and simple nephrectomy, and cyst decortication in 8 each, nephroureterectomy in 3, partial nephrectomy and adrenalectomy in 2 each, and partial cystectomy, ureterectomy and ureterolithotomy in 1 each, while 16 underwent robotic laparoendoscopic single site surgery, including partial nephrectomy in 11, nephroureterectomy in 3, and simple and radical nephrectomy in 1 each. Mean patient age was 52 years, mean body mass index was 23.4 kg/m(2), mean operative time was 201 minutes and mean estimated blood loss was 201 ml. Four intraoperative complications occurred, including 2 bowel serosal tears, diaphragm partial tearing and conversion to open radical nephrectomy. One case of postoperative bleeding was managed by transfusion. Surgical margins were negative in the 13 patients who underwent partial nephrectomy. Mean hospital stay was 4.5 days (range 1 to 16). CONCLUSIONS Our homemade single port device is cost-effective, provides adequate range of motion and is more flexible in port placement for laparoendoscopic single site surgery than the current multichannel port.

Initial experience of robotic nephroureterectomy: a hybrid-port technique

To report a new technique of robot‐assisted laparoscopic nephroureterectomy (RANU) using a hybrid port, as RANU has recently become a minimally invasive treatment option for upper tract transitional cell carcinoma (TCC).

Robotic radical prostatectomy for patients with locally advanced prostate cancer is feasible: Results of a single-institution study

OBJECTIVES The aim of this study was to compare the outcomes of robotic prostatectomy (RP) in patients with clinically localized or locally advanced prostate cancer (PC). PATIENTS AND METHODS Between July 2005 and February 2008, we performed RP in 357 patients by using the da Vinci robot system and a transperitoneal approach. We defined locally advanced PC as cases with a clinical T-stage >/=T3a with any serum prostate-specific antigen (PSA) or Gleason score. Among the 321 men not treated with neoadjuvant hormonal therapy, 200 patients had clinically localized PC and 121 patients had locally advanced PC. We compared perioperative variables and early surgical outcomes between the two groups. RESULTS Although advanced PC patients had significantly higher mean preoperative PSA levels, prostatectomy Gleason scores, and extracapsular extension rates, there were no significant differences in mean operation time, estimated blood loss, duration of bladder catheterization, hospital stay, or initiation of a regular postoperative diet between the two groups. Except for some early cases, a bilateral extended lymphadenectomy was performed without difficulty in both groups. Although both the frequency of lymph node invasion and the positive surgical margin rates were higher in the advanced PC patients, the positive surgical margin rate (48.8%) in the present study was similar to those of open radical retropubic prostatectomy in other studies. The overall complication rate did not differ between the two groups. Two intraoperative rectal injuries occurred in patients with locally advanced PC and were closed primarily without specific problems, except for 1 case. CONCLUSIONS Our results suggest that RP may be performed safely on patients with locally advanced PC.

Laparoendoscopic Single-Site Surgeries: A Single-Center Experience of 171 Consecutive Cases

Purpose We report our experience to date with 171 patients who underwent laparoendoscopic single-site surgery for diverse urologic diseases in a single institution. Materials and Methods Between December 2008 and August 2010, we performed 171 consecutive laparoendoscopic single-site surgeries. These included simple nephrectomy (n=18; robotic surgeries, n=1), radical nephrectomy (n=26; robotic surgeries, n=2), partial nephrectomy (n=59; robotic surgeries, n=56), nephroureterectomy (n=20; robotic surgeries, n=12), pyeloplasty (n=4), renal cyst decortications (n=22), adrenalectomy (n=4; robotic surgeries, n=2), ureterolithotomy (n=10), partial cystectomy (n=3), ureterectomy (n=1), urachal mass excision (n=1), orchiectomy (n=1), seminal vesiculectomy (n=1), and retroperitoneal mass excision (n=1). All procedures were performed by use of a homemade single-port device with a wound retractor and surgical gloves. A prospective study was performed to evaluate outcomes in 171 cases. Results Of the 171 patients, 98 underwent conventional laparoendoscopic single-site surgery and 73 underwent robotic laparoendoscopic single-site surgery. Mean patient age was 53 years, mean operative time was 190.8 minutes, and mean estimated blood loss was 204 ml. Intraoperative complications occurred in seven cases (4.1%), and postoperative complications in nine cases (5.3%). There were no complications classified as Grade IIIb or higher (Clavien-Dindo classification for surgical complications). Conversion to mini-incision open surgery occurred in seven (4.1%) cases. Regarding oncologic outcomes, no cancer-related events occurred during follow-up other than one aggressive progression of Ewing sarcoma. Conclusions Laparoendoscopic single-site surgery is technically feasible and safe for various urologic diseases; however, surgical experience and long-term follow-up are needed to test the superiority of laparoendoscopic single-site surgery.

Comparison of oncological results, functional outcomes, and complications for transperitoneal versus extraperitoneal robot-assisted radical prostatectomy: a single surgeon's experience.

BACKGROUND AND PURPOSE To compare the oncologic results, functional outcomes, and complications of transperitoneal (TP) and extraperitoneal (EP) robotic radical prostatectomy. PATIENTS AND METHODS From June 2007 to April 2009, 105 patients underwent TP robotic radical prostatectomy, and 155 patients underwent EP robotic radical prostatectomy. Clinicopathological and perioperative data were compared between the two groups. Postoperative complications and functional outcomes including potency and incontinence were assessed. RESULTS Patient demographics were similar in the TP and EP groups. No significant differences in positive surgical margins were noted between the groups. The total operative time, number of lymph nodes removed, and estimated blood loss were also not significantly different. However, the robot console time was shorter for the EP group than for the TP group (89.1 vs. 107.8 minutes, p = 0.03). Postoperative pain scale scores were lower in the EP group than in the TP group (2.7 vs. 6.3, p < 0.001). The incidence of ileus and hernia were lower in the EP group; however, the incidence of lymphocele was higher in the EP group. Postoperative potency and continence rates were similar between the groups; however, the EP group had a faster recovery of continence compared with the TP group. CONCLUSIONS The EP approach has similar oncological and perioperative results, less postoperative pain, less bowel-associated complication, and better functional outcomes than those of the TP approach. The EP approach may be an important alternative in robotic radical prostatectomy.

Failure and malfunction of da Vinci Surgical systems during various robotic surgeries: experience from six departments at a single institute.

OBJECTIVES To analyze the mechanical failures and malfunctions of the da Vinci Surgical (S) System during various robotic surgeries in 6 different departments at our institute and also evaluated the solutions for the failures and malfunctions. METHODS From July 2005 to December 2008, a total of 1797 robotic surgeries were performed at our institute. The surgeries were performed using 4 da Vinci surgical systems (1 standard da Vinci system from July 2005 to July 2007 and 3 da Vinci S systems from July 2007 to December 2008). Mechanical failures or malfunctions occurred in 43 cases. We evaluated the robotic surgeries according to the type of surgery and the department. We analyzed the cases involving conversion to open or laparoscopic surgeries and those in which there was a malfunction with the instrument. RESULTS There were 43 cases (2.4%) of mechanical failure with the da Vinci system from a total of 1797 robotic surgeries. This included 24 (1.3%) cases of mechanical failure or malfunction and 19 cases (1.1%) of instrument malfunction. The mechanical malfunction included 1 on/off failure, 5 console malfunctions, 6 robotic arm malfunctions, 2 optic system malfunctions, and 10 system errors. One open and 2 laparoscopic conversions (3 cases; 0.17%) were performed. CONCLUSIONS Mechanical failure or malfunction occurred during robotic surgery in 43 cases (2.4%), and the open or laparoscopic conversion rate during surgery was very low (0.17%). We found the mechanical failure or malfunction to be rare.

Trends of Presentation and Clinical Outcome of Treated Renal Angiomyolipoma

Purpose The purpose of this study is to set guidelines for the management of renal angiomyolipoma (AML), clinical prognosis according to tumor size, in association with tuberous sclerosis complex (TSC), multiplicity, radiographic finding, and treatment modality. Materials and Methods Between March 1998 and October 2008, 129 out of 254 patients with AML who underwent surgical intervention or angioembolization were enrolled. Diagnosis of AML was determined by the presence of a low attenuated component on CT imaging or by pathological confirmation. Indications of treatment were intractable pain, hematuria, suspicion of malignancy, large tumor size, spontaneous rupture, and radiographically equivocal tumors in which a differential diagnosis was needed to rule out malignancy. Parameters including age, sex, tumor size, multiplicity, radiographic characteristics, association with TSC, and treatment modality were reviewed. Results Age at presentation was 50.6 years and mean tumor size was 3.5 cm. Presentation symptoms were flank pain, hematuria, spontaneous rupture, and fatigue. 97 (75.2%) patients were incidentally discovered. 100 (77.5%) were females. 68 (52.7%) underwent nephron-sparing surgery (NSS), 35 (27.1%) radical nephrectomy, and 26 (20.2%) angioembolization. TSC was accompanied in 12 (9.3%) patients. No patient developed renal function impairment during the mean follow-up period of 64.8 months. Patients with TSC presented at a younger age, along with larger, bilateral, and multiple lesions. Conclusion Significant differences in clinical manifestations and treatment outcomes were noted in respect to tumor characteristics, association with TSC, and treatment modality. Considering the benign nature of AML, these parameters ought to be considered when deciding upon active surveillance or prophylactic intervention.

Efficacy and Safety of Photodynamic Therapy for Recurrent, High Grade Nonmuscle Invasive Bladder Cancer Refractory or Intolerant to Bacille Calmette-Guerin Immunotherapy

PURPOSE We evaluated the effectiveness of photodynamic therapy using Radachlorin in patients with high grade, nonmuscle invasive bladder cancer refractory or intolerant to bacillus Calmette-Guérin therapy who refused radical cystectomy. MATERIALS AND METHODS Between July 2009 and December 2011 photodynamic therapy was performed in 22 men and 12 women. Radachlorin (0.5 to 0.6 mg/kg) was injected intravenously 2 to 3 hours before photodynamic therapy. After complete transurethral resection, a diffuser using a 22Fr cystoscope was placed in the bladder for irradiation with a 662 nm laser. Output beam power was adjusted to 1.8 W and the light dose was 15 J/cm(2). Photodynamic therapy was performed for 16 to 30 minutes. Recurrence after photodynamic therapy was followed by regular cystoscopy at 1, 2 and 3 months, and at 3-month intervals thereafter for up to 2.8 years. Efficacy was assessed by cystoscopy, cytology and histology, and defined as the number of patients who were tumor free after initial photodynamic therapy. RESULTS Mean ± SD patient age was 62.94 ± 8.71 years. Average followup was 26.74 ± 6.34 months (median 28.12). As the primary efficacy outcome, the recurrence-free rate was 90.9% at 12 months, 64.4% at 24 months and 60.1% at 30 months. As the secondary efficacy outcome, there was no statistical difference in mass size, carcinoma in situ, number of previous bacillus Calmette-Guérin administrations, number of transurethral bladder resections or tumor multiplicity on Kaplan-Meier analysis (each p >0.05). No evidence of severe adverse effects was detected after photodynamic therapy. CONCLUSIONS Photodynamic therapy with Radachlorin is a safe, effective treatment for nonmuscle invasive bladder cancer refractory or intolerant to bacillus Calmette-Guérin therapy in select patients.

Lymphocele after extraperitoneal robot-assisted radical prostatectomy: A propensity score-matching study

To investigate the incidence of lymphocele and determine the risk factors for postoperative lymphocele after extraperitoneal robot‐assisted radical prostatectomy by using propensity score‐matching.

Initial Experience With Laparoendoscopic Single-site Nephrectomy and Nephroureterectomy in Children

OBJECTIVES To assess the clinical utility and safety of laparoendoscopic single-site surgery (LESS) nephrectomy and nephroureterectomy in children by analyzing 6 consecutive cases performed by a single surgeon. METHODS Since March 2009, we have been performing LESS nephrectomy and nephroureterectomy in children. The indications have been recurrent pyelonephritis related to vesicoureteral reflux with an atrophic kidney and continuous urinary incontinence related to an ectopic ureter. A homemade port was placed through an umbilical incision, and the laparoscopic transperitoneal nephrectomy procedures were performed using various combinations of standard and articulating laparoscopic instruments. The patients undergoing a LESS procedure were evaluated prospectively, and the data were collected during and after surgery. RESULTS A total of 6 procedures, including nephrectomy (4 cases) and nephroureterectomy (2 cases), were completed without intraoperative or postoperative complications. The median operation time was 112 minutes (range 90-148), and the median blood loss was 0 mL (range 0-50). All patients received only oral ibuprofen syrup for pain control and were discharged on postoperative day 2. As the surgeon gained experience, the length of the umbilical incision was decreased from 2.0 to 1.0 cm. CONCLUSIONS Pediatric LESS nephrectomy and nephroureterectomy can be performed safely with a very small incision. LESS performed by an experienced laparoscopic surgeon has the potential to become an alternative first-line therapy for ablative procedures in children.