Wooju Jeong

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

PURPOSEnWe 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.nnnMATERIALS AND METHODSnBetween 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.nnnRESULTSnOf 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).nnnCONCLUSIONSnOur 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.

Positive surgical margins after robotic assisted radical prostatectomy: A multi-institutional study

PURPOSEnPositive surgical margins are an independent predictive factor for biochemical recurrence after radical prostatectomy. We analyzed the incidence of and associative factors for positive surgical margins in a multi-institutional series of 8,418 robotic assisted radical prostatectomies.nnnMATERIALS AND METHODSnWe analyzed the records of 8,418 patients who underwent robotic assisted radical prostatectomy at 7 institutions. Of the patients 323 had missing data on margin status. Positive surgical margins were categorized into 4 groups, including apex, bladder neck, posterolateral and multifocal. The records of 6,169 patients were available for multivariate analysis. The variables entered into the logistic regression models were age, body mass index, preoperative prostate specific antigen, biopsy Gleason score, prostate weight and pathological stage. A second model was built to identify predictive factors for positive surgical margins in the subset of patients with organ confined disease (pT2).nnnRESULTSnThe overall positive surgical margin rate was 15.7% (1,272 of 8,095 patients). The positive surgical margin rate for pT2 and pT3 disease was 9.45% and 37.2%, respectively. On multivariate analysis pathological stage (pT2 vs pT3 OR 4.588, p<0.001) and preoperative prostate specific antigen (4 or less vs greater than 10 ng/ml OR 2.918, p<0.001) were the most important independent predictive factors for positive surgical margins after robotic assisted radical prostatectomy. Increasing prostate weight was associated with a lower risk of positive surgical margins after robotic assisted radical prostatectomy (OR 0.984, p<0.001) and a higher body mass index was associated with a higher risk of positive surgical margins (OR 1.032, p<0.001). For organ confined disease preoperative prostate specific antigen was the most important factor that independently correlated with positive surgical margins (4 or less vs greater than 10 ng/ml OR 3.8, p<0.001).nnnCONCLUSIONSnThe prostatic apex followed by a posterolateral site was the most common location of positive surgical margins after robotic assisted radical prostatectomy. Factors that correlated with cancer aggressiveness, such as pathological stage and preoperative prostate specific antigen, were the most important factors independently associated with an increased risk of positive surgical margins after robotic assisted radical prostatectomy.

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).

The feasibility of laparoendoscopic single-site nephrectomy: Initial experience using home-made single-port device

OBJECTIVESnTo report our early experience with laparoendoscopic single-site (LESS) nephrectomy using home-made single-port device for benign nonfunctioning kidney.nnnMETHODSnA total of 14 patients with benign nonfunctioning kidney underwent transperitoneal LESS nephrectomy by 2 experienced laparoscopic surgeons. The indications for nephrectomy were nonfunctioning kidney associated with ectopic kidney (n = 2), ureteropelvic junction obstruction (n = 5), genitourinary tuberculosis (n = 4), ureter stone (n = 2), and ureter stricture (n = 1).nnnRESULTSnAll procedures were completed successfully. The mean operative time was 151 (85-230) minutes, estimated blood loss 108 (negligible-500) mL, and postoperative hospital stay 3.1 (2-6) days. There were no major complications.nnnCONCLUSIONSnLESS nephrectomy is a feasible and safe surgical option for benign nonfunctioning kidney.

Robot-assisted Laparoendoscopic Single-site Surgery: Partial Nephrectomy for Renal Malignancy

OBJECTIVESnTo describe our experience with robot-assisted laparoendoscopic single-site surgery (LESS) to perform partial nephrectomy and evaluate a hybrid homemade port system as an effective access technique.nnnMETHODSnFrom December 2008 to September 2009, robot-assisted LESS to perform partial nephrectomy through a hybrid homemade port was performed to treat 14 cases of renal cell carcinoma. The data, including patient characteristics, operative records, complications, and pathologic results, were analyzed.nnnRESULTSnThe mean tumor size was 3.2 cm, the mean ischemic time was 30 minutes, and the mean operative time was 233 minutes. We used the hybrid homemade port technique in 10 cases. All surgical margins after partial nephrectomy were negative for malignancy. No port-related complications were reported. Two cases required conversion to mini-incisional partial nephrectomy.nnnCONCLUSIONSnRobot-assisted LESS for performing partial nephrectomy using a hybrid homemade port system is a safe and feasible treatment technique. It provided access for meticulous suturing on the renal parenchyma using articulating robot arms and ready access to the surgical field for the assistant.

Laparoscopic Partial Nephrectomy Versus Robot-Assisted Laparoscopic Partial Nephrectomy

PURPOSEnLaparoscopic partial nephrectomy (LPN) is an alternative treatment modality for small-sized renal tumors. Robot-assisted LPN (RLPN) has also been performed with an advantage in repairing the defect after a resection of the tumor. We compared the perioperative data of patients treated with LPN with patients who underwent RLPN.nnnMATERIALS AND METHODSnFrom September 2006 to April 2008, 26 patients were treated with LPN and 31 with RLPN. Three arms were used for RLPN; camera was inserted through the 12 mm umbilical trocar port. Laparoscopic Bulldog clamps were used for clamping the renal hilum. We retrospectively compared each group on tumor size, operative time, estimated blood loss, warm ischemic time, and hospital stay.nnnRESULTnOperative time of LPN was shorter than that of RLPN (p = 0.034). Tumor size, estimated blood loss, and hospital stay were not significantly different in each group. No case was converted to open surgery. One patient in the RLPN group, however, was converted to robot-assisted radical nephrectomy because of severe bleeding.nnnCONCLUSIONnRLPN is safe and feasible for small-sized renal tumors. Warm ischemic time is within reasonable limits. Associated morbidity is also low.

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

OBJECTIVESnTo 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.nnnMETHODSnFrom 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.nnnRESULTSnThere 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.nnnCONCLUSIONSnMechanical 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.

Comparison of Laparoscopic Radical Nephrectomy and Open Radical Nephrectomy for Pathologic Stage T1 and T2 Renal Cell Carcinoma With Clear Cell Histologic Features: A Multi-institutional Study

OBJECTIVESnTo assess the oncologic efficacy of laparoscopic radical nephrectomy (LRN) compared with open radical nephrectomy (ORN) in patients with clear cell renal cell carcinoma (RCC).nnnMETHODSnWe analyzed the data from 2561 patients who had undergone radical nephrectomy for RCC at 26 institutions in Korea from June 1998 to December 2007. The clinical data of 631 patients with clear cell RCC in the LRN group were compared with the clinical data of 924 patients in the ORN group. The patients with Stage pT3 or greater and those with lymph node or distant metastases were excluded to avoid a selection bias. To evaluate the technical adequacy and oncologic outcome, we compared the perioperative parameters and 5-year overall and disease-free survival rates.nnnRESULTSnThe operative time was significantly longer in the LRN group than in the ORN group (219 ± 77 vs 182 ± 62 minutes, P < .001), but the estimated blood loss and complication rate were significantly lower in the LRN group than in the ORN group (P < .001 and P < .001, respectively). On univariate analysis, the LRN group had 5-year overall (93.5% vs 89.8%, P = .120) and recurrence-free (94.0% vs 92.8%, P = .082) survival rates equivalent to those of the ORN group. Even after adjusting for age, sex, T stage, tumor grade, and body mass index in a Cox proportional hazards model, statistically significant differences between the 2 groups were not found for the 5-year overall (hazard ratio 1.523, P = .157) and recurrence-free (hazard ratio 0.917, P = .773) survival rates.nnnCONCLUSIONSnOur large multi-institutional data have shown that LRN provides survival outcomes equivalent to those of ORN in patients with Stage pT1-T2 clear cell RCC.

Yonsei Experience in Robotic Urologic Surgery - Application in Various Urological Procedures

Purpose The da Vinci® robot system has been used to perform complex reconstructive procedures in a minimally invasive fashion. Robot-assisted laparoscopic radical prostatectomy has recently established as one of the standard cares. Based on experience with the robotic prostatectomy, its use is naturally expanding into other urologic surgeries. We examine our practical pattern and application of da Vinci® robot system in urologic field. Patients and Methods Robotic urologic surgery has been performed during a period from July 2005 to August 2008 in a total of 708 cases. Surgery was performed by 7 operators. In our series, radical prostatectomy was performed in 623 cases, partial nephrectomy in 43 cases, radical cystectomy in 11 cases, nephroureterectomy in 18 cases and other surgeries in 15 cases. Results In the first year, robotic urologic surgery was performed in 43 cases. However, in the second year, it was performed in 164 cases, and it was performed in 407 cases in the third year. In the first year, only prostatectomy was performed. In the second year, partial nephrectomy (2 cases), nephroureterectomy (3 cases) and cystectomy (1 case) were performed. In the third year, other urologic surgeries than prostatectomy were performed in 64 cases. The first robotic surgery was performed with long operative time. For instance, the operative time of prostatectomy, partial nephrectomy, cystectomy and nephroureterectomy was 418, 222, 340 and 320 minutes, respectively. Overall, the mean operative time of prostatectomy, partial nephrectomy, cystectomy and nephrourectectomy was 179, 173, 309, and 206 minutes, respectively. Conclusion Based on our experience at a single-institution, robot system can be used both safely and efficiently in many areas of urologic surgeries including prostatectomy. Once this system is familiar to surgeons, it will be used in a wide range of urologic surgery.

Robot-assisted laparoscopic radical prostatectomy in the Asian population: Modified port configuration and ultradissection

We have carried out over 360 cases of robot‐assisted laparoscopic radical prostatectomy (RARP) to date. In the present study, we detail our current technique at Yonsei University College of Medicine. The six‐port transperitoneal approach is utilized. The most lateral two ports were placed medially and caudally in patients with a small pelvis to avoid interference between the ports and the pelvis (modified port configuration). Lymph node dissection is carried out in the external iliac, obturator and infraobturator area. The dissection on the lateral border of the bladder neck is carried out until it reaches the seminal vesicle (ultradissection). After transection of the bladder neck, vasa seminal vesicles are dissected further. Neurovascular bundles are preserved in selected patients. The dorsal venous complex (DVC) and the urethra are transected without suturing. Urethrovesical anastomosis is carried out with 3‐0 monocryl running suture, incorporating with the edge of DVC. The puboprostatic collar and bladder are incorporated by 3‐0 monocryl running suture (puboperineoplasty). Between November 2007 and September 2008, RARP was carried out using this technique in 182 patients. Median height, weight, body mass index and prostate‐specific antigen (PSA) were 168u2003cm, 68u2003kg, 24u2003kg/M2 and 7.1u2003ng/mL, respectively. Mean operative time was 192u2003min and average blood loss was 250u2003mL. Median catheterization time was 8u2003days. Positive surgical margin rates for pT2, pT3 and pT4 disease was 12.7, 48 and 100%, respectively. Intraoperative complication rate was 2.7%. Fifty‐five patients completed a minimum of 10u2003months follow up. Their continence rate was 91%. RARP is a safe and feasible surgical modality for prostate cancer among Asian patients with a small pelvis. Our technique achieves a precise bladder neck dissection.