Woong Kyu Han

Laparoendoscopic Single-site Surgery in Urology: Worldwide Multi-institutional Analysis of 1076 Cases

BACKGROUND Laparoendoscopic single-site surgery (LESS) has gained popularity in urology over the last few years. OBJECTIVE To report a large multi-institutional worldwide series of LESS in urology. DESIGN, SETTING, AND PARTICIPANTS Consecutive cases of LESS done between August 2007 and November 2010 at 18 participating institutions were included in this retrospective analysis. INTERVENTION Each group performed a variety of LESS procedures according to its own protocols, entry criteria, and techniques. MEASUREMENTS Demographic data, main perioperative outcome parameters, and information related to the surgical technique were gathered and analyzed. Conversions to reduced-port laparoscopy, conventional laparoscopy, or open surgery were evaluated, as were intraoperative and postoperative complications. RESULTS AND LIMITATIONS Overall, 1076 patients were included in the analysis. The most common procedures were extirpative or ablative operations in the upper urinary tract. The da Vinci robot was used to operate on 143 patients (13%). A single-port technique was most commonly used and the umbilicus represented the most common access site. Overall, operative time was 160±93 min and estimated blood loss was 148±234 ml. Skin incision length at closure was 3.5±1.5 cm. Mean hospital stay was 3.6±2.7 d with a visual analog pain score at discharge of 1.5±1.4. An additional port was used in 23% of cases. The overall conversion rate was 20.8%; 15.8% of patients were converted to reduced-port laparoscopy, 4% to conventional laparoscopy/robotic surgery, and 1% to open surgery. The intraoperative complication rate was 3.3%. Postoperative complications, mostly low grade, were encountered in 9.5% of cases. CONCLUSIONS This study provides a global view of the evolution of LESS in the field of minimally invasive urologic surgery. A broad range of procedures have been effectively performed, primarily in the academic setting, within diverse health care systems around the world. Since LESS is performed by experienced laparoscopic surgeons, the risk of complications remains low when stringent patient-selection criteria are applied.

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.

What are ‘true normal’ liver stiffness values using FibroScan®?: a prospective study in healthy living liver and kidney donors in South Korea

Aims: To identify the normal range of liver stiffness (LS) values by recruiting healthy living liver and kidney donors in South Korea.

Predictors of Kidney Volume Change and Delayed Kidney Function Recovery After Donor Nephrectomy

PURPOSE To our knowledge the effects of preoperative kidney volume in living donors on the post-donation change in size and function of the remaining kidney have not been investigated. We studied the association between preoperative kidney volume, and volume change and delayed kidney function recovery in donors. MATERIALS AND METHODS From 2007 to 2008 we investigated 222 living donors. Kidney volume before and 6 months after surgery was estimated using the voxel count method. We analyzed correlations of kidney volume with patient characteristics, kidney function and actual kidney weight. To identify predictors of the volume increase of the remaining kidney and predictors of delayed kidney function recovery we performed regression analysis. RESULTS Mean +/- SD total kidney volume was 311.9 +/- 50.6 cc and it correlated with weight, body surface area and kidney function (p <0.001). The mean volume increase in the remaining kidney was 27.6% +/- 9.7% (range 4.5% to 66.1%). Younger age (p <0.001) and lower preoperative volume of the remaining kidney (p = 0.019) were significant predictors of a greater increase in kidney volume on multiple linear regression analysis. Older age (OR 1.07, p <0.001), higher body mass index (OR 1.20, p = 0.008), lower preoperative kidney volume of the remaining kidney (OR 0.98, p = 0.003) and a lower preoperative diethylenetetramine pentaacetic acid glomerular filtration rate in the remaining kidney (OR 0.95, p = 0.017) were significant predictors of delayed kidney function recovery on multiple regression analysis. CONCLUSIONS Kidney volume measured by the voxel count method was accurate and correlated with kidney function. Preoperative kidney volume is an independent predictor of the volume increase and delayed kidney function recovery in donors that could be used clinically.

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

OBJECTIVES To report our early experience with laparoendoscopic single-site (LESS) nephrectomy using home-made single-port device for benign nonfunctioning kidney. METHODS A 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). RESULTS All 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. CONCLUSIONS LESS nephrectomy is a feasible and safe surgical option for benign nonfunctioning kidney.

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

OBJECTIVES To 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. METHODS From 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. RESULTS The 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. CONCLUSIONS Robot-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

PURPOSE Laparoscopic 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. MATERIALS AND METHODS From 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. RESULT Operative 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. CONCLUSION RLPN is safe and feasible for small-sized renal tumors. Warm ischemic time is within reasonable limits. Associated morbidity is also low.

Urological laparoendoscopic single site surgery: Multi-institutional analysis of risk factors for conversion and postoperative complications

PURPOSE We analyzed the incidence of and risk factors for complications and conversions in a large contemporary series of patients treated with urological laparoendoscopic single site surgery. MATERIALS AND METHODS The study cohort consisted of consecutive patients treated with laparoendoscopic single site surgery between August 2007 and December 2010 at a total of 21 institutions. A logistic regression model was used to analyze the risks of conversion, and of any grade and only high grade postoperative complications. RESULTS Included in analysis were 1,163 cases. Intraoperatively complications occurred in 3.3% of cases. The overall conversion rate was 19.6% with 14.6%, 4% and 1.1% of procedures converted to reduced port laparoscopy, conventional laparoscopic/robotic surgery and open surgery, respectively. On multivariable analysis the factors significantly associated with the risk of conversion were oncological surgical indication (p=0.02), pelvic surgery (p<0.001), robotic approach (p<0.001), high difficulty score (p=0.004), extended operative time (p=0.03) and an intraoperative complication (p=0.001). A total of 120 postoperative complications occurred in 109 patients (9.4%) with major complications in only 2.4% of the entire cohort. Reconstructive procedure (p=0.03), high difficulty score (p=0.002) and extended operative time (p=0.02) predicted high grade complications. CONCLUSIONS Urological laparoendoscopic single site surgery can be done with a low complication rate, resembling that in laparoscopic series. The conversion rate suggests that early adopters of the technique have adhered to the principles of careful patient selection and safety. Besides facilitating future comparisons across institutions, this analysis can be useful to counsel patients on the current risks of urological laparoendoscopic single site surgery.

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.

Normal liver elasticity values using acoustic radiation force impulse imaging: A prospective study in healthy living liver and kidney donors

Background and Aim:  Although several studies have investigated the normal range of liver elasticity using acoustic radiation force impulse (ARFI) elastography in healthy volunteers, they could not strictly exclude the morphological and functional liver abnormalities. The aim of this study was to identify the normal range of ARFI velocity by recruiting healthy living liver and kidney donors who passed the full laboratory tests and imaging studies.