Two-port laparoscopic radical cystectomy with reusable umbilical system: a feasibility study.

OBJECTIVE: To describe the technique and report outcomes of laparoscopic radical cystectomy using 2 ports (2-port LRC) for muscle-invasive bladder cancer. PATIENTS AND METHODS: Prospective study was performed between November 2011 and October 2012 to standardize 2-port LRC, lymph node dissection, and urinary diversion. Twenty patients were intervened (8 ileal conduit, 12 neobladder) and followed up for >1 yr. Median follow-up was 75.5 weeks (interquartile range, 65.2-86 weeks). A reusable system placed through the umbilicus and laparoscopic curved instruments with double rotation, plus one 10-mm extra port placed in the right iliac fossa were used. Neobladder or conduit was performed extracorporeally. Preoperative, perioperative, and pathologic outcomes and long-term security data are presented. RESULTS: Median age was 69.5 years; body mass index, 27.4 kg/m(2); operative time, 335 minutes; estimated blood loss, 337 mL; hospital stay, 9 days; intraoperative transfusion rate, 10%; and visual analog pain score, 3 at day 3. Surgical margin was positive in a case (5%); 3 (15%) were pT0, 2 (10%) pT1, 5 (25%) pT2, 6 (30%) pT3a, 3 (15%) pT3b, and 1 (5%) pT4. The number of nodes removed was 18.5 (interquartile range, 16-29.2), 4 (20%) positive. Complications were major in 2 (10%; fecal peritonitis and urinary sepsis) and minor in 4 (20%; ileus and 3 postoperative transfusion) cases. No case required additional analgesia. Incision was totally hidden in the umbilicus. Continence rate in neobladders was 91.7% at daytime and 75% at nighttime. Study limitation was the absence of a comparative cohort. CONCLUSION: Umbilical 2-port LRC is feasible with good oncologic and functional outcomes, low postoperative pain, and absence of abdominal wall complications. Difficulties have slowed laparoendoscopic single-site radical cystectomy, but umbilical 2-port LRC is a very acceptable alternative for minimally invasive surgery of muscle-invasive bladder cancer.

Umbilical laparoendoscopic urological surgery with a novel reusable device.

OBJECTIVE: The aims of this study were to present cumulative experience with umbilical laparoendoscopic urological surgery using a reusable device and to evaluate outcomes and complications in the first 100 patients. MATERIAL AND METHODS: Patients undergoing umbilical surgery with the KeyPort system and DuoRotate instruments (Richard Wolf, Knittlingen, Germany) were evaluated prospectively. Demographic, intraoperative and postoperative data were assessed. RESULTS: Between October 2011 and July 2012, 79 pelvic (66 radical prostatectomy, 10 radical cystectomy, one diverticulectomy, one bilateral orchiectomy, one ureter reimplantation) and 21 renal (seven radical nephrectomy, six partial nephrectomy, five nephroureterectomy, two pyeloplasty, one pyelolithotomy) surgeries were performed through the umbilicus using this platform. Follow-up was 56.7 ± 12.6 weeks (mean ± SD). Mean age was 64.3 ± 10.3 years, body mass index 29 ± 4.6 kg/m(2), operative time 232 ± 106 min and estimated blood loss 260 ± 95 ml. Conversion to standard multiport laparoscopy was not necessary. An accessory port was used in 87 cases to facilitate suturing and conduct drainage extraction. Postoperative complications occurred in 24 cases (six Clavien grade I, 12 grade II, one grade IIIa, two grade IIIb, two grade IVa, one grade IVb). Mean hospital stay was 4.2 ± 4 days. Total transfusion rate was 10%. Mean visual analogue pain scale at day 2 was 2.1 ± 1.3 (0-10). Visual analogue wound satisfaction scale at month 1 was 9.2 ± 0.6 (0-10). No cancer-related events occurred during follow-up. Late complications (4%) were not related to the surgical approach. CONCLUSIONS: Umbilical KeyPort surgery is technically feasible for a great variety of procedures, both ablative and reconstructive. This access offers adequate surgical outcomes, scarce postoperative pain and security for the patient in the short term. Its reusable nature implies a noticeable economic advantage.

Initial experience of umbilical laparoendoscopic single-site nephron-sparing surgery with KeyPort and DuoRotate system.

OBJECTIVES: To present the feasibility of laparoendoscopic single-site (LESS) nephron-sparing surgery (NSS) using new reusable umbilical single-port system and instruments. METHODS: A prospective study was performed to evaluate operative data and patient outcomes after LESS-NSS with KeyPort®, a tri-channel single-port placed through a 2.5-cm umbilical incision, and specific DuoRotate® instruments. Patient characteristics, operative time, estimated blood loss (EBL), complications, visual analog pain scale (VAPS), and visual analogue wound satisfaction scale (VAWSS) scores were registered. RESULTS: Six consecutive nonselected patients with indication of NSS and normal contralateral kidney were offered LESS-NSS. An accessory 3.5 mm port that facilitated renoraphy and unclamped technique was used in 4 (66.7%) cases each. Median tumor maximum size was 4.0 (1-7.5) cm; age 64 (31-76) years; body mass index 28.4 (22.1-39.3) kg/m(2); operative time 233.5 (140-250) min; EBL 500 (200-500) mL; difference in hemoglobin 2.3 (0.1-4.6) g/dL. VAPS at day 2 was 0.7/10 and the median length of stay 3 (2-4) days. One case (16.7%) needed transfusion. None required conversion to standard laparoscopy or use of other additional ports. Postoperative complications occurred in 3 (50%) and major complications in 1 (16.7%). Incisions were totally hidden in the umbilicus. Pathology revealed angiomyolipoma (3), renal cell carcinoma (2), and chronic inflammation (1). Tumor margins were negative in all cases with malignancy. VAWSS at first month was 9.4 (8.1-10). At a median follow-up of 24 (10-32) weeks, no patient developed complications related to the approach. CONCLUSIONS: Umbilical LESS-NSS through a new single-port system of reusable nature, with or without the help of an accessory port and occasionally without clamping, can be effectively and very economically performed with minimum postoperative pain. Good candidates are patients with presumed benign renal masses that appreciate the cosmetic advantage of the approach.

Umbilical KeyPort bilateral laparoscopic orchiectomy in patient with complete androgen insensitivity syndrome.

MAIN FINDINGS: A 22-year-old woman with complete androgen insensitivity syndrome (CAIS) presenting with primary amenorrhea and normal female external genitalia was referred for laparoscopic gonadectomy. She had been diagnosed several years earlier but was reluctant to undergo surgery. Case HYPOTHESIS: Diagnosis of this X-linked recessive inherited syndrome characterizes by disturbance of virilization in males with an AR mutation, XY karyotipe, female genitalia and severely undescended testis with risk of malignization. The optimal time to orchidectomy is not settled; neither the real risk of malignancy in these patients. Early surgery impacts development of a complete female phenotype, with enlargement of the breasts. Based on modern diagnostic imaging using DCE-MRI and surgical technology with single port laparoscopic access we hypothesize that the optimum time for gonadectomy is not at the time of diagnosis, but once feminization has completed. PROMISING FUTURE IMPLICATIONS: An umbilical laparoendoscopic single-site access for bilateral gonadectomy appears to be the first choice approach as leaves no visible incision and diminishes the psychological impact of surgery in a patient with CAIS absolutely reassured as female. KeyPort, a single port access with duo-rotate instruments developed by Richard Wolf facilitates this surgery and allows excellent cosmetic results.

Umbilical KeyPort bilateral laparoscopic orchiectomy in patient with complete androgen insensitivity syndrome

MAIN FINDINGS: A 22-year-old woman with complete androgen insensitivity syndrome (CAIS) presenting with primary amenorrhea and normal female external genitalia was referred for laparoscopic gonadectomy. She had been diagnosed several years earlier but was reluctant to undergo surgery. CASE HYPOTHESIS: Diagnosis of this X-linked recessive inherited syndrome characterizes by disturbance of virilization in males with an AR mutation, XY karyotipe, female genitalia and severely undescended testis with risk of malignization. The optimal time to orchidectomy is not settled; neither the real risk of malignancy in these patients. Early surgery impacts development of a complete female phenotype, with enlargement of the breasts. Based on modern diagnostic imaging using DCE-MRI and surgical technology with single port laparoscopic access we hypothesize that the optimum time for gonadectomy is not at the time of diagnosis, but once feminization has completed. PROMISING FUTURE IMPLICATIONS: An umbilical laparoendoscopic single-site access for bilateral gonadectomy appears to be the first choice approach as leaves no visible incision and diminishes the psychological impact of surgery in a patient with CAIS absolutely reassured as female. KeyPort, a single port access with duo-rotate instruments developed by Richard Wolf facilitates this surgery and allows excellent cosmetic results.

Safety study of umbilical single-port laparoscopic radical prostatectomy with a new DuoRotate system.

BACKGROUND: Laparoendoscopic single-site (LESS) radical prostatectomy (RP) has been performed through different approaches. A new DuoRotate manual system developed by Richard Wolf (KeyPort; Richard Wolf GmbH, Knittlingen, Germany) can be applied to RP. OBJECTIVES: Our aim was to describe the surgical technique and report early outcomes of KeyPort LESS-RP to determine if this procedure is feasible and safe. DESIGN, SETTING, AND PARTICIPANTS: Prospective study performed between October 2011 and January 2012 to standardize LESS-RP. A total of 31 procedures were performed (10 with and 21 without neurovascular preservation, 8 with and 23 without pelvic lymph node dissection). SURGICAL PROCEDURE: LESS-RP was performed using the methods outlined in the manuscript. All patients underwent LESS RP by the same surgical team. Access was achieved via a tri-channel reusable KeyPort and one 3.5-mm extra port to facilitate urethrovesical anastomosis and drainage extraction. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Preoperative, perioperative, and pathologic outcomes data are presented. RESULTS AND LIMITATIONS: The mean age of the patients was 64 yr; mean body mass index: 30.7 kg/m(2); mean prostate-specific antigen level: 7 ng/ml; mean operative time: 207 min; and mean estimated blood loss: 258 ml. The average length of stay was 2.9 d and visual analog pain score (range: 0 [no pain] to 10) at day 2 was 1.2. Five focal positive margins (16.7%) were encountered (4.4% for pT2 and 57.1% for pT3). Five cases (16.7%) were pT2a, 3 (10%) were pT2b, 15 (50%) were pT2c, and 7 (23.3%) were pT3a. Lymph node dissection results were negative in all patients. Major complications occurred in two patients (6.5%) (hypercapnia with respiratory acidosis and rectourethral fistula) and minor complications in four (12.9%) (atrial fibrillation, orchitis, transfusion, and vomiting). No case required additional analgesia. Incision was totally hidden in the umbilicus. Study limitations included short follow-up (mean: 20.2 ± 4.1 wk), premature functional data, and absence of a comparative cohort. CONCLUSIONS: The KeyPort system allows performance of umbilical RP with few complications, a low positive-margin rate, excellent aesthetic results, and very low postoperative pain levels.

Percutaneous ureteral catheterization in laparoscopic surgery: value of nephroscopy needle trocar.

OBJECTIVES: To report our experience with use of the nephroscopy needle trocar for percutaneous catheterization. In multiple urologic procedures, surgeons use ureteral catheters to decrease morbidity, increase the success rate, and allow for postoperative radiographic follow-up. The advent of laparoscopic surgery has logically required catheterization to be adapted to our laparoscopic procedures. METHODS: The expansion of our daily practice to include multiple laparoscopic procedures showed us the difficulties inherent to ureteral catheterization in laparoscopic surgery. During our experience of >1000 laparoscopic procedures, we have used more or less complex catheterization techniques. After developing the use of the nephroscopy needle trocar for laparoscopic urinary diversion and finding that such use simplified the procedure, this technique was extended to all other laparoscopic procedures in which catheterization is required. RESULTS: We analyzed the use of the nephroscopy needle trocar in 15 ureteropyeloplasty, 21 ileal conduit, and 4 laparoscopic ureteral reimplantation procedures. The mean operating time required for anterograde catheterization in ureteropelvic junction stenosis was 3 minutes, 35 seconds, and the mean operating time for retrograde catheterization was 2 minutes, 20 seconds. Anterograde catheterization was impossible in 1 case. No cases of a false ureteral tract occurred. CONCLUSIONS: The results of our analysis have shown that the use of the nephroscopy needle trocar for percutaneous catheterization in laparoscopic surgery markedly simplifies the procedure, with the resultant savings in operating time.