Chylous ascites after laparoscopic donor nephrectomy.

INTRODUCTION: The aim of this study was to determine the incidence, presentation, management, and outcomes of chylous ascites following laparoscopic donor nephrectomy. METHODS: An Internet-based, multi-institutional survey was performed using http://www.surveymonkey.com. An email invitation to the voluntary survey was sent to 30 transplant centers and posted on CenterSpan, an email forum for transplant surgeons. The number of living donor transplantations and the number of cases of chylous ascites with clinical information, treatment and outcomes were sought from the questionnaire. RESULTS: A total of 12 centers responded and reported 7683 cases of live donor nephrectomy. The reported incidence of postoperative chylous ascites was 0.013% (n = 12). Six centers reported 10 cases of chylous ascites following laparoscopic donor nephrectomy and 2 cases after open donor nephrectomy. Among the eight patients who developed chylous ascites following laparoscopic donor nephrectomy, presentation was typically 2 weeks after the date of initial surgery. Conservative therapy was successful in 50% of cases. Refractory ascites managed secondarily with surgical intervention had a success rate of 100%. CONCLUSION: Chylous ascites is a rare complication following laparoscopic donor nephrectomy. Initial treatment should be conservative, with surgical therapy reserved for refractory cases.

Wound healing and antimicrobial activity of two classical formulations of Laghupanchamula in rats.

BACKGROUND: Wounds affect a large number of patients and seriously reduce the quality of life. The wound as a medical problem was first discussed by Maharshi Agnivesha in Agnivesha Samhita (later known as Charaka Samhita) as Vrana. Laghupanchamula denotes a combination of the roots of five herbs. However, in Ayurvedic classics, besides four common herbs viz. Kantakari, Brihati, Shalaparni and Prinshniparni, the fifth one is either Gokshura (LPG) or Eranda (LPE), and both formulations have been documented to have wound healing (Vrana) activity. OBJECTIVE: The present study was undertaken to determine the in vivo wound healing activity and in vitro antimicrobial activity of 50% ethanolic extract of Laghupanchamula containing Gokshura (LPGE) and Laghupanchamula containing Eranda (LPEE) in rats with acute toxicity in mice. MATERIALS AND METHODS: LPGE and LPEE (1000 mg/kg) was administered orally, once daily for 10 days (incision wound model) or for 24 days (excision wound model) in rats. LPGE and LPEE was studied for its in vitro antimicrobial and in vivo wound breaking strength (WBS) (incision model) and rate of contraction, period of epithelization and histology of skin (excision model). RESULTS AND CONCLUSION: LPGE and LPEE showed antimicrobial activity against skin pathogens, enhanced WBS, rate of contraction, skin collagen tissue formation and early epithelization period with low scar area indicating enhanced healing with histological evidence of more collagen formation in skin tissues. LPGE and LPEE also showed anti-bacterial activity and seemed to be safe, and use of both formulations in Laghupanchamula for their wound healing and anti-microbial activities is thus authenticated.

Analgesic and hypnotic activities of Laghupanchamula: A preclinical study.

BACKGROUND: In Ayurvedic classics, two types of Laghupanchamula -five plant roots (LP) have been mentioned containing four common plants viz. Kantakari, Brihati, Shalaparni, and Prinshniparni and the fifth plant is either Gokshura (LPG) or Eranda (LPE). LP has been documented to have Shothahara (anti-inflammatory), Shulanashka (analgesic), Jvarahara (antipyretic), and Rasayana (rejuvenator) activities. AIM: To evaluate the acute toxicity (in mice), analgesic and hypnotic activity (in rats) of 50% ethanolic extract of LPG (LPGE) and LPE (LPEE). MATERIALS AND METHODS: LPEG and LPEE were prepared separately by using 50% ethanol following the standard procedures. A graded dose (250, 500 and 1000 mg/kg) response study for both LPEE and LPGE was carried out for analgesic activity against rat tail flick response which indicated 500 mg/kg as the optimal effective analgesic dose. Hence, 500 mg/kg dose of LPEE and LPGE was used for hot plate test and acetic acid induced writhing model in analgesic activity and for evaluation of hypnotic activity. RESULTS: Both the extracts did not produce any acute toxicity in mice at single oral dose of 2.0 g/kg. Both LPGE and LPEE (250, 500, and 1000 mg/kg) showed dose-dependent elevation in pain threshold and peak analgesic effect at 60 min as evidenced by increased latency period in tail-flick method by 25.1-62.4% and 38.2-79.0% respectively. LPGE and LPEE (500 mg/kg) increased reaction time in hot-plate test at peak 60 min analgesic effect by 63.2 and 85.8% and reduction in the number of acetic acid-induced writhes by 55.9 and 65.8% respectively. Both potentiated pentobarbitone-induced hypnosis as indicated by increased duration of sleep in treated rats. CONCLUSION: The analgesic and hypnotic effects of LP formulations authenticate their uses in Ayurvedic system of Medicine for painful conditions.

Protective effects of Aegle marmelos fruit pulp on 2,4,6-trinitrobenzene sulfonic acid-induced experimental colitis.

BACKGROUND: Aegle marmelos (AM) fruit has been advocated in indigenous system of medicine for the treatment of various gastrointestinal disorders, fever, asthma, inflammations, febrile delirium, acute bronchitis, snakebite, epilepsy, leprosy, myalgia, smallpox, leucoderma, mental illnesses, sores, swelling, thirst, thyroid disorders, tumours and upper respiratory tract infections. OBJECTIVE: The objective of this study was to study the curative effect of 50% ethanol extract of dried fruit pulp of AM (AME) against 2,4,6-trinitrobenzene sulfonic acid (TNBS)-induced experimental colitis. MATERIALS AND METHODS: AME (200 mg/kg) was administered orally, once daily for 14 days after TNBS-induced colitis. Rats were given intracolonic normal saline or TNBS alone or TNBS plus oral AME. AME was studied for its in vitro antibacterial activity against Gram-negative intestinal bacteria and on TNBS-induced changes in colonic damage, weight and adhesions (macroscopic and microscopic), diarrhea, body weight and colonic levels of free radicals (nitric oxide and lipid peroxidation), antioxidants (superoxide dismutase, catalase and reduced glutathione) and pro-inflammatory marker (myeloperoxidase [MPO]) in rats. RESULTS: AME showed antibacterial activity against intestinal pathogens and decreased colonic mucosal damage and inflammation, diarrhea, colonic free radicals and MPO and enhanced body weight and colonic antioxidants level affected by TNBS. The effects of AME on the above parameters were comparable with sulfasalazine, a known colitis protective drug (100 mg/kg, oral). CONCLUSION: AME shows curative effects against TNBS-induced colitis by its antibacterial activity and promoting colonic antioxidants and reducing free radicals and MPO-induced colonic damage.

Anti-inflammatory activity of two classical formulations of Laghupanchamula in rats.

BACKGROUND: Laghupanchamula denotes combinations of roots of five herbs. However, in Ayurvedic classics besides four common herbs viz. Kantakari, Brihati, Shaliparni, and Prinshniparni, the fifth one is either Gokshura (Laghupanchamula with Gokshura LPG) or Eranda (Laghupanchamula with Eranda LPE), and both formulations have been documented to have shothahara (anti-inflammatory) action. OBJECTIVES: The present study was undertaken to compare the anti-inflammatory activity of 50% ethanolic extract of LPG (LPGE) and LPE (LPEE) in rats and safety in mice. MATERIALS AND METHODS: LPGE and LPEE were given orally, administered either just before or 60 min before experiment on mice and for 7 days to rats. Paw edema was induced by carrageenan (acute) and formalin (sub-acute), whereas granuloma pouch (sub-acute) was induced by turpentine in rats. RESULTS: Both LPGE and LPEE (1.0 g/kg) at 3 h after their administration showed inhibition of formalin-induced paw edema by 46.2% and 44.3% (P < 0.001) and carrageenan-induced paw edema by 53.9% and 60.4% (P < 0.001), respectively. After 7 days of treatment, both LPGE and LPEE showed 26.3% (P < 0.01) and 32.5% (P < 0.05) inhibition, respectively, against formalin-induced paw edema, and reduced weight of turpentine-induced granuloma pouch by 42.8% and 36.1% (P < 0.001), and volume of exudates by 31.2% and 36.2% (P < 0.001), respectively. No acute toxicity was observed in mice even with a 10.0-g/kg dose of both extracts. CONCLUSION: LPGE and LPEE significantly reduced acute and sub-acute inflammation, and showed effective and similar anti-inflammatory activity. They seemed to be safe, and use of both formulations in the Laghupanchamula for their anti-inflammatory activity is, thus, authenticated.

Pharmacological evaluation of extracts of Hedychium spicatum (Ham-ex-Smith) rhizome.

Hedychium spicatum (Ham-ex-Smith), known as Shati in Ayurvedic classics, is documented for the treatment of cough, hiccough, fever and asthma. The present study includes the evaluation of aqueous and ethanolic extracts of the dried rhizome of H. spicatum for anti-histaminic and ulcer-protective activities in guinea pig (GP), anti-inflammatory and analgesic activities in rat and acute toxicity in mouse. The extracts were administered orally, daily as suspension, in 1% carboxymethyl cellulose either for 7 days in GP studies or 60 min before or just before experiment in rats and mice. An initial dose-dependent anti-histaminic action of both the extracts (100, 200 and 400 mg/kg) was performed against histamine-induced bronchospasm in GPs. The 200 mg/ kg dose of aqueous and ethanolic extracts was selected both in GP and rat for further studies. GPs treated with aqueous and ethanolic extracts showed gastric ulcer protection against histamine-induced gastric ulcer compared with the control group. Both the extracts also showed an anti-inflammatory effect against carrageenan-induced paw edema in rats from 1 h onwards, and this was maximum at 3 h. Analgesic effect was determined by using hot plate and tail flick tests in rats, and both the extracts at 200 mg/kg showed a significant increase in the latent period from 30 min onwards till 120 min of their study period. Both the extracts did not show any toxic effect like increased motor activity, salivation, clonic convulsion, coma and death in mice even at the 2000 mg/kg dose (nearly 10 times of the optimal effective dose), indicating the safety of the extracts. The result confirms the indigenous use of this plant in respiratory disorders.

Laparoendoscopic single-site radical cystectomy and pelvic lymph node dissection: initial experience and 2-year follow-up.

OBJECTIVE: To 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. METHODS: A 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. RESULTS: A 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. CONCLUSIONS: Laparoendoscopic 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, single-operator-light endoscopic robot-assisted laparoscopic urology: pilot study in a pig model.

OBJECTIVES: To present our initial operative experience in which single-port-light endoscopic robot-assisted reconstructive and extirpative urological surgery was performed by one surgeon, using a pig model. MATERIALS AND METHODS: This pilot study was conducted in male farm pigs to determine the feasibility and safety of single-port, single-surgeon urological surgery. All pigs had a general anaesthetic and were placed in the flank position. A 2-cm umbilical incision was made, through which a single port was placed and pneumoperitoneum obtained. An operative laparoscope was introduced and securely held using a novel low-profile robot under foot and/or voice control. Using articulating instruments, each pig had bilateral reconstructive and extirpative renal surgery. Salient intraoperative and postmortem data were recorded. Results were analysed statistically to determine if outcomes improved with surgeon experience. RESULTS: Five male farm pigs underwent bilateral partial nephrectomy and bilateral pyeloplasty before a completion bilateral radical nephrectomy. There were no intraoperative complications and there was no need for additional ports to be placed. The mean (range) operative duration for partial nephrectomy, pyeloplasty, and nephrectomy were 120 (100-150), 110 (95-130) and 20 (15-30) min, respectively. The mean (range) estimated blood loss for all procedures was 240 (200-280) mL. The preparation time decreased with increasing number of cases (P = 0.002). CONCLUSIONS: The combination of a single-port, a robotic endoscope holder and articulated instruments operated by one surgeon is feasible. With a single-port access, the robot allows more room to the surgeon than an assistant.

Robotic partial nephrectomy without renal hilar occlusion.

OBJECTIVE: To evaluate operative outcomes among patients undergoing robotic partial nephrectomy (RPN) without renal hilar clamping. PATIENTS AND METHODS: This was a prospective observational study of patients undergoing RPN under perfused conditions (pRPN). Patients with solitary, radiographically enhancing renal cortical lesions gave consent for pRPN. Salient demographic data, including age, body mass index (BMI) and preoperative tumour size were obtained. Operative data, including mean operative time, estimated blood loss (EBL), and the presence of any complications, were collected. Renal function was evaluated before and after RPN. Remote adverse events were noted. The pRPN group was then retrospectively compared to a contemporary group of patients who had RPN with renal hilar occlusion. Endpoints for comparison included operative time, warm ischaemia time, EBL, length of hospitalization, and the rate of adverse events. RESULTS: Between February 2008 and December 2008, eight had underwent pRPN; the mean age was 59.3 years, mean BMI 28.7 kg/m(2), mean operative time 167 min, mean EBL 569 mL and mean hospitalization 3.75 days. Pathology showed renal cell carcinoma in five patients and oncocytoma in three; the mean tumour size was 2.4 cm. Final pathological margins were negative in all patients. Adverse events included one transfusion and one deep venous thrombosis. When compared to the contemporary group who had RPN with hilar clamping, the operative time was shorter (P = 0.035) and EBL greater (P = 0.018) in the pRPN group. There was no significant difference between the groups in transfusion rate, and no significant difference in renal function before and after surgery either group. CONCLUSIONS: For selected small renal cortical masses, RPN is safe without renal hilar occlusion. The EBL was higher during pRPN but with no significant difference in the rate of transfusion.

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.

Robotic laparoendoscopic single-site surgery using GelPort as the access platform.

BACKGROUND: Laparoendoscopic 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. OBJECTIVE: To evaluate the GelPort laparoscopic system as an access platform for robotic LESS (R-LESS) procedures. DESIGN, SETTING, AND PARTICIPANTS: Since 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. INTERVENTION: R-LESS cases performed with the GelPort included pyeloplasty (n=2), radical nephrectomy (n=1), and partial nephrectomy (n=1). MEASUREMENTS: Perioperative data were obtained for all patients including demographic data, operative indications, operative records, length of stay, complications, and pathologic analysis. RESULTS AND LIMITATIONS: For 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. CONCLUSIONS: Use 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.

Single-port laparoscopic abdominal sacral colpopexy: initial experience and comparative outcomes.

OBJECTIVES: To determine the efficacy and safety of single-port laparoscopic abdominal sacral colpopexy (ASC) for the treatment of female pelvic organ prolapse (POP). METHODS: A 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. RESULTS: From 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. CONCLUSIONS: Single-port laparoscopic ASC offers comparable efficacy and superior cosmesis compared to alternative approaches. Long-term follow-up is needed to confirm durability of repair.

Single-port urological surgery: single-center experience with the first 100 cases.

OBJECTIVES: To present perioperative outcomes in an observational cohort of patients who underwent LaparoEndoscopic Single Site (LESS) surgery at a single academic center. METHODS: A 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. RESULTS: Between 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. CONCLUSIONS: In 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.

NOTES transvaginal nephrectomy: first human experience.

OBJECTIVES: To present the operative outcomes of the first natural orifice translumenal endoscopic surgery (NOTES) transvaginal nephrectomy. METHODS: A 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. RESULTS: NOTES 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. CONCLUSIONS: Our 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.

Technological advances in robotic-assisted laparoscopic surgery.

In this article, the authors describe the evolution of urologic robotic systems and the current state-of-the-art features and existing limitations of the da Vinci S HD System (Intuitive Surgical, Inc.). They then review promising innovations in scaling down the footprint of robotic platforms, the early experience with mobile miniaturized in vivo robots, advances in endoscopic navigation systems using augmented reality technologies and tracking devices, the emergence of technologies for robotic natural orifice transluminal endoscopic surgery and single-port surgery, advances in flexible robotics and haptics, the development of new virtual reality simulator training platforms compatible with the existing da Vinci system, and recent experiences with remote robotic surgery and telestration.

Single-port laparoscopic retroperitoneal surgery: initial operative experience and comparative outcomes.

OBJECTIVES: To present the initial operative outcomes and comparative data among patients undergoing single-port laparoscopic retroperitoneal surgery (SPLRS). METHODS: A 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. RESULTS: From 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). CONCLUSIONS: The 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.

Single-port laparoscopic and robotic partial nephrectomy.

BACKGROUND: Partial nephrectomy (PN) for small renal masses provides effective oncologic outcomes. Single-port laparoscopic (SPL) and robotic surgeries are evolving approaches to advance minimally invasive surgery. OBJECTIVE: To determine the feasibility of laparoscopic and robotic single-port PN. DESIGN, SETTING, AND PARTICIPANTS: Since 2007, evaluation of patients undergoing SPL and single-port robotic (SPR) PN at a primary referral center was performed. Patients with small, solitary, exophytic-enhancing renal masses were selected. Patients with a solitary kidney, endophytic or hilar tumors, and previous abdominal and/or kidney surgery were excluded. Perioperative and pathologic data were entered prospectively into an institutional review board (IRB)-approved database. INTERVENTIONS: Tumor location determined either an open Hasson transperitoneal or retroperitoneal approach. A single multichannel port or Triport provided intra-abdominal access. The Harmonic Scalpel was used for tumor excision under normal renal perfusion. The da Vinci surgical robot was used for SPR cases. MEASUREMENTS: Patient demographics, perioperative, hematologic, and pathologic data as well as pain assessment using the Visual Analog Pain Scale (VAPS) were assessed. RESULTS AND LIMITATIONS: A total of seven patients underwent single-port PN (SPL=5, SPR=2). One patient with a right anterior upper-pole mass required conversion from SPL to standard laparoscopy following tumor excision because of intraoperative bleeding. Pathology revealed six lesions compatible with renal cell carcinoma (RCC) and one benign cyst. One negative frozen section came back focally positive on final histopathology. All other surgical margins were negative. A mean difference of 3.0+/-2.0 g/dl in hemoglobin was noted in all patients. Minimal pain was noted at discharge following both laparoscopic and robotic single-port surgery (VAPS=1.7+/-1.2 vs 1+/-0.5/10). CONCLUSIONS: SPL and SPR PN is feasible for select exophytic tumors. Robotics may improve surgical capabilities during single-port surgery.

Robotic single-port transumbilical surgery in humans: initial report.

OBJECTIVE: To describe our initial clinical experience of robotic single-port (RSP) surgery. PATIENTS AND METHODS: The da Vinci S robot (Intuitive, Sunnyvale, CA, USA) was used to perform radical prostatectomy (RP), dismembered pyeloplasty, and radical nephrectomy. A robot 12-mm scope and 5-mm robotic grasper were introduced through a multichannel single port (R-port, Advanced Surgical Concepts, Dublin, Ireland). An additional 5-mm or 8-mm robotic port was introduced through the same umbilical incision (2 cm) alongside the multichannel port and used to introduce robotic instruments. Vesico-urethral anastomosis and pelvi-ureteric anastomosis were successfully performed robotically using running intracorporeal suturing. RESULTS: All three RSP surgeries were performed through the single incision without adding extra umbilical ports or 2-mm instruments. For RP, the operative duration was 5 h and the estimated blood loss was 250 mL. The hospital stay was 36 h and the margins of resection were negative. For pyeloplasty, the operative duration was 4.5 h, and the hospital stay was 50 h. Right radical nephrectomy for a 5.5-cm renal cell carcinoma was performed in 2.5 h and the hospital stay was 48 h. The specimen was extracted intact within an entrapment bag through the umbilical incision. There were no intraoperative or postoperative complications. At 1 week after surgery, all patients had minimal pain with a visual analogue score of 0/10. CONCLUSIONS: Technical challenges of single-port surgery that may limit its widespread acceptance can be addressed by using robotic technology. Articulation of robotic instruments may render obsolete the long-held laparoscopic principles of triangulation especially for intracorporeal suturing. We report the initial series of robotic surgery through a single transumbilical incision.

Single-port laparoscopic radical prostatectomy.

OBJECTIVES: To present the initial experience in laparoscopic radical prostatectomy performed exclusively through an umbilical incision using a single three-channel port and specially designed flexible laparoscopic instrumentation. METHODS: Since November 26, 2007, we have performed single-port laparoscopic radical prostatectomy in 4 patients diagnosed with prostate cancer. Patients with early-stage prostate cancer (T1c), no previous pelvic surgery, and a body mass index

Probe ablative treatment for small renal masses: cryoablation vs. radio frequency ablation.

PURPOSE OF REVIEW: Localized renal cell carcinoma has an excellent 5-year survival when treated surgically. Apart from extirpative treatment, ablative techniques are becoming more popular to minimize patient morbidity. Clinically, radio frequency ablation and cryoablation can be performed percutaneously or laparoscopically. Oncological effectiveness of ablative techniques is encouraging as 3-year data are emerging. Our review highlights the current literature demonstrating the effectiveness of cryoablation and radio frequency ablation performed laparoscopically or percutaneously. RECENT FINDINGS: Cryoablation performed laparoscopically or percutaneously offers excellent oncological outcomes with single-session therapy. With 3-year cancer-specific survival of 98%, laparoscopic cryoablation is safe and can be performed with minimal insult to overall renal function. Local recurrence rates and metastatic progression also seem to favor cryoablation over radio frequency ablation (4.6 vs. 11.7% and 1.2 vs. 2.3%, respectively). Radio frequency ablation also offers similar survival rates; however, re-treatment rates are higher (8.8%). Radio frequency ablation also carries a higher rate of collecting system injuries when performed percutaneously. SUMMARY: Cryoablation and radio frequency ablation are effective treatment modalities for small renal masses in the infirm patient. Given patient and technical variability, superiority of either radio frequency ablation or cryoablation cannot be confirmed based on available literature. However, there is a trend towards higher recurrence and re-treatment rates after radio frequency ablation.