Robotic Partial Nephrectomy in the Treatment of Renal Angiomyolipoma.

PURPOSE: To present the experience and efficacy of Robotic Partial Nephrectomy (RPN) for the management of renal angiomyolipomas (AMLs) with regard to renal function preservation and perioperative outcomes. PATIENTS AND METHODS: We retrospectively searched our RPN database for pathologically confirmed renal AML patients between 2006 and 2014. Clinical presentation, perioperative complications, and postoperative outcomes of the patients were analyzed. Preoperative imaging findings were reviewed to examine their ability to predict pathology of AML. RESULTS: From 1005 RPN performed in our center during the study period, 53 patients met our inclusion criteria. The mean age at presentation was 54.1 (± 13) years, and 42 (79.2%) patients were female. Median tumor size was 2.8 (interquartile range [IQR], 1.8-4.6) cm. The indication for RPN was suspicious radiologic features for malignancy in 42 (79.2%) patients and acute retroperitoneal hemorrhage risk and pain in 11 (20.8%) patients who were found to have AML according to preoperative imaging. Mean estimated blood loss was 198 (± 194) mL, and 5 (9.4%) patients required blood transfusion. Postoperative complications occurred in 8 (15%) patients. Median estimated glomerular filtration rate within the latest follow-up was 86.9 (IQR, 69.7-100.1) mL/minute/1.73 m(2) with a median of 91% (IQR, 80.4-103) preservation. None of patients developed urinary fistula or pseudoaneurysm requiring second intervention. No local recurrences occurred with a median follow-up of 7 (IQR, 1-17) months. CONCLUSION: Given the low complication rate and preservation of renal function after RPN for AML, it can be considered a reliable method for AML treatment. The majority of AMLs were not suspected based on preoperative imaging. Further diagnostic methods are needed to differentiate benign from malignant lesions.

Urine leak in minimally invasive partial nephrectomy: analysis of risk factors and role of intraoperative ureteral catheterization

Purpose To investigate risk factors for urine leak in patients undergoing minimally invasive partial nephrectomy (MIPN) and to determine the role of intraoperative ureteral catheterization in preventing this postoperative complication. Materials and Methods MIPN procedures done from September 1999 to July 2012 at our Center were reviewed from our IRB-approved database. Patient and tumor characteristics, operative techniques and outcomes were analyzed. Patients with evidence of urine leak were identified. Outcomes were compared between patients with preoperative ureteral catheterization (C-group) and those without (NC-group). Univariable and multivariable analyses were performed to identify factors predicting postoperative urine leak. Results A total of 1,019 cases were included (452 robotic partial nephrectomy cases and 567 laparoscopic partial nephrectomy cases). Five hundred twenty eight patients (51.8%) were in the C-group, whereas 491 of them (48.2%) in the NC-group. Urine leak occurred in 31(3%) cases, 4.6% in the C-group and 1.4% in the NC-group (p<0.001). Tumors in NC-group had significantly higher RENAL score, shorter operative and warm ischemic times. On multivariable analysis, tumor proximity to collecting system (OR=9.2; p<0.01), surgeon’s early operative experience (OR=7.8; p<0.01) and preoperative moderate to severe CKD (OR=3.1; p<0.01) significantly increased the odds of the occurrence of a postoperative urine leak. Conclusion Clinically significant urine leak after MIPN in a high volume institution setting is uncommon. This event is more likely to occur in cases of renal masses that are close to the collecting system, in patients with preoperative CKD and when operating surgeon is still in the learning curve for the procedure. Our findings suggest that routine intraoperative ureteral catheterization during MIPN does not reduce the probability of postoperative urine leak. In addition, it adds to the overall ...

Robotic partial nephrectomy for caliceal diverticulum: a single-center case series.

The aim of this study is to examine the role of robotic partial nephrectomy (RPN) in the management of caliceal diverticula by assessing our single-center outcomes. Between July 2007 and July 2013, 7 of 670 patients underwent RPN procedures as a reason of caliceal diverticula. The indications for RPN in all cases were recurrent urinary tract infection and pain attributed to the diverticulum in addition to failed management by endourologic or extracorporeal shockwave lithotripsy (SWL) treatments. One patient with a calcified diverticulum and another with an unsuccessful SWL treatment underwent RPN without further endourologic intervention. The other five patients had a history of unsuccessful percutaneous nephrolithotomy (one case), ureteroscopy (URS) (two cases), and a combination of SWL+URS (two cases). No intraoperative or postoperative complications were observed. No patient was readmitted postoperatively. Unique features of the robotic platform facilitate the excision of diverticulum and subsequent kidney reconstruction for this benign, but complex pathology.

Urine leak in minimally invasive partial nephrectomy: analysis of risk factors and role of intraoperative ureteral catheterization.

PURPOSE: To investigate risk factors for urine leak in patients undergoing minimally invasive partial nephrectomy (MIPN) and to determine the role of intraoperative ureteral catheterization in preventing this postoperative complication. MATERIALS AND METHODS: MIPN procedures done from September 1999 to July 2012 at our Center were reviewed from our IRB-approved database. Patient and tumor characteristics, operative techniques and outcomes were analyzed. Patients with evidence of urine leak were identified. Outcomes were compared between patients with preoperative ureteral catheterization (C-group) and those without (NC-group). Univariable and multivariable analyses were performed to identify factors predicting postoperative urine leak. RESULTS: A total of 1,019 cases were included (452 robotic partial nephrectomy cases and 567 laparoscopic partial nephrectomy cases). Five hundred twenty eight patients (51.8%) were in the C-group, whereas 491 of them (48.2%) in the NC-group. Urine leak occurred in 31(3%) cases, 4.6% in the C-group and 1.4% in the NC-group (p<0.001). Tumors in NC-group had significantly higher RENAL score, shorter operative and warm ischemic times. On multivariable analysis, tumor proximity to collecting system (OR=9.2; p<0.01), surgeon's early operative experience (OR=7.8; p<0.01) and preoperative moderate to severe CKD (OR=3.1; p<0.01) significantly increased the odds of the occurrence of a postoperative urine leak. CONCLUSION: Clinically significant urine leak after MIPN in a high volume institution setting is uncommon. This event is more likely to occur in cases of renal masses that are close to the collecting system, in patients with preoperative CKD and when operating surgeon is still in the learning curve for the procedure. Our findings suggest that routine intraoperative ureteral catheterization during MIPN does not reduce the probability of postoperative urine leak. In addition, it adds to the overall operative time.

Robotic single port suprapubic transvesical enucleation of the prostate (R-STEP): initial experience.

UNLABELLED: What's known on the subject? and What does the study add? Single port transvesical enucleation of the prostate (STEP) performed through a solitary suprapubic incision using a single access port inserted directly into the bladder has been demonstrated to be technically feasible but still challenging.3. Despite being feasible and providing adequate relief of bladder outlet obstruction, robotic STEP carries a high risk of complications. Further evolution of the technique is likely to be strictly dependent on the development of instrumentation. OBJECTIVE: To report our initial experience with a novel robot assisted single port procedure for the management of benign prostatic hyperplasia (BPH). METHODS: Between March 2009 and July 2010, nine patients with symptomatic BPH were scheduled for robotic single port suprapubic transvesical enucleation of the prostate (R-STEP). Prior to intervention, all were submitted to preoperative transrectal ultrasound of the prostate and uroflowmetry. The surgical procedure included an initial transurethral incision of the prostatic apex. With the patient in the supine position, an approximate 3 cm lower midline incision was made. A cystotomy was created and a GelPort(®) laparoscopic system positioned in the bladder. The da Vinci S™ robotic operating system was docked through the GelPort(®) platform and enucleation was performed. Perioperative outcomes and short-term postoperative functional outcomes were assessed. Intra-operative and postoperative complications, graded according to the Dindo-Clavien system, were recorded. RESULTS: One patient was excluded from the analysis as the procedure was aborted and converted to open simple prostatectomy. Median operative time was 3.9 h. Median visual analogue pain scale on discharge was 2. Estimated blood loss was 425 mL. Two patients required intra-operative blood transfusion. Postoperatively, two patients developed clot retention and required evacuation and fulguration (grade IIIb), one of them had a deep vein thrombosis (grade II) and a urinary tract infection (grade II). One patient was admitted to the intensive care unit after a myocardial infarction (grade IVa). All patients were discharged after a median of 4.5 days. There was almost three and four times postoperative improvement in both median maximum flow (Qmax) and average flow (Qave) rates, respectively. CONCLUSION: The first series of R-STEP is reported herein. Despite being feasible and providing adequate relief of bladder outlet obstruction, the procedure carries a high risk of complications. Further evolution of the technique is likely to be strictly dependent on the development of instrumentation. Thus, its role in the surgical armamentarium of BPH remains to be determined.

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 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

Robotic salvage retropubic prostatectomy after radiation/brachytherapy: initial results.

OBJECTIVE: To report on the initial four patients who had robotic salvage retropubic prostatectomy (SRP) for biochemical recurrence after radiation therapy, and to review the surgical outcome of robotic cystoprostatectomy for bladder cancer in two patients who previously had prostate cancer. PATIENTS AND METHODS: Since February 2006, four patients had SRP for biochemical failure after radiation and/or brachytherapy. Transrectal biopsy of the prostate confirmed locally recurrent disease and a metastatic evaluation including bone scan and computed tomography of the abdomen and pelvis were negative in all cases. The SRP was done using a six-port transperitoneal approach. An additional two patients had a robotic cystoprostatectomy for bladder cancer, in whom radiation was provided previously for prostate cancer. A retrospective analysis of the immediate and short-term surgical outcome was reviewed. RESULTS: SRP was completed in all patients with no major complication or conversion to an open approach. The mean operative duration was 125 min, the mean (range) blood loss was 117 (50-250) mL and the mean hospital stay was 2.7 days. Of the four patients undergoing SRP, three had extracapsular extension and the first two had positive margins, while no patients had rectal injuries or significant blood loss. The lymph nodes were negative in all the patients. Three patients were continent within a month while one continued to use two to three pads/day at 3 weeks of follow-up. In the two patients who had cystoprostatectomy there were no major complications or increased surgical difficulty. CONCLUSIONS: SRP is technically possible and with limited perioperative morbidity. Further studies are warranted to validate the oncological and functional outcomes of SRP after radiation and/or brachytherapy. Moreover, the robotic approach for radical cystoprostatectomy in patients who have had prostate radiation is feasible, with no increase in perioperative morbidity.

Single-port laparoscopic surgery in urology: initial experience.

OBJECTIVES: To present our initial experience with single-port laparoscopic urologic surgery using the Uni-X Single Port Access Laparoscopic System, a single port, multichannel cannula, with specially designed curved laparoscopic instrumentation. METHODS: We performed single-port laparoscopic surgery in 10 patients, including renal cryotherapy in 4, wedge kidney biopsy in 1, radical nephrectomy in 1, and abdominal sacrocolpopexy in 4. For the transperitoneal approach, the multichannel port was inserted transumbilically, and for retroperitoneoscopy, the port was inserted at the tip of the 12th rib. Data were collected prospectively into our institutional review board-approved data registry. RESULTS: Since September 25, 2007, a total of 10 patients have undergone single-port laparoscopic surgery for various upper abdominal and pelvic pathologic findings. All cases were completed successfully, without conversion to a standard laparoscopic approach. The total operative time for the various kidney procedures was 2.5 hours (range 2 to 3.2) and was 2.5 hours (range 2 to 3) for sacrocolpopexy. The mean blood loss was 100 mL for the renal procedures and 90 mL for sacrocolpopexy. The hospital stay was 2.8 days (range 1 to 8) for the kidney procedures and 2 days for sacrocolpopexy. One complication occurred in a patient with baseline congestive heart failure who underwent cryoablation and required oxygen mask ventilation postoperatively that delayed her hospital discharge for 1 week. The same patient, who was anemic preoperatively, was transfused with 3 U of packed red blood cells, although the postoperative computed tomography scan revealed a small perinephric hematoma. CONCLUSIONS: Single-port laparoscopic renal cryotherapy, wedge kidney biopsy, radical nephrectomy, and abdominal sacrocolpopexy are safe and feasible. Additional experience and continued investigation are warranted.