Comments on the extraperitoneal approach for standard laparoscopic radical prostatectomy: what is gained and what is lost.

Laparoscopic extraperitoneal radical prostatectomy (LERP) is considered the standard care treatment option for the management of localized and locally advanced prostatic cancer (PCa) in many institutes worldwide. In this work, the main advantages and disadvantages of LERP approach are reviewed with regard to its outcomes, the complication management, the learning curve, and the extend of pelvic lymph node dissection (PLND). It is concluded that LERP demonstrates comparable cancer control, urinary continence, and potency outcomes with the open and the robot-assisted radical prostatectomy, while offering advantages in complication management in comparison to the transperitoneal approach. Learning curve of LERP is considered long and stiff and significantly affects perioperative outcomes and morbidity, cancer control, and functional results. Thus, close mentoring especially in the beginning of the learning curve is advised. Finally, LERP still has a role in the limited or modified PLND offered in intermediate risk PCa patients.

Laparoendoscopic single-site extraperitoneal inguinal hernia repair: initial experience in 10 patients.

BACKGROUND AND PURPOSE: Recent technical advances and a trend toward laparoscopic single incision surgery have led us to explore the feasibility of laparoendoscopic single-site (LESS) hernia repair. PATIENTS AND METHODS: We present our technique and initial experience with LESS extraperitoneal inguinal hernia repair in 10 consecutive men with unilateral inguinal hernias. Age range was 43.7 (28-64) years. Mean body mass index was 28 (range 24-30). Six were left inguinal hernias. There were six indirect and four direct hernias. Three patients had undergone previous open appendectomy. Incarcerated or bilateral hernias were excluded from our initial series. All cases were performed by three surgeons who were experienced in conventional totally extraperitoneal laparoscopic hernia repair as well as experienced in LESS. A literature review of current single-port inguinal hernia repair data is also presented. RESULTS: The mean operative time was 53 minutes (range 45-65 min). The average length of skin incision was 2.8 cm (range 2.3-3.2 cm). No drain was necessary in any of the patients, while no recordable bleeding was observed. There were no intraoperative or immediate postoperative complications. Hospitalization period was 2 days for all patients. After a limited follow-up of 1 month, there have been no recurrences and no complaints of testicular pain. The results of the current series compare favorably with those found in a literature review. CONCLUSION: LESS extraperitoneal inguinal hernia repair is both feasible and safe, although more technically demanding than its conventional laparoscopic counterpart. Although the cosmetic result with the former approach may prove superior, there are standing questions regarding the complications and long-term outcome. Randomized and if possible blinded trials that compare conventional and single-incision laparoscopic hernia repair may help to distinguish the most advantageous technique.

Laparoendoscopic single-site surgery radical nephrectomy.

The indications, instrumentation, surgical technique, and complications of laparoendoscopic single-site radical nephrectomy (LESS-RN) are being described in detail in an attempt to familiarize urologists with this novel laparoscopic technique. Our initial experience of 30 consecutive cases of LESS-RN is reported. The results indicate that, in experienced hands, LESS-RN is feasible and safe, with results comparable to those of conventional laparoscopic radical nephrectomy. Nevertheless, larger series of patients are needed to prove if the increased technical difficulty of LESS-RN justifies its use in routine urologic practice.

Endoscopic extraperitoneal radical prostatectomy after previous transurethral resection of prostate: oncologic and functional outcomes of 100 cases.

OBJECTIVES: To study radical prostatectomy that has been reported to be more challenging and associated with complications in patients with history of transurethral resection of prostate (TURP). METHODS: In our series, 100 of 2300 patients had undergone endoscopic extraperitoneal radical prostatectomy (EERPE) after previous TURP. All patients included in the study had at least 1-year follow-up. Patient demographics, mean blood loss, mean catheterization time, complications, functional and oncologic outcome were reviewed. RESULTS: In all, 100 patients underwent EERPE and 26 of these patients were treated by nerve-sparing EERPE. Lymphadenectomy was performed in 45 patients. Operative time and mean blood loss were similar to previous EERPE series. The transfusion rate and mean time of catheterization were slightly higher than general EERPE population. Positive surgical margin rates were 7% for pT2 and 36% for pT3/4. At 12-month follow-up, 94% of the patients did not experience prostate-specific antigen level>or=0.1 ng/mL. The overall complication rate was 14%. At 12 months, 93% of patients were continent, 4% used 1-2 pads/day and 3% needed >2 pads/day. The potency rates for the 26 patients who underwent nerve-sparing EERPE were 52.6% and 66.7% at 6 and 12 months, respectively. CONCLUSIONS: Patients who had previously undergone TURP should be considered for radical treatment with EERPE. The procedure is safe even though technically more demanding. Perioperative, functional, and short-term oncologic outcome is promising and directly comparable to existing EERPE experience. Potency results were lower in comparison with existing EERPE series.

Hemostasis during nerve-sparing endoscopic extraperitoneal radical prostatectomy.

The incidence of bleeding during laparoscopic radical prostatectomy has been reported to range between 1% and 7.6%. Postoperative bleeding complications have been encountered in 0.7% of endoscopic extraperitoneal radical prostatectomy cases and require endoscopic or open re-intervention. Thus, bleeding complications represent a significant factor of intra- and postoperative morbidity. We review our experience with endoscopic extraperitoneal radical prostatectomy, and we propose methods to prevent and manage intraoperative bleeding complications. In addition, special technical considerations regarding the nerve-sparing procedures are presented.

Comparative assessment of laparoscopic single-site surgery instruments to conventional laparoscopic in laboratory setting.

INTRODUCTION: Laparoendoscopic single-site surgery (LESS) represents the latest innovation in laparoscopic surgery. We compare in dry and animal laboratory the efficacy of recently introduced pre-bent instruments with conventional laparoscopic and flexible instruments in terms of time requirement, maneuverability, and ease of handling. MATERIALS AND METHODS: Participants of varying laparoscopic experience were included in the study and divided in groups according to their experience. The participants performed predetermined tasks in dry laboratory using all sets of instruments. An experienced laparoscopic surgeon performed 24 nephrectomies in 12 pigs using all sets of instruments. Single port was used for all instrument sets except for the conventional instruments, which were inserted through three ports. The time required for the performance of dry laboratory tasks and the porcine nephrectomies was recorded. Errors in the performance of dry laboratory tasks of each instrument type were also recorded. RESULTS: Pre-bent instruments had a significant advantage over flexible instruments in terms of time requirement to accomplish tasks and procedures as well as maneuverability. Flexible instruments were more time consuming in comparison to the conventional laparoscopic instruments during the performance of the tasks. There were no significant differences in the time required for the accomplishment of dry laboratory tasks or steps of nephrectomy using conventional instruments through appropriate number of ports in comparison to pre-bent instruments through single port. DISCUSSION: Pre-bent instruments were less time consuming and with better maneuverability in comparison to flexible instruments in experimental single-port access surgery. Further clinical investigations would elucidate the efficacy of pre-bent instruments.

Laparoendoscopic single-site surgery: early experience with tumor nephrectomy.

BACKGROUND AND PURPOSE: Laparoendoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery. We performed LESS for renal tumor nephrectomy in eight patients to assess feasibility and perioperative outcome. PATIENTS AND METHODS: Eight patients with a body mass index (BMI)

Technique of laparoscopic-endoscopic single-site surgery radical nephrectomy.

BACKGROUND: Laparoscopic-endoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery. OBJECTIVE: To assess the feasibility of LESS radical nephrectomy (LESS-RN). DESIGN, SETTING, AND PARTICIPANTS: Ten patients with body mass index (BMI) < or = 30 underwent LESS-RN for renal tumour by two experienced laparoscopists. SURGICAL PROCEDURE: TriPort (Olympus Winter & Ibe, Hamburg, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and flexible grasper and scissors was used. A 5-mm 30 degrees camera was also used. The standard laparoscopic transperitoneal nephrectomy technique was performed. MEASUREMENTS: Patient demographics, operative details, and final pathology were prospectively recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. RESULTS AND LIMITATIONS: Ten cases were successfully accomplished (two right-sided tumours and eight left-sided tumours; tumour diameter ranges: 4-8 cm). The mean patient age was 63.5 yr (22-77 yr), and median BMI was 23.56 (18.2-26.6). The mean operative time was 146.4 min (120-180 min), and the mean blood loss was 202 ml (50-900 ml). Pathological examination observed organ-confined T1 renal cell carcinoma in nine cases and pT3b tumour in one case. One bleeding complication occurred. Limitations regarding the intraoperative instrument ergonomics and the requirement for ambidexterity of the surgeon were noted. CONCLUSIONS: LESS-RN proved to be safe and feasible. Further clinical investigation in comparison to the established techniques should take place to evaluate the outcome of LESS-RN.