Laparoendoscopic single-site surgery in urology: worldwide multi-institutional analysis of 1076 cases

Optimizing ergonomics during open, laparoscopic, and robotic-assisted surgery: A review of surgical ergonomics literature and development of educational illustrations

BACKGROUND

The surgical profession is plagued with a high prevalence of work-related musculoskeletal disorders. While numerous interventions have been tested over the years, surgical ergonomics education is still uncommon.

METHODS

The available literature on surgical ergonomics was reviewed, and with input from surgeons, recommendations from the review were used to create pictorial reminders for open, laparoscopic, and robot-assisted surgical modalities. These simple pictorial ergonomic recommendations were then assessed for practicality by residents and surgeons.

RESULTS

A review of the current literature on surgical ergonomics covered evidence-based ergonomic recommendations on equipment during open and laparoscopic surgery, as well as proper adjustment of the surgical robot for robot-assisted surgeries. Ergonomic operative postures for the three modalities were examined, illustrated, and assessed.

CONCLUSIONS

The resulting illustrations of ergonomic guidelines across surgical modalities may be employed in developing ergonomic education materials and improving the identification and mitigation of ergonomic risks in the operating room.

Single-port robot-assisted pyeloplasty using the da Vinci SP system versus multi-port pyeloplasty: Comparison of outcomes and costs

OBJECTIVE

To investigate the feasibility of single-port (SP) robotic pyeloplasty by comparing perioperative outcomes with those of multiport (MP) robotic pyeloplasty.

MATERIALS AND METHODS

We reviewed the data from patients who underwent robot-assisted pyeloplasty for ureteropelvic junction obstruction (UPJO) at a single tertiary institution between March 2016 and May 2022. Radiographic and symptomatic improvements were assessed 3 months postoperatively. Propensity score matching was performed for age, sex, body mass index, and hydronephrosis grade.

RESULTS

Of the 15 S P-pyeloplasty and 28 MP-pyeloplasty cases, 14 from each group were matched using 1:1 matching. The SP group had shorter console and operative times without significant differences. Blood loss was lower in the SP group than in the MP group (p = 0.019). The length of hospital stay, opioid use on the operative day, and pain score at discharge did not differ between the two groups. The mean cost for surgery was higher in the SP group than in the MP group (p < 0.001). The mean cost of hospitalization was comparable between the two groups (p = 0.083). The cosmetic numerical rating scale scores were significantly higher in the SP group (p = 0.014). Symptoms improved in all patients, and the radiographic improvement rates were 92.9% in the SP group and 100% in the MP group.

CONCLUSION

SP-pyeloplasty showed cosmetic benefits, lower blood loss, operative time, and console time compared with MP-pyeloplasty. In patients who underwent surgery for UPJO for the first time, SP surgery can show comparable outcomes when compared to MP surgery.

Low anterolateral incision for single-port extraperitoneal robot-assisted pyeloplasty: description of technique and initial experience

PURPOSE

This study aims to describe the surgical steps for the single-port low anterolateral extraperitoneal approach to pyeloplasty, report its feasibility, and share the initial outcomes of our experience.

METHODS

We analyzed all consecutive patients who underwent single-port low anterolateral extraperitoneal pyeloplasty due to ureteropelvic junction obstruction (UPJO). The surgical steps included a pure single-port approach through a 3.5 cm low anterolateral incision two fingerbreadths above the superior pubic ramus. The ureter was localized and followed cranially, a dismembered pyeloplasty was performed, and a running ureteropelvic anastomosis was completed. No drains were placed. The urinary catheter was removed upon discharge, and the ureteral stent after 3-5 weeks.

RESULTS

A total of eight cases (two adults and six children) were completed successfully, without complications or conversions. Median operative time, console time, and estimated blood loss were 208.5 min, 114.5 min, and 10.0 ml, respectively. All patients were discharged within 24 h, except for one that required urinary output observation due to retention. There were no major postoperative complications. The median pain score at discharge was 0/10. Only one patient was prescribed PRN opioids at discharge. The readmission rate was 0.0%. All patients were asymptomatic on their last follow-up with no definitive obstruction on imaging, and no requirement for additional procedures or stents.

CONCLUSION

Single-port low anterolateral extraperitoneal pyeloplasty is a feasible alternative for surgical treatment of UPJO in adult and pediatric patients with improved recovery outcomes.

Implementation of single-port robotic urologic surgery: experience at a large academic center

The Single-Port (SP) robotic system is increasingly being implemented in the United States, allowing for several minimally invasive urologic procedures to be performed. The present study aims to describe our single-center experience since the adoption of the SP platform. We retrospectively collected and analyzed consecutive SP cases performed at a major teaching hospital in the Midwest (Rush University Medical Center) from December 2020 to December 2023. Demographic variables were collected. Surgical and pathological outcomes were analyzed in the overall cohort and for each type of procedure. The study timeframe was divided into two periods to assess the evolution of SP technical features over time. In total, 160 procedures were performed, with robot-assisted radical prostatectomy (RARP) being the most common (49.4%). Overall, 54.4% of the procedures were extraperitoneal, with a significantly higher adoption of this approach in the second half of the study period (30% vs 74.3%, p < 0.001). A "plus one" assistant port was adopted in 38.1% of cases, with a shift towards a "pure" single-port surgery in the most recent procedures (21.1% vs 76.7%, p < 0.001). The median LOS was 33.5 h (30-48), with a rate of any grade and CD ≥ 3 postoperative complications of 9.4% and 2.5%, respectively, and a 30-day readmission rate of 1.9%. SP robotic surgery can be safely and effectively implemented for various urologic procedures. With increasing experience, the SP platform allows shifting away from transperitoneal procedures, potentially minimizing postoperative pain, and shortening hospital stay and postoperative recovery.

A prospective study on single-port versus multiport patient-reported surgical outcomes

Introduction

We sought to determine potential patient reported advantages of the da Vinci single-port (SP) robotic system for urological procedures compared with the previous model, the da Vinci multiport (MP) system. The SP model utilizes a single 30 to 40 mm incision rather than multiple 5 to 22 mm incisions. This project aims to prospectively investigate the impact of the novel SP system on patient reported cosmetic and psychometric surgical outcomes.

Methods

We conducted a prospective study of patients who underwent uro-oncologic surgery by three urologists at the University of Illinois Chicago from April to November 2021. Study participants completed a Patient Scar Assessment Questionnaire 20 and 90 days post-procedure. The Patient Scar Assessment Questionnaire is a reliable measure of surgical scars that includes five subscales: Appearance, Symptoms, Consciousness, Satisfaction with Appearance, and Satisfaction with Symptoms. Higher scores represented worse reported outcomes.

Results

On Postoperative Day 20, there were 77 responses (53 SP and 24 MP). Patients receiving SP procedures reported more favourable outcomes in terms of appearance, symptoms, consciousness, and pain medication. On Day 90, there were 37 responses (24 SP and 13 MP). Patients receiving SP procedures reported more favourable outcomes in terms of appearance. No significant differences were seen on Day 90 in terms of pain, medication, symptoms, consciousness, or satisfaction.

Conclusions

This study demonstrates the superiority of the SP in patient reported cosmetic and pain outcomes on short- and long-term follow-up after uro-oncological surgical procedures. Symptomatic and cosmetic advantages are present at the 20 day follow-up, with better scar appearance being significant 90 days after surgery.

Initial experience of laparoendoscopic single-site radical prostatectomy with a novel purpose-built robotic system

Objective

This prospective single-arm clinical trial aimed to evaluated the feasibility and safety of the application of the SHURUI system (Beijing Surgerii Technology Co., Ltd., Beijing, China), a novel purpose-built robotic system, in single-port robotic radical prostatectomy.

Methods

Sixteen patients diagnosed with prostate cancer were prospectively enrolled in and underwent robotic radical prostatectomy from October 2021 to August 2022 by the SHURUI single-port robotic surgical system. The demographic and baseline data, surgical, oncological, and functional outcomes as well as follow-up data were recorded.

Results

The mean operative time was 226.3 (standard deviation [SD] 52.0) min, and the mean console time was 183.4 (SD 48.3) min, with the mean estimated blood loss of 116.3 (SD 90.0) mL. The mean length of postoperative hospital stay was 4.50 (SD 0.97) days. Two patients had postoperative complications (Clavien-Dindo Grade II), and both patients improved after conservative treatment. All patients' postoperative prostate-specific antigen levels decreased to below 0.2 ng/mL 1 month after discharge. The mean prostate-specific antigen level further decreased to a mean of 0.0219 (SD 0.0641) ng/mL 6 months after surgery. Thirty days postoperatively, 12 out of 16 patients reported using no more than one urinary pad per day, and all patients reported satisfactory urinary control without the need for pads 6 months after surgery.

Conclusion

The SHURUI system is safe and feasible in performing radical prostatectomy via both transperitoneal and extraperitoneal approaches. Tumor control and urinary continence were satisfying for patients enrolled in. The next phase involves conducting a large-scale, multicenter randomized controlled trial to thoroughly assess the effectiveness and safety of the new technology in a broader population.

Outcomes of single-port robotic ureteral reconstruction using the da Vinci SP® system

PURPOSE

The da Vinci SP^® robotic system enables three double-jointed wristed instruments and a fully wristed three-dimensional camera to be placed through a single port. This study presents our experience with robot-assisted ureteral reconstruction using the SP system and reports its outcomes.

MATERIALS AND METHODS

Between December 2018 and April 2022, a single surgeon performed robotic ureteral reconstruction using the SP system in 39 patients: 18 underwent pyeloplasty and 21 received ureteral reimplantation. Demographic and perioperative patient data were collected and analyzed. Radiographic and symptomatic improvements were assessed 3 months after surgery.

RESULTS

In pyeloplasty group, 12 patients (66.7%) were female and two patients (11.1%) had undergone previous surgery for ureteral obstruction. The median operative time was 152 minutes, the median blood loss was 8 mL, and the median length of stay in hospital was 3 days. There was one case of a complication involving postoperative percutaneous nephrostomy (PCN). In ureteral reimplantation group, 19 patients (90.5%) were female and ten patients (47.6%) had undergone gynecological surgery that caused ureteral obstruction. The median operative time was 152 minutes, the median blood loss was 10 mL, and the median length of stay in hospital was 4 days. We observed one case of open conversion and two cases of complications (colonic serosal tearing and postoperative PCN after ileal ureter replacement). The radiographic results and symptoms successfully improved following both surgeries.

CONCLUSIONS

Despite adhesion-related complications, the SP system appears to be safe and effective for use in robot-assisted ureteral reconstruction.

Single-Port Robotic Applications in Urology

Objective: The da Vinci single-port (SP) platform represents the latest innovation in minimally invasive urologic surgery, and the adoption of this technology by urologists is increasing. In this article, we briefly describe the evolution of minimally invasive and single-site surgery, and offer a comprehensive review of the current literature on the SP platform. Materials and Methods: For relevant articles, three electronic databases, including PubMed, Scopus, and Web of Science, were searched from their inception until August 15, 2022. The published literature to date within SP robotic surgery in urology will be discussed. Evidence Synthesis: There are relatively few high-quality studies on the SP system, but there are multiple case series describing unique indications and surgical approaches with the SP robot, demonstrating safety and feasibility in the hands of experienced robotic surgeons. There also are an increasing number of prospective, larger cohort studies comparing outcomes between SP and multiport (MP) approaches that show benefits of the SP system regarding improved cosmesis, postoperative pain control, and decreased length of stay. Conclusions: Multiple prospective studies have shown benefits regarding cost and pain control for SP platform procedures compared to the traditional MP robotic approach. While its high cost and learning curve represent barriers to adoption, the SP platform represents a critical development in minimally invasive surgery. As this technology is further implemented at more institutions, long-term, high-quality data should accrue that will demonstrate its true value.

Single-port robotic partial nephrectomy: impact on perioperative outcomes and hospital stay

Single-port (SP) robotic surgery is a novel technology and is at the beginning of its adoption curve in urology. The goal of this narrative review is to provide an overview of SP-robotic partial nephrectomy (PN) 4 years after the introduction of the da Vinci SP dedicated platform, focusing on perioperative outcomes, length of stay, and surgical technique. A nonsystematic review of the literature was conducted. The research included the most updated articles that referred to SP robotic PN. Since its commercial release in 2018, several institutions have reproduced robotic PN by using the SP platform, both via a transperitoneal and a retroperitoneal approach. The published SP-robotic PN series are generally based on preliminary experiences by surgeons who had previous experience with conventional multi-arms robotic platforms. The reported outcomes are encouraging. Overall, three studies reported that SP-robotic PN cases had nonsignificantly different operative time, estimated blood loss, overall complications rate, and length of stay compared to the conventional 'multi-arms' robotic PN. However, in all these series, renal masses treated by SP had overall lower complexity. Moreover, two studies underlined decreased postoperative pain as a major pro of adopting the SP system. This should reduce/avoid the need for opioids after surgery. No study compared SP-robotic versus multi-arms robotic PN in cost-effectiveness. Published experience with SP-robotic PN has reported the feasibility and safety of the approach. Preliminary results are encouraging and at least noninferior with respect to those from the multi-arms series. Prospective comparative studies with long-term oncologic and functional results are awaited to draw more definitive conclusions and better establish the more appropriate indications of SP robotics in the field of PN.

Clinical implications for da Vinci SP partial nephrectomy in high complexity tumors; Propensity score matching analysis

PURPOSE

To compare surgical outcomes between robot-assisted laparoendoscopic single-site surgery using the da Vinci Si or Xi system and the da Vinci SP system for partial nephrectomy.

MATERIAL AND METHODS

From 2008 to 2020, 66 partial nephrectomies were performed using a single-site robotic approach: 44 used the da Vinci Xi or Si system (R-LESS group) and 22 used the da Vinci SP system (SP group). After 1:1 propensity score-matching, surgical outcomes were compared between groups Results: Median patient age was 51.5 years. Median tumor size was 2.1 cm and was not significantly different between groups. Median operation time was longer in the R-LESS group (R-LESS vs SP: 180 min vs 155 min, p=0.034), but median warm ischemic time was comparable between groups. Estimated blood loss was higher in the R-LESS group (R-LESS vs SP: 215 mL vs 20 mL, p<0.001). Median operation time was significantly shorter in the SP group in patients with moderate to high complexity tumors (R-LESS vs SP: 200 min vs 172 min, p=0.035). Rates of trifecta achievement were similar between groups (63.6% in both groups, p=1.00).

CONCLUSIONS

R-LESS and da Vinci SP methods are both feasible approaches for single-site incision robotic partial nephrectomy. The da Vinci SP platform allows "true" single-site surgery without additional ports and provides a wider working space. It was associated with better performance than R-LESS partial nephrectomy. In moderate to high complex tumors, operation time was shorter with SP partial nephrectomy than with R-LESS partial nephrectomy, suggesting that the SP method is especially advantageous for managing complex renal tumors.

Da Vinci SP Single-Port Robotic Surgery in Gynecologic Tumors: Single Surgeon's Initial Experience with 100 Cases

PURPOSE

To report preliminary experience of single-port robotic surgery using the da Vinci SP surgical system in gynecologic tumors.

MATERIALS AND METHODS

This was a retrospective study on 100 consecutive patients who underwent da Vinci SP single-port robotic surgery between November 2018 and January 2021. All procedures were performed by an experienced gynecologic surgeon using a single 2.5-cm umbilical incision.

RESULTS

Of the 100 cases, the procedures included myomectomy (n=76), hysterectomy (n=2), endometrial cancer surgical staging (n=14), radical hysterectomy (n=3), radical trachelectomy (n=3), and ovarian cystectomy (n=2). None of the cases was converted to robotic multiport or open surgery. The median docking time was 5.0 minutes [interquartile range (IQR), 3.0-7.0], the median console time was 107.5 minutes (IQR, 78.7-155.8), and the median total operation time was 250.0 minutes (IQR, 215.0-310.0). The median estimated blood loss was 50.0 mL (IQR, 30.0-100.0), and the median change in hemoglobin level was 0.8 g/dL (IQR, 0.3-1.3). The median pain scores rated on a numerical rating scale immediately after and at 6, 12, and 24 hours after surgery were 5, 2, 2, and 2, respectively. The mean duration of postoperative hospitalization was 2.8 days.

CONCLUSION

Da Vinci SP single-port robotic surgery was successfully performed in various gynecologic tumors without significant complications. Therefore, this surgical system could be applied in patients who want precise gynecologic surgery while minimizing surgical incision.

Longitudinal analysis of retroperitoneoscopic adrenalectomy regarding cosmesis outcomes: comparison of lateral transperitoneal and reduced port laparoscopic adrenalectomy

The aim of this study is to compare patient-reported cosmesis and satisfaction outcomes between lateral retroperitoneoscopic adrenalectomy (LRA), laparoendoscopic single site and reduced port adrenalectomy (LESS/RP-A) and lateral transperitoneal laparoscopic adrenalectomy (LTA). A total of 26, 86 and 50 patients who underwent LRA, LESS/RP-A and LTA were included in the study. All LESS/RP-A cases were performed taking the transumbilical approach. We mailed a questionnaire to all patients 1, 3, 6, 9 and 12 months after operation. Questionnaires inquiring about cosmesis (0: very ugly, 10: very beautiful) on the basis of a visual analogue scale were administered. The mean scores of cosmesis at postoperative months 1, 3, 6, 9 and 12 were 7.11, 7.00, 6.57, 5.25 and 5.46 for the LRA group, 8.43, 8.86, 8.95, 8.46 and 9.09 for the LESS/RP-A group and 7.18, 7.74, 7.58, 7.44 and 8.09 for the LTA group. The difference in cosmesis score between the LRA and LESS/RP-A groups gradually increased after surgery, and the cosmesis score for the LRA group was significantly lower at every postoperative point. The difference in cosmesis score between the LRA and LTA groups gradually increased after surgery, and the cosmesis score for the LRA group was significantly lower at postoperative months 9 (p = 0.015) and 12 (p = 0.002). This study is the first comprehensive longitudinal analysis of patient-reported cosmesis outcomes between LRA, LESS/RP-A and LTA. LRA was the surgical procedure that resulted in lower cosmesis scores when compared with those following the LESS/RP-A and LTA procedures.

Comparison of intraoperative and short-term postoperative outcomes between robot-assisted laparoscopic multi-port pyeloplasty using the da Vinci Si system and single-port pyeloplasty using the da Vinci SP system in children

PURPOSE

We compared the intraoperative and postoperative outcomes of single-port robot-assisted laparoscopic pyeloplasty (S-RALP) using the da Vinci SP® system and conventional multi-port robot-assisted laparoscopic pyeloplasty (M-RALP) in pediatric patients.

MATERIALS AND METHODS

Multi-port and single-port pyeloplasty have been performed in pediatric patients in our institution since October 2015 and February 2019, respectively. We conducted an entire cohort comparison. Considering the learning curve of M-RALP, we defined the last 15 cases of M-RALP as a subgroup of M-RALP and compared this subgroup with the entire cohort of S-RALP patients.

RESULTS

Thirty-one patients who underwent multi-port pyeloplasty and 15 patients who underwent single-port pyeloplasty were enrolled in this study. Age, height, body weight, laterality, surgical indication, and ipsilateral differential renal function were statistically similar in the M-RALP and S-RALP groups. The median operative time (3.0 h vs. 2.4 h; p=0.01) and the median console time (2.2 h vs. 1.5 h; p<0.001) were longer in the M-RALP group than in the S-RALP group. There was no significant difference in operative time or console time between the M-RALP subgroup and the S-RALP group. There were no significant differences in the length of hospitalization, pain score, morphine-equivalent use of analgesics, or postoperative differential renal function in all comparisons.

CONCLUSIONS

This study confirmed that pyeloplasty using the da Vinci® SP system can be started by robotic surgeons who can overcome the learning curve. Robot-assisted laparoscopic single-port pyeloplasty is feasible in noninfant pediatric patients.

Comparison of Chief Surgeons' and Assistants' Feelings of Fatigue Between Laparoendoscopic Single-site and Conventional Laparoscopic Adrenalectomy

BACKGROUND

Our objective was to compare the surgical staff's feelings of fatigue between laparoendoscopic single-site adrenalectomy (LESS-A) and conventional laparoscopic adrenalectomy (CLA) before and after surgery.

METHOD

Data were collected for surgical procedures performed between June 2011 and September 2017 (57 LESS-A and 37 CLA). Each procedure in both groups was performed by the same chief surgeon. The subjective fatigue feelings of the key members of the surgical team (chief surgeon, scopist, assistant surgeon) were assessed using the "Jikaku-sho shirabe" questionnaire, which contained questions about work-related feelings of fatigue. It consisted of 25 subjective items for 5 factors drawn from factor analysis (drowsiness, instability, uneasiness, local pain or dullness, and eyestrain). For each item, the participants were requested to estimate the intensity of their feelings using a five-point rating scale before and after surgery.

RESULTS

There was no significant difference in operative time (p = 0.231) between the LESS-A and CLA procedure groups. For the chief surgeon, local pain or dullness (p = 0.603) and eyestrain (p = 0.086) were similar between the LESS-A and CLA procedures. The scopists and assistant surgeons in the LESS-A group did not suffer local pain or dullness (p = 0.793 and p = 0.240, respectively). They did, however, suffer more eyestrain than those in the CLA group (p = 0.001 and p = 0.001, respectively).

CONCLUSION

Although LESS-A is generally considered to be a technically difficult procedure, the results of this study demonstrate that the feelings of physical fatigue are roughly equivalent between LESS-A and CLA procedures.

Laparoendoscopic single-site simultaneous bilateral nephrectomy: first reported case series

Bilateral renal tumors in patients on dialysis are usually managed with bilateral nephrectomy. With traditional laparoscopy, this procedure requires the insertion of multiple trocars. Laparoendoscopic single-site surgery (LESS) uses a single umbilical incision to insert multiple instruments and is also employed for extraction of specimens. This technique appears especially useful for bilateral nephrectomy, since many access ports can be spared. We describe 5 cases of simultaneous bilateral radical nephrectomies performed at a single academic institution. We had no intraoperative complications and a mean operating time of 155 minutes. Four patients could be resected using this approach; one case was converted to a traditional laparoscopy. One case had a postoperative complication. We believe this technique is feasible, and can be accomplished with acceptable morbidity and ade-quate operative time.

Comparison of Laparoendoscopic Single-Site and Laparoscopic Radical Cystectomy for Male Patients with Bladder Cancer: Perioperative and Oncologic Outcomes

Objective: To compare the surgical and early oncological outcomes in patients with bladder cancer who had laparoendoscopic single-site radical cystectomy (RC) or laparoscopic RC. Materials and Methods: From July 2012 to May 2019, 28 consecutive men suffering from bladder cancer underwent laparoendoscopic single-site RC or laparoscopic RC with extracorporeally ileal conduit diversion. Data regarding the patient characteristics, surgical outcomes, and short-term oncological outcomes were analyzed retrospectively. Results: Compared with laparoscopic RC, laparoendoscopic single-site RC was associated with less postoperative pain (mean, 4.67 versus 6.08 scores; P = .004), and shorter convalescence (time to ambulation, mean, 1.13 days versus 2.15 days; P = .000; hospital stay after surgery, mean, 13 days versus 19 days; P = .001). In addition, differences in patient characteristics, mean total operation time, and mean estimated blood loss were not statistically significant between laparoendoscopic single-site RC and laparoscopic RC groups. There was no difference in the early or late complication rate between the two groups as well. It is also revealed that there was no significant difference in the overall survival rate at 24 months between laparoendoscopic single-site RC and laparoscopic RC groups. Conclusions: Based on our initial experience with laparoendoscopic single-site RC, it is a safe procedure with acceptable complications and oncological outcomes. Notably, laparoendoscopic single-site RC is associated with less postoperative pain and rapider convalescence compared with the historical series of laparoscopic RC. However, further comparative studies with longer follow-up period are warranted to validate this procedure.

Retroperitoneal single-site robot-assisted partial nephrectomy using Lapsingle Vision advanced access platform: initial three case reports

Robot-assisted partial nephrectomy is currently the standard for treatment of small renal mass. Recently, robot-assisted single site surgery has been introduced. However, there have been few reports of retroperitoneal approaches. Herein, we report initial case series of retroperitoneal single-site robot-assisted partial nephrectomy using the da Vinci Xi surgical system using the Lapsingle Vision advanced access platform. Three patients have undergone retroperitoneal single-site robot-assisted partial nephrectomy due to incidental finding of renal mass. Operation duration, estimated blood loss, warm ischemia time, estimated glomerular filtration rate (eGFR) change, and complication were evaluated. Renal cell carcinoma of the two clear cell type and one chromophobe was diagnosed based on the pathological examination. Initial two cases were successfully completed with minimal bleeding and warm ischemic time within 25 minutes. The last 3rd case has been converted to multiport operation due to limited retroperitoneal space and difficulty in managing upper pole renal mass. Retroperitoneal single-site robot-assisted partial nephrectomy is a feasible treatment modality for treatment of posterior or lateral renal masses. Additional cases are needed to confirm the safety and efficacy of this technique.

Robot-assisted laparoendoscopic single-site upper urinary tract surgery with da Vinci Xi surgical system: Initial experience

Purpose

The da Vinci Xi robot surgical system was newly released with several upgrades and modifications made to its previous Si platform; to further enhance the capabilities to carry out minimally invasive surgery. This study aimed to evaluate the intraoperative and postoperative outcomes of robot laparoendoscopic single-site surgery performed with the da Vinci Xi system.

Materials and Methods

Retrospective chart review of patients undergoing of robot laparoendoscopic single-site by a single surgeon using the Xi single-site platform from November 2016 and May 2019. For the da Vinci Xi system, multichannel port and "Lap Single Vision" port access platform were placed through a single periumbilical incision.

Results

Fourteen patients underwent single-site surgery with benign cases (n=9) and partial nephrectomy cases (n=5). Among surgeries for the partial nephrectomy patients, one case of conversion to multiport robotic surgery occurred due to difficulty of tumor resection. Other major intraoperative complication, renal vein injury, was occurred in a patient who underwent a pyelolithotomy. The patient required a blood transfusion however, we were able to repair the vascular injury using prolene suture without additional port placement and open conversion. In our series, there were no conversions to open. The postoperative course was uneventful in all patients; only Clavien-Dindo III complications occurred.

Conclusions

Our preliminary experience with robot laparoendoscopic single-site surgery using the da Vinci Xi system demonstrated feasibility and safety in selected patients. Further studies with a greater number of patients in multiple settings will help to fully elucidate the role of da Vinci Xi surgical system in single-site surgery.

Single-port robotic partial and radical nephrectomies for renal cortical tumors: initial clinical experience

To describe our institution's initial experience with radical (RN) and partial nephrectomy (PN) using the SP robotic system. The recent FDA approval of the da Vinci^® SP robotic platform has led to its use in minimally invasive approaches to urologic malignancies. There are little data on its feasibility and safety after implementation for radical and partial nephrectomy. All patients who underwent PN or RN using the SP system at our institution were reviewed. All PNs were performed off-clamp. Patient demographics, preoperative imaging, operative approaches, and perioperative outcomes were collected and analyzed. Sixteen patients underwent PN (n = 13) or RN (n = 3) utilizing the SP robotic system between January 2019 and June 2019. Average age was 58.6 ± 13.9 and 61.0 ± 1.7 years in each group, respectively. A retroperitoneal approach was performed in 7 (53.8%) PN patients and 1 (33.3%) RN patient. A transperitoneal approach was performed in 6 (46.1%) PNs and 2 (66.7%) RNs. Mean operative time and median estimated blood loss for PN was 176.9 ± 64.0 min and 200 (50-800) ml compared to 176.3 ± 73.8 min and 50 (50-400) ml for RN. There was one operative conversion (7.7%) to an open approach in the PN group. Length of hospital stay postoperatively averaged 1.9 ± 1.3 days and 3.3 ± 1.2 days for patients undergoing partial and radical nephrectomy, respectively. SP partial and radical nephrectomies through transperitoneal and retroperitoneal approaches appear to be feasible surgical techniques in the management of cortical renal masses. Off-clamp PN is also a feasible approach using the SP system. However, further study is needed to establish its safety and use in renal surgery across multiple institutions and larger patient cohorts.

Long-Term Follow-Up of Laparoendoscopic Single-Site Partial Nephrectomy for Nonfunctioning Moieties of Renal Duplication and Fusion Anomalies in Infants and Children

Objectives: To report on long-term follow-up and outcomes of infants and small children who have undergone laparoendoscopic single-site (LESS) partial nephrectomy to manage upper urinary tract duplication and fusion anomalies. Materials and Methods: A retrospective review was performed evaluating outcomes of pediatric patients who underwent LESS partial nephrectomy for upper urinary tract duplication and fusion anomalies from January 2012 to July 2015, by a single surgeon at a tertiary pediatric referral center. Demographic and perioperative data were reviewed as well as follow-up imaging. Descriptive statistics were used for analysis. Results: A total of 18 patients were identified. Additional access was used for two patients to complete the procedure. Median follow-up was 39 months. No short-term complications were encountered. Three patients were noted to have abnormal postoperative ultrasounds: two perinephric fluid collections and one atrophy of the remaining ipsilateral moiety. One fluid collection resolved completely, and the other decreased in size. Complete atrophy of the ipsilateral moiety occurred. No secondary procedures were required. Conclusions: LESS partial nephrectomy is safe for renal duplication and fusion anomalies with good long-term outcomes. Although it can be safely performed, it is a technically demanding procedure and has been discontinued in favor of robotic partial nephrectomy.

Retroperitoneal laparoendoscopic single-site approach for renal cyst decortication - first experience and a review of literature

Laparoendoscopic single-site (LESS) approach has been successfully employed for a number of urologic procedures. The retroperitoneal approach further limits the working space and instrument movement during LESS surgery, but has the advantage of a faster post-operative recovery and lower complications rate. We present our first experience using retroperitoneal LESS approach for a renal cyst decortication in a 40-year-old patient. The operative time was 40 minutes, the blood loss was minimal and we did not encounter significant conflicts between the instruments. The patient was discharged 2 days after the procedure and returned to full normal activity within one week. We consider that the retroperitoneal LESS approach is feasible for upper tract urologic surgery. Pre-bent instruments might further improve surgical gestures and extend the indications for more complex procedures. Nevertheless, the advent of reusable devices is expected to increase the cost-effectiveness of LESS and expand its use.

Robotic single site radical hysterectomy plus pelvic lymphadenectomy in gynecological cancers

Objective

To evaluate the feasibility and the safety of robotic single-site radical hysterectomy (RSSRH) plus pelvic lymphadenectomy (PL) in endometrial or cervical cancer.

Methods

Patients with endometrial cancer (EC) International Federation of Gynecology and Obstetrics (FIGO) stage II, early cervical cancer (ECC) FIGO stage IB1 or locally advanced cervical cancer (LACC) FIGO stage IB2–IIB with clinical response ≥50% after neo-adjuvant chemotherapy (NACT) were enrolled in a prospective cohort trial. All cases were performed using the da Vinci Si Surgical Single Site System^®.

Results

Between April 2014 and November 2016, twenty patients were included in our pilot study. Three and 17 patients underwent type B1 or C1 RSSRH plus PL, respectively. The median age of patients was 46 years (range, 36–68 years) and the median body mass index was 23.5 kg/m² (range, 19.1–36.3 kg/m²). The median total operative time was 190 minutes (range, 90–310 minutes). The median blood loss was 75 mL (range, 20–700 mL) and the median number of pelvic lymph nodes removed was 16 (range, 5–27). No laparoscopic/laparotomic conversions were reported and the median time to discharge was 6 days (range, 4–16 days). No intra-operative complications occurred while 4 (20%) post-operative complications were reported: one pelvic abscess, one lymphorrea, one bowel perforation, and one vaginal dehiscence.

Conclusion

RSSRH plus PL is technically feasible in patients affected by gynecological cancer.

Robotic laparoendoscopic single-site radical prostatectomy (R-LESS-RP) with daVinci Single-Site® platform. Concept and evolution of the technique following an IDEAL phase 1

To describe the evolution of robotic laparoendoscopic single-site radical prostatectomy (R-LESS-RP) performed with the daVinci Single-Site Platform® and a home-made multiport aimed to overcome classical drawbacks of LESS, still present with this platform. Between 09/2015 and 06/2017 12 patients underwent R-LESS RP for clinical localized prostate cancer. Following a "phase 1 (development-stage)" innovation, development, exploration, assessment, long-term study (IDEAL) framework, different solutions were drawn to overcome drawbacks of daVinci Single-Site Platform®, included 3 (A, B, and C) multi-ports developed and evaluated in term of advantages/drawbacks concerning ergonomy. The end points of this study were: feasibility, safety, efficacy, by reporting rational description of multiports configuration, demographics, perioperative variables, functional and oncological results. Semi-flexible robotic 5-mm needle-holder instead of Maryland forceps, 30° lenses up and barbed-suture allowed overcoming limits of robotic-platform. Multiport-C (GelPOINT Advanced-Access® and an extra 8-mm robotic trocar outside the multiport) showed the best compromise to ensure both surgeon and bed-side assistant to reproduce a standard robotic procedure. No conversion to either standard robotic or open technique or intraoperative complications occur in any case. Two patients experienced "high-grade" Clavien-Dindo complications. After 12.4 months follow-up, all patients were continent without any sign of biochemical relapse and among 5 preoperative potent patients submitted to nerve-sparing dissection, 4 reported good erectile-function. R-LESS-RP is feasible and safe in the hands of experienced minimally-invasive surgeons. Do date, we recommend a hybrid solution with a home-made multiport and use of an additional standard robotic trocar which allows the use endowrist® technology instruments.

Evaluation of the Role of Laparoendoscopic Single-Site Surgery vs Minilaparoscopy for Treatment of Upper Urinary Tract Pathologies: Prospective Randomized Comparative Study

OBJECTIVES

To present the first prospective randomized comparison between laparoendoscopic single-site surgery (LESS) and minilaparoscopy (ML) for treatment of upper urinary tract pathologies.

PATIENTS AND METHODS

Between January 2013 and June 2015, patients with different upper urinary pathologies were blindly randomized to both LESS and ML. All procedures were done by single experienced surgeon. Both cohorts were compared regarding demographic data, peri and postoperative characteristics, and visual analog pain scale (VAS). Cosmetic outcome was assessed after 12 months using patient scar assessment scale (PSAS) and observer scar assessment scale (OSAS).

RESULTS

Sixty patients were randomized into two equal groups with comparable demographic and preoperative characteristics. Indications included nephrectomy, pyeloplasty, cyst marsupialization, adrenalectomy, and repair of retrocaval ureter. Operative time was 167 ± 24 and 145 ± 39 minutes in LESS and ML groups, respectively (p = 0.09). Estimated blood loss was 59 ± 34 and 43 ± 42 mL in both groups, respectively (p = 0.2). VAS was 1.7 ± 0.6 and 2.8 ± 0.5 in both groups, respectively (p = 0.02). PSAS and OSAS were 5.9 ± 0.85 and 10.6 ± 1.98 vs 8.9 ± 0.9 and 13.5 ± 6.3 in both groups, respectively (p > 0.05). There were no intraoperative complications, conversions to open surgery, or conventional laparoscopy in both groups. Mean postoperative Diclofenac Na was 151.7 ± 35.6 and 169.7 ± 47.3 mg in both groups, respectively (p = 0.04). Postoperative complications rate and hospital stay were comparable between both groups.

CONCLUSION

Both LESS and ML have comparable operative time, blood loss, complication rate, and hospital stay in treatment of upper urinary tract pathologies. However, LESS is associated with less analgesic requirement and better cosmetic outcome.

The Safety and Feasibility of the Single-Port Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair Through Retropubic Radical Prostatectomy Scar, Prospective, Case Series

Introduction: To avoid an additional scar, our novel single-port laparoscopic inguinal hernia repair technique that utilizes the previous prostatectomy scar was conducted. Inguinal hernia is one of the most common complications of radical prostatectomy that require surgical repair. At present, such surgical repair inevitably leaves additional scars on the abdominal wall. This case series study was performed to determine the safety and feasibility of this procedure in patients with inguinal hernia after radical prostatectomy. Subjects and Methods: All patients who underwent retropubic radical prostatectomy (RRP) in 2012-2016 and developed an inguinal hernia as a complication of RRP agreed to undergo single-port laparoscopic transabdominal preperitoneal (TAPP) repair of the inguinal hernia through the RRP scar. TAPP repair was performed using a homemade glove single port through a 2 cm wide incision into the upper part of the RRP scar. The duration between RRP and the development of inguinal hernia, TAPP repair operative time, follow-up duration, TAPP repair-related complications, and rate of inguinal hernia recurrence were recorded. Results: Of the 131 patients who underwent RRP in the study period, 12 (mean age, 67.58 ± 5.73 years) developed inguinal hernia during an average follow-up duration of 33.58 ± 16.49 months. None had a previous history of inguinal hernia. The inguinal hernias developed on average 3.83 ± 1.70 months after RRP. The mean operative time was 64.58 ± 6.20 minutes. There were no surgical complications or recurrence of inguinal hernia during follow-up. Conclusions: Single-port laparoscopic TAPP inguinal hernia repair through the previous prostatectomy scar is safe and feasible.

Different approaches to the prostate: The upcoming role of a purpose-built single-port robotic system

With the aim of minimising the patient’s postoperative pain, expediting recovery and improving cosmesis, the idea of performing a laparoscopic procedure through a single abdominal incision was introduced. In the present report, we describe five different access routes to the prostate that may be at the surgeon’s disposal with the potential of decreasing patient’s perioperative morbidity. Robotic radical prostatectomy has been refined and became a standard of care in surgery for localised prostate cancer. The advent of single-port robotic surgery has prompted the re-discovery of different access routes to the prostate and ideally all of them are feasible. The potential for avoiding the abdominal cavity will decrease the surgical morbidity and minimise the surgical dissection. In the near future, each of the described approaches could be chosen on the basis of the patient’s preoperative comorbidities, body habitus, anatomy, and disease characteristics and location.

Transurethral assistant transumbilical laparoendoscopic single-site radical prostatectomy

The laparoendoscopic single-site (LESS) technique is the latest technical innovation in laparoscopic surgery to undergo exponential development in urology. This study undertaken to illustrate our initial experience LESS radical prostatectomy (RP) and analyze early outcomes. Nineteen patients diagnosed with prostate cancer underwent LESS-RP in our institute. The patients were divided into two groups: conventional LESS and transurethral assistant LESS. Preoperative, perioperative, postoperative, pathologic, and functional outcomes data were assessed. With the help of a transurethral assistant, the mean operation and anastomosis time were decreased markedly. No focal positive margins were encountered. No prostate-specific antigen recurrence was detected 1 month postoperatively. Complete continence recovery (no pad) was observed in 32% of the patients at 1 month after the operation. No intraoperative and postoperative complications were reported. LESS-RP is a feasible and effective surgical procedure for treatment of prostate cancer. Moreover, transurethral assistant LESS could reduce the difficulty of LESS-RP and shorten the operation time.

Long-Term Outcomes of Laparoendoscopic Single-Site Nephrolithotomy for Caliceal Diverticular Calculi: A Case Series

OBJECTIVE

To evaluate the outcomes of laparoendoscopic single-site nephrolithotomy (LESS-NL) for symptomatic caliceal diverticular calculi.

PATIENTS AND METHODS

From November 2009 to March 2014, 11 cases of LESS-NL with a homemade single-port device for caliceal diverticular calculi were performed by a single experienced laparoscopic surgeon. All patients were assessed at postoperative 1 month, 1 year, and 3 years for symptom-free status and by CT for stone-free and caliceal diverticular obliteration status. All complications were categorized by the Clavien-Dindo classification. Demographic parameters and postoperative outcomes were retrospectively analyzed.

RESULTS

All procedures were effectively performed without conversion to open or conventional laparoscopic surgery. Median patient age was 53 years (range 22-73), and median diverticular size was 26 mm (range 15-58). Six patients (54.5%) had multiple stones, and five patients (45.5%) had a single stone; median stone size was 20.6 mm (range 12.1-66.4). The transperitoneal approach was used in seven patients (63.6%) and retroperitoneal approach in four patients (36.4%). Median operative time was 161 minutes (range 110-250), median estimated blood loss was 50 mL (range 20-400), and median hospital stay was 4 days (range 3-6). An additional needlescopic instrument was used in five cases (45.5%). There were three cases (27.3%) of grade I complications (two postoperative fever, one ileus), and no intraoperative or major complications. Median visual analog scale score significantly improved by discharge day (from 4.9 preoperatively to 1.4; p = 0.003). After a median follow-up of 38 months (range 36-41), all patients were symptom free with no evidence of stone or caliceal diverticulum on imaging.

CONCLUSIONS

LESS-NL is a safe, feasible, and definitive treatment option for symptomatic caliceal diverticular calculi.

Assessment of Postural Ergonomics and Surgical Performance in Laparoendoscopic Single-Site Surgery Using a Handheld Robotic Device

Purpose. New laparoscopic devices are being continuously developed to overcome some of the technical and ergonomic limitations of laparoendoscopic single-site (LESS) surgery. This study aims to assess the surgeon’s surgical performance and ergonomics during the use of a handheld, robotic-driven, articulating laparoscopic instrument during LESS surgery. Methods. Seven right-handed experienced surgeons took part in this study. A set of basic suturing tasks and digestive and urological procedures in a porcine model were performed. Surgeons used both a conventional laparoscopic needle holder and a robotic device. The learning curve, execution time, and precision using the surgical needle were assessed. The surgeon’s posture was analyzed using a motion tracking system and a data glove. Results. After the training period, execution time on the intracorporeal suturing was significantly shorter using the conventional needle holder. The precision was higher using the conventional instrument in the horizontal plane, but the number of attempts to position the needle was lower using the robotic device (1.625 ± 0.250 vs 1.188 ± 0.375 attempts). The extension of the elbow (134.681 ± 14.35° vs 120.631 ± 13.134°) and the flexion of the shoulder (26.122 ± 7.411° vs 18.475 ± 14.166°) were significantly lower using the robotic instrument. The wrist posture using the robotic device was ergonomically acceptable during both surgical procedures. Conclusions. Results show a positive learning curve in ergonomics and surgical performance using the robotic instrument during LESS surgery. This instrument improves the surgeon’s body posture and the needle positioning errors. The use of the robotic instrument is feasible and safe during LESS partial nephrectomy and sigmoidectomy procedures.

A randomized, prospective study of laparoendoscopic single-site plus one-port versus mini laparoscopic technique for live donor nephrectomy

PURPOSE

To compare the clinical outcomes of laparoendoscopic single-site plus one-port donor nephrectomy (LESSOP-DN) and mini laparoscopic donor nephrectomy (MLDN).

METHODS

A prospective randomized controlled trial was conducted from December 2014 to February 2016 in donors scheduled for left donor nephrectomy. Donor and recipient demographics and clinical outcomes including pain scores and questionnaires (BIQ: body image questionnaire, SF-36, patient-reported overall convalescence) were also compared.

RESULTS

A total of 121 eligible donors were recruited, of which 99 donors who were scheduled to undergo an operation on their left side were randomized into LESSOP-DN (n = 50) and MLDN (n = 49) groups. There were no significant demographic differences between the two groups. The renal extraction time in the LESS-DN group was shorter than that in the MLDN group (75.89 ± 13.01 vs. 87.31 ± 11.38 min, p < 0.001). Other perioperative parameters and complication rates were comparable between the two groups. The LESSOP-DN group had a smaller incision length than the MLDN group (4.89 ± 0.68 vs. 6.21 ± 1.11 cm, p < 0.001), but cosmetic scores and body image scores were similar in the two groups (p = 0.905, 0.217). Donor quality of life (SF-36) and recovery and satisfaction data were comparable between the two groups. Delayed graft function (DGF) occurred in one recipient undergoing MLDN procedure (2.1%) and progressed to graft failure.

CONCLUSIONS

There were no differences in cosmetic satisfaction between groups despite the smaller incision size of LESSOP-DN. Safety parameters and subjective measures of postoperative morbidity were similar between the two groups.

The Safety and Feasibility of the Single-Port Laparoscopic Repair of Intraperitoneal Bladder Rupture

OBJECTIVE

To evaluate the efficacy and safety of laparoendoscopic single-site surgery (LESS) in the repair of intraperitoneal bladder rupture.

PATIENTS AND METHODS

All consecutive patients who underwent LESS for intraperitoneal bladder rupture in three hospitals in Korea were included prospectively in this study. LESS was performed using a homemade single-port device composed of an Alexis wound retractor and a surgical glove.

RESULTS

Of the 22 patients, 18 were male. The mean age was 40.50 ± 11.83 years. The mean body mass index was 24.19 ± 2.61 kg/m². The cause of rupture was trauma (n = 21) or iatrogenic injury (n = 1). The mean bladder rupture diameter was 3.41 ± 1.01 cm. LESS bladder rupture repair was completed effectively in all patients. The mean operative time was 89.05 ± 11.29 minutes. The mean length of hospital stay was 2.91 ± 0.53 days. Postoperatively, none of the patients required patient-controlled analgesia, and none developed major complications. The urethral Foley catheter was removed 7.68 ± 2.08 days after surgery.

CONCLUSIONS

LESS repair of intraperitoneal bladder rupture, which involves a homemade single-port device, was a feasible and safe alternative to conventional laparoscopy in this case series.

Laparoscopic Versus Open Adrenalectomy for Localized/Locally Advanced Primary Adrenocortical Carcinoma (ENSAT I-III) in Adults: Is Margin-Free Resection the Key Surgical Factor that Dictates Outcome? A Review of the Literature

BACKGROUND

The aim of this study was to review the current literature on the role of laparoscopic adrenalectomy (LA) in the treatment of primary adrenocortical carcinoma (ACC; European Network for the Study of Adrenal Tumors [ENSAT] I-III) in adults.

MATERIALS AND METHODS

Nonrandomized controlled trials published between January 1999 and February 2017 were identified by searching the Pubmed, EMBASE, Cochrane Library, and Google Scholar databases. Primary and secondary endpoints included surgical and pathological parameters (patients age, tumor size, ENSAT stage, type of surgical approach, and period of follow-up), surgical outcomes (operative time, estimated blood loss, length of hospital stay, conversion rate to laparotomy, R0 resection, and surgical margin's status), and oncological outcomes (rate of recurrence, disease-free survival [DFS], and overall survival [OS] rates).

RESULTS

A total of 13 studies encompassing data on 1171 patients were included in the review. Compared with open approach, LA demonstrated lower tumor size, shorter operative time, lower intraoperative blood loss, shorter postoperative hospital stay, and equivalent local recurrence rates. No significant differences were observed between groups treated with an open or laparoscopic approach for the following criteria: R0 surgical resection status, tumor overall recurrence, and postoperative DFS and OS rates.

CONCLUSIONS

LA appears to be equivalent to open method for localized/locally advanced primary ACC (ENSAT I-III) in terms of R0 resection rate, overall recurrence, DFS, and OS, therefore suggesting that the extent of surgery with adequate tumor resection is the predominant endpoint, rather than the surgical approach itself. Multicenter randomized controlled trials with long follow-up time periods exploring the long-term oncological outcomes are required to determine the benefits of the laparoscopic over the open approach in adrenocortical carcinoma.

Robot-assisted laparoendoscopic single site adrenalectomy: A comparison of 3 different port platforms with 3 case reports

RATIONALE

Laparoscopic adrenalectomy is currently the standard of care for adrenal lesion. Minimal invasive laparoscopic surgery such as laparoendoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) have been developed to improve cosmetic outcomes and reduce postoperative pain. However, there are still some problems related to instruments and port limitation during LESS surgery. Robot-assisted laparoscopic surgery may help to overcome these problems, and port platforms selection is an important issue.

PATIENT CONCERNS

Three cases received robot-assisted LESS adrenalectomy due to adrenal tumor were enrolled. Blood loss, hospital stay, and analgesia injection were compared.

DIAGNOSES

Preoperative evaluations were done in a usual manner. Benign tumors were suspect for two patients, while metastatic tumor could not be excluded for the other patient with prior malignancy history. The pathology reports were all benign adrenal cortical adenoma after operation.

INTERVENTIONS

Three different port platforms, Da Vinci Single-Site Surgical Platform, GelPOINT, and homemade glove port were used. Trans-peritoneal approach was used for two patients, while the other one received trans-retroperitoneal approach. The advantage and disadvantage of different port platforms were discussed.

OUTCOMES

All patients underwent the operation smoothly without major complications or conversion to open surgery. Blood loss amount was small, hospital stay was short, and only one patient received one single dose of opioid analgesia injection after the surgery.

LESSONS

The main problems of LESS are the loss of a working triangle and the limitations of the instruments. Robot-assisted LESS may help surgeons overcome part of these problems. Many different port platforms are available, and based on our initial experience, we believe that the GelPoint may be a more suitable platform, for it maintains the endo-wrist function of the Da Vinci instruments, and allows the surgeon to design the position of ports freely to minimize external and internal collision.

Robot-Assisted Extraperitoneal Radical Prostatectomy, Single Site Plus Two Model

PURPOSE

To demonstrate a feasible procedure of robot-assisted extraperitoneal radical prostatectomy single site plus two model to overcome the limitation of traditional single-port laparoscopic surgery.

MATERIALS AND METHODS

All consecutive cases of robot-assisted extraperitoneal radical prostatectomy single site plus two model between November 2015 and April 2016 in our institution were included. We analyze the surgical and continence outcome.

RESULTS

Twenty cases were included in the analysis. All cases successfully completed without any necessity for conversion to a standard laparoscopic approach or open surgery. The average age is 64.3 ± 8.2 years and average body mass index is 24.3 ± 2.9 kg/m². Eight focal positive margins (40%) (5 in T2 and 3 in T3a disease) were encountered and all occurred at the apex. For continence outcomes, 9 (45%) patients need average 0-1 pads/day and 2 (10%) patients need average 3 pads/day after surgery, but most recover after several months. No intraoperative complications or major postoperative complications were recorded, excluding blood transfusion in one case.

CONCLUSIONS

Robot-assisted extraperitoneal radical prostatectomy single site plus two model is technically feasible and safe in our experience. It can also be performed in patients that have previously received intraperitoneal abdominal surgery using the extraperitoneal approach. We can take this procedure into account for minimal invasive surgical option.

New Hybrid Mini-laparoendoscopic Single-site Partial Nephrectomy With Early Unclamped Technique for Renal Tumors With Intermediate PADUA Score (IDEAL Phase 2a)

OBJECTIVE

To evaluate a new hybrid technique, which we defined as mini-laparoendoscopic single-site partial nephrectomy (MILESS-PN), for renal masses presenting an intermediate PADUA score.

MATERIALS AND METHODS

Forty consecutive cases of MILESS-PN performed between April 2013 and November 2015 were included in this study. Mini-laparoendoscopic single-site surgery consisted of the simultaneous use of two 3-mm pararectal trocars and an umbilical SILS trocar; the sequence of steps of MILESS-PN was comparable with standard laparoscopic partial nephrectomy. Demographic data and the main perioperative and oncological outcome parameters were gathered and analyzed.

RESULTS

The median operative time was 134.6 (interquartile range [IQR] 110-180) minutes with a median warm ischemia time of 12.1 (IQR 9.5-15.5) minutes. Postoperatively, 4 early complications were recorded and the median hospital stay was 4.2 (IQR 3.5-6.0) days. The median renal tumor size was 3.6 (IQR 2.4-5.3) cm with a median PADUA score of 8.3 (IQR 8-9). The definitive pathologic results revealed a renal cell carcinoma in 32 cases (80%), an angiomyolipoma in 3 cases (7.5%), and an oncocytoma in 5 cases (12.5%). All tumors were removed with negative surgical margins, and at the median follow-up of 34.5 (IQR 24-48) months, all patients were alive without evidence of tumor recurrence or port-site metastasis. A statistically significant decrease in the estimated glomerular filtration rate (eGFR) was observed postoperatively (postoperative vs preoperative median eGFR: 87.6 [IQR 70.4-101.8] and 104.7 [IQR 82.7-123.3], P <.0001) and at 6 months (6 months vs preoperative eGFR 93.6 [IQR 79.1-110.2] and 104.7 [IQR 82.7-123.3], P <.0001).

CONCLUSION

MILESS-PN for renal tumors with an intermediate PADUA score in well-selected patients is not associated with increased risks for the patients, presenting excellent oncological and functional results at the midterm follow-up. Mini-laparoendoscopic single-site surgery could represent a valid alternative to laparoendoscopic single-site surgery or minilaparoscopy because of its higher surgical reproducibility.

Laparoendoscopic Single-Site Radical Cystectomy vs Conventional Laparoscopic Radical Cystectomy for Patient with Bladder Urothelial Carcinoma: Matched Case-Control Analysis

OBJECTIVE

Laparoendoscopic single-site surgery (LESS) is increasingly popular in urology. However, data on LESS radical cystectomy (LESS-RC) are immature, and no adequate comparative study has assessed conventional laparoscopic radical cystectomy (CL-RC) vs LESS-RC. The primary aim of this study was to compare efficiency and safety of LESS-RC and CL-RC for patients with bladder urothelial carcinoma (BUC).

MATERIALS AND METHODS

A retrospective and case-matched control comparative analysis was performed of patients who underwent LESS-RC (n = 54) and CL-RC (n = 108) from January 2011 to June 2015. Oncologic, complication and perioperative outcomes were collected and evaluated.

RESULTS

LESS-RC vs CL-RC was associated with less estimated blood loss (EBL; median, 270 vs 337.5 mL; p = 0.014), postoperative pain (median, 4.0 vs 6.0 scores; p = 0.001), and shorter convalescence (time to ambulation and oral intake, median, 2.5 vs 3 days; p = 0.002 and 5 vs 6 days; p = 0.004, respectively). No significant differences were noted for LESS-RC and CL-RC regarding the lymph node yield (median: 18 vs 20; p = 0.101). Median follow-up time was 33.5 months (interquartile range [IQR]: 23-41.3 months) and 33 months (IQR: 23-43 months) for the LESS-RC and CL-RC groups, respectively. No significant differences were noted for LESS-RC and CL-RC regarding estimated 24-month overall survival (86.7% vs 88.1%, p = 0.703), cancer-specific survival (88.3% vs 90.9%, p = 0.539), and recurrence-free survival (80.2% vs 87.5%, p = 0.619), even when substratified according to tumor stage (pT₃ or higher) and lymph node status (pN+). Early, late, and 90-day overall complication rates were similar. In multivariate analyses, LESS-RC was not associated with recurrence and worse survival rates, but was associated with 90-day overall complications.

CONCLUSIONS

This study demonstrated that LESS-RC and CL-RC have comparable efficiency and safety for patients with BUC. Compared to CL-RC, LESS-RC was with less postoperative pain, lower EBL, and more rapid convalescence, but was associated with 90-day overall complications.

Laparoendoscopic single-site surgery for the treatment of different urological pathologies: Defining the learning curve of an experienced laparoscopist

Objectives

To define the learning curve of laparoendoscopic single-site surgery (LESS) of an experienced laparoscopist.

Patients and methods

Patients who had LESS, since its implementation in December 2009 until December 2014, were retrospectively analysed. Procedures were divided into groups of 10 and scored according to the European Scoring System for Laparoscopic Operations in Urology. Different LESS indications were done by one experienced laparoscopist. Technical feasibility, surgical safety, outcome, as well as the number of patients required to achieve professional competence were assessed.

Results

In all, 179 patients were included, with mean (SD) age of 36.3 (17.5) years and 25.4% of the patients had had previous surgeries. Upper urinary tract procedures were done in 65.9% of patients and 54.7% of the procedures were extirpative. Both transperitoneal and retroperitoneal LESS were performed in 92.8% and 7.2% of the patients, respectively. The intraoperative and postoperative complication rates were 2.2% and 5.6% (Clavien–Dindo Grade II 3.9% and IIIa 1.7%), respectively. In all, 75% of intraoperative complications and all conversions were reported during the first 30 LESS procedures; despite the significantly higher difficulty score in the subsequent LESS procedures. One 5-mm extra port, conversion to conventional laparoscopy and open surgery was reported in 14%, 1.7%, and 1.1% of the cases, respectively. At mean (SD) follow-up of 39.7 (11.4) months, all the patients that underwent reconstructive LESS procedures but one were successful.

Conclusion

In experienced hands, at least 30 LESS procedures are required to achieve professional competence. Although difficult, both conversion and complication rates of LESS are low in experienced hands.

Initial experience with the new da Vinci single-port robot-assisted platform

OBJECTIVE

To describe our experience in the first cases of urological surgeries performed with the da Vinci single-port robot-assisted platform.

MATERIAL AND METHODS

We performed 5 single-port robot-assisted surgeries (R-LESS) between May and October 2014. We performed 3 ureteral reimplant surgeries, one ureteropyeloplasty in an inverted kidney and 1 partial nephrectomy. The perioperative and postoperative results were collected, as well as a report of the complications according to the Clavien classification system.

RESULTS

Of the 5 procedures, 4 were performed completely by LESS, while 1 procedure was reconverted to multiport robot-assisted surgery. There were no intraoperative complications. We observed perioperative complications in 4 patients, all of which were grade 1 or 2. The mean surgical time was 262minutes (range, 230-300).

DISCUSSION

In our initial experience with the da Vinci device, R-LESS surgery was feasible and safe. There are still a number of limitations in its use, which require new and improved R-LESS platforms.

Comparative study of hybrid laparoendoscopic single-site (LESS) partial nephrectomy and conventional multiport laparoscopy

OBJECTIVE

To investigate the surgical and oncological outcomes of hybrid laparoendoscopic single-site (LESS) in partial nephrectomy with reusable components compared with multiport laparoscopy.

MATERIAL AND METHOD

Hybrid LESS technique with auxiliary 3.5mm trocar (n=20) was compared with conventional multiport laparoscopy (n=26) by a prospective, paired, nonrandomized, and comparative study in partially nephrectomized patients.

RESULTS

Follow-up average was 31±18.6 months. In one case, LESS was converted to laparoscopy. No differences were found regarding age, sex, body mass index, laterality, localization, tumor size or use of double J stent. Dominance of Loop-I (P=0.09) and benign histology (P=0.05) were observed in the LESS group. Neither there were differences regarding operating time, ischemia time, use of hemostatic materials, estimated blood loss, postoperative hemoglobin levels, transfusion or other complications. In any case, to extend the skin incision for specimen extraction was not necessary. Drainage time (P=0.006) and hospital stay (P=0.003) were better in LESS patients. Concerning complications, no significant differences were observed according Clavien-Dindo scale. In laparoscopic group one patient died of pulmonary embolism after hospital discharge. No positive margins were observed in any case. During follow-up neither tumor recurrence nor disease progression were observed.

CONCLUSIONS

Regarding surgical outcomes, partial nephrectomy by LESS technique does not imply improvements, excepting shorter hospital stay, probably due to accurate surgical hemostasis and/or selection of cases. No surgical and oncological risks are involved, as well as no improvement in ischemia time, blood loss or transfusion rate. We find no significant difference in cosmetic outcomes.

Current status of robotic single-port surgery

Robotic-assisted laparoscopic surgery in urology is an ever progressing field, and boundaries are constantly broken with the aid of new technology. Advancements in instrumentation have given birth to the era of robotic laparoendoscopic single-site technique (R-LESS). R-LESS however, has not gained widespread acceptance due to technical hurdles such as adequate triangulation, robotic arm clashing, decreased access for the bedside assistant, lack of wrist articulation, continued need for an axillary/accessory port, lack of robust retraction, and ergonomic discomfort. Many innovations have been explored to counter such limitations. We aim to give a brief overview of a history and development of R-LESS urologic surgery and outline the latest advancements in the realm of urologic R-LESS. By searching PubMed selectively for relevant articles, we concluded a literature review. We searched using the keywords: robotic laparoscopic single incision, robotic laparoendoscopic single-site, single incision robotic surgery, and R-LESS. We selected all relevant articles in that pertained to single-site robotic surgery in urology. We selected all relevant articles that pertained to single-site robotic surgery in urology in a table encompassed within this article. The development of the R-LESS procedures, instrumentations, and platforms has been an evolution in progress. Our results showed the history and evolution toward a purpose-built single-port robotic platform that addresses previous limitations to R-LESS. Even though previous studies have shown feasibility with R-LESS, the future of R-LESS depends on the availability of purpose-built robotic platforms. The larger concern is the demonstration of the definitive advantage of single-site over the conventional multiport surgery.

Comparative study of multiport laparoscopy and umbilical laparoendoscopic single-site surgery with reusable platform for treating renal masses

INTRODUCTION

Umbilical laparoendoscopic single-site (LESS) surgery is an increasingly used modality for treating renal masses. We present a prospective comparison between LESS renal surgery and conventional laparoscopy.

MATERIAL AND METHOD

A comparative paired study was conducted that evaluated the surgical results and complications of patients with renal neoplasia treated with LESS surgery (n=49) or multiport laparoscopy (n=53). The LESS approach was performed with reusable material placed in the navel and double-rotation curved instruments. An additional 3.5-mm port was employed in 69.4% of the cases. We assessed demographic data, the type of technique (nephrectomy, partial nephrectomy and nephroureterectomy), surgical time, blood loss, haemoglobin, need for transfusion, number and severity of complications (Clavien-Dindo), hospital stay, histological data and prognosis.

RESULTS

There were no differences in follow-up, age, sex, body mass index, preoperative haemoglobin levels or type of surgery. Conversion occurred in 2 cases (1 in each group). The surgical time was equivalent (P=.6). Intraoperative transfusion (P=.03) and blood loss (P<.0001) was lower with LESS, postoperative haemoglobin levels were higher (P<.0001) and haemostatic agents were used more frequently (P<.0001). There were no differences in the number (P=.6) or severity (P=.47) of complications. The length of stay (P<.0001), the proportion of patients with drainage (P=.04) and the number of days with drainage (P=.0004) were lower in LESS. Twenty-five percent of the lesions operated on with LESS were benign, but the mean size was similar in the 2 groups (P=.5). Tumour recurrence and/or progression were more frequent in multiport laparoscopy (P=.0013).

CONCLUSIONS

Umbilical LESS surgery with reusable platform enables various surgical techniques to be performed when treating renal masses, with time consumption and safety comparable to conventional laparoscopy. The LESS approach is advantageous in terms of blood loss and hospital stay.

Influence of scars on body image consciousness with respect to gender following laparoendoscopic single-site versus conventional laparoscopic surgery

OBJECTIVE

The aim of this study was to evaluate and compare the cosmetic outcomes of laparoscopic single-site surgery (LESS) and conventional laparoscopy (CL) in the treatment of ureteropelvic junction obstruction (UPJO) and urachal remnant removal. LESS is thought to produce better cosmetic results than CL; however, patients' perception of their scars has not been assessed. This study compared the subjective body image and cosmesis ratings of patients who had undergone LESS or CL for UPJO and urachal remnant removal.

MATERIALS AND METHODS

Fifty patients who underwent LESS or CL for UPJO or urachal remnant removal between June 2008 and June 2015 were included. Cosmetic outcomes were evaluated using the Body Image Questionnaire (BIQ) and Photo-Series Questionnaire (PSQ).

RESULTS

The body image and cosmetic scores were significantly higher for patients who underwent LESS than for those who underwent CL, for both pyeloplasty and urachal remnant removal (p < .05 each). When performed for either a pyeloplasty or urachal remnant removal, significantly greater BIQ and PSQ scores were observed in females after LESS compared to CL, but not in males.

CONCLUSION

LESS for UPJO and urachal remnant removal has better self-reported body image and cosmesis ratings than CL. This trend is particularly strong in female patients.