Laparoendoscopic Single-Site Urological Surgery Using a Homemade Single Port Device: The First 70 Cases Performed at a Single Center by One Surgeon

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.

Single-port laparoscopic-assisted ovariohysterectomy with a modified glove-port technique in dogs

Objective

To describe a single‐port laparoscopic‐assisted ovariohysterectomy (LOHE) with a modified glove‐port technique in dogs and compare it with previously published laparoscopic techniques for LOHE in dogs.

Study design

Prospective clinical study and technique description.

Animals

Forty‐two healthy female dogs.

Methods

Laparoscopic‐assisted ovariohysterectomy was performed with a custom‐made single‐port device. The total duration of surgery from first incision to skin closure was compared with previously published durations of LOHE in dogs. Short‐term complications were recorded.

Results

The median total duration of surgery was 24 minutes (range, 17.5–39.5; mean, 25.73; SD, 6.12), which was shorter than that described in most previously reported studies of LOHE in dogs (range, 20.8 ± 4.00–60.0 ± 18.45 minutes; P < .001). Intraoperative complications were minor, but wound complications occurred in 12 of 42 (29%) dogs.

Conclusion

Single‐port LOHE with the glove‐port technique in combination with a wound retractor and nonarticulated instruments was completed in all dogs. This technique was faster than what has been previously reported for other LOHE, but local wound complications were common.

Clinical relevance

The glove‐port technique described here offers a low‐cost alternative to other commercially available single‐port devices.

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-port Surgery: Paving the Way for the Future

Adoption of robotic technology in urology has been widely popularized as it provides considerable advantages over standard techniques, including improved instrument dexterity, three-dimensional high-definition optics, and enhanced ergonomics. As a result, these features have facilitated the adaptation of robotics for laparoendoscopic single-site surgery (LESS) to overcome challenges with clashing, suturing, and intra-abdominal triangulation. Since the inception of robotic LESS by our institution in 2008,(1) many centers have gone on to study this approach in various urologic applications. Herein we discuss the evolution of robotic LESS access, instrumentation, and outcomes with special focus on up-and-coming technology.

An innovative procedure of laparoscope combined with endoscopy for gastrointestinal stromal tumor resection and cholecystectomy: A case report and literature review

The present study reports a novel approach to laparoscopic and endoscopic cooperative surgery for gastric gastrointestinal stromal tumor (GIST) resection and cholecystectomy, and conducts a review of the associated literature. The novel surgical procedure was performed on one patient who was diagnosed with a GIST and cholecystic polypus. The GIST was resected using an insulation-tipped diathermic electrosurgical knife under the guide of an endoscope. Subsequently, a cholecystectomy was performed by inserting two more 5-mm trocars and instruments transumbilically, guided using an endoscope. The tumor and the gallbladder were exteriorized using a peroral approach and the incision lining of the stomach was sutured laparoscopically. The procedure was successfully performed and the patient experienced no discomfort during the 5-year follow-up. In conclusion, the present study demonstrates that laparoscopic and endoscopic cooperative surgery is feasible and would be an ideal choice for invisible abdominal scar surgery, in particular for multi-visceral resection.

Retroperitoneal Laparoendoscopic Single-Incision Radical Nephrectomy Without Special Platforms: A Single-Center Initial Experience

OBJECTIVES

To describe the initial experience of retroperitoneal laparoendoscopic single-incision radical nephrectomy (LESI-RN) without special platforms and use of conventional laparoscopic instruments and assess the safety and feasibility of LESI-RN.

SUBJECTS AND METHODS

Twenty patients who underwent LESI-RN were enrolled in this study. A 5-cm arc skin incision was performed at the midpoint between the costal arch and iliac crest on the midaxillary line. Trocars of 10, 5, and 11 mm were placed at the middle, left end, and right end of the arc incision, respectively. Demographic parameters and perioperative data were retrospectively analyzed and compared with the patients who underwent conventional retroperitoneal laparoscopic radical nephrectomy (LRN).

RESULTS

The LESI-RN patients had a significantly lower visual analogue scale (4.4 ± 1.9 versus 5.6 ± 1.4; P = .031) and analgesic requirement (18.5 ± 11.2 versus 28.6 ± 16.1; P = .026) compared with the conventional LRN group. The operation time in the LESI-RN group was longer than that in the conventional LRN group (P = .001). The two procedures were essentially similar in terms of the time to liquid intake and hospital stay after operation (P > .05).

CONCLUSIONS

LESI-RN is a safe and feasible surgical strategy, which combines the common principles of using straight instruments and working triangulation in conventional LRN with advantages of cosmesis and minimal invasiveness in laparoendoscopic single-site surgery. The surgical and oncological efficacy of LESI-RN is similar to that of conventional LRN but with significantly improved control of postoperative pain and cosmetic results.

The association of hypotension with the insertion of an abdominal retractor during lower abdominal surgery in pediatric patients: a retrospective observational study

BACKGROUND

The Alexis(®) wound retractor is composed of an inner- and outer-ring, with the inner-ring placed inside the abdominal cavity. This placement can constrict the internal organs and large vessels, especially in children, which can lead to hypotension. Our study aimed to investigate the relation between the incidence of hypotension and insertion of the wound retractor during lower abdominal surgery in pediatric patients.

METHODS

We retrospectively examined 161 pediatric patients (<4 years old), who underwent lower abdominal surgery, regardless of abdominal retractor type. Hypotension was defined as a decrease in systolic blood pressure of >15% from baseline. We used logistic regression to predict hypotension using the following nine parameters: age, height, weight, American Society of Anesthesiologists physical status (ASA-PS), sex, laterality of the operation (unilateral or bilateral), presence or absence of caudal block, wound length, and type of retractor (retractors with or without an inner-ring).

RESULTS

Logistic multivariate regression analysis revealed that a retractor with an inner-ring use (odds ratio 3.28, 95% CI 1.41-7.63, P = 0.006) and younger age (odds ratio 1.07 per month, 95% CI 1.02-1.12, P = 0.010) were independent risk factors associated with hypotension following lower abdominal surgery in this age group.

CONCLUSIONS

Patient age and use of a wound retractor with an inner-ring are independent risk factors associated with hypotension during insertion of the abdominal retractor in lower abdominal surgery.

Current status of robotic laparoendoscopic single-site partial nephrectomy

Robotic laparoendoscopic single-site partial nephrectomy is increasingly carried out in an attempt to improve the cosmetic outcome of minimally-invasive procedures. However, the actual role of this novel technique remains to be determined. The present article reviews evidence and examines updates of robotic laparoendoscopic single-site partial nephrectomy outcomes reported in more contemporary studies. A comprehensive online systematic search of PubMed, Scopus and Web of Science databases according to Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria recommendations was carried out in January 2014, identifying data from 2008 to 2014 regarding robotic laparoendoscopic single-site partial nephrectomy. The majority of medical evidence to date is based on case reports or retrospective studies. Current studies show that robotic laparoendoscopic single-site partial nephrectomy is a feasible procedure carried out in an acceptable length of operative time, and resulting in a desirable cosmetic outcome and less postoperative pain. However, comparable studies show that robotic laparoendoscopic single-site partial nephrectomy is inferior to the conventional approach, especially with regard to warm ischemia time. Furthermore, the numerous limitations that exist with the utilization of the current commercial single-site devices make robotic laparoendoscopic single-site PN more challenging and more complicated for surgeons compared with conventional procedures. Further significant improvements, along with more studies, are required in order to develop the ideal robotic laparoendoscopic single-site robotic platform and overcome the current limitations. For the time being, robotic laparoendoscopic single-site partial nephrectomy procedures could be applicable in patients with low tumor size and complexity, and should not be routinely applied in all cases.

New technologies in robotic surgery: the Korean experience

PURPOSE OF REVIEW

The development of the robotic systems has made surgery an increasingly technology-driven field. Since the introduction of the first robotic platform in 2005, surgical practice in South Korea has also been caught up in the global robotic revolution. Consequently, a market focused on improving the robotic systems was created and Korea has emerged as one of its frontrunners. This article reviews the Korean experience in developing various robotic technologies and then Korea's most recent contributions to the development of new technologies in robotic surgery.

RECENT FINDINGS

The goal of new technologies in the field of robotic surgery has been to improve on the current platforms by eliminating their disadvantages. The pressing goal is to develop a platform that is less bulky, more ergonomic, and capable of providing force feedback to the surgeon. In Korea, the Lapabot and two new robotic systems for single-port laparoscopic surgery are the most recent advances that have been reported.

SUMMARY

Robotic surgery is rapidly evolving and Korea has stayed in the forefront of its development. These new advancements in technology will eventually produce better robotic platforms that will greatly improve the manner in which surgical care is delivered.

Outcomes of a single-port laparoscopic appendectomy using a glove port with a percutaneous organ-holding device and commercially-available multichannel single-port device

Purpose

A laparoscopic appendectomy is now commonly performed. The push in recent years toward reducing the number of ports required to perform this surgery has led to the development of a single-port laparoscopic appendectomy (SPA). We compared postoperative pain after an SPA using a glove port with a percutaneous organ-holding device (group 1) with that of an SPA using a commercially-available multichannel single-port device (group 2).

Methods

Between March 2010 and July 2011, a retrospective study was conducted of a total of 77 patients who underwent an SPA by three surgeons at department of surgery, Kangbuk Samsung Medical Center. Thirty-eight patients received an SPA using a glove port with a percutaneous organ-holding device. The other 39 patients received an SPA using a commercially-available multichannel single port (Octo-Port or SILS Port). Operative details and postoperative outcomes were collected and evaluated.

Results

There were no differences in the mean operative times, times to pass gas, postoperative hospital stays, or cosmetic satisfaction scores between the two groups. The pain score in the first 24 hours after surgery was higher in group 2 than group 1 patients (P < 0.001). Furthermore, the trocar used in group 2 was more expensive than that used in group 1.

Conclusion

An SPA using a glove port with a percutaneous organ-holding device was associated with a lower pain score during the first 24 hours after surgery because of the shorter fascia incision length and a cheaper cost than an SPA using a commercially-available multichannel single-port device.

Laparoendoscopic single-site surgery with a single channel versus conventional laparoscopic varicocele ligation: a prospective randomized study

PURPOSE

The objective of this study was to evaluate the safety and feasibility of single channel laparoscopy in the treatment of patients with varicocele.

PATIENTS AND METHODS

Ninety patients with clinically palpable varicoceles were randomly assigned to receive laparoendoscopic single-site with a single channel varicocele ligation (LESS[sc]-VL) (n=45) or conventional transperitoneal laparoscopic varicocele ligation (CTL-VL) (n=45). Patient characteristics, perioperative details, total procedural cost, time to return to work, visual analogue scale (VAS) pain score, semen parameters, and cosmetic results were recorded.

RESULTS

There were no differences in operative time (P=0.102), postoperative hospitalization time (P=0.130), total cost (P=0.112), or postoperative complications (P>0.05) between the two groups. Time to return to normal activities was shorter in the LESS(sc)-VL group than that in the CTL-VL group (P=0.018). The mean of all semen parameters were improved statistically 3 months after ligation (P<0.001). The VAS incision pain score was significantly lower 6 and 24 hours after surgery in patients who underwent LESS(sc)-VL(P<0.05). Patients who underwent LESS(sc)-VL had a better cosmetic result, reflected by both the verbal response scale and the numeric scale (P=0.008 and P=0.005, respectively).

CONCLUSIONS

LESS(sc)-VL is a safe and effective minimally invasive surgical alternative for varicocelectomy. Compared with CTL-VL, LESS(sc)-VL may decrease postoperative pain and hide the surgical incision better within the umbilicus.

Single-port laparoscopic retroperitoneal surgery using a modified single-port device in urology

OBJECTIVES

To investigate the use of a flexible instrument platform in performing single-port laparoscopic retroperitoneal urologic surgeries and to verify the safety and feasibility of these surgeries.

METHODS

The homemade instrument platform consisted of two control loops and a powder-free surgical glove to form multichannels. 56 patients underwent this kind of single-port surgery for different urologic diseases, including radical nephrectomy in 31 patients, nephroureterectomy in 7 patients, partial nephrectomy in 8 patients, living donor nephrectomy in 4 patients, adrenalectomy in 3 patients, renal cyst surgery in 2 patients and ureterolithotomy in 1 patient.

RESULTS

All surgeries were completed successfully with no switch to conventional laparoscopic or open surgery. The mean hospital stay was 13.13 days (range 6-36). All patients were satisfied without major complications.

CONCLUSIONS

Retroperitoneal laparoendoscopic single-site surgery using our cost-effective homemade instrument platform appears to be a feasible and safe surgical strategy to perform retroperitoneal laparoscopic urologic surgery.

Retroperitoneal laparoendoscopic single-site radical nephrectomy using a low-cost, self-made device: initial experience with 29 cases

OBJECTIVES

To introduce a low-cost, self-made device for single-port retroperitoneal laparoscopic radical nephrectomy and to evaluate outcomes compared with conventional laparoscopy after initial experience using this device.

METHODS

Twenty-nine renal cancer patients underwent retroperitoneal laparoendoscopic single-site radical nephrectomy using a self-made single-port device with multiple manipulation channels for passage of routine laparoscopic instruments and specimen removal. A control group of 29 patients who were matched by age, gender, and cancer stage underwent conventional laparoscopy. Outcomes were analyzed retrospectively.

RESULTS

There were no significant differences in age, gender, body mass index, T stage, and maximum tumor diameter between groups (P > .05). The laparoendoscopic single-site surgery group had a significantly shorter duration of postoperative hospitalization than the conventional laparoscopy group (7.14 ± 1.38 days vs 8.17 ± 1.54 days, P = .009).

CONCLUSIONS

Retroperitoneal laparoscopic radical nephrectomy using our self-made single-port device appears to be a feasible, safe, and low-cost surgical strategy.

Feasibility of robotic laparoendoscopic single-site partial nephrectomy for renal tumors >4 cm

BACKGROUND

Laparoendoscopic single-site (LESS) urologic procedures have gained significant interest worldwide in an attempt to further reduce morbidity and minimize scarring associated with conventional laparoscopic surgery. The robotic technology has overcome some of the limitations of manual single-incision surgery relating to lack of triangulation, instrument collision, and surgical exposure. There are no data on robotic LESS partial nephrectomy (PN) for renal tumors >4 cm.

OBJECTIVES

To evaluate the feasibility of robotic LESS PN for renal tumors >4 cm.

DESIGN, SETTING, AND PARTICIPANTS

Data from 67 consecutive patients who underwent robotic LESS PN were collected between May 2009 to January 2011.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Patients were stratified into two groups: 20 patients with renal tumors >4 cm (group 1) and 47 patients with renal tumors ≤ 4 cm (group 2). Perioperative data were recorded and comparisons between the two groups were analyzed using the Mann-Whitney U test for continuous variables and Fisher exact test for categorical variables.

RESULTS AND LIMITATIONS

No statistically significant differences were found between the two groups in demographic information, operative complications, pathologic characteristics, mean decline in estimated glomerular filtration rate, estimated blood loss, operative times, conversion rate, or positive surgical margins. However, group 1 had a higher mean nephrometry score (p<0.01), longer warm ischemia time (p = 0.007), and longer length of stay (p = 0.046). Its retrospective design and being conducted at a single center were the main limitations of this study.

CONCLUSIONS

This study demonstrated the feasibility and safety of robotic LESS PN for tumors >4 cm. Patients with tumors >4 cm had a statistically significant, higher mean nephrometry score, longer warm ischemia time, and longer length of stay, but there was no increased risk of adverse outcomes. A long-term study is needed to confirm the durable renal preservation and oncologic outcomes for patients with larger tumor burden.

Laparoendoscopic single site varicocele ligation: comparison of testicular artery and lymphatic preservation versus complete testicular vessel ligation

PURPOSE

We compared postoperative outcomes in patients treated with laparoendoscopic single site varicocele ligation with or without testicular artery and lymphatic preservation.

MATERIALS AND METHODS

A total of 80 patients with left varicocele were randomly divided into 2 groups and treated with laparoendoscopic single site varicocele ligation with preservation of the testicular artery and lymphatics (40 in group 1) or complete ligation of the testicular vessels and lymphatics (40 in group 2). Operative time, hospital stay, return to normal activity, postoperative visual analog scale pain scores and complications were analyzed. In patients with subfertility preoperative and 3-month postoperative semen analyses were performed. In patients with scrotal pain preoperative and 12-month postoperative visual analog scale pain scores were analyzed.

RESULTS

A total of 35 patients per group completed the study. Hospital stay, return to normal activity and postoperative pain scores did not differ between the groups. No major complications were observed. Mean ± SD operative time was 60.7 ± 10.7 and 48.6 ± 6.0 minutes in groups 1 and 2, respectively (p <0.001). Patients with subfertility, including 22 in group 1 and 21 in group 2, showed improved semen parameters 3 months postoperatively but postoperative values did not differ between the groups. The 17 patients in each group with scrotal pain showed decreased pain scores 12 months postoperatively with no difference between the groups.

CONCLUSIONS

Laparoendoscopic single site varicocele ligation is feasible. No differences in postoperative outcomes and complications were observed when preserving or not preserving the testicular artery and lymphatics.

Retroperitoneal laparoendoscopic single-site surgery by single trocar technique: initial experience with renal cyst decortication

OBJECTIVE

To retrospectively review our initial experience with respect to evaluating the feasibility and safety of retroperitoneal laparoendoscopic single-site surgery (LESS) for renal cyst decortication using the single trocar technique.

PATIENTS AND METHODS

Between April 2010 and November 2011, 45 patients with symptomatic simple renal cyst have undergone retroperitoneal LESS using the single trocar technique by the same experienced laparoscopic surgeon. A 10-mm 0° laparoscope with a 6-mm working channel and straight conventional laparoscopic instruments were used during all the procedures. Salient demographic and operative data were recorded, including age, body mass index, operative time, estimated blood loss, perioperative complications, analgesic requirement, etc.

RESULTS

Forty-three cases were accomplished successfully. In the remaining 2 patients dense adhesions around the renal cyst were encountered, and the operations were completed with an additional 5-mm trocar. The mean operative time was 49 minutes. The mean estimated blood loss was 12 mL. The mean in-hospital analgesic requirement was 2.8 mg of morphine equivalent. The mean time for ambulation postoperatively was 2 days; at the same time the drainage catheter was removed. The mean hospital stay was 3 days. There were no major perioperative complications, but superficial wound infection was noted in 1 patient.

CONCLUSIONS

Our initial experience with retroperitoneal LESS by the single trocar technique shows the safety and feasibility for renal cyst decortication and provides acceptable operative outcomes.

Laparoendoscopic single-site repair of bladder rupture using a home-made single-port device: initial experience of treatment for a traumatic intraperitoneal bladder rupture

We report our initial experience with a laparoendoscopic single-site (LESS) repair of a bladder rupture using a home-made single-port device. A 37-year-old man presented to the emergency department with complaints of voiding difficulty and gross hematuria after blunt trauma. Cystography and computed tomography revealed an intraperitoneal bladder rupture. The patient underwent LESS repair of a bladder rupture using the Alexis wound retractor, which was inserted through the umbilical incision. A home-made single-port device was made by fixing 6½ surgical gloves to the outer rim of the retractor and securing the glove finger to the end of 3 trocars with a tie. Using the flexible laparoscopic instruments and rigid instruments, LESS surgery was performed using a procedure similar to conventional laparoscopic surgery. The patient did not have any voiding problem after removal of the urethral Foley catheter on the 10th postoperative day. To our knowledge, this is the first published report of LESS repair of a traumatic bladder rupture using a home-made single-port device in the literature.

Laparoendoscopic single-site surgery for benign urologic disease with a homemade single port device: design and tips for beginners

Purpose

A single surgeon skilled in conventional laparoscopic surgery used laparoendoscopic single-site surgery (LESS) to treat benign urological diseases. This study reports our surgical results and introduces a simple technique with tips based on our experience.

Materials and Methods

LESS surgery was performed on 116 patients by use of a homemade single-port device composed of an Alexis wound retractor and a powder-free surgical glove. Cases were 44 varicocelectomies (including 8 bilateral cases), 38 renal cyst marsupializations (including 3 bilateral cases), 26 ureterolithotomies (with 1 concomitant ureterolithotomy and contralateral renal cyst marsupialization), 4 prostatic enucleations, and 4 bladder rupture repairs. The mean patient age was 44.43±16.46 years (range, 11 to 76 years), and the male-to-female ratio was 87:29.

Results

In one ureterolithotomy case, LESS was converted to conventional laparoscopic surgery. The mean operative time was 87.03±45.03 minutes, the estimated blood loss was 61.90 ml (range, 0 to 2,000 ml), and the mean hospital stay was 3.03±2.12 days. Two patients underwent single-port transvesical enucleation of the prostate (STEP) requiring patient-controlled anesthesia. No patients developed major complications, and all patients were satisfied, with 75.86% expressing a high degree of satisfaction.

Conclusions

We report successful treatment outcomes for LESS in 116 cases of benign urological disease. Our findings suggest that LESS can replace conventional laparoscopy.

Concomitant laparoendoscopic single-site surgery for vesicolithotomy and finger-assisted single-port transvesical enucleation of the prostate

Transurethral resection of the prostate is the most common surgery for benign prostatic hyperplasia. However, it doesn't work best for men with very large prostate and bladder stones. Herein we report our initial experience with concomitant laparoendoscopic single-site surgery and finger-assisted single-port transvesical enucleation of the prostate for the treatment of the condition.

Laparo-endoscopic single-site surgery: recent advances in urology

Significant advances have been achieved in the field of urologic laparo-endoscopic single-site surgery (LESS) since the first reported clinical series in 2007. The aim of the present review paper is to summarize and critically analyze the most recent advances in the field of urologic LESS. A literature review was performed using PubMed to retrieve publications related to LESS in urology over the last two years (from January 2011 to May 2012). In the free-text protocol, the following terms were applied: LESS; single port laparoscopy; single incision laparoscopy. Despite unsolved challenges, LESS can be regarded as an emerging trend in minimally invasive urologic surgery and it has significantly evolved, becoming a widely applicable technique in a relatively short time. Outcomes demonstrate that a broad range of procedures can be effectively and safely done, given a solid laparoscopic surgical background and stringent patient-selection criteria. The recent introduction of a purpose-built instrumentation is likely to further foster the application of robotics to LESS. Further improvements are needed before this technique might reach a widespread adoption. Future advances in the field of robotic technology are expected to overcome the current limitations of LESS.

Transumbilical laparoendoscopic single-site surgery: more than 1-year experience in radical nephrectomy and its learning curve study

PURPOSE

The aim is to report our 1-year experience in transumbilical Laparoendoscopic single-site (LESS) radical nephrectomy (LESS-RN) and assess its learning curve.

PATIENTS AND METHODS

From September 2009 to December 2010, 18 consecutive patients with a solitary renal tumor underwent transumbilical LESS-RN. We grouped measured parameters on the basis of the first nine (group A) and last nine (group B) patients, and compared both subgroups with the control group (C), which was composed of the initial nine consecutive patients who underwent conventional laparoscopic RNs performed by the same surgeon.

RESULTS

There was one LESS patient converted to conventional laparoscopic surgery for intraoperative hemorrhage and transfused. The mean for measured parameters of the groups A, B, C were: age: 58.6, 57.2, and 59.2 years, respectively (P>0.05); American Society of Aneshesiologists score: 1.9, 2.0, and 2.0, respectively (P>0.05); body mass index: 25.2, 23.5, and 23.1 kg/m(2), respectively (P>0.05); lesion size at CT scan: 5.0, 4.6, and 6.2 cm, respectively (P=0.039); operative skin to skin time: 191.6, 123.9, and 122.2 minutes, respectively (P=0.000); estimated blood loss: 172.2, 246.7, and 116.7 mL, respectively (P>0.05); incision length: 5.6, 5.9, and 7.4 cm, respectively (P=0.000); hospital stay: 5.8, 5.8, and 5.8 days, respectively (P>0.05). At the latest follow-up, all patients did not present any local recurrence or metastasis.

CONCLUSIONS

In selected patients, the transumbilical LESS-RN can be safely performed with favorable outcomes. While a learning curve certainly exists, it appears to be short for an experienced laparoscopic surgeon.

Single-port transvesical enucleation of the prostate for benign prostatic hyperplasia with severe intravesical prostatic protrusion

OBJECTIVES

To introduce the surgical techniques of a single-port transvesical enucleation of the prostate (STEP) for enlarged prostates with severe intravesical prostatic protrusion (IPP) presenting with lower urinary tract symptoms (LUTS).

PATIENTS AND METHODS

Our study included 7 patients with prostates larger than 80 mL and with severe IPP who underwent STEP. All the procedures were performed using a home-made single-port device through a 3-cm midline incision at the level three fingerbreadths above the symphysis pubis. Rigid laparoscopic instruments and Harmonic Scalpels(®) were used to enucleate the large adenoma of the prostate.

RESULTS

All the procedures were completed satisfactorily, with no intra and early postoperative complications. The mean resected prostatic weight was 54.14 ± 8.38 g, and the mean operative time was 191.86 ± 40.88 min. The mean time for catheterization was 5.29 ± 1.80 days. The postoperative 3-month international prostate symptoms score (IPSS) and maximal flow rate (Qmax) were improved following STEP (IPSS; 23.57 ± 2.15 vs. 11.43 ± 2.44, Qmax; 17.14 ± 3.44 mL/s vs. 6.71 ± 2.29 mL/s).

CONCLUSIONS

Laparoendoscopic single-site surgery (LESS) and enucleation of the prostate with rigid laparoscopic instruments might be difficult but is feasible. STEP may be a new treatment option for use in open prostatectomies for enlarged prostates with severe IPP in carefully selected patients.

Laparoendoscopic single-site renal cyst marsupialization using a homemade single-port device has a role as a feasible treatment option

AIM

In patients with a renal cyst and concurrent symptoms, we examined the effectiveness and safety of laparoendoscopic single-site surgery (LESS) for renal cyst marsupialization using a homemade single-port device (HSPD) by a single surgeon (S.W.L.).

PATIENTS AND METHODS

The present study was conducted on a total of 31 patients with a renal cyst. A LESS renal cyst marsupialization was performed using a HSPD based on the Alexis® wound retractor and a powder-free surgical glove. In our study, the mean age was 55.29 ± 10.86 (range 31-73) years and the mean size of the renal cyst was 6.83 ± 1.09 cm.

RESULTS

All the surgical procedures were successfully performed. The mean operative time was 101.35 ± 16.04 min. Of the patients who underwent the procedure, none presented with major complications. In 7 patients who had pain preoperatively, there was a significant difference in the visual analogue pain scale score at 6.86 ± 0.69 preoperatively and 1.71 ± 0.49 at postoperative week 4 (p < 0.001). The number of patients who were satisfied with the postoperative outcome was 29 (93.5%).

CONCLUSIONS

In patients with a simple renal cyst, LESS renal cyst marsupialization using a HSPD might be considered as a feasible, safe surgical treatment option.

Laparoendoscopic single-site ureterolithotomy for upper ureteral stone disease: the first 30 cases in a multicenter study

PURPOSE

We evaluated the usefulness of laparoendoscopic single-site (LESS) ureterolithotomy with a homemade single port device for upper ureteral stones in patients in whom previous shockwave lithotripsy or ureteroscopic stone surgery had failed or the stone was suspected to be impacted.

PATIENTS AND METHODS

LESS ureterolithotomy was performed on 30 patients by using a homemade single port device composed of an Alexis wound retractor and surgical glove. The mean age of the patients was 42.47±11.15 years (range 24-65 y), and the male-to-female ratio was 13:17. The mean stone diameter was 1.77±0.47 cm. One patient underwent a bilateral operation for bilateral ureteral stones.

RESULTS

The LESS surgery was converted to conventional laparoscopic surgery in one case. The mean operative time was 110.43±43.75 minutes. The mean length of hospital stay was 3.40±1.54 days. None of the patients used patient-controlled anesthesia, and none presented with major complications. The visual analog pain scale score improved significantly by postoperative day 7 (from 6.87±1.61 preoperatively to 1.67±1.16; P<0.001), and 28 (93.3%) patients said they were satisfied with the postoperative outcome. Postoperative radiologic evaluation revealed that the stones had been removed completely in 28 cases. There were no cases of urinary leakage.

CONCLUSION

LESS ureterolithotomy using a homemade single port device can be considered to be a feasible and safe alternative to conventional laparoscopic ureterolithotomy.