Laparoendoscopic single-site radical nephrectomy for large renal masses

Novel methods for mapping the cavernous nerves during radical prostatectomy

The cavernous nerves, which course along the surface of the prostate gland, are responsible for erectile function. During radical prostatectomy, urologists are challenged in preserving these nerves and their function. Cavernous nerves are microscopic and show variable location in different patients; therefore, postoperative sexual potency rates are widely variable following radical prostatectomy. A variety of technologies, including electrical and optical nerve stimulation, dye-based optical fluorescence and microscopy, spectroscopy, ultrasound and magnetic resonance imaging have all been used to study cavernous nerve anatomy and physiology, and some of these methods are also potential intraoperative methods for identifying and preserving cavernous nerves. However, all of these technologies have inherent limitations, including slow or inconsistent nerve responses, poor image resolution, shallow image depth, slow image acquisition times and/or safety concerns. New and emerging technologies, as well as multimodal approaches combining existing methods, hold promise for improved postoperative sexual outcomes and patient quality of life following radical prostatectomy.

Roles of NOTES and LESS in management of small renal masses

INTRODUCTION

Over the last 2 decades, open surgery has been largely displaced by laparoscopic surgery for the treatment of renal masses. Recently, minimally invasive surgical techniques, such as laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES), have been developed for such purpose.

METHODS

In the present literature review, the current status of treatment for small renal masses was investigated. The advantages and disadvantages of LESS and NOTES are presented to confirm the feasibility and reproducibility of these techniques.

RESULTS

LESS significantly reduces pain and offers excellent cosmetic outcomes with comparable oncological and perioperative results, and NOTES offers the potential for surgery by various approach without any transcutaneous abdominal incision in management of small renal masses.

CONCLUSION

When the technical limitations are overcome, clinical application of LESS and NOTES is expected to increase. Further prospective and comparative studies are needed to clarify the application of these new techniques.

Oncologic and Functional Outcomes of Laparoendoscopic Single-Site Radical Nephrectomy for Localized Kidney Cancer: A Single Surgeon's Series with a Minimum of 3-Year Follow-Up

OBJECTIVE

To evaluate intermediate-term oncologic and renal functional outcome of laparoendoscopic single-site radical nephrectomy (LESS-RN) in the treatment of localized kidney cancer.

METHODS

We performed a chart review of patients who underwent LESS-RN between 2009 and 2011 at our institution. Patients with a minimum of 3 years of follow-up were included in this study. The demographic data and main perioperative outcome variables were analyzed. Estimated glomerular filtration rate was calculated using the Modification of Diet Renal Disease equation. Upstaging of chronic kidney disease (CKD) was calculated. The Kaplan-Meier method was used to calculate overall survival (OS), cancer-specific survival (CSS), and cancer-free survival (CFS). Multivariate logistic regression was performed to show predicting factors for an undesirable outcome arbitrarily defined as any one or more of the following events: surgical conversion, complication of Clavien grade >2, new onset of CKD stages ≥3 at the latest follow-up, or cancer recurrence or metastasis.

RESULTS

A total of 51 patients were included with a median follow-up of 41 (interquartile range: 38-45) months. The OS, CSS, and CFS rates at 3 years were 100%, 100%, and 98%, respectively. There was a 74.5% (38/51) upstaging of CKD at the latest follow-up, with 22 patients (43.1%) who developed a new onset of CKD stages ≥3. Multivariate analysis showed that patient age, body mass index, Charlson comorbidity index, early surgeon experience, and follow-up duration (all p < 0.05) have increased the odds of an undesirable outcome.

CONCLUSIONS

For localized kidney cancer, LESS-RN is effective in oncologic control at an intermediate follow-up interval but, similar to other kinds of RN technique, it is associated with worsened renal functional outcomes.

Position of laparo-endoscopic single-site surgery nephrectomy in clinical practice and comparison (matched case-control study) with standard laparoscopic nephrectomy

INTRODUCTION

One way how to reduce morbidity and improve cosmesic of kidney surgery is single site laparoscopy. Relatively well described concept but without defined position in clincal practise.

AIM

To report of institutional experience with laparoendoscopic single-site surgery (LESS) nephrectomy (NE) and compare (matched case-control study) it with that of standard laparoscopic NE (LNE).

MATERIAL AND METHODS

In the period 8/2011 to 10/2013, we performed 183 mini-invasive NE (132 tumours, 51 benign aetiology); 45 of them (24.6%) were LESS, the rest LNE. The main but not absolute indications for LESS were: non-obese men, and less advanced tumours. In 13 patients undergoing LESS-NEs (28.9%) there was a transumbilical approach. For the rest, a pararectal incision was performed and an accessory port was added in 31.1% (14) - 2/22 (9.1%) left sided, 12/23 (52.2%) right sided. Twenty-four LESS-NE were performed by a more experienced surgeon (mean operation time (MOT) 73.1 min), 21 LESS-NE by 4 other surgeons (MOT 132.8 min). These 24 were compared with 43 LNE done by the same surgeon before the period of LESS (1/2007-8/2011) and with similar characteristics of cases (body mass index (BMI) ≤ 35 kg/m(2), less advanced tumour).

RESULTS

We found no statistically significant differences in any of the parameters studied. The MOT 73.1 min vs. 75.0 min (p = 0.78), BMI 27.4 kg/m(2) vs. 29.2 kg/m(2) (p = 0.08), blood loss 54.7 vs. 39.2 (p = 0.47). Complications (4.2% vs. 11.6%) were only of internal character in origin. No conversion in either group. In LESS-NE, staplers were used more frequently (more expensive than clips) for division of renal hilar vessels (70.8% vs. 51.2%). The mean price of LESS-NE was €367 higher.

CONCLUSIONS

The LESS NE performed by an experienced surgeon is a safe and efficient method for the surgical treatment of both malignant and benign renal conditions in patients with BMI < 30 kg/m(2) and with low-stage tumours. The LESS NE is more expensive compared to LNE.

Laparoendoscopic single-site surgery in kidney surgery: clinical experience and future perspectives

Laparoscopic surgery of the upper urinary tract has reduced the morbidity related to large abdominal incisions and has resulted in significant advantages over open surgery. Nevertheless, the pursuit for even more minimally invasive alternatives to laparoscopy has led to the concept of scarless surgery and the approach of laparoendoscopic single-site surgery (LESS). LESS is currently a feasible approach for the majority of kidney surgical procedures, and there is intense debate regarding its efficiency and advantages. In the present review of the literature, the current status of upper urinary LESS and its advantages and disadvantages, as well the technological and technical evolution, are presented.