The Effect of Previous Abdominal Surgery on Urological Laparoscopy:

Single Port Radical Prostatectomy as a Viable Option for Highly Complex Patients: A Single Center Experience

OBJECTIVE

To explore the safety and feasibility of the Da Vinci single-port (SP) platform in robotic-assisted radical prostatectomy (SP-RARP), aiming to provide a viable option for patients with surgical and medical complexities that might otherwise limit their access to common minimally invasive technique.

METHODS

Data from 60 medically and surgically highly complex patients undergoing SP-RARP between December 2018 and December 2023 were analyzed. Variables included patient characteristics, surgical history, intraoperative and postoperative outcomes. Statistical analysis was conducted using Stata 17.0.

RESULTS

Fifty-three percent of cases had a hostile abdomen (HA) (≥1 major abdominal surgery), and 47% were medically highly complex (American Society of Anesthesiologists score ≥3, Charlson Comorbidity Index ≥5, and a body mass index ≥30). The extraperitoneal approach was used in 56% of HA cases and 68% of MHC cases. Intraoperative complications occurred in 12%, exclusively with the transperitoneal approach in HA cases. Postoperative complications (Clavien-Dindo ≥3) were 6% and 14%, respectively, with no significant difference between approaches. Same-day discharge was possible in 44% of HA cases and 54% of MHC cases, with significant statistical differences favoring the extraperitoneal approach in both groups.

CONCLUSION

SP-RARP, particularly the extraperitoneal approach, is a viable option for highly complex and challenging cases, providing acceptable oncological and functional outcomes. Prospective studies are crucial for further validating the safety and feasibility of SP-RARP in this patient population.

Feasibility and outcomes of laparoscopic renal intervention after prior open ipsilateral retroperitoneal surgery

BACKGROUND AND PURPOSE

Treating patients with renal-cell carcinoma (RCC) after previous retroperitoneal surgery (renal or adrenal) is technically challenging. We present our initial experience with laparoscopic renal interventions (LRI) after previous open retroperitoneal surgery in patients needing ipsilateral renal intervention. We report on feasibility, functional and oncologic outcomes of LRI after previous open retroperitoneal surgery.

PATIENTS AND METHODS

We reviewed records of patients undergoing attempted laparoscopic or robot-assisted renal intervention after at least one previous open ipsilateral retroperitoneal surgery. We identified 34 patients who underwent 39 staged attempted LRI after 48 previous open ipsilateral renal or adrenal surgeries. The LRI included 20 minimally invasive partial nephrectomies (MIPN), 11 laparoscopic radiofrequency ablations (LRFA), and 8 laparoscopic nephrectomies (LTN). Demographic, perioperative, renal functional, and oncologic outcome data were collected. Statistical analyses were performed to identify risks for conversion to open surgery.

RESULTS

No attempted nephron-sparing procedure resulted in kidney loss. Overall conversion rate of the cohort was 28% and was highest in the MIPN group (40%). On univariate analysis, only multiple tumors that were treated significantly increased chances of open conversion (P<0.01). Subset analysis demonstrated similar rates of blood loss, operative times, and conversion rates in patients undergoing partial nephrectomy having previous open partial nephrectomy compared with previous open adrenal surgery only. There was no significant difference in preservation of renal function between MIPN and LRFA, with more than 85% of preoperative renal function preserved. Mean follow-up of 11.9 months (range 1-97.5 mos) metastasis-free survival and overall survival was 94.1% and 97%, respectively.

CONCLUSIONS

LRI after previous open ipsilateral retroperitoneal surgery is feasible. Repeated partial nephrectomy has the highest conversion risks among the laparoscopic renal interventions and appears to be independent of previous renal or adrenal procedure. Attempting repeated LRI for multiple tumors is a significant risk factor for open conversion. Renal functional and oncologic outcomes are encouraging at early follow-up.

Conversions in laparoscopic renal surgery: causes and outcomes

PURPOSE

We examined conversions in laparoscopic renal surgery, evaluating the causes and outcomes.

PATIENTS AND METHODS

A single institution review of all laparoscopic renal surgeries, excluding renal donors, over a nine-year period was performed. Cases were evaluated for intraoperative results, conversions, and complications.

RESULTS

399 laparoscopic renal surgeries were identified (394 available for review) with 41 conversions (31 open, 8 hand-assisted, 2 retroperitoneal). Intraoperative and postoperative complications occurred in 3.0% and 12.2%, respectively. The most common reason for conversion was a lack of progress (20), followed by difficult anatomy (8), tumor thrombus (5), and bleeding (4). Open conversion rates for hand-assisted laparoscopic (HAL), transperitoneal laparoscopic, retroperitoneal laparoscopic (RPL), and robot-assisted were 17.1%, 6.9%, 13.2%, and 1.8%, respectively, although HAL and RPL were more often used for bilateral procedures, previous abdominal surgery, and large specimens (P<0.05). Surgical indication significantly impacted perioperative outcome, where autosomal dominant polycystic kidney disease and partial nephrectomy were associated with the highest rate of open conversion (13%), while nephroureterectomy had the highest rate of complications (40%). Cases in which there were large specimens weighing over 1500 g were converted in 40% of cases vs 8.2% for smaller specimens, P<0.001. Previous abdominal surgery did not impact conversion rate (11.9% without vs 9.3% with previous surgery, P=0.401). Cases that were converted had a significantly higher blood loss, operative time, transfusion rate, hospital stay, and complication rate (P<0.05).

CONCLUSIONS

Rate of conversion to an open procedure is significantly impacted by surgical indication, specimen size, and surgical technique. Any conversion is associated with an increased perioperative morbidity.