Recent advances in urologic laparoscopic surgeries: laparoendoscopic single-site surgery, natural orifice transluminal endoscopic surgery, robotics and navigation

Laparoendoscopic radical prostatectomy (LRP): stepwise transition from multi-site to single-site with the aid of the transurethral port

PURPOSE

To describe our initial experience with laparoendoscopic radical prostatectomy (LRP) and a stepwise transition towards transurethral assisted laparoendoscopic single-site RP (TU-LESS RP).

PATIENTS AND METHODS

From Jan. 2007 to Dec. 2016, 195 patients underwent RP, of which 89 patients were performed by LRP (Group A), 106 by TU-LESS RP (Group B). The peri-operative data were collected and analyzed. All data referring to patient demographics, surgery, pathology, and peri-operative outcomes were recorded. The cosmetic result was investigated by the Patient Scar Assessment Questionnaire (PSAQ). Analysis of variance or Chi squared test were adopted to analyze the data.

RESULTS

195 procedures were completed successfully. The operation time (109.6 ± 31.9 vs. 151.5 ± 87.3, P = 0.025) and anastomosis time (10.1 ± 4.8 vs. 21.8 ± 9.9, P < 0.001) of Group B was significantly reduced compared with Group A. Estimated blood loss in Group B was significantly lower than that in Group A (95.9 ± 11.1 vs. 180.2 ± 99.7, P = 0.006). About perioperative complications, Group B was also less compared with Group A (1.9% vs. 7.9%, P = 0.047). As to the usage of postoperative analgesics, Group B apparently used less than that in Group A (6.6% vs. 62.9%, P < 0.001), which is consistent with the visual analogue scale (VAS) of the two groups (1.7 ± 1.3 vs. 7.8 ± 1.1, P < 0.001). Patients in Group B were significantly more satisfied with incision healing than in group A (74.9 ± 9.3 vs. 49.7 ± 5.8, P < 0.001). There was no significant difference both in BCR rate and time between Group B and Group A. In urination control, more patients in Group B did not have urinary incontinence 3 month after RP compared with Group A (81.1% vs. 67.4%, P = 0.028).

CONCLUSIONS

LESS RP is proved to be feasible for the proper patients, but it is difficult to popularized due to inconvenient operation. While by means of TU-LESS, operating difficulty can be significantly decreased. TU-LESS RP will be wildly accepted by surgeons and patients because of cosmetic satisfaction and quicker recovery.

Acute kidney injury and its impact on renal prognosis after robot-assisted laparoscopic radical prostatectomy

BACKGROUND

This study assessed the incidence and impact of acute kidney injury (AKI) on renal prognosis in patients who underwent robot-assisted laparoscopic radical prostatectomy (RARP).

METHODS

Medical records of 305 patients treated with RARP were retrospectively reviewed. The patients with postoperative AKIs were dichotomized into early AKI (immediately after surgery) and late AKI (1-7 days after surgery). The impact of AKIs and their risk factors were statistically assessed.

RESULTS

Early and late AKI were observed in 143 (46.9%) and 12 (3.9%) patients, respectively. Hypertension and console time were independent risk factors for early AKI. Among the patients with preoperative eGFR ≥60 mL/min, the eGFR decline 12 months after surgery was significantly greater in patients with early AKI than that without early AKI (-6.8 vs -3.2 mL/min, P = .02).

CONCLUSIONS

Approximately half of patients developed early AKI after RARP. The patients with early AKI had reduced renal function 12 months after surgery.

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.

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.

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.

Laparoendoscopic single-site surgeries: A multicenter experience of 469 cases in Japan

OBJECTIVE

To report on a multi-institutional series of non-robotic urological laparoendoscopic single-site surgery in Japan.

METHODS

Consecutive cases of laparoendoscopic single-site surgery carried out between February 2009 and December 2012 at nine academic institutions were included. We examined the surgical outcomes, including conversion and complications rates.

RESULTS

Four hundred and sixty-nine cases were included in the analysis. The most common procedure was adrenalectomy (n = 177) and the second most common procedure was radical nephrectomy (n = 143). The procedures also included nephroureterectomy (n = 40), living donor nephrectomy (n = 40), pyeloplasty (n = 30), urachal remnant excision (n = 9), simple nephrectomy (n = 7), radical prostatectomy (n = 6) and others (n = 17). The access sites included umbilicus (n = 248, 53%) and other sites (n = 221, 47%). A transperitoneal approach was used in 385 cases (82%), and retroperitoneal approach in 84 cases (18%). The median operation time of all procedures was 198 min. Conversion to reduced port surgery, conventional laparoscopy, or open surgery was noted in 27 cases (5.8%), 12 cases (2.6%), and two cases (0.4%), respectively, with an overall conversion rate of 8.7%. Intraoperative complications occurred in 10 cases (2.1%). Post-operative complications were noted in 29 cases (6.2%), including five major complications (1.1%). No mortality was recorded in this series.

CONCLUSIONS

Non-robotic laparoendoscopic single-site surgery is technically feasible and safe for various urologic diseases in Japan. Furthermore, urological laparoendoscopic single-site surgery is a promising minimally invasive surgical option that is feasible for experienced urological surgeons in intermediate-volume centers as well as high-volume centers.

Application of laparospic ultrasonography in surgery of small renal cell carcinoma

PURPOSE

: To assess the clinic value of application of laparospic ultrasonography (LU) in partial nephrectomy of small renal cell carcinoma.

MATERIALS AND METHODS

From 2007 to 2011, 28 small renal cell carcinoma patients in ou clinic underwent laparoscopic partial nephrectomy with LU. For comparison with preoperative conventional ultrasound and CT, we collected ultrasonic performance of the affected side kidney, renal tumor location, size, echo change, blood supply situation and the relationship with the surrounding tissue.

RESULTS

LU could more clearly show the tumor interior structure and blood supply, as well as the relationship with the surrounding tissue. It also can provided doctor assistance with real-time tumor resection, reducing operative complications.

CONCLUSIONS

LU can clearly show tumor internal structure and blood supply, which is helpful for explicit diagnosis. Moreover, it supplies accurate information for surgeons and assists surgery. Therefore LU has an important guiding value in partial nephrectomy for small renal cell carcinoma.

Inattentional blindness increased with augmented reality surgical navigation

BACKGROUND

Augmented reality (AR) surgical navigation systems, designed to increase accuracy and efficiency, have been shown to negatively impact on attention. We wished to assess the effect "head-up" AR displays have on attention, efficiency, and accuracy, while performing a surgical task, compared with the same information being presented on a submonitor (SM).

METHODS

Fifty experienced otolaryngology surgeons (n = 42) and senior otolaryngology trainees (n = 8) performed an endoscopic surgical navigation exercise on a predissected cadaveric model. Computed tomography-generated anatomic contours were fused with the endoscopic image to provide an AR view. Subjects were randomized to perform the task with a standard endoscopic monitor with the AR navigation displayed on an SM or with AR as a single display. Accuracy, task completion time, and the recognition of unexpected findings (a foreign body and a critical complication) were recorded.

RESULTS

Recognition of the foreign body was significantly better in the SM group (15/25 [60%]) compared with the AR alone group (8/25 [32%]; p = 0.02). There was no significant difference in task completion time (p = 0.83) or accuracy (p = 0.78) between the two groups.

CONCLUSION

Providing identical surgical navigation on a SM, rather than on a single head-up display, reduced the level of inattentional blindness as measured by detection of unexpected findings. These gains were achieved without any measurable impact on efficiency or accuracy. AR displays may distract the user and we caution injudicious adoption of this technology for medical procedures.

Navigation surgery using an augmented reality for pancreatectomy

AIM

The aim of this study was to evaluate the utility of navigation surgery using augmented reality technology (AR-based NS) for pancreatectomy.

METHODS

The 3D reconstructed images from CT were created by segmentation. The initial registration was performed by using the optical location sensor. The reconstructed images were superimposed onto the real organs in the monitor display. Of the 19 patients who had undergone hepatobiliary and pancreatic surgery using AR-based NS, the accuracy, visualization ability, and utility of our system were assessed in five cases with pancreatectomy.

RESULTS

The position of each organ in the surface-rendering image corresponded almost to that of the actual organ. Reference to the display image allowed for safe dissection while preserving the adjacent vessels or organs. The locations of the lesions and resection line on the targeted organ were overlaid on the operating field. The initial mean registration error was improved to approximately 5 mm by our refinements. However, several problems such as registration accuracy, portability and cost still remain.

CONCLUSION

AR-based NS contributed to accurate and effective surgical resection in pancreatectomy. The pancreas appears to be a suitable organ for further investigations. This technology is promising to improve surgical quality, training, and education.

Laparoscopic partial nephrectomy for the treatment of large cystic nephroma in children

Abstract Background: Cystic nephroma (CN) is a rare benign renal neoplasm. The differential diagnosis of cystic partially differentiated nephroblastoma is only possible with pathological findings. Therefore, surgical resection is necessary to diagnose suspected CN lesions. Because CN is usually well demarcated and has a good prognosis, partial nephrectomy is recommended for its treatment. However, to our knowledge, laparoscopic treatment of CN has not been reported. We describe 2 cases of large CNs successfully treated: Case 1 was a 9-month-old boy with a lower polar mass in the right kidney, which occupied two-thirds of the kidney, and Case 2 was a 9-month-old boy with an upper polar mass in the left kidney, which occupied three-fourths of the kidney.

MATERIALS AND METHODS

Using the transperitoneal approach, the lesion was detected by a laparoscopic ultrasound probe, and vessels in the affected region were dissected. After the renal artery was clamped with bulldog clips, the parenchyma of the affected region was divided with an ultrasonically activated scalpel. The partly cut pelvis was closed by suturing, and the resected stump was coated with hemostatic agents and covered with the pediculate peritoneum.

RESULTS

The lesion was not exposed during surgery, and the microscopic features were consistent with CN in both cases. Residual renal function was good, and no residual tumor was found in both cases for over a year.

CONCLUSIONS

Laparoscopic partial nephrectomy is a feasible approach to treat large CNs. When it is difficult to close the resection stump by parenchymal suturing, covering the stump with hemostatic agents and pediculate peritoneum is feasible.