Laparoendoscopic Single-site Nephroureterectomy Research Articles

Initial experience of transurethral-assisted laparoendoscopic single-site nephroureterectomy

PurposeWe describe a new transurethral technique for distal ureter management and the improvement of intraoperative exposure during LESS-NU. MethodsA total of 20 transurethral assisted LESS-NU were performed between May 2018 and December 2020 in our institution. The access route for the operation was via a single-port, with four channels placed through a transumbilical incision. After the lower ureter was separated from the bladder wall, a 1470 laser working channel was placed through the urethra to precisely cut the ureteral orifice. Following this, a self-made urethra auxiliary port was inserted through the bladder cuff opening to facilitate a resection of the ureter and kidney. The peri-operative and postoperative data were then retrospectively collected and analysed. ResultsAll procedures were completed successfully and one patient needed an additional port. The mean operative time was 196.8 ± 45.8 min and the mean estimated blood loss was 58.9 ± 32.0 ml. The days required for the surgical drain removal and the hospital stay were 4.6 ± 4.6 and 11.1 ± 6.4 days, respectively. One patient developed a fever following surgery but there were no major complications. During the average follow-up period, which lasted 25.5 months, one patient developed spinal cord metastasis and died 8 months after surgery. No obvious abnormalities were found in any of the other patients. ConclusionThe tansurethral approach of the distal ureter for LESS-NU is deemed safe and efficient. The technique used offers accurate control of the distal ureter and good exposure of LESS.

Comparison of modified transumbilical laparoendoscopic single-site nephroureterectomy and retroperitoneal laparoscopic nephroureterectomy: initial experience.

IntroductionOwing to the development of the laparoendoscopic single-site (LESS) procedure, transumbilical LESS nephroureterectomy (LESS-NU) has become a new approach for treating upper tract urothelial carcinoma.AimThe aim of this study is to introduce a modified LESS-NU procedure with bladder cuff excision for treating upper tract urothelial carcinoma (UTUC). We compared its clinical efficacy and postoperative outcomes in terms of follow-up time with traditional retroperitoneal laparoscopic nephroureterectomy (RL-NU).Material and methodsFrom May 2014 to May 2019, we performed nephroureterectomy on 42 patients using the retroperitoneal approach and a modified LESS approach. A retrospective analysis was conducted for the evaluation of the clinical and postoperative outcomes between the two groups.ResultsThe study included 25 LESS-NU and 17 RL-NU patients. All the procedures were completed successfully. The LESS-NU group had a significantly shorter mean operative time than the RL-NU group (204.4 min, 236.18 min, p = 0.005). The differences in skin incision length (2.88 cm, 8.94 cm, p < 0.001) and oral analgesic dose (n = 1.12, n = 2.75, p < 0.001) between LESS-NU and RL-NU were statistically significant.ConclusionsModified LESS-NU is a feasible and safe procedure. Compared with the retroperitoneal laparoscopic approach, the single-site approach did not alter the patients’ position. LESS-NU is a better procedure for treating UTUC than RL-NU in terms of cosmetic result and postoperative pain.

Our experience of tissue glue injection in tubeless percutaneous nephrolithotomy

Our experience of tissue glue injection in tubeless percutaneous nephrolithotomy

V11-13 LAPAROENDOSCOPIC SINGLE SITE NEPHROURETERECTOMY: TECHNIQUE &amp; INITIAL EXPERIENCE

You have accessJournal of UrologyAdrenal/Single Port Surgery/LESS/NOTES1 Apr 2015V11-13 LAPAROENDOSCOPIC SINGLE SITE NEPHROURETERECTOMY: TECHNIQUE & INITIAL EXPERIENCE Jenna She, Alison Rutledge, and Albert Tiu Jenna SheJenna She More articles by this author , Alison RutledgeAlison Rutledge More articles by this author , and Albert TiuAlbert Tiu More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2611AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Open radical nephroureterectomy remains the “gold standard” treatment for upper urinary tract urothelial carcinoma. Laparoendoscopic single site (LESS) nephroureterectomy has raised significant interest worldwide to reduce morbidity and scarring associated with conventional laparoscopy. The objective of this study is to investigate the techniques, safety and feasibilities of LESS nephroureterecomy for upper urinary tract urothelial carcinoma. METHODS We retrospectively reviewed a prospectively maintained database to identify patients who underwent laparoendoscopic single site nephroureterectomy for upper urinary tract urothelial carcinoma. Perioperative data were recorded along with functional and oncological outcomes. Our technique was performed using the GelPOINT device (Applied Medical, Rancho Santa Margarita, CA, USA) through a peri-umbilical incision. We placed four ports into the GelPOINT (3x10mm and 1x12mm). Our management of the distal ureter and badder cuff mimicked those of the open approach in all cases. The bladder cuff was dissected circumferentially around the ureteric orifice. The bladder defect was closed with continuous running barbed V-Loc (Covidien, Dublin, Ireland). RESULTS A total of three patients were identified (2 female, 1 male) from July 2013 to July 2014. The mean age was 66 years old (59-69 and mean BMI was 26. There were two left sided upper urinary tract tumour and one right sided upper urinary tract tumour. Of these tumours two were located in the upper ureter and one was in the mid ureter. The mean pre-operative and post-operative creatinine was 90 umol/L and 110 umol/L respectively. The mean estimated blood loss was 266 mL and the mean total operative time was 210 minutes. The mean length of hospital stay was 3 days. None of the patients were converted to open surgery. There was one post operative complication of urinary tract infection. None of the patients required blood transfusion. The final histology confirmed one high grade Ta urothelial carcinoma and two high grade T1 urothelial carcinoma. Of the two high grade T1, one has concurrent carcinoma in-situ. There was no positive surgical margin. At the median follow up of 6 months there was no local or distal recurrences CONCLUSIONS Our initial LESS nephroureterectomy experience is comparable to other minimal invasive & open series. There is a potential in the future for long term follow up analysis across multi-institutions. Significant improvements are required to address the current challenges of LESS. Careful selection of patients for LESS nephroureterectomy is crucial © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e910-e911 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jenna She More articles by this author Alison Rutledge More articles by this author Albert Tiu More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Comparison of Pediatric Robotic-assisted Laparoscopic Nephroureterectomy and Laparoendoscopic Single-site Nephroureterectomy

To compare outcomes between pediatric robotic-assisted laparoscopic nephroureterectomy (RALNU) and laparoendoscopic single-site nephroureterectomy (LESSNU). A retrospective cohort study was performed of all patients who underwent RALNU and LESSNU at a single pediatric institution from April 2009 to April 2013. Patient demographics, perioperative details, and outcomes were reviewed. Thirty-two patients (20 men, 12 women) were identified. Twenty-four patients underwent RALNU and 8 patients underwent LESSNU. There was no significant blood loss, intraoperative complication, or conversion to open or standard laparoscopy for either procedure. Median age was 55.1 months (range 4.5-171.8 months) for RALNU and 51.6 months (range 16.3-144.9 months) for LESSNU (P = .695). Median weight was 19.1 kg (range 7-55 kg) for RALNU and 16.9 kg (range 11-41 kg) for LESSNU (P = .727). Median operative time was 227 minutes (range 112-362 minutes) for RALNU and 174 minutes (range 74-288 minutes) for LESSNU (P = .028). Median length of hospital stay was 2 days (range 1-4 days) for RALNU and 1 day (range 0-6 days) for LESSNU (P = .134). Median in-patient postoperative narcotic use of morphine-equivalent was 0.03 mg/kg/day (range 0-0.2) for RALNU and <0.01 mg/kg/day (range 0-0.2) for LESSNU (P = .134). Median in-patient postoperative Ketorolac use was <0.01 mg/kg/day (range 0-0.8) for RALNU and <0.01 mg/kg/day (range 0-0.5) for LESSNU (P = .784). Median follow-up was 22 months (range 0.8-48.4 months) for RALNU and 18.8 months (range 0.3-29.4 months) for LESSNU (P = .361). We observed 2 complications (8.3%) in RALNU and 1 in LESSNU (P = 1). LESSNU has a significantly shorter operative time with comparable in-patient postoperative narcotics use as compared to RALNU.

Editorial Comment

Advances in minimally invasive surgical techniques have been evolving at a fast pace. Since the introduction of laparoscopic surgery, numerous minimally invasive alternatives have been described, such as single site laparoscopy, robotic-assisted laparoscopic surgery, and natural orifice endoscopic procedures. Unfortunately, breakthrough surgical procedures are not regularly submitted to the scientific rigor of other therapeutic innovations and are often influenced by the powerful impact of the medical device industry. Therefore, academic surgeons should take on the role of applying sound scientific methodology to newer surgical techniques in order to ensure that patients receive the safest and most cost-effective treatment modality. From this perspective, the authors should be congratulated for their report comparing 2 minimally invasive techniques for laparoscopic nephroureterectomy in the treatment of benign conditions in children against conventional laparoscopic nephrectomy (CLN). Comparison of Pediatric Robotic-assisted Laparoscopic Nephroureterectomy and Laparoendoscopic Single-site NephroureterectomyUrologyVol. 83Issue 2PreviewTo compare outcomes between pediatric robotic-assisted laparoscopic nephroureterectomy (RALNU) and laparoendoscopic single-site nephroureterectomy (LESSNU). Full-Text PDF

Single-incision laparoscopic nephroureterectomy in children of all age groups

Background/PurposeThe purpose of this study was to assess different surgical approaches for laparoendoscopic single-site nephroureterectomy according to weight groups. MethodsLESS nephroureterectomy was performed in 11 children. Indication for nephrectomy was a non-functioning kidney owing to vesicoureteral reflux or giant cystic dysplasia. Children below 10kg body weight underwent LESS nephroureterectomy through an umbilical incision using one 5mm and two 3mm trocars (Manhattan technique). Patients above 10kg were operated on using a metal multi-use single-site single port (X-Cone). ResultsMedian age at operation was 12months (0.75-128), and median weight was 8.5kg (3.1-67). Median operating time was 110minutes (50–260). Eight children underwent LESS nephroureterectomy using the Manhattan-technique, and three patients were operated on with the X-Cone. All operations were carried out in a transperitoneal technique without using additional trocars. There were no complications. Recovery was uneventful in all children. ConclusionsLESS nephroureterectomy for pediatric patients can be done safely and efficiently, irrespective of age and weight. However, different surgical approaches have to be considered owing to the fact that single-site ports are not available for small children and infants. Both techniques will benefit from future development of instruments and trocars more suitable for small children. The question whether LESS provides even less trauma than in conventional laparoscopy remains doubtful.

Laparoendoscopic single-site nephroureterectomy for upper urinary tract urothelial carcinoma: outcomes of an international multi-institutional study of 101 patients

To report a large multi-institutional series of laparoendoscopic single-site (LESS) nephroureterectomy (NU). Data on all cases of LESS-NU performed between 2008 and 2012 at 15 institutions were retrospectively gathered. The main demographic data and perioperative outcomes were analysed. The study included 101 patients whose mean (SD) age was 66.4 (9.9) years and mean (SD) body mass index was 24.8 (4) kg/m², and of whom 29.7% had undergone previous abdominal/pelvic surgery. The mean (SD) operating time was 221.4 (73.7) min, estimated blood loss 231.7 (348.0) mL. A robot-assisted LESS technique was applied in 25.7% of cases. An extra trocar was inserted in 28.7% of cases to complete the procedure. Conversion to open surgery was necessary in three cases (3.0%). There was no bladder cuff excision in 20.8% of cases, and excision was carried out using a variety of techniques in the remaining cases. Six intra-operative complications occurred (5.9%). The mean (SD) length of hospital stay was 6.3 (3.5) days. The overall postoperative complication rate was 10.0%, and most of the complications were low grade (Clavien grades 1 and 2). The mean tumour size was 3.1 (1.9) cm. Pathological staging was pTis in two patients, pTa in 12 patients, pT1 in 42 patients, pT2 in 20 patients, pT3 in 23 patients and pT4 in two patients. Pathological grade was high in 71 and low in 30 patients. At a mean follow-up of 14 months, six patients (5.9%) had died. Disease recurrence (including distant and bladder recurrence) was detected in 22.8% of patients, with a mean time to recurrence of 11.5 months. This study reports the largest multi-institutional experience of LESS-NU to date. Peri-operative outcomes mirror those of published standard laparoscopy series. Despite encouraging early findings, longer follow-up is needed to determine the oncological efficacy of the procedure.

Initial Experience of Laparoendoscopic Single-site Nephroureterectomy with Bladder Cuff Excision for Upper Urinary Tract Urothelial Carcinoma Performed by a Single Surgeon

To present our experience with the first 10 consecutive cases of laparoendoscopic single-site nephroureterectomy (LESSNU) with bladder cuff excision for upper tract urothelial carcinoma. Ten patients (6 men and 4 women; 6 renal pelvis and 4 ureter) underwent LESSNU by a single surgeon. We made a 4-cm single incision at the umbilicus using a homemade single-port device. The single-port device was made with a surgical glove and Alexis wound retractor. LESSNU was performed by the same technique of conventional laparoscopic NU. The mean age was 62.79 ± 7.93 years. The mean total operative time, time for nephrectomy, and time for bladder cuff excision were 225.6 ± 365.87, 80.00 ± 29.03, and 145.63 ± 42.63 minutes. The mean estimated blood loss was 187.50 ± 83.45 mL. On surgical pathologic examination, four patients were pT(1)N(0), four patients were pT(2)N(0), one patient was pT(3)N(0), and one patient was pT(3)N(2). There was one positive surgical margin in a pT(3)N(2) patient. The mean number of lymph nodes dissected was 2.5 (range 0-9). One incision extension was performed because of complete renal hilar lymphadenectomy by open technique (for the pT(3)N(2) patient), and one open conversion with a Gibson incision was performed because of severe adhesions around the distal ureter (the pT(3)N(0) patient). There were one case of transient ileus and one of fever that were improved with conservative treatment. The mean hospital stay was 4.75 ± 3.37 days. Eight patients who underwent LESSNU successfully were satisfied with their operations. LESSNU for upper urinary tract urothelial carcinoma seems to be feasible and safe, but it is still challenging for advanced cases.

Laparoendoscopic Single-Site Nephroureterectomy and En Bloc Resection of Bladder Cuff with an Endoloop

Introduction: To present the initial experience of laparoendoscopic single-site (LESS) nephroureterectomy via the transperitoneal approach using a homemade single port and bladder-cuff resection by endoloop. Materials and Methods: LESS nephroureterectomy was performed with a homemade single port created using an Alexis wound retractor as an access platform through a 4-cm incision over umbilicus.1 This video included a brief presentation of a 57-year-old woman who presented with painless gross hematuria. An upper tract high-grade urothelial carcinoma was identified. The LESS nephroureterectomy and bladder-cuff resection were performed through the same incision over the umbilicus. The distal ureters were resected with an endoloop.2 The procedure was completed. No additional ports were used. The outside shots demonstrating the maneuvering the instruments were also included in our slides. Results and Conclusions: Between August 2009 and May 2010, we have performed LESS nephroureterectomy for five consecutive patients with upper tract urothelial carcinomas. The mean operative time was 284.0 ± 94.9 minutes. The mean estimated blood loss was 70.0 ± 24.5 mL. The mean hospital stay was 5.6 ± 3.5 days. Complete bladder-cuff resection was confirmed grossly in all cases. None of our cases had a urinary leakage, which was confirmed by cystography postoperatively. There is only one laparoscopic conversion caused by tight adhesions of renal hilum surroundings, which made progress difficult. There was no operation-related complication. Histopathologic examination demonstrated negative-resection margins in all cases. Our initial experience revealed that LESS nephroureterectomy and use of endoloop to complete bladder-cuff resection is a safe and feasible procedure for upper urinary tract urothelial carcinoma. Further prospective and long-term studies are warranted to provide more solid evidence with regard to perioperative benefits and oncologic control. All authors have declared no conflicts of interest. Runtime of video: 8 mins 45 secs

Editorial Comment

The authors are to be commended on exploring the merits of the LESS platform for partial nephrectomy in a child. Although they demonstrate the feasibility and safety of this approach, as well as the benefit of improved cosmesis and reduced analgesic requirement, which has been reported by other investigators in pediatric patients, 1 Kaouk J.H. Palmer J.S. Single-port laparoscopic surgery: initial experience in children for varicocelectomy. BJU Int. 2008; 102: 97-99 Crossref PubMed Scopus (178) Google Scholar , 2 Park Y.H. Kang M.Y. Jeong M.S. Choi H. Kim H.H. Laparoendoscopic single-site nephrectomy using a homemade single-port device for single-system ectopic ureter in a child: initial case report. J Endourol. 2009; 23: 833-835 Crossref PubMed Scopus (69) Google Scholar , 3 Bayazit Y. Aridogan I.A. Abat D. Satar N. Doran S. Pediatric transumbilical laparoendoscopic single-site nephroureterectomy: initial report. Urology. 2009; 74: 1116-1119 Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar they acknowledge some of the key drawbacks that have been encountered and commented upon by other pioneers in this field (e.g., longer warm ischemia time, difficulty suturing, instrument clashing). 4 Aron M. Canes D. Desai M.M. Haber G.P. Kaouk J.H. Gill I.S. Transumbilical single-port laparoscopic partial nephrectomy. BJU Int. 2009; 103: 516-521 Crossref PubMed Scopus (145) Google Scholar Although this report is limited by its lack of long-term follow up, it adds to a growing body of exciting literature on the feasibility of increasingly complex minimally invasive procedures using various LESS platforms. Nonetheless, pediatric LESS partial nephrectomy is a procedure whose limitations are a direct consequence of the limited experience and evolving enabling technology. As such, its performance and evaluation should be carried out by experienced minimally invasive/pediatric urological surgeons. Ideally, a prospective multicenter comparison with multiport laparoscopy should be performed in the pediatric population to determine whether there is any substantive advantage for the LESS platform. Pediatric Laparoendoscopic Single-site Partial Nephrectomy: Initial ReportUrologyVol. 76Issue 1PreviewWe present a case of transumbilical laparoendoscopic single-site surgery (LESS) for partial nephrectomy in a child. Full-Text PDF ReplyUrologyVol. 76Issue 1PreviewWe appreciate the reviewer's comments. Presently, laparoscopic partial nephrectomy is considered a key treatment measure for small renal mass cases. Particularly in cases of a large-sized mass or those in which a mass was placed in the location where resection could not be easily performed, surgery after the clamping of renal vessels is considered crucial to reduce the bleeding or to more easily confirm the tumor resection margin. From this aspect, the current initial clinical report in pediatric urology describes a LESS partial nephrectomy after the clamping of renal vessels. Full-Text PDF

Laparoendoscopic Single-Site Nephroureterectomy with Bladder Cuff Excision for Upper Urinary Tract Transitional-Cell Carcinoma: Technical Details Based on Oncologic Principles

To describe our technical details of laparoendoscopic single-site (LESS) nephroureterectomy with bladder cuff excision for the management of upper urinary tract transitional-cell carcinoma (TCC) based on oncologic principles. Two patients underwent LESS nephroureterectomy for upper urinary tract TCC. In both cases, we used a homemade single-port device that consisted of a wound retractor and a surgical glove. Using the flexible laparoscopic instruments, nephrectomy was performed using procedures similar to those of conventional laparoscopic nephrectomy. Bladder cuff excision was performed laparoscopically using the same procedure with open technique. All procedures were completed successfully without conversion to conventional laparoscopic or open surgery and without additional extraumbilical trocars or incisions. LESS nephreoureterectomy with bladder cuff excision was performed in 385 and 285 minutes with estimated blood loss of 100 and 350 mL, respectively. Both patients were discharged on postoperative day 3 without perioperative complications. LESS nephroureterectomy with bladder cuff excision for upper urinary tract TCC is a minimally invasive technique that may reproduce the open surgical technique and adhere to oncologic principles.

Early Experience of Laparoendoscopic Single-Site Nephroureterectomy for Upper Urinary Tract Tumors

PurposeWe evaluated the feasibility of a laparoendoscopic single-site (LESS) nephroureterectomy for an upper urinary tract tumor.Materials and MethodsBetween March 2009 and September 2009, 4 patients with upper urinary tract tumors underwent LESS nephroureterectomy. The mean age of the 2 female and 2 male patients was 69 years old, and their mean body mass index was 23.0. We used a homemade single-port device made with a surgical glove and a wound retractor, which were put into a 4 cm periumbilical incision. Operations with articulating and rigid laparoscopic instruments were performed transperitoneally. An open technique with a 4 cm additional midline incision and laparoscopic technique with an endoscopic stapler were used for the treatment of the distal ureter and bladder cuff.ResultsAll cases were completed successfully, without conversion to conventional laparoscopy or open surgery. The mean operative time was 169.5 minutes. The mean estimated blood loss was 361.4 ml. One patient had transfusion and wound infection. The mean hospital stay was 7.8 days. The mean specimen weight and tumor size were 271.8 g and 2.9 cm. Pathologic results of all cases showed urothelial carcinoma with a negative surgical margin. Three patients were in stage T3N0M0 and 1 was in stage T2N0M0.ConclusionsOur initial experience shows that LESS nephroureterectomy with a homemade single-port device is technically feasible. However, long term follow-up for the effect on cancer control and technical development for comfortable surgery are needed.

Editorial Comment

This is an original manuscript describing a nephrectomy using a single-port laparoscopic approach in a pediatric patient. It is evident that as laparoscopy evolves, our desire for less invasive surgery is leading surgeons to develop novel surgical approaches, such as natural orifice or laparoendoscopic single site (LESS) surgery. But the question remains, “How far are we going to make the laparoscopic approach more minimal and less invasive?” Pediatric Transumbilical Laparoendoscopic Single-site Nephroureterectomy: Initial ReportUrologyVol. 74Issue 5PreviewTo present a case of laparoendoscopic single-site surgery (LESS) nephroureterectomy (NUx), a type of embroyonic natural orifice translumenal endoscopic surgery, which is one of the recent innovations in the era of laparoscopy, in a child. Full-Text PDF ReplyUrologyVol. 74Issue 5PreviewRecently, laparoscopic surgery has gained popularity and become one of the standard techniques in most of the surgical departments, although it has technical difficulties and a steep learning curve. The experience gained in standard laparoscopic surgery, technical improvements, and technological innovations constituted a base for successful operations with LESS. There is an ongoing improvement in the technology to perform LESS in a safe and easy manner. Full-Text PDF Editorial CommentUrologyVol. 74Issue 5PreviewSingle-port surgery is a form of minimally invasive surgery, which uses basic concepts from laparoscopy but with a whole new dimension in manipulation. In the conventional laparoscopic surgery, 3-5 incisions are made where instruments are inserted. Because it uses only 1 port, single-port surgery has only 1 entry site and scarring is limited to that site externally. For most surgeons, the single-port approach is more challenging than conventional laparoscopy because the surgeon has less freedom of movement with all the instruments entering the same entry point. Full-Text PDF