Laparoendoscopic Single-site Nephrectomy Research Articles

Incisional Laparoendoscopic Single-Site (iLESS) Nephrectomy Using the GelPort Device: A Training Bridge to LESS Surgery

Incisional Laparoendoscopic Single-Site (iLESS) Nephrectomy Using the GelPort Device: A Training Bridge to LESS Surgery

Incisional Laparoendoscopic Single-Site (iLESS) Nephrectomy Using the GelPort Device: A Training Bridge to LESS Surgery

Incisional Laparoendoscopic Single-Site (iLESS) Nephrectomy Using the GelPort Device: A Training Bridge to LESS Surgery

Initial Experience With Laparoendoscopic Single-site Nephrectomy and Nephroureterectomy in Children

To assess the clinical utility and safety of laparoendoscopic single-site surgery (LESS) nephrectomy and nephroureterectomy in children by analyzing 6 consecutive cases performed by a single surgeon. Since March 2009, we have been performing LESS nephrectomy and nephroureterectomy in children. The indications have been recurrent pyelonephritis related to vesicoureteral reflux with an atrophic kidney and continuous urinary incontinence related to an ectopic ureter. A homemade port was placed through an umbilical incision, and the laparoscopic transperitoneal nephrectomy procedures were performed using various combinations of standard and articulating laparoscopic instruments. The patients undergoing a LESS procedure were evaluated prospectively, and the data were collected during and after surgery. A total of 6 procedures, including nephrectomy (4 cases) and nephroureterectomy (2 cases), were completed without intraoperative or postoperative complications. The median operation time was 112 minutes (range 90-148), and the median blood loss was 0 mL (range 0-50). All patients received only oral ibuprofen syrup for pain control and were discharged on postoperative day 2. As the surgeon gained experience, the length of the umbilical incision was decreased from 2.0 to 1.0 cm. Pediatric LESS nephrectomy and nephroureterectomy can be performed safely with a very small incision. LESS performed by an experienced laparoscopic surgeon has the potential to become an alternative first-line therapy for ablative procedures in children.

Laparoendoscopic Single-Site (LESS) nephrectomy in a patient undergoing Continuous Ambulatory Peritoneal Dialysis (CAPD)

Purpose: To assess the feasibility, safety, and outcomes of transumbilical single port laparoscopic nephrectomy in a patient undergoing continuous ambulatory peritoneal dialysis (CAPD) treatment. Materials and Methods: A patient was a 62-year-old woman who had been using CAPD for 4 months because of end-stage renal disease (ESRD) secondary to diabetic nephropathy. She was referred to the urology clinic, due to suffering from the left pyonephrosis and non-functioning kidney with a proximal ureteric stone. Then she underwent percutaneous nephrostomy to drain the pus. After this resolved, she underwent LESS nephrectomy. Medical records were reviewed, and laboratory values and outcomes were analyzed. Results: The procedure was successfully completed without conversion to conventional laparoscopic or open surgery. Operative time was 160 minutes. Moreover, the specimen can be easily and rapidly extracted through the TriPort without the use of an additional entrapment bag. Estimated blood loss was 200 mL and pain scale was 0-1, with no morphine requirements. On the same day of the operative procedure, a double-lumen hemodialysis (HD) catheter was introduced for postoperative HD. The patient underwent hemodialysis treatment via a subclavian catheter after the operation and she was discharged home on the sixth postoperative day with a functioning CAPD catheter, with no further problems. After 2 weeks, the patient switched from HD to CAPD without complications. Pathological analysis revealed chronic pyelonephritis. Postoperative hematocrit, blood urea nitrogen, and creatinine were 39.3%, 22 mg/dL, 2.3 mg/dL respectively. The scars receded into the umbilicus and were hardly visible. Conclusion: LESS nephrectomy is a feasible technique with advantages of less pain, shortened convalescence, improved cosmesis, and absence of wound complications. Int Braz J Urol. 2010; 36 (Video #9): 781_2 Available at: www.brazjurol.com.br/videos/november_december_2010/Permpongkosol _781_782video.htm Correspondence address: Dr. Sompol Permpongkosol Division of Urology Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University Rama 6 Road Bangkok, 10400, Thailand Email: sompolpermpong@gmail.com doi: 10.1590/S1677-55382010000600032

Reply

We appreciate the constructive comments by the editors and Dr. Elder regarding our initial series of LESS nephrectomy in infants, children, and adolescents. We agree with Dr. Elder's comment that the benefits of LESS surgery compared with other modalities, such as conventional laparoscopic surgery and robotic surgery, have not yet been demonstrated, and that future investigations, such as prospective multicenter comparisons of the different minimally invasive modalities, are necessary. However, initial data from the adult literature may suggest a trend towards lower morbidity in evaluating post-discharge parameters. 1 Canes D. Desai M.M. Aron M. et al. Transumbilical single-port surgery: evolution and current status. Eur Urol. 2008; 53: 1020-1030 Abstract Full Text Full Text PDF Scopus (348) Google Scholar The design of new specific tools may be necessary to assess differences in morbidity between LESS and conventional multi-port minimally invasive surgery. Editorial CommentUrologyVol. 76Issue 6PreviewThe authors present a nice series of children who underwent successful laparoscopic simple nephrectomy using single-port technology. Two of the study's co-authors are internationally renowned for laparoendoscopic single-site (LESS) urologic surgical procedures in adults, and Koh et al1 have demonstrated its application in children. Is LESS nephrectomy better than standard laparoscopic nephrectomy in children? I think it will be difficult to identify any significant advantages in measurable outcomes, such as blood loss, operative time, cost, analgesic use, length of stay, and complication rate, just as there have been no apparent differences in adults. Full-Text PDF

Minimally Invasive Nephrectomy: The Influence of Laparoendoscopic Single-site Surgery on Patient Selection, Outcomes, and Morbidity

To define clinical scenarios in urology for which laparoendoscopic single-site surgery (LESS) is indicated and likely to be successful. We report a series of LESS nephrectomies and compare patient characteristics with traditional laparoscopic nephrectomies performed during the same time period. We retrospectively reviewed all laparoscopic nephrectomies (conventional or LESS) performed by a single surgeon at our institution since our initial LESS cases in August 2007. Patients were not randomized; instead the surgeon used clinical judgment to decide with the patient which procedure should be performed. Factors that may have influenced this decision were retrospectively analyzed. Of all minimally invasive nephrectomies, 47% were performed using LESS technique (30/64). One conversion from LESS to standard laparoscopy occurred. Patients undergoing LESS had a smaller median age (47 vs 63.5 years, P = .004), body mass index (24.4 vs 28.4, P = .001), tumor size in nephrectomies performed for suspected malignancy (4 cm vs 6 cm, P = .043), and hospital length of stay (42.7 vs 46.1 hours, P = .006). LESS patients were also more likely to be undergoing a nephrectomy for a benign indication (50% vs 15%, P = .006). The complication rate for LESS and conventional laparoscopy was 13% (4/30) and 15% (5/34), respectively, with similar distributions across Clavien grades. With appropriate patient selection, almost 50% of minimally invasive nephrectomies can be performed using LESS with similar complication rates and outcomes compared with traditional laparoscopy. Younger, thinner patients with nononcological indications or smaller tumors are prime candidates for LESS nephrectomy.

Laparoendoscopic Single-Site Porcine Nephrectomy Using A Novel Valveless Trocar System

The AirSeal™ access system is a novel laparoscopic trocar that uses airflow to create insufflation pressure without the need for a physical seal or valve. By eliminating all valve elements within the lumen of the canula, the port provides a platform that accommodates multiple instruments of any diameter, shape, or combination and is ideally suited for laparoendoscopic single-site surgery (LESS). We present our initial experience with valveless trocars in traditional urologic laparoscopic cases and a porcine LESS nephrectomy series. Nine transperitoneal LESS nephrectomies were performed in a live porcine model using the 27-mm oval valveless trocar. All working instruments were placed through the single port, and the specimen was extracted through the 4-cm port site. All cases were completed without technical or operative complications. The porcine single-port nephrectomy (n=9) was successfully performed in a mean operative time of 24 minutes through the single 27-mm oval trocar. This accommodated a 5-mm laparoscope, multiple 5-mm instruments, the Endo GIA stapler, and the 15-mm Endocatch bag without loss of insufflation pressure. Condensation and smudging of the laparoscope were minimized, improving visualization and efficiency. The system allowed for use of suction without significant loss of insufflation pressure. The initial experience with the AirSeal valveless trocar system in LESS is encouraging. This technology may offer significant benefits over traditional laparoscopic trocars and single -port platforms and appears particularly suited to facilitate LESS.

Laparoendoscopic Single-site Nephrectomy in Pediatric Patients: Initial Clinical Series of Infants to Adolescents

To present our initial clinical series of laparoendoscopic single-site (LESS) nephrectomy using an umbilical incision in children ranging from infants to adolescents. Laparoscopic surgery in pediatric urology is increasingly being performed for many intra-abdominal ablative procedures, such as nephrectomy for poorly functioning kidneys. We have previously reported our initial experience with LESS surgery in the adult population. A total of 11 pediatric patients (age range 0.1-16.2 years, mean 5.7) underwent LESS nephrectomy using an umbilical incision. The perioperative clinical parameters were reviewed retrospectively. The 11 LESS pediatric nephrectomies were technically successful without conversion to conventional laparoscopy or open surgery. An accessory port was used in 5 of the cases early in the clinical series. Of the 11 patients, 2 were infants, aged 39 days and 3.5 months. The mean operative time was 139 minutes (range 85-205), and the mean hospital stay was 1.5 days (range 1.0-2.1). Complications included delayed hydrocele formation in 2 male patients. The results of our study have shown that LESS nephrectomy using a single umbilical incision in pediatric patients is technically feasible with good outcomes. Additional studies are needed to evaluate the expected benefits of this novel technique. Also, miniaturization of currently available equipment is needed to adapt to the small working spaces available in the pediatric patient.

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

Nefrectomía simple laparoscópica NOTES y LESS con el uso de instrumentos laparoscópicos estándar: Experiencia inicial en 3 casos

NOTES and LESS laparoscopic simple nephrectomy with the use of standard laparoscopic instruments: Initial experience in 3 cases Introduction: Natural orifi ce transluminal endoscopic surgery (NOTES) and Laparoendoscopic Single Site Surgery (LESS) are emerging technologies, which allows to performed surgical procedures avoiding any sur- gical scars. However there are some problems due to the lack of equipment available for these procedures. The aim of these study is to present our initial experience with the transvaginal nephrectomy NOTES and LESS using standard laparoscopic instruments. Material and Methods: Two female patients (23 and 26 years old) with diagnosis of recurrent urinary tract infection and renal atrophy. A laparoscopic simple nephrectomy with transvaginal NOTES assistance was performed, using one access port for the camera and two abdominal work ports of 10 and 3mm. In a third patient (15 years old) a transumbilical LESS nephrectomy was preformed with the use of standard laparoscopic instruments. Results: Average operative time was 110 min (40-200), with an estimated blood loss of 200 cc. There were no perioperative complications and all patients were discharged 36 hours after surgery. Conclusion: Laparoscopic simple nephrectomy with transvaginal NOTES assistance and LESS are technically feasible with the use of standard laparoscopic instruments. Special access trocars and instruments development for this procedure will allow to performed a pure technique without the use of abdominal incisions

719 LAPAROENDOSCOPIC SINGLE-SITE NEPHRECTOMY USING A MODIFIED UMBILICAL INCISION AND A HOMEMADE TRANSUMBILICAL PORT

You have accessJournal of UrologyTechnology & Instruments: Robotics/Laparoscopy/Ureteroscopy I1 Apr 2010719 LAPAROENDOSCOPIC SINGLE-SITE NEPHRECTOMY USING A MODIFIED UMBILICAL INCISION AND A HOMEMADE TRANSUMBILICAL PORT Won Sik Ham, Ho Song Yu, Won Sik Chang, Woong Kyu Han, Koon Ho Rha, Sang Won Han, Young Deuk Choi, and Sung Joon Hong Won Sik HamWon Sik Ham More articles by this author , Ho Song YuHo Song Yu More articles by this author , Won Sik ChangWon Sik Chang More articles by this author , Woong Kyu HanWoong Kyu Han More articles by this author , Koon Ho RhaKoon Ho Rha More articles by this author , Sang Won HanSang Won Han More articles by this author , Young Deuk ChoiYoung Deuk Choi More articles by this author , and Sung Joon HongSung Joon Hong More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1207AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Laparoendoscopic single-site surgery (LESS) has been proposed as an alternative to conventional laparoscopy. To assess the clinical utility of LESS nephrectomy using a modified umbilical incision and homemade transumbilical port in cases requiring extirpative surgery. METHODS Seventeen patients (median age 51 yr, range 0.6-81; median body mass index 22.8, range 14.4-31.2) underwent LESS nephrectomies that were performed by a single surgeon for treatment of benign and malignant conditions. A homemade port was placed through a modified umbilical incision, the length of which had been determined preoperatively. The laparoscopic transperitoneal nephrectomy procedures were performed with various combinations of standard and articulating laparoscopic instruments. Patient characteristics and perioperative outcomes, including pathologic results, were recorded prospectively. RESULTS All 17 extirpative surgeries including simple nephrectomy (seven cases), radical nephrectomy (nine cases), and nephroureterectomy (one case), were completed successfully. The median operation time was 168 min (range 82-220) and the median blood loss was 250 ml (range 0-1050). All specimens were extracted intact through a modified umbilical incision (median length 2.5 cm, range 1.5-6.0). Final pathological analysis revealed a nonfunctioning kidney in five cases, a dysplastic kidney in two cases, a mixed epithelial and stromal tumor in one case, renal cell carcinoma in eight cases (T1: five cases, T3: three cases), and Ta ureter transitional cell carcinoma in one case. Although several technical challenges were experienced, these were overcome by the ambidexterity of the surgeon. CONCLUSIONS LESS nephrectomy using a homemade port and modified umbilical incision is both feasible with minimal incision and cost-effective. Our technique may be more useful for extirpative procedures in which a specimen needs to be removed intact, because incision length can be adjusted freely. Prospective comparisons are warranted to more clearly elucidate the utility of this surgical technique. Seoul, Republic of Korea© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e280 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Won Sik Ham More articles by this author Ho Song Yu More articles by this author Won Sik Chang More articles by this author Woong Kyu Han More articles by this author Koon Ho Rha More articles by this author Sang Won Han More articles by this author Young Deuk Choi More articles by this author Sung Joon Hong More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Feasibility of Laparoendoscopic Single-Site Nephrectomy: Initial Experience Using Home-made Single-port Device

To report our early experience with laparoendoscopic single-site (LESS) nephrectomy using home-made single-port device for benign nonfunctioning kidney. A total of 14 patients with benign nonfunctioning kidney underwent transperitoneal LESS nephrectomy by 2 experienced laparoscopic surgeons. The indications for nephrectomy were nonfunctioning kidney associated with ectopic kidney (n = 2), ureteropelvic junction obstruction (n = 5), genitourinary tuberculosis (n = 4), ureter stone (n = 2), and ureter stricture (n = 1). All procedures were completed successfully. The mean operative time was 151 (85-230) minutes, estimated blood loss 108 (negligible-500) mL, and postoperative hospital stay 3.1 (2-6) days. There were no major complications. LESS nephrectomy is a feasible and safe surgical option for benign nonfunctioning kidney.

Reply

Laparoendoscopic single-site (LESS) surgery is in its infancy, as urological procedures are being performed at only a few select centers worldwide and technical modifications are rapidly evolving. Nevertheless, it is important that we continually evaluate our results to determine the appropriate role for this surgical approach. Because few techniques begin as randomized trials, retrospective series are often evaluated first. As such, we have attempted to compare a single surgeon's experience with this novel technique to conventional laparoscopy. Although our experience with both LESS nephrectomy 1 Raman JD, Bagrodia A, Cadeddu JA. Single-incision, umbilical laparoscopic versus conventional laparoscopic nephrectomy: a comparison of perioperative outcomes and Short-Term measures of convalescence. Eur Urol. (in press). Google Scholar and LESS pyeloplasty has yet to demonstrate a perioperative advantage, it is premature to conclude that the technique itself should be abandoned. Importantly, we have demonstrated no significant disadvantage to these techniques. As experience with this new technique accumulates, it is important that surgeons be transparent in their reporting, such that practitioners and patients may determine their own conclusions regarding surgical benefit. Certainly, this has been the experience of the reviewer who chooses to perform laparoscopic pyeloplasty with 3 5-mm ports despite no reported evidence of benefit (compared to other trocar configurations) in published studies to the best of our knowledge. Perioperative Outcomes in Patients Undergoing Conventional Laparoscopic Versus Laparoendoscopic Single-site PyeloplastyUrologyVol. 74Issue 5PreviewTo compare the outcomes of laparoendoscopic single-site (LESS) surgery with conventional laparoscopic pyeloplasty (CLP) before LESS can be widely accepted. LESS surgery is a novel technique for performing laparoscopic pyeloplasty through a single incision. Full-Text PDF Editorial CommentUrologyVol. 74Issue 5PreviewI applaud the authors' steps toward the objective comparison of LESS surgery and standard laparoscopy, but their conclusions are overstated. Despite finding no differences in perioperative outcomes, they encourage further studies and suggest that with “increased surgical experience, it is possible that benefits in perioperative morbidity will emerge for LESS surgery.” Is that likely? Let us consider the following. Full-Text PDF

Laparoendoscopic Single-Site Surgery: Early Experience with Tumor Nephrectomy

Laparoendoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery. We performed LESS for renal tumor nephrectomy in eight patients to assess feasibility and perioperative outcome. Eight patients with a body mass index (BMI) <or=30 underwent single-port nephrectomy for renal tumor by an experienced laparoscopic surgeon. Tri-Ports were used through a transumbilical incision in all cases. A flexible grasper and a 5-mm 30-degree high-definition camera were used in addition to standard laparoscopic equipment. Patient demographics; operative details, including procedure duration, blood loss, and complications; and final pathology results were prospectively recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. All LESS nephrectomy operations were successfully accomplished without the need to convert to conventional laparoscopy. The median patient age was 60.75 years (range 22-76 years) and median BMI was 22.95 (range 18.2-26.1). The median operative duration was 141 minutes (range 120-180 min), and the median blood loss was 103 mL (range 50-150 mL). Histologic evaluation confirmed complete excision of an intact specimen. All cases revealed organ-confined T(1) renal-cell carcinoma (two right-sided and six left-sided, tumor diameter range 4-8 cm). A tumor with an adjacent simple renal cyst was excised in one patient. No intraoperative or postoperative complications occurred. LESS was a feasible and safe approach in a selected group of patients (low BMI and stage tumor). LESS nephrectomy was made possible with the use of multi-instrument port and flexible instruments. The oncologic outcome was not compromised. Further evaluation of LESS surgery needs prospective, randomized studies.

Single‐port ‘scarless’ laparoscopic nephrectomies: the United Kingdom experience

To present the UK experience to date with laparoendoscopic single-site surgery (LESS) simple nephrectomy. Five female patients underwent LESS nephrectomy; three procedures were carried out with the umbilicus as the port of entry (U-LESS). All cases were completed uneventfully. The operative duration was 45-150 min and blood loss was negligible. There were no conversions to conventional multi-port laparoscopy or open surgery. Recovery was uneventful with only minor complications in two patients; convalescence was rapid. LESS nephrectomy offers a safe, cosmetic alternative to conventional multi-port laparoscopy, with younger female patients being especially happier with the 'scarless' outcome of U-LESS. LESS certainly appears to be more in these situations.

Laparoendoscopic Single-Site Nephrectomy Using a Homemade Single-Port Device for Single-System Ectopic Ureter in a Child: Initial Case Report

A 3-year-old girl with a history of continuous urinary incontinence was found to have a right single-system ectopic ureter. She underwent laparoendoscopic single-site nephrectomy without any intraoperative or postoperative complications. To the best of our knowledge, this is the first case report of a laparoendoscopic single-site nephrectomy for single-system ectopic ureter in a child.