Laparoendoscopic Single-site Partial Nephrectomy Research Articles

Long-Term Follow-Up of Laparoendoscopic Single-Site Partial Nephrectomy for Nonfunctioning Moieties of Renal Duplication and Fusion Anomalies in Infants and Children.

Objectives: To report on long-term follow-up and outcomes of infants and small children who have undergone laparoendoscopic single-site (LESS) partial nephrectomy to manage upper urinary tract duplication and fusion anomalies. Materials and Methods: A retrospective review was performed evaluating outcomes of pediatric patients who underwent LESS partial nephrectomy for upper urinary tract duplication and fusion anomalies from January 2012 to July 2015, by a single surgeon at a tertiary pediatric referral center. Demographic and perioperative data were reviewed as well as follow-up imaging. Descriptive statistics were used for analysis. Results: A total of 18 patients were identified. Additional access was used for two patients to complete the procedure. Median follow-up was 39 months. No short-term complications were encountered. Three patients were noted to have abnormal postoperative ultrasounds: two perinephric fluid collections and one atrophy of the remaining ipsilateral moiety. One fluid collection resolved completely, and the other decreased in size. Complete atrophy of the ipsilateral moiety occurred. No secondary procedures were required. Conclusions: LESS partial nephrectomy is safe for renal duplication and fusion anomalies with good long-term outcomes. Although it can be safely performed, it is a technically demanding procedure and has been discontinued in favor of robotic partial nephrectomy.

True Single-Site Partial Nephrectomy Using the SP Surgical System: Feasibility, Comparison with the Xi Single-Site Platform, and Step-By-Step Procedure Guide.

Background: Robotic laparoendoscopic single-site (LESS) partial nephrectomy is not widely used because of its limitations, and true single-site surgery has not previously been possible. To investigate the feasibility of partial nephrectomy using the novel SP surgical system, compare perioperative outcomes using this system and the previous Xi single-site platform (XiSSP), and describe how true single-site partial nephrectomy is possible with the SP system. Methods: Retrospective chart review of patients undergoing robotic partial nephrectomy by a single surgeon using the SP surgical system or XiSSP from December 14, 2016 to June 14, 2019. For the SP system, a GelPOINT access platform was placed through a single periumbilical incision. A 25-mm multichannel robotic port and assistant's ports were placed in the GelSeal cap. No additional incisions were required for the assistant or liver traction. The primary outcomes were intraoperative and postoperative complications. Results: Fourteen patients underwent single-site partial nephrectomy with the SP surgical system (n = 9) or XiSSP (n = 5). No limitations were noted for accessing tumors in the upper aspect of the kidney using the SP system. One case of tumor fracture occurred with the SP system, and one case of conversion to multiport robotic surgery occurred with the XiSSP. The postoperative course was uneventful in all patients; only Clavien-Dindo 1 complications occurred. Conclusions: True single-site partial nephrectomy was performed safely with the SP surgical system. The SP system resolved many limitations associated with LESS and the XiSSP.

Pediatric Partial Nephrectomy for Upper Urinary Tract Duplication Anomalies: A Comparison Between Different Surgical Approaches and Techniques

ObjectiveTo review and compare 4 different surgical approaches for partial nephrectomy of a nonfunctioning moiety in children with upper urinary tract duplication anomalies. Materials and methodsA retrospective review of all pediatric patients who underwent open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), robotic partial nephrectomy (RPN), or laparoendoscopic single site partial nephrectomy (LESS-PN) for the treatment of a nonfunctioning moiety in a duplicated collecting system at 2 medical centers between 2007 and 2017. Patient demographics, perioperative data, surgical techniques, complications, and results were compared. ResultsA total of 59 pediatric patients underwent partial nephrectomy for an upper urinary tract duplication anomaly during a 10-year period: 24 OPN, 7 LPN, 18 RPN, and 10 LESS-PN. Median age was 16 months (interquartile range 9-49.7). Median weight was 10.7 Kg (interquartile range 8.8-16.4). Median estimated blood loss was comparable between all minimally invasive approaches, but significantly increased in the open approach. OPN required more narcotics (0.554 mg Morphine equivalent/Kg/day, range 0.03-6.13) and Acetaminophen (72.12 mg/Kg/day, range 0-209.06) than all other groups in the study. Median operating time in OPN (154.5 minutes, range 108-413) and LESS-PN (140 minutes, range 65-245) were found to be significantly shorter in comparison to LPN (190 minutes, range 159-355), and RPN (256 minutes, range 163-458); (P = .03, .005, .02, and .005). ConclusionMinimally invasive approaches (LPN, RPN, and LESS-PN) for partial nephrectomy in upper urinary tract duplication anomalies may be associated with decreased postoperative analgesia requirements, shorter hospital stay, less blood loss, and less use of drains in comparison to the open approach, while demonstrating efficacy and safety.

Assessment of Postural Ergonomics and Surgical Performance in Laparoendoscopic Single-Site Surgery Using a Handheld Robotic Device.

New laparoscopic devices are being continuously developed to overcome some of the technical and ergonomic limitations of laparoendoscopic single-site (LESS) surgery. This study aims to assess the surgeon's surgical performance and ergonomics during the use of a handheld, robotic-driven, articulating laparoscopic instrument during LESS surgery. Seven right-handed experienced surgeons took part in this study. A set of basic suturing tasks and digestive and urological procedures in a porcine model were performed. Surgeons used both a conventional laparoscopic needle holder and a robotic device. The learning curve, execution time, and precision using the surgical needle were assessed. The surgeon's posture was analyzed using a motion tracking system and a data glove. After the training period, execution time on the intracorporeal suturing was significantly shorter using the conventional needle holder. The precision was higher using the conventional instrument in the horizontal plane, but the number of attempts to position the needle was lower using the robotic device (1.625 ± 0.250 vs 1.188 ± 0.375 attempts). The extension of the elbow (134.681 ± 14.35° vs 120.631 ± 13.134°) and the flexion of the shoulder (26.122 ± 7.411° vs 18.475 ± 14.166°) were significantly lower using the robotic instrument. The wrist posture using the robotic device was ergonomically acceptable during both surgical procedures. Results show a positive learning curve in ergonomics and surgical performance using the robotic instrument during LESS surgery. This instrument improves the surgeon's body posture and the needle positioning errors. The use of the robotic instrument is feasible and safe during LESS partial nephrectomy and sigmoidectomy procedures.

Robotic laparoendoscopic single-site (LESS) zero-ischemia partial nephrectomy: a preliminary report

Objective This study is to explore the safety, feasibility and efficacy of robotic laparoendoscopic single-site(LESS) zero-ischemia partial nephrectomy. Methods Two patients underwent robotic laparoendoscopic single-site zero-ischemia partial nephrectomy by our urologic surgical team at 22-May-2017 and 31-May-2017 in our institution. The salient patient demographics and tumor characteristics, including age, gender, body mass index (kg/m2), Charlson Co-morbidity Index (Age-weighted), tumor laterality, diameter (cm), R. E.N.A.L. nephrometry score and preoperative split renal function GFR [ml/(min·1.73 m2)] were: 73/56, female/male, 25.2/19.8, 2/0, left/right, 1.8/1.4, 5a/4a, left 43.8、right 49.2/left 38.8、right 48.7 respectively. A 2-3 cm longitudinal skin incision was made at 4 cm below the inferior margin of rib arch at the level of midaxillary line (case NO.1 )or peri-umbilicus (case NO.2). The da Vinci Si robotic Single-site™ Port was inserted. The line of Toldt was incised with the colon medially mobilized. Gerota's fascia was opened, the main renal artery or its branches were dissected, then the renal mass fully dissected and exposed. The renal mass was entirely removed with approximately 0.5-1.0 cm surrounding normal renal parenchyma (unclamping in case NO.1, and selective branch clamping in case NO.2) and kidney reconstruction was conducted with 1-0 Quill Suture via hem-o-lock sliding technique. Results The two procedures were smoothly completed without any extra skin incision. Operative duration, estimated blood loss and skin incision length was respectively 230/190 min, 100/60 ml, 3.6/2.5 cm. Duration of two selective renal artery branches clamping in case NO.2 was 39 and 24 min. Postoperative pain measured by the visual analog pain scale (VASP) at day 1, day 2, day 3 was 5/4, 3/3, 2/1, Time off oral intake, duration of drainage and length of stay after surgery was 2/4 d、2/4 d、6/7d, respectively. The recovery of both patients were uncomplicated and discharged smoothly. Pathological examination revealed oncocytoma in case NO.1 and papillary renal cell carcinoma in case NO.2. Conclusions The initial experience shows the robotic laparoendoscopic single-site zero-ischemia partial nephrectomy is a safe, feasible and efficacious procedure. It may exhibit clinical benefits for patients in terms of pain control, convalescence and cosmesis, but in this early stage the clinical indications should be strictly controlled. Key words: Robot; Laparoendoscopic single-site surgery; Partial nephrectomy; Kidney neoplasms

Comparative study of hybrid laparoendoscopic single-site (LESS) partial nephrectomy and conventional multiport laparoscopy

ObjectiveTo investigate the surgical and oncological outcomes of hybrid laparoendoscopic single-site (LESS) in partial nephrectomy with reusable components compared with multiport laparoscopy. Material and methodHybrid LESS technique with auxiliary 3.5mm trocar (n=20) was compared with conventional multiport laparoscopy (n=26) by a prospective, paired, nonrandomized, and comparative study in partially nephrectomized patients. ResultsFollow-up average was 31±18.6 months. In one case, LESS was converted to laparoscopy. No differences were found regarding age, sex, body mass index, laterality, localization, tumor size or use of double J stent. Dominance of Loop-I (P=0.09) and benign histology (P=0.05) were observed in the LESS group. Neither there were differences regarding operating time, ischemia time, use of hemostatic materials, estimated blood loss, postoperative hemoglobin levels, transfusion or other complications. In any case, to extend the skin incision for specimen extraction was not necessary. Drainage time (P=0.006) and hospital stay (P=0.003) were better in LESS patients. Concerning complications, no significant differences were observed according Clavien-Dindo scale. In laparoscopic group one patient died of pulmonary embolism after hospital discharge. No positive margins were observed in any case. During follow-up neither tumor recurrence nor disease progression were observed. ConclusionsRegarding surgical outcomes, partial nephrectomy by LESS technique does not imply improvements, excepting shorter hospital stay, probably due to accurate surgical hemostasis and/or selection of cases. No surgical and oncological risks are involved, as well as no improvement in ischemia time, blood loss or transfusion rate. We find no significant difference in cosmetic outcomes.

Hybrid laparoendoscopic single-site surgery of upper urinary tract with the use of mini-laparoscopic instruments: cosmetic outcome and midterm oncological outcome.

To evaluate the efficacy of mini-laparoscopic instruments in combination with laparoendoscopic single-site surgery (LESS) instruments for the performance of oncological urological surgery. Thirty-five patients underwent oncological hybrid LESS either mini-laparoscopic-assisted LESS partial nephrectomy (LESS-PN, n=12) or mini-laparoscopic-assisted LESS radical nephrectomy (LESS-RN, n=23). Perioperative data were prospectively collected. The patient and observer scar assessment scale (POSAS) was used for the evaluation of the cosmetic outcome. Mean tumor size treated by LESS-PNs was 28.8 (IQR 20.5-37.3) mm. Average operative time and blood loss were 123 (IQR 112.5-145) min and 158.3 (IQR 100-200) ml, respectively. Renal artery clamping took place in seven cases. LESS-RN was performed in cases with a mean tumor size of 60 (IQR 48-71.5) mm. The average operative time was 116.8 (IQR 100-130) min. Average blood loss was 137 (IQR 100-150) ml. Complications were limited to grade II according to Clavien classification. The oncological outcome, including midterm results, was directly comparable to the literature. Patients reported low pain scores and high satisfaction in terms of postoperative scarring. The POSAS scores confirmed the excellent cosmetic outcome of hybrid LESS. The combination of mini-laparoscopic and LESS instrumentation as routine equipment of oncological surgery provided an efficient option for urologic surgery. The combination of mini-laparoscopic and LESS instruments improves the intraoperative ergonomics of LESS-PN and LESS-RN. The provided surgical and oncological outcome compares favorably to the LESS and conventional laparoscopic literature.

Initial experience of percutaneous nephrolithotomy combined with retroperitoneal laparoendoscopic single-site partial nephrectomy in one-stage treatment of homolateral renal diseases

This study investigated the feasibility of percutaneous nephrolithotomy (PCNL) combined with retroperitoneal laparoendoscopic single-site partial nephrectomy (LESS-PN) in one-stage treatment of homolateral renal calculi and tumors. Between October 2010 and July 2014 one-stage PCNL combined LESS-PN surgery was performed in 23 patients with homolateral renal calculi and tumors. Patients included 17 male and 8 female, ranged from 31 to 66 years old with a median age of 42.7. Operative parameters and occurrence rate of complications were recorded. In all cases renal tumors were successfully removed without converting to open surgery. One-stage clearance rate for renal calculi was 21/23 (91.3%), leaving two cases for second-stage operation of flexible ureteroscope lithotomy. The operation time was 95–186 min; average 128 min. Intraoperative blood loss was 40–200 mL; average 130 mL. Median warm ischemia time was 23.8 ± 9.5 min. There were no serious post-operative complications such as massive hemorrhage or urine leakage. Length of stay was 5–7 days, average 6 days. There was no recurrence of renal calculus, renal tumors or ureterostenosis and kidney functions were normal. In conclusion, with good practice, one-stage combined operation of PCNL and retroperitoneal LESS-PN in removing homolateral renal tumors and calculi was safe, feasible and would potentially reduce the operative trauma.

Laparoendoscopic Single-Incision Triangulated Umbilical Surgery for Partial Nephrectomy: Early Experience in the First 13 Cases

Introduction: Nephron sparing surgery is the standard treatment for cT1a renal tumors. It has been shown consistently that laparoscopic partial nephrectomy (LPN) has similar oncological outcomes as open partial nephrectomy (OPN).1 In comparison to the open approach, LPN offers reduced morbidity, less pain, and a shorter convalescence. Laparoendoscopic single-site surgery (LESS) is the most recent approach to further minimize invasiveness of laparoscopic surgery. We introduced the concept of laparoendoscopic single-incision triangulated umbilical surgery (SITUS) in 2009.2 This concept was later applied in several clinical scenarios.3–6 The purpose of this study was to report our technique and initial experience with LESS partial nephrectomy in SITUS technique in clinical practice. Methods: From January 2010 to December 2012, patients treated by SITUS-PN were evaluated. Patients with small exophytic renal tumors were selected. Patients' characteristics, clinical data, PADUA and RENAL scores, perioperative, hematologic, and pathologic data, as well as pain evaluation using the Visual Analogue Pain Scale (VAPS) were assessed prospectively. Operative Principle: Patients were positioned in a standard 70° flank position. First, a “c”-shaped incision was performed in the umbilical crease. After dissection of the rectus fascia, the periumbilical skin was mobilized. A pneumoperitoneum was achieved by the Veress technique. A 5-mm camera trocar was placed in the paramedian line. The skin incision was stretched with Langenbeck hooks. A cranial 5-mm working trocar and, in a distance of 5 to 10 cm, an 11-mm caudal trocar were placed through the umbilical incision. Triangulation of the instruments was achieved, similar to conventional laparoscopy. The kidneys were exposed as in conventional laparoscopic surgery. To control bleeding from the renal cortex, one of the three different approaches were chosen: (1) The respective segment artery was clamped with a 2.0 Vicryl loop tagged standard laparoscopic bulldog clamp. (2) A parenchymal compression sling was placed below the tumor. (3) Two to three transparenchymal compression sutures were placed below the dissection level. Excision of the tumor was performed as in OPN. Finally, the defect was sealed with Tissucol fibrin glue. The specimen was removed and a drain was placed. Results: Thirteen patients (8 males and 5 females) with a mean age of 57 years (range, 39–81 years) underwent LESS/SITUS-PN (6 right/7 left renal units). The mean BMI was 28 ± 4 kg/m2, the mean PADUA and RENAL scores were 7.5 ± 1.0 and 5.6 ± 1.7, respectively, and the mean preoperative tumor size was 2.5 ± 1.1 cm. One patient was converted to conventional laparoscopy requiring two additional ports to treat a bleeding from renal vein. Ten patients were treated without hilar clamping. The average warm ischemia time was 22 ± 9 minutes (n = 3). The average operation time was 186 minutes (range, 135–251 minutes), and a mean blood loss of 2.1 g/dL (range 0.5–4.5 g/dL) in hemoglobin was noted. Pathology confirmed renal cell carcinoma in nine patients, oncocytoma in one patient, and benign cyst in three patients. No positive surgical margin was observed. During discharge, minimal discomfort was noted (VAPS = 0.2 ± 0.6 [range 0–2]/10]. Conclusion: LESS partial nephrectomy in SITUS technique is a viable option for the treatment of selected exophytic tumors. We declare that there were no commercial associations that might create a conflict of interest in connection with this article. Runtime of video: 6 mins

PE55: Laparoendoscopic single-site robotic partial nephrectomy was less painful than conventional approach without disadvantage of functional outcomes: 6-Month follow up

PE55: Laparoendoscopic single-site robotic partial nephrectomy was less painful than conventional approach without disadvantage of functional outcomes: 6-Month follow up

Current status of robotic laparoendoscopic single-site partial nephrectomy.

Robotic laparoendoscopic single-site partial nephrectomy is increasingly carried out in an attempt to improve the cosmetic outcome of minimally-invasive procedures. However, the actual role of this novel technique remains to be determined. The present article reviews evidence and examines updates of robotic laparoendoscopic single-site partial nephrectomy outcomes reported in more contemporary studies. A comprehensive online systematic search of PubMed, Scopus and Web of Science databases according to Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria recommendations was carried out in January 2014, identifying data from 2008 to 2014 regarding robotic laparoendoscopic single-site partial nephrectomy. The majority of medical evidence to date is based on case reports or retrospective studies. Current studies show that robotic laparoendoscopic single-site partial nephrectomy is a feasible procedure carried out in an acceptable length of operative time, and resulting in a desirable cosmetic outcome and less postoperative pain. However, comparable studies show that robotic laparoendoscopic single-site partial nephrectomy is inferior to the conventional approach, especially with regard to warm ischemia time. Furthermore, the numerous limitations that exist with the utilization of the current commercial single-site devices make robotic laparoendoscopic single-site PN more challenging and more complicated for surgeons compared with conventional procedures. Further significant improvements, along with more studies, are required in order to develop the ideal robotic laparoendoscopic single-site robotic platform and overcome the current limitations. For the time being, robotic laparoendoscopic single-site partial nephrectomy procedures could be applicable in patients with low tumor size and complexity, and should not be routinely applied in all cases.

‘Scarless' Laparoscopic Urologic Surgery by the Combination of Mini-Laparoscopic and Laparoendoscopic Single-Site Surgery Equipment

Objective: We evaluated reconstructive and oncological laparoendoscopic single-site surgery (LESS) combined with mini-laparoscopic instruments as standard equipment. Patients and Methods: 30 patients underwent reconstructive and oncological LESS: mini-laparoscopic-assisted LESS pyeloplasty (LESS-P, n = 18), mini-laparoscopic-assisted LESS partial nephrectomy (LESS-PN, n = 7) or mini-laparoscopic-assisted LESS radical prostatectomy (LESS-RP, n = 5). Perioperative data were prospectively collected. Results: The 18 LESS-P cases had operative times ranging between 120 and 180 min (average 147.9 min). Estimated blood loss ranged between 100 and 300 ml (average 202.1 ml). Two patients required additional management for failed reconstruction. LESS-PN was performed in 7 patients with tumor size ranging between 2.5 and 3.8 cm (average 2.7 cm). Average operative time and blood loss were 155 (140-180) min and 321.4 (250-550) ml, respectively. Renal artery clamping took place in 1 case. LESS-RP was performed in 5 patients; average operative time was 156 (140-180) min and average blood loss 196 (100-400) ml. Functional and oncological outcome was directly comparable to laparoscopic radical prostatectomy. Conclusion: The combination of LESS and mini-laparoscopic instrumentation as routine equipment of reconstructive LESS reveals a different perspective for ‘scarless' urologic surgery.

Pediatric laparo-endoscopic single site partial nephrectomy: Feasibility in infants and small children for upper urinary tract duplication anomalies

ObjectiveTo assess the feasibility and outcomes of laparo-endoscopic single site (LESS) partial nephrectomy (PN) in infants and small children for upper urinary tract duplication anomalies. Materials and methodsThe medical records of all patients undergoing LESS PN at a single pediatric institution were retrospectively reviewed for patient demographics, perioperative details, and outcomes. A cystoscopy was initially performed to place an externalized catheter into the ureter of the ipsilateral normal renal moiety. An Olympus TriPort, an Olympus Endoeye flexible tip laparoscope, standard 3- or 5-mm instrumentation, and a LigaSure Blunt were utilized. ResultsFour children (two boys, two girls) underwent LESS PN. Three patients underwent upper pole PN and one underwent lower pole PN. All procedures were performed for poorly functioning obstructed renal moieties (one ureterocele, one ureteropelvic junction obstruction and vesicoureteral reflux, and two ectopic ureters). Median age was 6.2 months (range 2.5–16.4 months). Median weight was 7.7 kg (range 6.1–12.6 kg). Median operative time was 126 min (range 97–180 min). No patient received inpatient postoperative narcotics. Median follow-up was 9.9 months (range 6.2–19.1 months). No postoperative complications were noted. Postoperative renal ultrasound demonstrated successful resection in all patients. ConclusionsLESS PN is technically feasible, safe, and effective for upper urinary tract duplication anomalies in infants and small children.

Laparoendoscopic Single-Site Partial Nephrectomy Without Hilar Clamping Using a Microwave Tissue Coagulator

To report our initial experience and evaluate the possibility of nonhilar clamp laparoendoscopic single-site (LESS) partial nephrectomy by using a microwave tissue coagulator. From December 2010 to May 2012, all patients with an exophytic, solitary, enhancing small (≤4.0 cm) renal mass were chosen to receive the study treatment. A multichannel port provided both a retroperitoneal and transperitoneal approach. A rigid, articulating apparatus was used to perform dissection, exposure of tumor, tissue coagulation, and resection without hilar clamping. Pathologic and hematologic data, subjective evaluation of pain, and scar appearance were analyzed. Nonhilar clamp LESS partial nephrectomy by using a microwave tissue coagulator was performed in seven patients (mean operative time, 208 min; mean blood loss, 39 mL; mean renal mass size, 1.7 cm); one procedure with uncontrolled bleeding needed to be converted to conventional laparoscopic partial nephrectomy. No transfusion was necessary. Pathologic investigation demonstrated six renal-cell carcinomas and one oncocytoma. The hemoglobin level decreased by a mean of 1.1 g/dL. Patients did not complain about pain, and they had great satisfaction with the results. The mean duration of hospital stay was 13.8 days. LESS partial nephrectomy without hilar clamping by using a microwave tissue coagulator is possible for renal masses, confers postoperative outcomes comparable to the standard counterpart, and assures patient satisfaction. By use of a microwave tissue coagulator, additional trocars were not necessary, and LESS partial nephrectomy could be accomplished through a single port, which reduced invasion and increased the cosmetic satisfaction of the patients.

Robot-assisted laparoendoscopic single-site partial nephrectomy with the novel da vinci single-site platform: initial experience.

PurposeTo report our initial clinical cases of robotic laparoendoscopic single-site (R-LESS) partial nephrectomy (PN) performed with the use of the novel Da Vinci R-LESS platform.Materials and MethodsThree patients underwent R-LESS PN from November 2013 through February 2014. Perioperative and postoperative outcomes were collected and intraoperative difficulties were noted.ResultsOperative time and estimated blood loss volume ranged between 100 and 110 minutes and between 50 and 500 mL, respectively. None of the patients was transfused. All cases were completed with the off-clamp technique, whereas one case required conversion to the conventional (multiport) approach because of difficulty in creating the appropriate scope for safe tumor resection. No major postoperative complications occurred, and all tumors were resected in safe margins. Length of hospital stay ranged between 3 and 7 days. The lack of EndoWrist movements, the external collisions, and the bed assistant's limited working space were noticed to be the main drawbacks of this surgical method.ConclusionsOur initial experience with R-LESS PN with the novel Da Vinci platform shows that even though the procedure is feasible, it should be applied in only appropriately selected patients. However, further improvement is needed to overcome the existing limitations.

Transperitoneal laparoendoscopic single-site nephrectomy combined with flexible 3-D laparoscope for partial nephrectomy in pigs：a preliminary experience

Objective To use transperitoneal laparoendoscopic single-site(LESS)partial nephrectomy combined with flexible 3-D laparoscope for partial nephrectomy in pigs,and to introduce our experience on LESS training in a pig model for partial nephrectomy.Methods A male pig was given general anesthesia and was put in a supine position.A 3.5cm incision was made through the right abdominal rectus. A multi- channel QuadPort(OlympusTM) was established. Artificial pneumoperitoneum was created by 14mmHg(1mmHg=0.133kPa);the lower pole and the kidney pedicle of the right kidney were isolated.The lower pole of the right kidney was resected after the renal artery was blocked.Figure-8 sutures were used to close the wound,with no notable bleeding noticed after opening the blood.The specimen was enclosed in an endoscopic pouch and pulled out from the incision.Results The procedure was smoothly completed without any extra incision.The operating time was 47 min;the period of renal artery occlusion was 21 min(5 min for resection,16 min for stitching);and the intraoperative blood loss was 20mL.There was no complication during the operation.Conclusion Our initial experience shows that 3D-LESS partial nephrectomy procedure is technically difficult,but it is safe,feasible and effective.Flexible 3D laparoscopy can provide clear 3D visualization,improving the operating accuracy and reducing the fighting of instruments.Thepig model used in this study can help surgeons to obtain experience on 3D-LESS partial nephrectomy.

Costs analysis of laparoendoscopic, single-site laparoscopic and open surgery for cT1 renal masses in a European high-volume centre

To analyse intraoperative costs and healthcare reimbursements of partial/radical nephrectomy in open and minimal invasive surgery (MIS), as laparoscopy and laparoendoscopic single-site surgery (LESS), for the treatment of renal tumour. In a non-randomized retrospective study, we selected 90 patients who underwent (01/2010-12/2011) partial and radical nephrectomy for clinical renal masses ≤7 cm (cT1N0M0) and divided them into laparoscopic [laparoscopic partial nephrectomy (LPN), laparoscopic radical nephrectomy (LRN)], LESS [laparoendoscopic single-site partial nephrectomy (LESS-PN), laparoendoscopic single-site radical nephrectomy (LESS-RN)] and open groups [open partial nephrectomy (OPN), open radical nephrectomy (ORN)]. Patients were matched for age, sex, body mass index, ASA score and tumour side. Primary endpoints were evaluation of intraoperative costs (general, laparoscopic, sutures, haemostatic agents, anaesthesia, and surgeon/nurses fee), total insurance and estimated daily reimbursement. MIS showed longer operative time (p ≤ .02) and shorter hospital stay (p ≤ .04). Total costs were higher (p ≤ .03) in MIS (LRN: 4,091.5 <euro>; LPN: 4,390.4 <euro>; LESS-RN: 3,866 <euro>; and LESS-PN: 3,450 <euro>) if compared with open (OPN: 2,216.8.8 <euro>, ORN: 1,606.4 <euro>). Laparoscopic materials incised mainly in total costs of MIS (38-58.1 %). Reusable instruments reduced LESS laparoscopic costs (LESS-PN: 1,312.2 <euro> vs. LRN: 2,212.2 <euro>, p < .0001). Intraoperative frozen section and DJ ureteric stenting (general costs) (p ≤ .008) and haemostatic agents use (p ≤ .01) were higher in nephron sparing surgery (NSS), due to more frequent use of ancillary procedures necessary for a safe management of such an approach. Estimated anaesthesia costs and doctor/nurses fee were higher in MIS (p ≤ .02). Whereas total final reimbursements were comparable (p ≥ .8), estimated daily reimbursements were lower in MIS (p < .001) due to higher intraoperative costs and longer operative time. Well-known advantages offered by MIS/NSS face higher total intraoperative costs and 'paradoxical' reduced healthcare reimbursement. We believe that local health systems should consider a subclassification with different compensations, which will incentive NSS and MIS approaches.

Analysis of oncological outcomes and renal function after laparoendoscopic single‐site (LESS) partial nephrectomy: a multi‐institutional outcome analysis

To report on a large multi-institutional series of laparoendoscopic single-site (LESS) partial nephrectomy (PN) and analyse renal function and short-term oncological outcomes. We conducted a retrospective analysis of consecutive cases of LESS-PN performed between November 2007 and March 2012 at 11 participating institutions. Demographic data and data on the main peri-operative outcomes and complications were gathered and analysed. Kidney function was evaluated by measuring serum creatinine concentration and estimated glomerular filtration rate (eGFR). Chronic kidney disease was defined in stages for each patient according to the National Kidney Foundation, Kidney Disease Outcomes Quality Initiative. A total of 190 cases were included in this analysis. The mean renal tumour size was 2.6 cm, and the mean PADUA score was 7.2. The median operating time was 170 min with a median estimated blood loss of 150 mL. A clampless technique was used in 70 cases (36.8%) and the median warm ischaemia time (WIT) was 16.5 min. PADUA score independently predicted the length of WIT (low vs high score: odds ratio 5.11, CI 1.50-17.41, P = 0.009; intermediate vs high score: odds ratio 5.13, CI 1.56-16.88, P = 0.007). The overall postoperative complication rate was 14.7%. Where a clamping technique was used, a significant increase in serum creatinine concentration and a significant decrease in eGFR were observed postoperatively and at 6 months. On multivariate analysis PADUA score was the only predicting factor. Overall survival rates were 99, 97 and 88% at 12-, 24- and 36-month follow-up, respectively, while disease-free survival rates were 98% at 12-month and 97% at 24- and 36-month follow-up. The study showed that LESS-PN is effective in terms of renal function preservation and oncological control at short- and intermediate-term follow-up.

Robotic Laparoendoscopic Single-site Transumbilical Partial Nephrectomy: Functional and Oncologic Outcomes at 2 Years

To assess the functional and oncologic outcomes of robotic laparoendoscopic single site surgery (LESS) partial nephrectomy with a minimum of 2-year follow-up. Thirty-nine consecutive patients who had undergone robotic LESS partial nephrectomy were identified with a minimum of 2-year follow-up. Perioperative data were recorded along with functional and oncologic outcomes. Patient's estimated glomerular filtration rate was determined using the Modification of Diet in Renal Disease formula. A univariate analysis was performed using independent samples t test. Data are presented as medians with interquartile range and counts or frequencies with percentages or proportion. The median age was 51 (45, 59). The median resected tumor size was 3 cm (2, 3.7), and the median operative time was 185 minutes (135, 237). The median estimated blood loss was 150 mL (70, 150), and the median warm ischemia time was 25 minutes (17, 35). The estimated glomerular filtration rate did not change significantly at 24 month follow-up with a mean decrease of 6.4 mL/minute/1.73 m(2) (-7.5%, P = .22). Renal cell carcinoma was confirmed in 33 patients (85%) with tumor stage pT1a in 26 patients (78%). There was 1 patient with a positive surgical margin. At a median follow-up of 26 months (24, 32), there was no local recurrence and only 1 distant recurrence was detected. This study appears to be the first to report on intermediate term functional and oncologic outcomes after robotic LESS partial nephrectomy. It has shown comparable results with other minimal invasive surgical options.

Is LESS partial nephrectomy feasible for most urologists?

Partial nephrectomy has become the standard of care for small renal masses, with minimally-invasive techniques such as laparoscopic, robotic-assisted and laparoendoscopic single-site surgery (LESS) becoming increasingly popular. However, the complexity of the procedure generates uncertainty as to whether successful outcomes of LESS partial nephrectomy from large-volume centres can be translated into smaller urology practices.