Pure Laparoscopic Radical Research Articles

"Hepatic hilum area priority, liver posterior first": An optimized strategy in laparoscopic resection for type III-IV hilar cholangiocarcinoma.

In recent years, pure laparoscopic radical surgery for Bismuth-Corlette type III and IV hilar cholangiocarcinoma (HCCA) has been preliminarily explored and applied, but the surgical strategy and safety are still worthy of further improvement and attention. To summarize and share the application experience of the emerging strategy of "hepatic hilum area dissection priority, liver posterior separation first" in pure laparoscopic radical resection for patients with HCCA of Bismuth-Corlette types III and IV. The clinical data and surgical videos of 6 patients with HCCA of Bismuth-Corlette types III and IV who underwent pure laparoscopic radical resection in our department from December 2021 to December 2023 were retrospectively analyzed. Among the 6 patients, 4 were males and 2 were females. The average age was 62.2 ± 11.0 years, and the median body mass index was 20.7 (19.2-24.1) kg/m2. The preoperative median total bilirubin was 57.7 (16.0-155.7) μmol/L. One patient had Bismuth-Corlette type IIIa, 4 patients had Bismuth-Corlette type IIIb, and 1 patient had Bismuth-Corlette type IV. All patients successfully underwent pure laparoscopic radical resection following the strategy of "hepatic hilum area dissection priority, liver posterior separation first". The operation time was 358.3 ± 85.0 minutes, and the intraoperative blood loss volume was 195.0 ± 108.4 mL. None of the patients received blood transfusions during the perioperative period. The median length of stay was 8.3 (7.0-10.0) days. Mild bile leakage occurred in 2 patients, and all patients were discharged without serious surgery-related complications. The emerging strategy of "hepatic hilum area dissection priority, liver posterior separation first" is safe and feasible in pure laparoscopic radical surgery for patients with HCCA of Bismuth-Corlette types III and IV. This strategy is helpful for promoting the modularization and process of pure laparoscopic radical surgery for complicated HCCA, shortens the learning curve, and is worthy of further clinical application.

Safety and feasibility of same-day discharge laparoscopic radical prostatectomy: a systematic review.

PurposeDay case or same-day discharge (SDD) pure laparoscopic or robot-assisted radical prostatectomy (RP) has risen over the last few years with the aim of discharging patients within 24 h, reducing costs and length of stay, and facilitating return to active life. We perform a systematic review of literature to evaluate the feasibility of SDD RP.MethodsA systematic review search was performed and the following bibliographic databases were accessed: PubMed, Science Direct, Scopus, and Embase. This was carried out in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines.ResultsBased on the literature search of 509 articles, 12 (1378 patients) met the inclusion criteria (mean age: 63 years). All studies were unicentric except one. The mean SDD surgeries experience per centre was 66 cases .The means operative time and blood loss were 154 min and 126.5 ml, respectively. Mean SDD failure was 7.4%. Concomitant lymph node dissection was performed in 56.2%. The overall complication rate was 10.2% of cases; with a majority of Clavien grade I or II. Mean readmission rate after discharge was 5%. SDD generated cost reductions compared to inpatient surgery with variable differences according to the considered healthcare system.ConclusionsDay-case RP is a safe and feasible strategy in selected cases with multicentre proofs of concept. Its widespread use in routine practice needs further research due to biases in patient selection. Implementation of peri-operative pathways such as ERAS and prehabilitation improves patient adherence to SDD.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00345-022-03944-1.

Comparison of oncological outcomes for hand-assisted and pure laparoscopic radical nephroureterectomy: results from the Taiwan Upper Tract Urothelial Cancer Collaboration Group.

Laparoscopic radical nephroureterectomy (LNU) has gradually become the new standard treatment for localized upper tract urothelial cancer (UTUC). With more blunt dissection and tactile sensation, hand-assisted LNU might shorten the operative time compared with the pure laparoscopic approach. However, whether the use of the hand-assisted or the pure laparoscopic approach has an effect on oncological outcomes remains unclear. We retrospectively identified 629 patients with non-metastatic UTUC who underwent hand-assisted (n = 515) or pure LNU (n = 114) at 9 hospitals in Taiwan between 2004 and 2019. Overall survival, cancer-specific survival, recurrence-free survival, and bladder recurrence-free survival were compared between these two groups using inverse-probability of treatment weighting (IPTW) derived from the propensity scores for baseline covariate adjustment. The median follow-up period was 32.9 and 28.7months in the hand-assisted and the pure groups, respectively. IPTW-adjusted Cox proportional hazards models showed that the laparoscopic approach (pure vs. hand-assisted) was not significantly associated with all-cause mortality (HR 0.79, 95% CI 0.49-1.24, p = 0.304), cancer-specific mortality (HR 0.88, 95% CI 0.51-1.51, p = 0.634), or extra-vesical recurrence (HR 0.65, 95% CI 0.41-1.04, p = 0.071). However, the pure laparoscopic approach was significantly associated with lower intra-vescial recurrence (HR 0.64, 95% CI 0.43-0.96, p = 0.029) for patients who underwent LNU. Kaplan-Meier curves also revealed that the pure laparoscopic approach was associated with better bladder recurrence-free survival compared with the hand-assisted laparoscopic approach in both the original cohort and the IPTW-adjusted cohort (log-rank p = 0.042 and 0.027, respectively). The performance of hand-assisted or pure LNU does not significantly affect the all-cause mortality, cancer-specific mortality, or extra-vesical recurrence for patients with non-metastatic UTUC. However, the hand-assisted laparoscopic approach could increase the risk of intra-vesical recurrence for patients who undergo LNU.

Evaluating the Oncological Outcomes of Pure Laparoscopic Radical Nephroureterectomy Performed for Upper-Tract Urothelial Carcinoma Patients: A Multicenter Cohort Study Adjusted by Propensity Score Matching

To evaluate the oncological feasibility of pure laparoscopic radical nephroureterectomy (p-LRNU) for upper tract urothelial carcinoma (UTUC) compared with conventional LRNU (c-LRNU) using a propensity-adjusted multi-institutional collaboration dataset. Among the 503 UTUC patients who underwent RNU, we identified 219 who underwent c-LRNU (laparoscopic nephrectomy with open bladder cuff resection) and 72 who underwent p-LRNU (dissecting the kidney, ureter, and bladder cuff under complete laparoscopy). We adopted a propensity score (PS) matching method to achieve homogeneity with respect to patient backgrounds. PS matching-adjusted Cox-regression analysis was performed to evaluate the risk factors that influenced oncological outcomes. Sixty-eight p-LRNU and 68 c-LRNU patients were matched. Overall, 51 (37.0%) developed intravesical recurrence (IVR), 21 (15.4%) had disease recurrence, and 20 (14.7%) died. Patients who underwent p-LRNU had a significantly shorter operation time and less blood loss than those who underwent c-LRNU. Although no significant differences in 3-year recurrence-free survival were found between the two methods, atypical recurrence sites were observed in the p-LRNU group, including the brain, sigmoid colon, vagina, and peritoneum. Regarding IVR, the 3-year IVR-free survival rate was 41.8% in the p-LRNU group, which was significantly lower than that in the c-LRNU group (66.6%, p = 0.004). Multivariate analysis demonstrated that a history of bladder cancer, ureteral cancer, and p-LRNU were independent risk factors for subsequent IVR. Although p-LRNU is less invasive, the current technique may increase the incidence of atypical disease recurrence and subsequent IVR due to extravesical and intravesical tumor dissemination.

ASO Author Reflections: Discussing the Oncological Feasibility of Performing Pure Laparoscopic Radical Nephroureterectomy for Upper-Tract Urothelial Carcinoma Patients: Results from a Multi-institution Collaborative Study Adjusted by Propensity Score Matching.

ASO Author Reflections: Discussing the Oncological Feasibility of Performing Pure Laparoscopic Radical Nephroureterectomy for Upper-Tract Urothelial Carcinoma Patients: Results from a Multi-institution Collaborative Study Adjusted by Propensity Score Matching.

163 - Comparing the oncological outcomes between pure laparoscopic radical nephroureterectomy and laparoscopic assisted nephroureterectomy for upper-tract urothelial carcinoma: A multi-center cohort study adjusted by propensity score matching

163 - Comparing the oncological outcomes between pure laparoscopic radical nephroureterectomy and laparoscopic assisted nephroureterectomy for upper-tract urothelial carcinoma: A multi-center cohort study adjusted by propensity score matching

Effect of Robot-assisted Surgery on Anesthetic and Perioperative Management for Minimally Invasive Radical Prostatectomy under Combined General and Epidural Anesthesia.

Robot-assisted surgery and pure laparoscopic surgery are available for minimally invasive radical prostatectomy (MIRP). The differences in anesthetic management between these two MIRPs under combined general and epidural anesthesia (CGEA) remain unknown. This study therefore aimed to determine the effects of robot-assisted surgery on anesthetic and perioperative management for MIRP under CGEA. This retrospective observational study analyzed data from patients' electronic medical records. Data on demographics, intraoperative variables, postoperative complications, and hospital stays after MIRPs were compared between patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP) and those treated by pure laparoscopic radical prostatectomy (LRP). There were no differences in background data between the 102 who underwent RALP and 112 who underwent LRP. Anesthesia and surgical times were shorter in the RALP group than in the LRP group. Doses of anesthetics, including intravenous opioids, and epidural ropivacaine, were lower in the RALP group. Although estimated blood loss and volume of colloid infusion were lower in the RALP group, the volume of crystalloid infusion was larger. Intraoperative allogeneic transfusion was not required in either group. There was no difference between groups in the incidences of postoperative cardiopulmonary complications or postoperative nausea and vomiting. Hospital stays after the procedure were shorter in the RALP group. Robot-assisted surgery required varied consumption of anesthetics and infusion management during MIRP under GCEA. It also shortened postoperative hospital stays, without increasing rates of postoperative complications.

Pure laparoscopic radical nephrectomy and inferior vena caval tumor thrombus removal in patients with complicated renal tumor.

Pure laparoscopic radical nephrectomy and inferior vena caval tumor thrombus removal in patients with complicated renal tumor.

The Association of Robot-assisted Versus Pure Laparoscopic Radical Nephrectomy with Perioperative Outcomes and Hospital Costs

BackgroundAlthough robot assistance can facilitate the advantages of minimally invasive surgery, it is unclear whether it offers benefits in settings in which laparoscopic surgery has been established as the standard of care. ObjectiveTo examine the comparative effectiveness of robot-assisted laparoscopic radical nephrectomy (RALRN) and laparoscopic radical nephrectomy (LRN) using a nationwide data set. Design, setting, and participants8316 adults who underwent RALRN or LRN for non-urothelial renal cancer from the Nationwide Inpatient Sample from 2010 to 2013. InterventionRALRN and LRN. Outcome measurements and statistical analysisThe associations of surgical approach with perioperative outcomes and total hospital costs were evaluated using multivariable logistic regression. Results and limitationsOver the study period, utilization of RALRN increased from 46% to 69%. Compared to LRN, RALRN was associated with lower rates of intraoperative (0.9% vs 1.8%; p<0.001) and postoperative complications (20.4% vs 27.2%; p<0.001), but there were no differences in perioperative blood transfusion (5.6% vs 6.2%; p=0.27) and prolonged hospitalization (7.2% vs 7.1%; p=0.81). RALRN was also significantly associated with higher total hospital costs (median $16 207 vs $15 037; p<0.001). In multivariable analyses, RALRN remained independently associated with a lower risk of intraoperative (odds ratio [OR] 0.50; p=0.001) and postoperative complications (OR 0.72; p<0.001) but not perioperative blood transfusion (OR 1.10; p=0.34), and with a higher risk of prolonged hospitalization (OR 1.29; p=0.007) and higher mean total hospital costs (+$1468; p<0.001). There was no effect modification by hospital volume. ConclusionsAlthough RALRN was independently associated with a reduction in perioperative complications compared to LRN, it was associated with prolonged hospitalization and higher total hospital costs. These relationships must be interpreted in light of potential differences in case mix. Patient summaryAlthough robot-assisted laparoscopic radical nephrectomy was independently associated with a reduction in perioperative complications compared to laparoscopic radical nephrectomy, it was associated with prolonged hospitalization and higher total hospital costs.

L’introduction de la chirurgie robot-assistée pour la prostatectomie totale s’accompagne-t-elle d’une modification du nombre d’interventions secondaires pour troubles fonctionnels génito-urinaires ?

To study the impact of changing the technique of radical prostatectomy [pure laparoscopic radical (PR-Lap) to robot-assisted radical prostatectomy (RP-Rob)] on the rate of secondary procedures for urinary incontinence (UI) and erectile dysfunction (ED). Retrospective study evaluating the number and type of surgical procedures for post-RP UI and DE between 2008 and 2015, according to the technique of (RP-Lap or RP-Rob). Between 2008 et 2015, 2046 RP were performed in our department including 372 RP-Lap and 1674 RP-Rob. Among these patients, 84 (4%) had a surgical procedure for post-RP UI (18 AMS800, 9 balloons Pro-Act, and 57 male slings) and 15 (0.7%) had implantation of penile prosthesis for post-RP ED; 16 (0.7%) patients had both procedures. The mean delay between RP and UI surgery decrease from 3.2 years in 2008 to 1 year in 2015 and remain stable for penile prosthesis implantation (mean delay: 3.4 years). The overall rates of secondary procedures for UI and DE remained stable and below 5% and 1.7%, respectively, even during the transition period. For each year of PR studied, the rates of secondary procedure were higher in the RP-Lap group. Changing the technique of RP from RP-Lap to PR-Rob has a favorable impact on the rate of secondary procedures for UI and ED from the outset.

Comparison of anesthetic management and outcomes of robot-assisted vs pure laparoscopic radical prostatectomy

Study objectiveLimited data are available regarding the anesthetic management and outcome of patients undergoing pure laparoscopic radical prostatectomy (LRP) and robotic-assisted LRP (RALP). Therefore, our primary objective was to compare the anesthetic management between these 2 groups. Our secondary objective was to determine the incidence of adverse outcomes associated with RALP, which requires an extreme Trendelenburg position. DesignA retrospective observational study. SettingUniversity teaching hospital. PatientsA total of 223 men, consisting of 97 LRP patients and 126 RALP patients, treated during a 3-year period (January 2010-December 2012) were retrospectively studied. InterventionsNone. MeasurementsInformation on patient demographics, type of anesthesia, anesthetic/pneumoperitoneum/surgical times, intraoperative fluids and blood products, estimated blood loss, intraoperative and postoperative opioid use, postoperative analgesic consumption, length of stay in the postanesthesia care unit, postoperative complications, and hospital stays was collected and compared. Main resultsThe estimated blood loss was higher in LRP patients than in RALP patients (median, 550 mL vs 200 mL; P < .001). Likewise, 24% of the LRP patients received intraoperative transfusions compared with 0.79% of the RALP patients (P < .001). The RALP patients had a longer anesthesia time (median, 276 vs 259 minutes; P = .032) and a greater intraoperative use of opioids (P < .001). The incidence of complications was similar in both groups with the exception of postoperative nausea and vomiting, which were observed more frequently among the RALP patients than among the LRP patients (33% vs 16%; P = .007). ConclusionsThis is the first report to compare the anesthetic management of RALP vs LRP. Anesthesiologists can expect RALP surgery to be associated with less blood loss and a need for fewer blood products than traditional LRP surgery. The anesthetic outcome of RALP was generally satisfactory except for a high incidence of postoperative nausea and vomiting.

AB118. Feasibility and safety evaluation of pure laparoscopic radical nephrectomy and thrombectomy for renal tumor patients with venous tumor thrombus.

ObjectiveTo evaluate the feasibility and safety of pure laparoscopic radical nephrectomy and thrombectomy for renal tumor patients with venous tumor thrombus.MethodsFrom Jan 2013 to Dec 2014, records of patients with renal tumor and venous thrombus treated in our institute were retrospectively reviewed. Thirteen patients underwent pure laparoscopic radical nephrectomy and thrombectomy, including seven patients with renal vein (RV) thrombus and six patients with inferior vena cava (IVC) thrombus. Retroperitoneal approach was undertaken for RV thrombus patients, while transperitoneal approach or combined retroperitoneal and transperitoneal approach for IVC thrombus patients. During the combined approach surgery, renal artery and lumbar vein were controlled through retroperitoneal approach, and the thrombectomy procedure was completed through transperitoneal approach.ResultsThere were nine male patients and four female patients. All patients ranged from 30 to 78 years old (median, 55 years old). Seven patients were diagnosed by routine medical examination, while six patients had clinical symptoms, including four with gross hematuria and two with flank pain. All patients underwent operations successfully. Operation time ranged from 84 to 456 minutes (median 195 minutes). The blood loss ranged from 50 to 150 mL (median, 50 mL) for RV tumor thrombus patients, and 100 to 2,500 mL (median, 325 mL) for IVC tumor thrombus patients. All patients recovered well after surgery without major complications. With the postoperative pathological examination, the average tumor maximum diameter was 7.9±2.5 cm. Eleven cases of clear cell renal cell carcinoma, one case of chromophobe renal cell carcinoma and one case of renal metastatic osteosarcoma were showed in our study. Median follow-up time was 13 months (2-22 months). No decease was observed at the last follow-up. Three patients experienced distant metastasis after surgery, including two patients with multiple pulmonary metastases and one patient with lumbar vertebral metastasis.ConclusionsPure laparoscopic radical nephrectomy and thrombectomy is feasible and safe, with promising oncological prognosis. Combined retroperitoneal and transperitoneal procedures can take both the advantages of these two approaches and simplify operative manipulations.

Pure laparoscopic radical cystectomy with orthotopic U-shape ileal neobladder: report of 19 cases

Objective To report the surgical methods and results of pure laparoscopic radical cystectomy with orthotopic U-shape ileal neobladder. Methods From August 2010 to April 2014, 19 patients with locally advanced bladder cancer (cT2-3N0-2M0) underwent pure laparoscopic radical cystectomy and Endo-GIA assisted orthotopic U-shape ileal neobladder reconstruction. Perioperative and follow-up data were collected. Results The surgeries were successful in all 19 cases with the operating time ranging from 261 to 380 min, blood loss of 100 to 350 ml. Postoperative hospital stay was 21±4 (15-26) days, postoperative intestinal function recovery time at 1.9±0.4 (1.5-2.3) days. Surgical margins were all negative. Lymph node positive rate was 32% (6/19). Complications were including 1 case of lymphatic leakage; 3 cases of new bladder and urethra anastomotic fistula. There were 17 cases of urinary incontinence, all these cases were improved after 3 months, but there were still 8 cases of night-time incontinence. Three cases had unilateral ureteral reflux, ureter mild hydrocephalus, 1 of the cases had recurrent infections within 1 month after surgery. After the anti-inflammatory and catheterization treatment, the symptoms were improved. Two cases had unilateral ureteral anastomotic stricture, one underwent percutaneous nephrostomy and cystoscope-assisted double J tube placement, another underwent laparoscopic ureteral neobladder reimplantation. One case had bilateral ureteral stenosis due to recurrent infections, and underwent bilateral laparoscopic ureteral-new bladder reimplantation. Patients were followed up for 8-42 months, no recurrence or distant metastasis was found. Conclusion Pure laparoscopic radical cystectomy with endo-GIA assisted orthotopic U-shape ileal neobladder can reduce surgical trauma and help patient′s postoperative recovery. Key words: Urinary bladder neoplasms; Pure laparoscopy; Radical cystectomy; Orthotopic U-shape ileal neobladder

Laparoscopic radical cholecystectomy with lymph node dissection for gallbladder carcinoma.

Laparoscopic surgery has been widely employed in the field of digestive surgery, since the minimally invasive procedure provides a significant benefit to patients. However, laparoscopic curative surgery for gallbladder cancer has been rarely described. The aim of this study was to evaluate the effectiveness and validity of laparoscopic radical cholecystectomy with lymph node dissection (Lap-RC) to treat with T1b/T2 gallbladder carcinoma. A total of 11 patients underwent Lap-RC for gallbladder carcinoma from November 2001 until June 2013. While 4 patients were preoperatively diagnosed with T1b/T2 gallbladder carcinoma, 7 patients were diagnosed with incidental T1b/T2 gallbladder carcinoma by postoperative pathological examination after laparoscopic cholecystectomy. Common bile duct resection and biliary tract reconstruction were performed in 2 cases. End points in this clinical study were tumor recurrence and survival of patients. Mean operative time was 196 min, and average hospital stay after surgery was 6.4 days, excluding 2 cases with biliary tract reconstruction. One patient died of recurrence of cancer 89 months after surgery, and another patient died of other reason with local recurrence 39 months after the operation. The other 9 patients were all alive without recurrence at this writing. The 5-year survival rate was 100 % for T1b patients and 83.3 % for T2. These results indicate that almost equivalent outcomes compared with open surgery in terms of curability were achieved. We conclude that pure laparoscopic radical cholecystectomy with lymph node dissection is safe and beneficial for the patients with T1b/T2 gallbladder carcinoma.

Laparoscopic Surgery in Transplanted Patients: A Series of Case Report and Literature Review.

Following the enthusiastic effort by many experts around the world in Minimal Invasive Surgery (MIS) in the past several decades, we already have a big consensuses on the feasibility and advantages of this technique in nearly all the major open surgery. However there is still very few reports of application of MIS in the transplanted patients. Because, we all are still concerning about the similar superiority of MIS in such patients with complex abdominal organ transplantation like liver, kidney, pancreas and small bowel. Here we would to share with our limited experience on the laparoscopic intervention in acute abdomen as well as major abdominal surgery including malignancy. We reported 6 cases who underwent laparoscopic surgery for presumed acute appendicitis in a 52y/o male 8 months after deceased donor liver transplant (DDLT) and in a 50y/o patient 16 months after deceased donor kidney transplant (DDKT). Acute appendicitis in both patients were highly suspected preoperatively in computed tomography and early exploration with laparoscopic technique prompted early diagnosis, treatment and excellent surgical outcomes.A case of small right colon cancer not detected in preoperative computed tomography progressed quickly within one month after transplant had been managed with pure laparoscopic right hemi-colectomy and radical lymph node dissection. The specimen showed good surgical margin with enough lymph node numbers dissected. The fourth patient sustained chylous ascites 6 moths after LDLT and laparoscopy is very important for diagnosis, evaluation of peritoneal cavity, and placement of drain to release symptoms. He was also successfully managed by complete parenteral nutrition, octreotide, and low fat diet with medium chained triglyceride. We also like to expressed a case of morbid obesity (male, 41y/o) with BMI of 41 kg/m2 received laparoscopic sleeve gastrectomy three years after DDKT with good postoperative weight loss and resolution of diabetes, hypertension, high lipid level and renal dysfunction. The recent patient with incisional hernia of subcostal wound about one and half years after DDLT received laparoscopic hernia repair with dual mesh. All the patients had been operated without any significant difference from those with non-transplant patients and recovered uneventfully with all the benefits of MIS.

Does Robotic Assistance Confer an Economic Benefit during Laparoscopic Radical Nephrectomy?

While robotic assisted radical nephrectomy is safe with outcomes and complication rates comparable to those of the pure laparoscopic approach, there is little evidence of an economic or clinical benefit. From the 2009 to 2011 Nationwide Inpatient Sample database we identified patients 18 years old or older who underwent radical nephrectomy for primary renal malignancy. Robotic assisted and laparoscopic techniques were noted. Patients treated with the open technique andthose with evidence of metastatic disease were excluded from analysis. Descriptive statistics were performed using the chi-square and Mann-Whitney tests, and the Student t-test. Multiple linear regression was done to examine factors associated with increased hospital costs and charges. We identified 24,312 radical nephrectomy cases for study inclusion, of which 7,787 (32%) were performed robotically. There was no demographic difference between robotic assisted and pure laparoscopic radical nephrectomy cases. Median total charges were $47,036 vs $38,068 for robotic assisted vs laparoscopic surgery (p <0.001). Median total hospital costs for robotic assisted surgery were $15,149 compared to $11,735 for laparoscopic surgery (p <0.001). There was no difference in perioperative complications or the incidence of death. Compared to the laparoscopic approach robotic assistance conferred an estimated $4,565 and $11,267 increase in hospital costs and charges, respectively, when adjusted for adapted Charlson comorbidity index score, perioperative complications and length of stay (p <0.001). Robotic assisted radical nephrectomy results in increased medical expense without improving patient morbidity. Assuming surgeon proficiency with pure laparoscopy, robotic technology should be reserved primarily for complex surgeries requiring reconstruction. Traditional laparoscopic techniques should continue to be used for routine radical nephrectomy.

Pure Retroperitoneal Laparoscopic Radical Nephrectomy for Left Renal Cell Carcinoma with Differential Extensions of Level I Renal Vein Tumor Thrombus

To describe a large clinical series of pure laparoscopic radical nephrectomy (LRN) for left renal cell carcinoma (RCC) with differential extensions of level I renal vein (RV) tumor thrombus using a retroperitoneal approach. Ten left RCC patients with RV tumor thrombus underwent pure retroperitoneal LRN. Operation procedures were different for patients with varying length of the RV tumor thrombus. Based on our experience, four grades were defined based on the distal limit of the thrombus. Grade 1: tip of the thrombus was located between the renal sinus and the left gonadal vein (or adrenal vein); Grade 2: tip of the thrombus was located between the left gonadal vein and the abdominal aorta; Grade 3: tip of the thrombus was riding on the abdominal aorta; Grade 4: tip of the thrombus was located in the interaortocaval region. According to this classification, grade 1 in 3 patients, grade 2 in 2, grade 3 in 3, and grade 4 in 2. Pure retroperitoneal LRN and thrombectomy were successfully performed for all the patients without requiring open surgery. The mean tumor size for each of the four grades was 5.9, 6.4, 5.8, and 7.6 cm, respectively; the mean thrombus length was 2.1, 3.5, 5.2, and 7.1 cm, respectively; the mean operative time was 85, 103, 137, and 190 minutes, respectively; the average surgical bleeding volume was 67, 110, 143, and 225 mL, respectively. Better procedures are needed to increase the working space for patients with higher grades of thrombus. Surgical margins were negative for all patients. With a mean follow-up of 29 months, two patients developed metastatic disease. Despite the technical challenges, pure retroperitoneal LRN for left RCC patients with differential extensions of RV tumor thrombus is safe and feasible in selected patients. However, it is important to note that surgery will be more difficult for patients with higher grades of thrombus.

Pure Laparoscopic Radical Heminephrectomy for a Large Renal-Cell Carcinoma in a Horseshoe Kidney

Horseshoe Kidneys are the most common renal fusion anomaly. When surgery is contemplated for renal-cell carcinoma in such kidneys, aberrant vasculature and isthmusectomy are the major issues to consider. We describe a case of a pure laparoscopic radical heminephrectomy with hand-sewn management of the isthmus for a 11 cm tumour in a horseshoe kidney. A 47-year-old man complaining of palpable left flank mass for two months. Magnetic resonance of the abdomen revealed a 11 cm renal mass arising from the left moiety of an incidentally discovered horseshoe kidney. Preoperative CT angiography revealed a dominant anterior renal artery feeding the upper and midpole, with two other arteries feeding the lower pole and isthmus. The patient was placed in a modified flank position. A four-port transperitoneal technique was used, the colon was reflected. Renal pedicle was dissected and the renal arteries and renal vein were secured with polymer clips. The kidney was fully mobilized and a Satinsky clamp was placed on the isthmus for its division. A running 2-0 vicryl hand-sewn was used for parenchyma hemostasis. The specimen was extracted intact in a plastic bag through an inguinal incision. The operative time was 220 minutes, and the estimated blood loss was 200 mL. There were no immediate or delayed complications. The patient resumed oral intake on postoperative day 1 and was discharged on postoperative day 2. Pathologic examination of the specimen confirmed a 11 cm organ-confined chromophobe renal-cell carcinoma, with negative margins. Laparoscopic oncologic surgery in patients with horseshoe kidneys can be technically challenging. The presence of a large cancer in a horseshoe kidney should not preclude a purely laparoscopic approach. With the aid of a Satinsky clamp, the isthmus can be sharply divided and sutured in a fashion similar to the open technique. To our knowledge, this report represents the largest cancer (11 cm) removed laparoscopically in the context of a horseshoe kidney.

Retropubic, Laparoscopic, or Robotic Radical Prostatectomy: Is There Any Real Difference?

The surgical management of localized prostate cancer has evolved over the last 20 years. The "gold standard" open radical prostatectomy (ORP) has been replaced largely by the robotic-assisted laparoscopic radical retropubic prostatectomy (RALP) as the most common surgical approach to treat localized prostate cancer. Pure laparoscopic radical prostatectomy (LRP), still performed by a limited number of surgeons, was more commonly utilized before the widespread availability of the robotically assisted technique. The general consensus based on the current literature is that RALP is associated with less blood loss and a shorter hospital stay but at a higher cost when compared to ORP. The literature continues to be conflicted concerning outcome measures such as impotence and urinary incontinence. Large series of long-term oncologic follow-up are not yet available; however, the data suggest that oncologic control is similar between RALP and ORP. Considerable disparities in measurement and reporting practices of perioperative outcomes continue to make direct comparisons difficult. Future prospective studies of perioperative outcomes should aim to use rigorous methodology and established criteria for standardized reporting.

Pure Laparoscopic Radical Cystectomy with Ileal Conduit: A Single Surgeon's Mid-Term Outcomes

PurposeThe use of laparoscopic radical cystectomy (LRC) for muscle-invasive bladder cancer is not yet widespread because of the technical difficulties of the procedure and the lengthy operating time. In this study, we report a single surgeon's experience with LRC.Materials and MethodsThirty patients (25 men and 5 women) with bladder cancer underwent LRC and ileal conduit by a single surgeon between November 2007 and May 2011. An extracorporeal urinary diversion was performed through 5-6 cm midline incision for specimen extraction.ResultsThe median operating time and estimated blood loss were 527.5 minutes and 275 mL, respectively. There was no conversion to open surgery. The median time to oral intake and postoperative hospital stay were 5 days and 12 days, respectively. The rates of immediate, early postoperative and late postoperative complication were 3.3%, 20% and 20%, respectively. With 16 months of median follow-up, the overall and recurrence-free survival rates were 70% and 56.7%, respectively.ConclusionLRC is feasible for the management of invasive bladder cancer and, with appropriate patient selection, can be a good alternative to open or robot-assisted radical cystectomy in the era of robot-assisted surgery.