Robot-assisted ureteral reconstruction using a tubularized peritoneal flap: a novel technique in a chronic porcine model.

OBJECTIVE: To evaluate the feasibility and functional outcomes in porcine models of a novel robotic surgical technique for the treatment of complex ureteral injuries and strictures. MATERIALS AND METHODS: Six pigs underwent robotic ureteral reconstruction using a long tabularized peritoneal flap and followed for 6-9 weeks after the surgery. Ureteral flap vascularity, intra-renal pressure, patency of the conduct, endoscopic aspect of the flap, renal function and histopathology were evaluated. RESULTS: All animals successfully underwent ureteral reconstruction using a tubularized peritoneal flap. Median operative time was 223 min (162-360). Flap tubularization suture took 31 min (19-47), and proximal anastomosis took 20 min (15-38). Bladder mobilization with psoas hitch and distal anastomosis took 9 min (7-12) and 23 min (13-46), respectively. On follow-up, significant shrinkage of the ureteral flap in both length and width was observed. Antegrade pyelograms confirmed dilation and tortuosity of the proximal ureter, dilation of the renal pelvis, and major and minor calyxes without any definitive strictures. Microscopically, focal urothelial lining was seen in the neoureter. Creatinine level was significantly higher at the end of the follow-up period (p = 0.003). CONCLUSIONS: Robot-assisted ureteral reconstruction using a tubularized peritoneum flap is technically feasible and reproducible. The flap sustained abundant vascular supply after different intervals of follow-up and the peritoneal mesenchymal cells differentiated into urothelium and myofibroblasts. Further studies are needed to address the issue of functional obstruction to improve long-term renal function outcomes.

The transrectal single port laparoscopic radical prostatectomy in a cadaver model.

OBJECTIVE: To explore the feasibility of laparoscopic trans-rectal Natural Orifice Transluminal Endoscopic Surgery (NOTES) radical prostatectomy in a cadaveric model and to define anatomical landmarks of this surgical route. MATERIALS AND METHODS: After the ethical clearance, the study was conducted in Turkish Council of Forensic Medicine. With the cadaver in an exaggerated lithotomy position, a full thickness incision was made on the anterior wall of the rectum. The anteriorly visible Denonvilliers' fascia was incised sharply, exposing the posterior surface of the prostate. A single-port device (GelPOINT(®)Path) was inserted transanally passing the incision on the anterior wall of the rectum, into the bluntly created space between rectum and prostate. Three, 10 mm ports were placed through the GelPOINT(®)Path, at 3, 6, and 9 o'clock positions. A 5 mm, 0° degree lens was introduced at 6 o'clock position; followed by laparoscopic scissors and laparoscopic grasper. Prostatic and periprostatic anatomy was defined as encountered during each step of the procedure. RESULTS: Exposure of the posterior surface of the prostate and seminal vesicles was easily achieved. No additional openings of the rectal wall were made. Surgical specimen was extracted keeping its integrity. CONCLUSION: Transrectal radical prostatectomy is technically feasible in the cadaver model, being facilitated by previous experience with perineal surgery. Anatomical observations during the present experimental study suggest that the transrectal NOTES route provides good exposure of the operative field and easy access to the posterior surface of prostate, Future experimental endeavors should focus on reproducibility of this approach and feasibility of lymph node dissection using trans-rectal route.

Laparoendoscopic single site surgery versus conventional laparoscopy for transperitoneal pyeloplasty: A systematic review and meta-analysis.

We aimed to review studies comparing the outcomes of the laparoendoscopic single site (LESS) pyeloplasty with those of conventional laparoscopic pyeloplasty (CLP). A systematic review of the literature was performed according to the PRISMA (preferred reporting items for systematic reviews and meta-analysis) criteria. The methodological quality of the studies was rated according validated scales. The level of evidence (LE) was reported as described by the Oxford criteria. Preoperative demographic parameters and perioperative outcomes between the two surgical techniques were assessed. A meta-analysis of the included studies was performed. A total of 5 studies were elected for the analysis, including 164 cases, 70 (42.6%) of them being LESS and 94 (57.4%) being CLP. Four studies were observational retrospective comparative studies (LE: 3a-4); one was a prospective randomized controlled trial (LE: 2b). There was no significant difference in age, body mass index, gender, side and presence of the crossing vessel, between the groups. There was no significant difference regarding the operative time (weight mean difference [WMD]: -7.02; 95% confidence interval [CI]: -71.82-57.79; P = 0.83) and length of hospital stay (WMD: 0.04; 95% CI: -0.11-0.20; P = 0.58), whereas the estimated blood loss was statistically lower for LESS (WMD: -16.83; 95% CI: -31.79--1.87; P = 0.03). The postoperative use of analgesic favored the LESS group but without reaching statistical significance (WMD: -7.52; 95% CI: -17.56-2.53; P = 0.14). In conclusion, LESS pyeloplasty offers comparable surgical and functional outcomes to CLP while providing the potential advantages of less blood loss and lower analgesic requirement. Thus, despite being more technically challenging, LESS pyeloplasty can be regarded as a minimally invasive approach for patients seeking fewer incisional scars.

Use of biological Glue (Bioglue®) in laparoscopic partial nephrectomy: a study in pigs.

INTRODUCTION: Partial nephrectomy is the standard of care for localized renal tumors. However, bleeding and warm ischemia time are still controversial when laparoscopic surgeries are carried out. Herein, we aim to compare the outcomes from laparoscopic partial nephrectomy with and without the use of biological glue with purified bovine albumin and glutaraldehyde (BioGlue ®). MATERIALS AND METHODS: Twenty-four kidneys of 12 pigs were used in this study. A pre-determined lower pole segment was resected (3 cm x 1 cm) and one of two different hemostatic techniques was performed. In one kidney, hemostatic ″ U suture ″ (poliglecaprone 3.0) was performed and in the contra-lateral kidney, only the biological glue was applied. Data recorded was comprised of warm ischemia time (seconds) and estimated blood loss (mL) for each procedure. In cases of bleeding after glue administration, a complementary suture was done. RESULTS: Mean warm ischemia time was 492.9 ± 113.1 (351-665) seconds and 746 ± 185.3 (409-1125) seconds for biological glue and suture groups, respectively. There was a positive significant difference in terms of warm ischemia favoring the biological glue group over the suture group (p<0.001). Mean blood loss was 39.4 (0-115) mL for the biological glue group and 39.1 (5-120) mL for the suture group (p=0.62). CONCLUSION: Biological glue is an important tool for laparoscopic partial nephrectomies. It is effective for hemostatic control in selected cases, and it can be used in combination with the traditional suture techniques.

Use of biological Glue (Bioglue®) in laparoscopic partial nephrectomy: a study in pigs

Introduction Partial nephrectomy is the standard of care for localized renal tumors. However, bleeding and warm ischemia time are still controversial when laparoscopic surgeries are carried out. Herein, we aim to compare the outcomes from laparoscopic partial nephrectomy with and without the use of biological glue with purified bovine albumin and glutaraldehyde (BioGlue®). Materials and Methods Twenty-four kidneys of 12 pigs were used in this study. A pre-determined lower pole segment was resected (3 cm x 1 cm) and one of two different hemostatic techniques was performed. In one kidney, hemostatic “U suture” (poliglecaprone 3.0) was performed and in the contra-lateral kidney, only the biological glue was applied. Data recorded was comprised of warm ischemia time (seconds) and estimated blood loss (mL) for each procedure. In cases of bleeding after glue administration, a complementary suture was done. Results Mean warm ischemia time was 492.9±113.1 (351-665) seconds and 746±185.3 (409-1125) seconds for biological glue and suture groups, respectively. There was a positive significant difference in terms of warm ischemia favoring the biological glue group over the suture group (p<0.001). Mean blood loss was 39.4 (0-115) mL for the biological glue group and 39.1 (5-120) mL for the suture group (p=0.62). Conclusion Biological glue is an important tool for laparoscopic partial nephrectomies. It is effective for hemostatic control in selected cases, and it can be used in combination with the traditional suture techniques. .

Possible Detrimental Effects of Clamping Main Versus Segmental Renal Arteries for the Achievement of Renal Global Ischemia During Robot-Assisted Partial Nephrectomy.

PURPOSE: To determine the impacts of clamping the main renal artery vs individually clamping presegmental or segmental arteries at the time of global renal ischemia on the surgical and functional outcomes of robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS: Patients who underwent RAPN at our center from 2009 to September 2013 were assessed for details of intraoperative renal arterial anatomy. Cases were divided into two groups according to the type of global renal ischemia: Group 1 consisted of cases where one main renal artery (or hilum) was clamped; group 2 included cases where multiple arteries or multiple branches of arteries were individually clamped. Patient demographics, tumor characteristics, perioperative data, functional outcomes (as well as pathology findings) were assessed for both groups. Univariable and multivariable analyses were performed for identifying factors predicting early (at day 3) estimated glomerular filtration rate (eGFR) preservation postoperatively. RESULTS: Group 1 and group 2 included 468 and 111 patients, respectively. Estimated blood loss and warm ischemia time (WIT) were comparable between the two groups. A higher proportion of combined arterial and venous clamping was observed in group 1 (76.2% vs 52.3%; P=0.0001). On postoperative day 3, eGFR preservation was not significantly different between the two groups (P=0.87). On multivariable analysis, WIT and preoperative eGFR remained the only significant predictors of early eGFR preservation. The number of arterial vessels clamped during the procedure or simultaneous arterial/vein clamping were not predictors of early eGFR preservation. CONCLUSIONS: Perioperative outcomes of RAPN are not influenced by clamping the main renal artery compared with clamping multiple branches of the renal artery for achievement of global renal ischemia. WIT and baseline eGFR were confirmed to be significant predictors of postoperative renal function preservation after RAPN.

Robot-assisted laparoscopic partial nephrectomy in patients with previous abdominal surgery: single center experience.

BACKGROUND: The aim of this study is to report our single center experience with robotic partial nephrectomy (RPN) in patients with history of previous abdominal surgery (PAS). METHODS: Medical records of patients who underwent RPN for a single renal mass in our center from 2006 to 2013 were reviewed. Patients were divided in two groups: those who had history of PAS and those without history of PAS. Within the PAS group, four sub-groups were considered: (a) remote site of PAS in relation to RPN; (b) PAS in the proximity of RPN site; (c) previous umbilical hernia/abdominal hernia mesh repair; (d) major PAS. RESULTS: In total 627 patients were analyzed, and of these 321 patients had history of PAS (51.2%). On univariable and multivariable analyses, only Charlson Comorbidity Index, estimated blood loss, and tumor size were the significant predictors of complications. CONCLUSIONS: RPN can be safely performed in patients with history of PAS with surgical outcomes comparable with those obtained in patients without history of PAS.

Ipsilateral renal function preservation after robot-assisted partial nephrectomy (RAPN): an objective analysis using mercapto-acetyltriglycine (MAG3) renal scan data and volumetric assessment.

OBJECTIVE: To objectively assess ipsilateral renal function (IRF) preservation and factors influencing it after robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS: Our database was queried to identify patients who had undergone RAPN from 2007 to 2013 and had complete pre- and postoperative mercapto-acetyltriglycine (MAG3) renal scan assessment. The estimated glomerular filtration rate (eGFR) for the operated kidney was calculated by multiplying the percentage of contribution from the renal scan by the total eGFR. IRF preservation was defined as a ratio of the postoperative eGFR for the operated kidney to the preoperative eGFR for the operated kidney. The percentage of total eGFR preservation was calculated in the same manner (postoperative eGFR/preoperative eGFR × 100). The amount of healthy rim of renal parenchyma removed was assessed by deducting the volume of tumour from the volume of the PN specimen assessed on pathology. Multivariable linear regression was used for analysis. RESULTS: In all, 99 patients were included in the analysis. The overall median (interquartile range) total eGFR preservation and IRF preservation for the operated kidney was 83.83 (75.2-94.1)% and 72 (60.3-81)%, respectively (P < 0.01). On multivariable analysis, volume of healthy rim of renal parenchyma removed, warm ischaemia time (WIT) > 30 min, body mass index (BMI) and operated kidney preoperative eGFR were predictive of IRF preservation. CONCLUSIONS: Using total eGFR tends to overestimate the degree of renal function preservation after RAPN. This is particularly relevant when studying factors affecting functional outcomes after nephron-sparing surgery. IRF may be a more precise assessment method in this setting. Operated kidney baseline renal function, BMI, WIT >30 min, and amount of resected healthy renal parenchyma represent the factors with a significant impact on the IRF preservation. RAPN provides significant preservation of renal function as shown by objective assessment criteria.

The impact of extended warm ischemia time on late renal function after robotic partial nephrectomy.

PURPOSE: To evaluate the effect of warm ischemia time (WIT) on late renal function in patients undergoing robotic partial nephrectomy (RPN). PATIENTS AND METHODS: From January 2009 to June 2013, patients with tumors ≤7 cm (cT1) undergoing RPN at our center with at least 1-year renal function data were included. Patients with deterioration of renal function due to coexisting medical conditions and patients with a solitary kidney were excluded from the analysis. We compared our cohort based on three WIT groups, namely, zero ischemia (WIT=0 minutes), limited ischemia (WIT ≤30 minutes), and extended ischemia (WIT >30 minutes). RESULTS: From the 665 patients undergoing RPN, 266 met our inclusion criteria. Median follow up for evaluation of estimated glomerular filtration rate (eGFR) was 24 months. Zero ischemia group had the highest percentage of renal function preservation (92.9%) followed by WIT ≤30 group (89.2%) and WIT >30 group (83.2%). On univariable analysis, pre-existing eGFR, tumor size, RENAL score, and WIT were significant predictors of degree of late eGFR preservation. On multivariable analysis, tumor size, pre-existing eGFR, and WIT grouping remained the only significant predictors of late renal function. There was no statistical significance in degree of late eGFR preservation between zero ischemia and WIT ≤30 groups. However, WIT >30 minutes was a negative predictor of late eGFR preservation when compared to WIT ≤30 minutes. CONCLUSIONS: WIT >30 minutes, preoperative eGFR, and tumor size were independent predictors of late eGFR deterioration after RPN in our series. With increase in the use of RPN in more complex tumors, the prolonged WIT associated with resection and reconstruction of such tumors needs to be mitigated.

Laparoendoscopic single-site (LESS) vs laparoscopic living-donor nephrectomy: a systematic review and meta-analysis.

The aim of this study was to provide a systematic review and meta-analysis of reports comparing laparoendoscopic single-site (LESS) living-donor nephrectomy (LDN) vs standard laparoscopic LDN (LLDN). A systematic review of the literature was performed in September 2013 using PubMed, Scopus, Ovid and The Cochrane library databases. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Weighted mean differences (WMDs) were used to measure continuous variables and odds ratios (ORs) to measure categorical ones. Nine publications meeting eligibility criteria were identified, including 461 LESS LDN and 1006 LLDN cases. There were more left-side cases in the LESS LDN group (96.5% vs 88.6%, P < 0.001). Meta-analysis of extractable data showed that LLDN had a shorter operative time (WMD 15.06 min, 95% confidence interval [CI] 4.9-25.1; P = 0.003), without a significant difference in warm ischaemia time (WMD 0.41 min, 95% CI -0.02 to 0.84; P = 0.06). Estimated blood loss was lower for LESS LDN (WMD -22.09 mL, 95% CI -29.5 to -14.6; P < 0.001); however, this difference was not clinically significant. There was a greater likelihood of conversion for LESS LDN (OR 13.21, 95% CI 4.65-37.53; P < 0.001). Hospital stay was similar (WMD -0.11 days, 95% CI -0.33 to 0.12; P = 0.35), as well as the visual analogue pain score at discharge (WMD -0.31, 95% CI -0.96 to 0.35; P = 0.36), but the analgesic requirement was lower for LESS LDN (WMD -2.58 mg, 95% CI -5.01 to -0.15; P = 0.04). Moreover, there was no difference in the postoperative complication rate (OR 1.00, 95% CI 0.65-1.54; P = 0.99). Renal function of the recipient, as based on creatinine levels at 1 month, showed similar outcomes between groups (WMD 0.10 mg/dL, -0.09 to 0.29; P = 0.29). In conclusion, LESS LDN represents an emerging option for living kidney donation. This procedure offers comparable surgical and early functional outcomes to the conventional LLDN, with a lower analgesic requirement. However, it is more technically challenging than LLDN, as shown by a greater likelihood of conversion. The role of LESS LDN remains to be defined.

Urine leak in minimally invasive partial nephrectomy: analysis of risk factors and role of intraoperative ureteral catheterization

Purpose To investigate risk factors for urine leak in patients undergoing minimally invasive partial nephrectomy (MIPN) and to determine the role of intraoperative ureteral catheterization in preventing this postoperative complication. Materials and Methods MIPN procedures done from September 1999 to July 2012 at our Center were reviewed from our IRB-approved database. Patient and tumor characteristics, operative techniques and outcomes were analyzed. Patients with evidence of urine leak were identified. Outcomes were compared between patients with preoperative ureteral catheterization (C-group) and those without (NC-group). Univariable and multivariable analyses were performed to identify factors predicting postoperative urine leak. Results A total of 1,019 cases were included (452 robotic partial nephrectomy cases and 567 laparoscopic partial nephrectomy cases). Five hundred twenty eight patients (51.8%) were in the C-group, whereas 491 of them (48.2%) in the NC-group. Urine leak occurred in 31(3%) cases, 4.6% in the C-group and 1.4% in the NC-group (p<0.001). Tumors in NC-group had significantly higher RENAL score, shorter operative and warm ischemic times. On multivariable analysis, tumor proximity to collecting system (OR=9.2; p<0.01), surgeon’s early operative experience (OR=7.8; p<0.01) and preoperative moderate to severe CKD (OR=3.1; p<0.01) significantly increased the odds of the occurrence of a postoperative urine leak. Conclusion Clinically significant urine leak after MIPN in a high volume institution setting is uncommon. This event is more likely to occur in cases of renal masses that are close to the collecting system, in patients with preoperative CKD and when operating surgeon is still in the learning curve for the procedure. Our findings suggest that routine intraoperative ureteral catheterization during MIPN does not reduce the probability of postoperative urine leak. In addition, it adds to the overall ...

Perineal robot-assisted laparoscopic radical prostatectomy: feasibility study in the cadaver model.

PURPOSE: To evaluate the feasibility of perineal robot-assisted laparoscopic radical prostatectomy (P-RALP) in the cadaver model. METHODS: The prostate was assessed by ultrasonography and cystoscopy in the lithotomy position. After incision and subcutaneous dissection, a single-port device was placed and the robot was docked. The rectourethralis muscle was divided and the levator ani fibers were split. The Denonvilliers fascia was incised and the posterior prostate and seminal vesicles were dissected. The apex was dissected and the urethra was transected. The anterior and lateral planes were dissected and the prostate pedicles were clipped. The prostate was freed from the bladder neck and the vesicourethral anastomosis was performed. The robot was undocked and the wound was sutured in layers. Cystoscopy confirmed integrity of the anastomosis. The specimen was sent for histopathology examination. RESULTS: Nerve-sparing P-RALP was successfully completed in three cadavers. Median time for setting was 23 minutes. Time for posterior dissection was 15 minutes. Dissection of the apex and section of the urethra took 9 minutes. Time for anterolateral dissection was 14 minutes. Time for bladder neck dissection was 7 minutes. Vesicourethral anastomosis took 8 minutes. Total operative time was 89 minutes. The prostate capsule was grossly intact and histopathology examination was negative for prostatic tissue in all distal urethral sections and in two of three bladder neck sections. CONCLUSIONS: P-RALP is feasible in the cadaver. Future studies should evaluate the feasibility of lymph node dissection through the same incision, clinical feasibility, and prospective comparisons with standard techniques.

Step-by-Step robotic heminephrectomy for duplicated renal collecting system.

INTRODUCTION: A duplicated renal collecting system is a relatively common congenital anomaly rarely presenting in adults. AIM: In this video we demonstrate our step-by-step technique of Robotic heminephrectomy in a patient with non-functioning upper pole moiety. MATERIALS AND METHODS: Following cystoscopy and ureteral catheter insertion the patient was placed in 60° modified flank position with the ipsilateral arm positioned at the side of the patient. A straight-line, three arm robotic port configuration was employed. The robot was docked at a 90-degree angle, perpendicular to the patient. Following mobilization the colon and identifying both ureters of the duplicated system, the ureters were followed cephalically toward, hilar vessels where the hilar anatomy was identified. The nonfunctioning pole vasculature was ligated using hem-o-lok clips. The ureter was sharply divided and the proximal ureteral stump was passed posterior the renal hilum. Ureteral stump was used as for retraction and heminephrectomy is completed along the line demarcating the upper and lower pole moieties. Renorrhaphy was performed using 0-Vicryl suture with a CT-1 needle. The nonfunctioning pole ureter was then dissected caudally toward the bladder hiatus, ligated using clips, and transected. RESULTS: The operating time was 240 minutes and blood loss was 100 cc. There was no complication post-operatively. CONCLUSIONS: Wrist articulation and degree of freedom offered by robotic platform facilitates successful performance of minimally invasive heminephrectomy in the setting of an atrophic and symptomatic renal segment.

Step-by-Step robotic heminephrectomy for duplicated renal collecting system

Introduction A duplicated renal collecting system is a relatively common congenital anomaly rarely presenting in adults. Aim In this video we demonstrate our step-by-step technique of Robotic heminephrectomy in a patient with non-functioning upper pole moiety. Materials and Methods Following cystoscopy and ureteral catheter insertion the patient was placed in 600 modified flank position with the ipsilateral arm positioned at the side of the patient. A straight-line, three arm robotic port configuration was employed. The robot was docked at a 90-degree angle, perpendicular to the patient. Following mobilization the colon and identifying both ureters of the duplicated system, the ureters were followed cephalically toward, hilar vessels where the hilar anatomy was identified. The nonfunctioning pole vasculature was ligated using hem-o-lok clips. The ureter was sharply divided and the proximal ureteral stump was passed posterior the renal hilum. Ureteral stump was used as for retraction and heminephrectomy is completed along the line demarcating the upper and lower pole moieties. Renorrhaphy was performed using 0-Vicryl suture with a CT-1 needle. The nonfunctioning pole ureter was then dissected caudally toward the bladder hiatus, ligated using clips, and transected. Results The operating time was 240 minutes and blood loss was 100 cc. There was no complication post-operatively. Conclusions Wrist articulation and degree of freedom offered by robotic platform facilitates successful performance of minimally invasive heminephrectomy in the setting of an atrophic and symptomatic renal segment. .

Robot-assisted partial nephrectomy for ≥ 7 cm renal masses: a comparative outcome analysis.

OBJECTIVE: To present our robotic partial nephrectomy (RPN) experience for renal masses ≥ 7 cm and compare the surgical outcomes in this cohort with those obtained for small (≤ 4 cm) renal masses. MATERIALS AND METHODS: We retrospectively reviewed our institutional review board-approved RPN database and identified patients undergoing RPN for tumors ≥ 7 cm. Surgical technique, renal function, oncologic, and pathologic data were analyzed and compared with the RPN for renal masses ≤ 4 cm. RESULTS: Overall, 441 patients were identified for the purpose of this study, including 29 cases and 412 controls. Median operative time (200 vs 180 min; P = .005), warm ischemia time (26.5 vs 19 min; P <.001), and estimated blood loss (250 mL [353] vs 150 mL [150]; P <.001) were significantly lower in the control group. Postoperative complications were significantly higher in the case group (37.9% vs 15.8%; P = .005). However, the percentages of major complications (Clavien grade ≥ III) were comparable (18.2% vs 17%; P = .57 for cases and controls respectively). Postoperative blood transfusion was higher for larger tumor group (24.1% vs 4.1%; P <.001). Positive margins were similar between groups (5.9% vs 3.3%; P = .45 for cases and controls respectively). There was no difference in estimated glomerular filtration rate decline between the two groups (12.2% vs 15.8% decline; P = .98). CONCLUSION: RPN represents a feasible and safe nephron-sparing surgery approach for highly selected (mostly exophytic growth pattern, polar location, and likelihood of benign histology) renal masses ≥ 7 cm in diameter.

Robot-assisted laparoscopic adrenalectomy: step-by-step technique and comparative outcomes.

BACKGROUND: Recent evidence supports the use of robotic surgery for the minimally invasive surgical management of adrenal masses. OBJECTIVE: To describe a contemporary step-by-step technique of robotic adrenalectomy (RA), to provide tips and tricks to help ensure a safe and effective implementation of the procedure, and to compare its outcomes with those of laparoscopic adrenalectomy (LA). DESIGN, SETTING, AND PARTICIPANTS: We retrospectively reviewed the medical charts of consecutive patients who underwent RA performed by a single surgeon between April 2010 and October 2013. LA cases performed by the same surgeon between January 2004 and May 2010 were considered the control group. SURGICAL PROCEDURE: The main steps of our current surgical technique for RA are described in this video tutorial: patient positioning, port placement, and robot docking; exposure of the adrenal gland; identification and control of the adrenal vein; circumferential dissection of the adrenal gland; and specimen retrieval and closure. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Demographic parameters and main surgical outcomes were assessed. RESULTS AND LIMITATIONS: A total of 76 cases (RA: 30; LA: 46) were included in the analysis. Median tumor size on computed tomography (CT) was significantly larger in the LA group (3cm [interquartile range (IQR): 3] vs 4cm [IQR: 3]; p=0.002). A significantly lower median estimated blood loss was recorded for the robotic group (50ml [IQR: 50] vs 100ml [IQR: 288]; p=0.02). The RA group presented five minor complications (16.7%) and one major (Clavien 3b) complication (3.3%), whereas four minor complications (8.7%) and one major (Clavien 3b) complication (2.3%) were observed in the LA group. No significant difference was noted between groups in terms of malignant histology (p=0.66) and positive margin rate (p=0.60). Distribution of pheochromocytomas in the LA group was significantly higher than in the RA group (43.5% vs 16.7%; p=0.02). CONCLUSIONS: The standardization of each surgical step optimizes the RA procedure. The robotic approach can be applied for a wide range of adrenal indications, recapitulating the safety and effectiveness of open surgery and potentially improving the outcomes of standard laparoscopy. PATIENT SUMMARY: In this report we detail our surgical technique for robotic removal of adrenal masses. This procedure has been standardized and can be offered to patients, with excellent outcomes.

Robotic partial nephrectomy for cystic renal masses: a comparative analysis of a matched-paired cohort.

OBJECTIVE: To compare the outcomes of robotic partial nephrectomy (RPN) for cystic and solid renal neoplasms. METHODS: Our RPN database was queried to identify consecutive patients who underwent RPN for cystic and solid renal masses in the period between July 2007 and July 2013. Cystic renal masses were diagnosed on cross-sectional imaging (computed tomography or magnetic resonance imaging). Matching was done between the patients with cystic renal masses and patients with solid renal masses (1:1 matching) by age, gender, tumor size, and nephrometry score. RESULTS: Of 647 cases, 55 patients with cystic masses (group 1) were matched with 55 patients with solid tumors (group 2). There was no cyst rupture or positive surgical margin observed in group 1. The volume of resected rim of healthy renal parenchyma surrounding the tumor was the same for both groups (P=.9). There was no difference between the groups in terms of percentage of glomerular filtration rate preservation postoperatively (85% vs 86%; P=.94). There was no difference in term of overall complications between the 2 groups. Thirty patients (54.5%) in group 1 and 47 patients (85.5%) in group 2 had renal cell carcinoma (P=.0001). CONCLUSION: RPN can be safely and effectively performed when treating a suspicious cystic renal neoplasm with outcomes resembling those obtained for solid masses. Thus, when a cystic renal mass in encountered, nephron-sparing surgery can be offered and RPN represents an effective tool for this approach.

Robotic partial nephrectomy for caliceal diverticulum: a single-center case series.

The aim of this study is to examine the role of robotic partial nephrectomy (RPN) in the management of caliceal diverticula by assessing our single-center outcomes. Between July 2007 and July 2013, 7 of 670 patients underwent RPN procedures as a reason of caliceal diverticula. The indications for RPN in all cases were recurrent urinary tract infection and pain attributed to the diverticulum in addition to failed management by endourologic or extracorporeal shockwave lithotripsy (SWL) treatments. One patient with a calcified diverticulum and another with an unsuccessful SWL treatment underwent RPN without further endourologic intervention. The other five patients had a history of unsuccessful percutaneous nephrolithotomy (one case), ureteroscopy (URS) (two cases), and a combination of SWL+URS (two cases). No intraoperative or postoperative complications were observed. No patient was readmitted postoperatively. Unique features of the robotic platform facilitate the excision of diverticulum and subsequent kidney reconstruction for this benign, but complex pathology.