Tubeless percutaneous nephrolithotomy: outcomes with expanded indications.

INTRODUCTION: Tubeless PCNL has been utilized to shorten hospital stay and improve patient postoperative pain control. Prior studies have excluded those patients with significant bleeding or other complications. Our objective was to evaluate the utility of tubeless PCNL in all patients irrespective of intraoperative outcome. MATERIALS AND METHODS: A retrospective review of the charts of patients who underwent PCNL at our institute was performed. Patients were assigned to one endourologist Who routinely performed tubeless PCNL and to a second endourologist who routinely left a small-bore pigtail nephrostomy. Preoperative demographics operative and postoperative outcomes were compared. RESULTS: Out of 159 patients included, 83 patients had tubeless PCNL while 76 patients had standard PCNL. There was no difference between groups regarding age, gender, ASA score, number, maximum diameter of stones, number of calyces involved, Stone density (HU), laterality and use of preoperative narcotics. While staghorn stones were more common in patients who underwent standard PCNL (p = 0.008). Tubeless patients had less number of access tracts (p ≤ 0.001), shorter hospital stay (1.7 vs. 3.0 days, p = 0.001) when compared to standard PCNL group. Multivariable analysis controlling for confounding factors including staghorn calculi and number of accesses confirmed that tubeless PCNL was associated with shorter hospital stay and less postoperative pain. There was no significant difference in complication rates between the two groups. CONCLUSION: Our report confirms the previous reports of shorter hospital stay, less pain and analgesia as compared to standard PCNL, and establishes its safety irrespective of bleeding, perforation, extravasation or other intraoperative issues that have previously been utilized as exclusionary criteria for this approach.

Tubeless percutaneous nephrolithotomy: outcomes with expanded indications

IntroductionTubeless PCNL has been utilized to shorten hospital stay and improve patient postoperative pain control. Prior studies have excluded those patients with significant bleeding or other complications. Our objective was to evaluate the utility of tubeless PCNL in all patients irrespective of intraoperative outcome.Materials and MethodsA retrospective review of the charts of patients who underwent PCNL at our institute was performed. Patients were assigned to one endourologist who routinely performed tubeless PCNL and to a second endourologist who routinely left a small-bore pigtail nephrostomy. Preoperative demographics operative and postoperative outcomes were compared.ResultsOut of 159 patients included, 83 patients had tubeless PCNL while 76 patients had standard PCNL. There was no difference between groups regarding age, gender, ASA score, number, maximum diameter of stones, number of calyces involved, stone density (HU), laterality and use of preoperative narcotics. While staghorn stones were more common in patients who underwent standard PCNL (p = 0.008). Tubeless patients had less number of access tracts (p ≤ 0.001), shorter hospital stay (1.7 vs. 3.0 days, p = 0.001) when compared to standard PCNL group. Multivariable analysis controlling for confounding factors including staghorn calculi and number of accesses confirmed that tubeless PCNL was associated with shorter hospital stay and less postoperative pain. There was no significant difference in complication rates between the two groups.ConclusionOur report confirms the previous reports of shorter hospital stay, less pain and analgesia as compared to standard PCNL, and establishes its safety irrespective of bleeding, perforation, extravasation or other intraoperative issues that have previously been utilized as exclusionary criteria for this approach.

Robot-assisted partial nephrectomy (RAPN) for completely endophytic renal masses: a single institution experience.

OBJECTIVE: To analyse the outcomes of robot-assisted partial nephrectomy (RAPN) for completely endophytic renal tumours. PATIENTS AND METHODS: Medical records of patients who had undergone RAPN for a completely endophytic (i.e. 3 points for the 'E' domain of the R.E.N.A.L. nephrometry score) enhancing renal mass at our Centre from 2006 to 2012 were retrieved from our prospectively maintained RAPN database and used for this analysis. Demographics, surgical and early postoperative outcomes were compared with those of patients with exophytic masses (i.e. 1 point for the 'E' domain) and those of patients with mesophytic masses (i.e. 2 points for the 'E' domain). RESULTS: In all, 65 patients (mean age 56 years; mean body mass index 29.4 kg/m(2) ; mean Charlson comorbidity index 3.2) were included in the study group, accounting for 16.7% of RAPN cases over the study period. The main surgical outcomes were: mean operative time 175 min, mean estimated blood loss 225 mL, and mean warm ischaemia time 21.7 min. Pathology showed a malignant histology in 48 cases (74%), mostly clear cell renal cell carcinoma. Two positive margins (3%) were found. Patients with a completely endophytic mass had smaller tumours on preoperative imaging (mean 2.6 vs 3.3 for mesophytic vs 3.7 cm for exophytic; P < 0.001), and higher overall R.E.N.A.L. score (mean 8.7 vs 7.6 vs 6.4; P < 0.001). There was a lower rate of unclamped cases in the endophytic group (3.1% vs 4.8% vs 18%; P < 0.001). There were no differences in intraoperative complications, length of hospital stay, positive margin rate, postoperative change in estimated glomerular filtration rate, given a similar length of follow-up (mean 12.6 vs 15.7 vs 14.5 months; P = 0.3). CONCLUSION: RAPN for completely intraparenchymal renal tumours can be safely and effectively performed in centres with significant robotic expertise, with surgical outcomes resembling those obtained in the general RAPN population.

Stone disease in living-related renal donors: long-term outcomes for transplant donors and recipients.

BACKGROUND AND PURPOSE: Historically, patients wishing to donate their kidney to living related recipients were deemed ineligible if preoperative imaging demonstrated nephrolithiasis. We assess the outcomes of donors with nephrolithiasis and the outcomes of their recipients. METHODS: Donors undergoing nephrectomy between 2001 and 2011 who had nephrolithiasis on preoperative computed tomography (CT) imaging or a history of stone passage were identified. A retrospective chart review documented donor and recipient demographics, donor 24-hour urine collections, stone size and location, stone events after transplant, and graft function. A seven-question telephone survey regarding development and/or presence of symptomatic nephrolithiasis was conducted. RESULTS: Fifty-four donor-recipient pairs met the inclusion criteria. Twenty-eight (51.9%) patients had valid preoperative 24-hour urine collection, seven (25%) of whom had hypercalciuria. Seven (13%) patients had previous symptomatic nephrolithiasis, but no stones on imaging. Forty-one patients donated a kidney with at least one stone, with a mean stone size of 2.4 mm (range 1-6 mm). Median follow-up for donors and recipients was 22.5 months (interquartile range [IQR] 1-79.3) and 47.4 months (IQR 25.1-76.1), with 50% and 77.7% having a follow-up of more than 2 years, respectively. One donor with nephrolithiasis on preoperative imaging who donated the contralateral kidney passed a stone spontaneously after visiting the emergency department. Otherwise, no other donors or recipients experienced any stone episodes during the follow-up period. CONCLUSION: The risk of clinical stone recurrence in donors and recipients is low: As such, presence of small caliceal stones should not constitute an exclusion for living-related kidney donation.

Controversies in ureteroscopy: Wire, basket, and sheath.

In the last one to two decades, flexible ureteroscopy has rapidly expanded its role in the treatment of urologic stone disease. With the frequent and expanded use of flexible ureteroscopy, other ancillary instruments were developed in order to ease and facilitate this technique, such as ureteral access sheaths (UAS) and a variety of wires and baskets. These developments, along with improved surgeon ureteroscopic competence, have often brought into question the need to implement the "traditional technique" of flexible ureteroscopy. In this review, we discuss a brief history of flexible ureteroscopy, its expanded indications, and the controversy surrounding the use of UAS, wires, and baskets.

Laparoendoscopic single-site pyeloplasty: outcomes of an international multi-institutional study of 140 patients.

OBJECTIVE: To report an international, multi-institutional series of laparoendoscopic single-site pyeloplasty (LESS-P) with analysis of functional outcomes. MATERIALS AND METHODS: LESS-P cases performed between October 2007 and June 2012 at 7 institutions worldwide per individual institutional protocols, entry criteria, and techniques were included. Patient characteristics, operative indications, perioperative outcomes, and postoperative follow-up were retrospectively collected and analyzed. RESULTS: The study included 140 adult patients (age 39.9 ± 15.7 years; body mass index 24.8 ± 4.2 kg/m(2); 15% with previous abdominal surgery) who underwent unilateral LESS-P, most of whom (94.3%) had dismembered reconstructions. Mean operative time was 202.1 ± 47 minutes with an estimated blood loss of 61.2 ± 44.6 mL. Robotic laparoendoscopic single-site surgery was applied in 31 patients (22.1%). A single 2-3 mm accessory port was used in 44 patients (31.4%) and a single 5-12 mm accessory port was added in 9 patients (6.4%), whereas 10 patients (7.1%) were converted to conventional multiport laparoscopy. No patients required conversion to open surgery, nor were any intraoperative complications reported. Length of hospitalization was 2.4 ± 1.6 days. The overall 90-day postoperative complication rate was 18.6%, mostly low-grade complications (Clavien I-II). With a mean follow-up of 14.0 ± 10.8 months, 93.4% had resolution of symptoms and 94.4% had radiographic evidence demonstrating resolution of ureteropelvic junction obstruction. Assessment of drainage with diuretic nuclear renal scan provided evidence of improvement in 86.5% of patients on their first postoperative renal scan. CONCLUSION: This study highlights the most comprehensive experience with LESS-P reported to date. Outcome measures parallel those of large published series of conventional laparoscopic pyeloplasty. Despite these encouraging findings, longer follow-up is needed to determine the efficacy and durability of this approach for the treatment of ureteropelvic junction obstruction.

Zero ischemia robotic partial nephrectomy: sequential preplaced suture renorrhaphy technique.

OBJECTIVE: To describe a robotic partial nephrectomy (PN) technique that eliminates renal global ischemia while decreasing parenchymal bleeding. METHODS: Before tumor resection, a suture is placed through the parenchyma adjacent to the tumor and deep to the planned edge of resection. The tumor resection is begun between the tumor edge and the preplaced suture and continued along the excision margin until some bleeding is encountered. A second suture is placed into the already excised parenchyma. This is repeated until the mass is completely excised, while suturing the parenchyma simultaneously. RESULTS: Fourteen patients underwent this technique between April 2008 and January 2013 by a single surgeon. Median age was 66 years and 64.3% (N = 9) were men. Median body mass index (BMI) was 27.5 Kg/m(2). Median radius, endophytic, nearness to collecting system, anterior/posterior, and location (RENAL) nephrometry score was 6.5. Median tumor size excised off clamp was 2.2 cm. Three patients had multiple tumors; 2 having a warm ischemia time (WIT) of 14.5 and 15 minutes. Median estimated blood loss (EBL) was 192.5 mL. Median operative time was 160 minutes. There were no Clavien grade 3 or 4 complications. One patient had a postoperative ileus and 1 patient had a blood transfusion and deep vein thrombosis. One patient had a positive tumor parenchymal margin, but negative excisional bed margin. Median hospital stay was 3 days and median follow-up was 8.4 months. CONCLUSION: Sequential preplaced suture renorrhaphy technique is a safe and effective technique that may be useful in renal function preservation by limiting or eliminating WIT while aiding in maximizing nephron preservation, especially in those patients with solitary kidneys and multiple tumors.

Robot-assisted partial nephrectomy for hilar tumors: perioperative outcomes.

OBJECTIVE: To compare perioperative outcomes of robot-assisted partial nephrectomy (RAPN) for hilar vs nonhilar tumors. MATERIALS AND METHODS: The study retrospectively reviewed 364 patients with available computed tomography scans undergoing RAPN. Demographic data and perioperative outcomes results were compared between the hilar (group 1, n = 70) and nonhilar tumors (group 2, n = 294). Multivariate analysis was used to identify predictors of warm ischemia time (WIT), estimated blood loss (EBL), major perioperative complications, and postoperative renal function. RESULTS: There were no differences with respect to demographic variables. Hilar tumors had higher RENAL (radius, exophytic/endophytic properties of the tumor, nearness of tumor deepest portion to the collecting system or sinus, anterior/posterior descriptor and the location relative to polar lines) scores (P <.001) and were larger (3.9 vs 2.6 cm, P <.001). Surgeries for hilar tumors were associated with greater operative time (210 vs 180 minutes, P <.001), longer WIT (27 vs 17 minutes, P <.001), and increased EBL (250 vs 200 mL, P = .04). No differences were noted in transfusion rate, length of stay, complications (overall and major) and positive margins. Postoperative estimated glomerular filtration rate showed no significant difference between hilar vs nonhilar patients on postoperative day 3 (70.12 vs 74.71 mL/min/1.73 m(2), P = .31) or at last follow-up (72.62 vs 75.78 mL/min/1.73 m(2), P = .40), respectively. Multivariate analysis found hilar location was independently associated with increased WIT without significant changes in EBL, major complications, or postoperative renal function. CONCLUSION: RAPN represents a safe and effective procedure for hilar tumors. Hilar location for patients undergoing RAPN in a high-volume institution seems not be associated with an increased risk of transfusions, major complications, or decline of early postoperative renal function.

Repeat robot-assisted partial nephrectomy (RAPN): feasibility and early outcomes.

OBJECTIVE: To demonstrate the feasibility, and to report our single-centre perioperative outcomes of repeat robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS: From June 2006 to June 2012, 490 patients underwent RAPN for a renal mass at our centre. Of these patients, nine who had undergone previous ipsilateral nephron-sparing surgery (NSS) were included in the analysis. Patient charts were reviewed to obtain demographic data, preoperative surgical history, operative details, and postoperative outcomes and follow-up data. RESULTS: In all, 12 tumours were removed in nine patients (median age 69 years; six female). A third of the operations were performed on patients with a solitary kidney. The median (range) R.E.N.A.L. nephrometry score for the resected masses was 7 (4-8). The warm ischaemia time was 17.5 min and in three of the nine patients an unclamped procedure was performed. No intraoperative complications were registered, whereas only two minor complications occurred postoperatively. There were no renal unit losses. All surgical margins were negative. There was no significant difference between mean preoperative and latest postoperative mean estimated glomerular filtration rates (70.5 vs 63.5 mL/min/1.73 m(2) , P > 0.05). At a mean (sd) follow-up of 8.3 (13) months, eight of the nine patients with a pathology diagnosis of malignant neoplasm were alive and free from disease at the latest follow-up. CONCLUSION: Although technically more demanding, repeat RAPN can be safely and effectively performed in patients presenting with local recurrence after primary NSS for kidney cancer.

Robotic retroperitoneal transvaginal natural orifice translumenal endoscopic surgery (NOTES) nephrectomy: feasibility study in a cadaver model.

OBJECTIVE: To evaluate the feasibility of pure robotic natural orifice translumenal endoscopic surgery (R-NOTES) nephrectomy. METHODS: Two R-NOTES nephrectomy approaches were attempted in 3 female cadavers. A single-port device was inserted through an incision in the posterior vaginal fornix. In the first approach, the peritoneal cavity was accessed in the lithotomy position. In the second approach, the retroperitoneum of 2 cadavers was accessed in the prone jackknife position. The ureter was identified and followed cranially. The hilum was stapled and the kidney was dissected. The specimen was extracted into a bag. The incision was closed with an open approach. RESULTS: The first approach was not possible because of collision of the robotic arms against the legs and limited bowel retraction. After modifying the approach, a right transvaginal R-NOTES retroperitoneal nephrectomy was successfully completed, without adding extra ports. Time for setup was 128 minutes. Time to identify the ureter was 53 minutes. Dissection and control of the renal pedicle was completed in 21 minutes. Time to complete the dissection and extraction of the kidney was 36 minutes. Time to complete the procedure was 238 minutes. There were no injuries to retroperitoneal organs or vessels. In the third cadaver, there was rectal injury during the access. We were unable to complete the procedure because of the cadaver height. CONCLUSION: Transvaginal R-NOTES nephrectomy is technically challenging but feasible in select female cadavers. Retroperitoneal approach in the prone jackknife position was instrumental in facilitating robotic access to the kidney through the vagina. Improvements in the technique and instrumentation are necessary to make this approach safe and reproducible.

Long term outcomes of lymphatic sparing laparoscopic varicocelectomy.

OBJECTIVE: To assess the long-term occurrence of hydroceles and varicocele recurrence in patients receiving lymphatic sparing laparoscopic varicocelectomy (LSLV) compared to those receiving plain laparoscopic varicocelectomy (PLV), and also to assess the growth of testicular volume postoperatively. METHODS: We employed a standard three-trocar configuration. The spermatic vessels were identified in the retroperitoneum above the internal inguinal ring. Lymphatics were dissected free from the spermatic artery and veins based on laparoscopic appearance. The spermatic artery and veins were divided between plastic locking clips. We performed a retrospective chart review of all pediatric patients who underwent laparoscopic varicocelectomy between June 2003 and January 2009. RESULTS: Of a total of 97 patients, 67 underwent LSLV with mean follow-up of 45.8 ± 20.7 months and 30 underwent PLV with mean follow-up of 40.8 ± 25.3 months (p = 15). There was a 4.5% hydrocele rate in the LSLV group compared to 43.3% in the PLV group. Of the patients who underwent a PLV and subsequently developed a hydrocele, 31% (n = 4) required a hydrocelectomy, vs none of those who developed a hydrocele after LSLV. Varicocele rate was 6% in the LSLV group vs 3.3% in the PLV group. However, when the artery was not preserved, the probability of recurrence in the LSLV group was 1.3%. Time to hydrocele formation was 16 months in the LSLV group vs 37 months in the PLV group. There was catch-up testicular growth in both groups. CONCLUSIONS: There appears to be increased risk of need for a hydrocelectomy after a PLV as compared to LSLV. Performing a lymphatic sparing, non-artery preserving, laparoscopic varicocelectomy has success and complication rates comparable with those of subinguinal microsurgical varicocelectomy. There appears to be excellent catch-up testicular growth with either laparoscopic varicocelectomy technique.

Endoscopic-guided versus fluoroscopic-guided renal access for percutaneous nephrolithotomy: a comparative analysis.

OBJECTIVE: To evaluate the intraoperative outcomes of percutaneous renal access using fluoroscopic-guided access (FGA) vs endoscopic-guided access (EGA). METHODS: A retrospective record review was conducted of patients undergoing percutaneous nephrolithotomy (PCNL), categorized by the method of achieving renal access. Patients were randomly assigned to 1 of 2 endourologists: 1 practicing EGA and the other practicing FGA. Patient demographics, baseline characteristics, and operative and postoperative outcomes were compared using univariate and multivariate analysis. RESULTS: From August 2010 to January 2012, 159 patients underwent PCNL (40% EGA, 60% FGA). No significant difference was observed between groups in age (P = .06), American Society of Anesthesiologists Physical Status Classification (P = .7), number of stones (P = .058), cumulative stone diameter (P = .051), number of calyces involved (P = .82), and stone density (P = .49). Body mass index (BMI) was higher in patients undergoing EGA (P = .013). Patients undergoing EGA had shorter fluoroscopy time (3.2 vs 16.8 minutes, P <.001) and lower access number (1.03 vs 1.22 P = .002). Fluoroscopy time was longer for FGA than for EGA after adjusting for BMI, staghorn stones, and access number (P <.001). No significant difference was noted in change in hemoglobin, blood transfusion rate, operative time, or intraoperative complications between groups. Procedures were aborted due to bleeding more commonly in the FGA (8%) than in the EGA group (0%, P = .02) A secondary procedure for stone management was required in 2 (3.2%) of the EGA group compared with 12 (12.5%) of the FGA group. CONCLUSION: EGA is safe and effective and leads to decreased fluoroscopy time, decreased need for multiple accesses, and decreased risk of early termination of the procedure or need for secondary procedures.

Robot-assisted ureteroneocystostomy: technique and comparative outcomes.

BACKGROUND AND PURPOSE: Ureteroneocystostomy can be used for the treatment of patients with a wide variety of ureteral pathology. Over the last decade, robot-assisted surgery has become more commonly used as a minimally invasive approach for reconstructive upper urinary tract procedures. The aim of this study is to present our experience with robot-assisted ureteroneocystosctomy (RUNC) with a comparison with that of open ureteroneocystostomy (OUNC). PATIENTS AND METHODS: Medical records of 25 patients who underwent RUNC and 41 patients who underwent OUNC or at our institution between 2000 and 2010 were retrospectively analyzed. Perioperative and postoperative data including demographics, surgical outcomes, and clinical and radiographic findings at postoperative follow-up were considered in the comparative analysis. Descriptive statistics were used to present the data. The significance of the difference between variables was evaluated using the Wilcoxon rank sum test for continuous and Fisher exact test for categorical variables. RESULTS: No significant differences were detected in terms of baseline patient characteristics between the two groups. The OUNC procedures were performed with a shorter median operative time (200 vs 279 min., P=0.0008), whereas RUNC patients had a shorter hospital stay (median 3 vs 5 days, P=0.0004), less narcotic pain requirement (morphine equivalent, mg 104.6 vs 290, P=0.0001), and less estimated blood loss (100 vs 150 mL, P=<0.0002). There as no significant difference in the rate of reoperation between groups: RUNC 2/25 (7.6 %) vs OUNC 4/41 (9.7%) P=0.8. Limitations include the retrospective nature of the study and the difference in indications for surgery. CONCLUSION: RUNC provides excellent outcomes with shorter hospital stay, less narcotic pain requirement, and decreased blood loss when compared with the open procedure. Advantages of the robotic platform for dissection and suturing can be useful for complex minimally invasive urologic reconstructive procedures.

Cryoablation versus minimally invasive partial nephrectomy for small renal masses in the solitary kidney: impact of approach on functional outcomes.

PURPOSE: We evaluated the change in renal function after renal cryoablation and partial nephrectomy based on tumor complexity according to the R.E.N.A.L. nephrometry score. MATERIALS AND METHODS: We retrospectively reviewed the data of patients who had a renal tumor in a solitary kidney, and underwent renal cryoablation and partial nephrectomy between December 2000 and January 2012. Renal tumor complexity was categorized into 3 groups by R.E.N.A.L. nephrometry score as low (4 to 6), intermediate (7 to 9) and high (10 to 12). All baseline demographic data, perioperative parameters and followup data including renal function were collected. Comparisons were made among similar tumor complexities. RESULTS: In the renal cryoablation and partial nephrectomy groups 29 patients (43 tumors) and 33 patients were identified, respectively. In all renal tumor complexities, renal cryoablation provided a better perioperative outcome in terms of median operative time, estimated blood loss, transfusion, hospital stay and complications. The median change in serum creatinine and estimated glomerular filtration rate was slightly greater in the partial nephrectomy group. However, the differences were not statistically significant for any of the tumor complexities. Three patients (10%) in the renal cryoablation group and 2 (6%) in the partial nephrectomy group required long-term dialysis. CONCLUSIONS: In patients with solitary kidneys, renal cryoablation is associated with superior perioperative outcomes compared to partial nephrectomy. Specifically, partial nephrectomy is not associated with greater loss of renal function than renal cryoablation regardless of the extent of tumor complexity.

Robotic partial nephrectomy for small renal masses in patients with pre-existing chronic kidney disease.

OBJECTIVE: To assess the outcomes of robotic partial nephrectomy in patients with pre-existing chronic kidney disease (CKD). MATERIALS AND METHODS: Patients who underwent robotic partial nephrectomy for renal tumors between 2007 and 2011 were identified from our prospectively maintained institutional database. Perioperative as well as short-term oncological and functional outcomes were assessed. A comparative analysis was performed between patients with pre-existing CKD (estimated glomerular filtration rate [eGFR] 15-60 mL/min, group 1, n = 52) and patients with eGFR >60 mL/min (group 2, n = 303). RESULTS: Group 1 patients were older (median 68 vs 57 years, P < .001), with higher American Society of Anesthesiology (ASA) score (3 vs 2, P < .001) and a higher Charlson comorbidity index (7 vs 4, P < .001). Warm ischemia time (WIT) was similar in both groups (18 vs 18 minutes, P = .52). Group 1 had a higher postoperative complication rate (40.4% vs 21.1%, P = .003). Pathologic and oncological data were similar. After a median follow-up of 3 months (interquartile: 1-10), deterioration of eGFR was lower in group 1 patients (-5% vs -12%, P = .004). No endstage renal disease was noted in either group. There was significantly less CKD upstaging in group 1 than in group 2 (11.5% vs 33.9%, P = .001). After multivariate analysis, preoperative eGFR and WIT were independent predictors of latest eGFR. Less than 15% of patients with normal baseline renal function developed CKD stage III or higher. CONCLUSION: Despite a high risk of surgical complications, robotic partial nephrectomy only marginally affects renal function in patients with pre-existing CKD.

Real-time robotic transrectal ultrasound navigation during robotic radical prostatectomy: initial clinical experience.

OBJECTIVE: To describe a novel robotic transrectal ultrasound platform for real-time navigation during robot-assisted laparoscopic radical prostatectomy (RALP) and to report its early clinical application. METHODS: Five men undergoing RALPs at our Institution agreed to participate in this Institutional Review Board-approved pilot study. All of them were eligible for a bilateral nerve sparing procedure. Before docking the da Vinci robot, a transrectal ultrasound tri-plane side-fire probe was placed. A modified ViKY Endoscope Holder was used during RALPs to move the probe thanks to a remote control placed under the console surgeon's control during RALPs. During each procedure, attempt was made to estimate prostate volume, define 12 reference points, and to precisely identify location of the neurovascular bundles using Doppler ultrasound. The TilePro was used during the procedures to allow real-time ultrasound imaging to guide robotic instruments during dissection. RESULTS: Median robotic transrectal ultrasound probe holder (R-TRUS) setup time was 11 minutes (interquartile range [IQR], 10-14). Prostate volume calculation, reference point definition, neurovascular bundle identification, and instrument tip visualization were successful in all men. In 1 patient with a large prostate (120 mL), R-TRUS was withdrawn during recto-prostatic dissection. There were no rectal injuries. CONCLUSION: R-TRUS during RALPs is feasible and safe. It allows real-time TRUS navigation and guidance. Further studies are needed to evaluate its impact on oncological and functional outcomes.

Robotic laparoendoscopic single-site surgery: From present to future.

THE CONTINUED EFFORT OF IMPROVING COSMESIS AND REDUCING MORBIDITY IN UROLOGIC SURGERY HAS GIVEN RISE TO NOVEL ALTERNATIVES TO TRADITIONAL MINIMALLY INVASIVE TECHNIQUES: Laparoendoscopic Single-site Surgery (LESS) and Natural Orifice Transluminal Endoscopic Surgery (NOTES). Despite the development of specialized access devices and instruments, the performance of complex procedures using LESS has been challenging due to loss of triangulation and instrument clashing. A robotic interface may represent the key factor in overcoming the critical restrictions related to NOTES and LESS. Although encouraging, current clinical evidence related to R-LESS remains limited as the current da Vinci(®) robotic platform has not been specifically designed for LESS. Robotic innovations are imminent and are likely to govern major changes to the current landscape of scarless surgery.

Robotic single-site kidney surgery: evaluation of second-generation instruments in a cadaver model.

OBJECTIVE: To evaluate the second generation of single-site instruments for robotic laparoendoscopic single-site surgery (R-LESS) for kidney procedures in a cadaver model. METHODS: Three procedures, including 1 pyeloplasty, 1 partial nephrectomy, and 1 nephrectomy, were conducted in a female cadaver model. A da Vinci Si system (Intuitive Surgical, Sunnyvale, CA) and the second generation of single-site instruments, specifically designed for R-LESS, were used. RESULTS: All the procedures were completed successfully without the addition of extra ports. Time to set up the port and instruments was 40 minutes. In the pyeloplasty, time to complete the anastomosis was 39 minutes. In the partial nephrectomy, simulated ischemia time was 21 minutes. In the nephrectomy, time to complete the resection was 13 minutes. No significant gas leak was noticed during the procedures. There were no injuries to intraabdominal organs or vessels. CONCLUSION: Robotic single-site renal surgery using a second generation of specifically designed instruments was feasible in a cadaver model, obviating many limitations of LESS. Lack of articulation at the tip of the instruments represents the main disadvantage of this novel instrumentation, especially in case of reconstructive procedures.

Ex-vivo ureteral spatulation during laparoscopic pyeloplasty: a novel approach to a difficult problem.

Ureteral spatulation and performance of the anastamosis to the renal pelvis are the most important and often technically demanding and time consuming steps in performing a laparoscopic pyeloplasty. We describe a novel ex-vivo technique of ureteral spatulation and placement of the apical anastamotic sutures. This technique is especially helpful in challenging cases where optimal angles may not be viable via pure laparoscopic technique. The technique was performed on six patients, five pediatric and one adult without any immediate complications or long-term stricture or anastamotic disruption.