A census of laparoscopic and robotic urological practice: a survey of minimally invasive surgery department of the Brazilian Society of Urology.

Minimally invasive urologic surgery has been developing in Brazil and now is a routine part of care in many regions and patients with different conditions benefit from it. Training in laparoscopic and robotic surgery has evolved and concerns exist both over the quality of surgical training and the practical effect on results of the urological training. This is an unprecedented study which undertook a census to determinate the current state of laparoscopic and robotic urological practice and to know the mains barriers to adequate practice in Brazil. In august 2017, surveys, consisting of an anonymous questionnaire with 15 questions, were sent via internet to the mailing list of the Brazilian Society of Urology (SBU). With these data, activities related to laparoscopy and robotic surgery of our urologists and the mains difficulties and barriers to practice laparoscopy and robotic surgery were evaluated. In our survey, 413 questionnaires were completed. Majority of the responders were currently working in the southeast region of Brazil (52.1%) and 75.5% of the surgeons performed laparoscopic surgery while, only 12.8%, robotic surgery. The lack of experience on the technique and the lack of equipment were the mains barriers and difficulties for not executing laparoscopic and robotic surgeries, respectively. Proper longitudinal training and access to good equipment in minimally invasive surgery are still barriers for urologists in our country.

Urologic surgery laparoscopic access: vascular complications.

Vascular injury in accidental punctures may occur in large abdominal vessels, it is known that 76% of injuries occur during the development of pneumoperitoneum. The aim of this video is to demonstrate two cases of vascular injury occurring during access in laparoscopic urologic surgery. The first case presents a 60-year old female patient with a 3cm tumor in the superior pole of the right kidney who underwent a laparoscopic partial nephrectomy. After the Verres needle insertion, output of blood was verified. During the evaluation of the cavity, a significant hematoma in the inferior vena cava was noticed. After the dissection, a lesion in the inferior vena cava was identified and controlled with a prolene suture, the estimated bloos loss was 300ml. The second case presents a 42-year old female live donor patient who had her right kidney selected to laparoscopic live donor nephrectomy. After the insertion of the first trocar, during the introduction of the 10mm scope, an active bleeding from the mesentery was noticed. The right colon was dissected and an inferior vena cava perforation was identified; a prolene suture was used to control the bleeding, the estimated blood loss was 200mL, in both cases the patients had no previous abdominal surgery. Urologists must be aware of this uncommon, serious, and potentially lethal complication. Once recognized and in the hands of experienced surgeons, some lesions may be repaired laparoscopically. Whenever in doubt, the best alternative is the immediate conversion to open surgery to minimize morbidity and mortality.

Impact of novel techniques on minimally invasive adrenal surgery: trends and outcomes from a contemporary international large series in urology.

OBJECTIVE: To evaluate contemporary international trends in the implementation of minimally invasive adrenalectomy and to assess contemporary outcomes of different minimally invasive techniques performed at urologic centers worldwide. METHODS: A retrospective multinational multicenter study of patients who underwent minimally invasive adrenalectomy from 2008 to 2013 at 14 urology institutions worldwide was included in the analysis. Cases were categorized based on the minimally invasive adrenalectomy technique: conventional laparoscopy (CL), robot-assisted laparoscopy (RAL), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML). The rates of the four treatment modalities were determined according to the year of surgery, and a regression analysis was performed for trends in all surgical modalities. RESULTS: Overall, a total of 737 adrenalectomies were performed across participating institutions and included in this analysis: 337 CL (46 % of cases), 57 ML (8 %), 263 LESS (36 %), and 80 RA (11 %). Overall, 204 (28 %) operations were performed with a retroperitoneal approach. The overall number of adrenalectomies increased from 2008 to 2013 (p = 0.05). A transperitoneal approach was preferred in all but the ML group (p < 0.001). European centers mostly adopted CL and ML techniques, whereas those from Asia and South America reported the highest rate in LESS procedures, and RAL was adopted to larger extent in the USA. LESS had the fastest increase in utilization at 6 %/year. The rate of RAL procedures increased at slower rates (2.2 %/year), similar to ML (1.7 %/year). Limitations of this study are the retrospective design and the lack of a cost analysis. CONCLUSIONS: Several minimally invasive surgical techniques for the management of adrenal masses are successfully implemented in urology institutions worldwide. CL and LESS seem to represent the most commonly adopted techniques, whereas ML and RAL are growing at a slower rate. All the MIS techniques can be safely and effectively performed for a variety of adrenal disease.

Retrocervical deep infiltrating endometriotic lesions larger than thirty millimeters are associated with an increased rate of ureteral involvement.

STUDY OBJECTIVE: To estimate the presence of ureteral involvement in deep infiltrating endometriosis (DIE) affecting the retrocervical area. DESIGN: Retrospective study of women undergoing laparoscopic treatment of DIE affecting the retrocervical area. DESIGN CLASSIFICATION: Canadian Task Force classification II-3. SETTING: Tertiary referral private hospital. PATIENTS: We evaluated 118 women who underwent laparoscopy for the treatment of retrocervical DIE lesions between January 2010 and March 2012. INTERVENTIONS: All women underwent laparoscopic surgery for the complete treatment of DIE. After surgery all specimens were sent for pathologic examination to confirm the presence of endometriosis. MEASUREMENTS: Patients with pathologically-confirmed retrocervical DIE were divided into 2 groups according to the size of the lesion (group 1: lesions ≥ 30 mm; group 2: lesions < 30 mm) and the rate of ureteral endometriosis was compared between both groups. MAIN RESULTS: Ureteral involvement was present in 17.9% (95% confidence interval [CI] 10%-29.9%) of women with retrocervical lesions ≥ 30 mm whereas in only 1.6% (95% CI 0.4%-8.5%) of those with lesions <30 mm (odds ratio = 13.3 [95% CI 1.6-107.3]). CONCLUSION: Patients undergoing surgery for retrocervical DIE lesions ≥ 30 mm in diameter have a greater risk of having ureteral involvement (17.9%).

Intravesical and transperitoneal laparoscopy in the management of tumor in the residual ureter.

The occurrence of tumor in the residual ureter after an incomplete nephroureterectomy required by a tumor of renal collecting system is an uncommon but a well described situation. The recommended treatment in this situation is the radical excision of the remaining ureter, being the open technique the most used approach. The aim of this video is to demonstrate a new approach using intravesical and transperitoneal laparoscopy to remove the residual ureter following the oncological concepts. A 67 year-old male patient underwent an incomplete open right radical nephroureterectomy for a transitional cell carcinoma of the renal collecting system. After 16 months, the cystoscopy diagnostic revealed a recurrence of it in the residual ureter. An intravesical approach followed by a transperitoneal laparoscopy has removed the remaining ureter. Operative time was 110 minutes, blood loss 100 mL, the patient was discharged on the first postoperative day and the Foley catheter was removed on the seventh one. Pathological examination revealed low grade transitional cell carcinoma and free surgical margins, no recurrence was observed after six months. To our knowledge, this is the first treatment description of a tumor in the residual ureter with these techniques. This approach can be a minimal invasive alternative in this unusual situation.

Urological laparoendoscopic single site surgery: multi-institutional analysis of risk factors for conversion and postoperative complications.

PURPOSE: We analyzed the incidence of and risk factors for complications and conversions in a large contemporary series of patients treated with urological laparoendoscopic single site surgery. MATERIALS AND METHODS: The study cohort consisted of consecutive patients treated with laparoendoscopic single site surgery between August 2007 and December 2010 at a total of 21 institutions. A logistic regression model was used to analyze the risks of conversion, and of any grade and only high grade postoperative complications. RESULTS: Included in analysis were 1,163 cases. Intraoperatively complications occurred in 3.3% of cases. The overall conversion rate was 19.6% with 14.6%, 4% and 1.1% of procedures converted to reduced port laparoscopy, conventional laparoscopic/robotic surgery and open surgery, respectively. On multivariable analysis the factors significantly associated with the risk of conversion were oncological surgical indication (p=0.02), pelvic surgery (p<0.001), robotic approach (p<0.001), high difficulty score (p=0.004), extended operative time (p=0.03) and an intraoperative complication (p=0.001). A total of 120 postoperative complications occurred in 109 patients (9.4%) with major complications in only 2.4% of the entire cohort. Reconstructive procedure (p=0.03), high difficulty score (p=0.002) and extended operative time (p=0.02) predicted high grade complications. CONCLUSIONS: Urological laparoendoscopic single site surgery can be done with a low complication rate, resembling that in laparoscopic series. The conversion rate suggests that early adopters of the technique have adhered to the principles of careful patient selection and safety. Besides facilitating future comparisons across institutions, this analysis can be useful to counsel patients on the current risks of urological laparoendoscopic single site surgery.

International multicenter trial on clinical natural orifice surgery--NOTES IMTN study: preliminary results of 362 patients.

OBJECTIVES: Natural orifice translumenal endoscopic surgery (NOTES) is evolving as a promising alternative for abdominal surgery. IMTN Registry was designed to prospectively document early results of natural orifice surgery among a large group of clinical cases. METHODS: Sixteen centers from 9 countries were approved to participate in the study, based on study protocol requirements and local institutional review board approval. Transgastric and transvaginal endoscopic natural orifice surgery was clinically applied in 362 patients. Intraoperative and postoperative parameters were prospectively documented. RESULTS: Mean operative time for transvaginal cholecystectomy was 96 minutes, compared with 111 minute for transgastric cholecystectomy. A general complication rate of 8.84% was recorded (grade I-II representing 5.8%, grade III-IV representing 3.04%). No requirement for any analgesia was found in one fourth of cholecystectomy and appendectomy patients. CONCLUSIONS: Results of clinical applications of NOTES in the IMTN Study showed the feasibility of different methods of this new minimally invasive alternative for laparoscopic and open surgery.

Adrenalectomy by retroperitoneal laparoendoscopic single site surgery.

BACKGROUND: Laparoscopic adrenalectomy is the current standard for treatment of benign adrenal disease. To reduce the invasiveness of surgery, new techniques have been recently proposed, such as mini-laparoscopy, natural orifice transluminal endoscopic surgery, and laparoendoscopic single site surgery (LESS). Herein, we describe one case of adrenalectomy by retroperitoneal LESS using conventional laparoscopic instruments and ports. CASE REPORT: A 52-year-old female patient with an incidental finding of a 3-cm mass in the left adrenal was referred to us. Preoperative blood concentrations of catecholamines, aldosterone, and cortisol, and urinary excretion of vanilmandelic acid were normal. She underwent an adrenalectomy by retroperitoneal LESS using conventional instruments and ports. Operative time and estimated blood loss were 82 minutes and ≤50cc, respectively. She was discharged 12 hours after surgery. No intra- or postoperative complications occurred. Pathological analysis of the specimen identified an adrenal cortical adenoma. CONCLUSION: Adrenalectomy by retroperitoneal LESS using conventional laparoscopic instruments is feasible. Further studies must be performed to evaluate safety, indications and benefits of this approach.

Laparoendoscopic Pfannenstiel nephrectomy using conventional laparoscopic instruments--preliminary experience.

PURPOSE: To confirm the feasibility of the laparoendoscopic Pfannenstiel nephrectomy using conventional laparoscopic instruments. MATERIALS AND METHODS: Since March 2009, laparoscopic nephrectomy through a Pfannenstiel incision has been performed in selected patients in our service. The Veress needle was placed through the umbilicus which allowed carbon dioxide inflow. One 5 mm (or 10 mm) trocar was placed at the umbilicus for the laparoscope, to guide the placement of three trocars over the Pfannenstiel incision. Additional trocars were placed as follows: a 10 mm in the midline, a 10 mm ipsilateral to the kidney to be removed (2 cm away from the middle one), and a 5 mm contralateral to the kidney to be removed (2 cm away from the middle one). The entire procedure was performed using conventional laparoscopic instruments. At the end of the surgery, trocars were removed and all three incisions were united into a single Pfannenstiel incision for specimen retrieval. RESULTS: Five nephrectomies were performed following this technique: one atrophic kidney, one kidney donation, two renal cancers and one bilateral renal atrophy. Median operative time was 100 minutes and median intraoperative blood loss was 100 cc. No intraoperative complications occurred and no patients required blood transfusion. Median length of hospital stay was 1 day (range 1 to 2 days). CONCLUSIONS: The use of the Pfannenstiel incision for laparoscopic nephrectomy seems to be feasible even when using conventional laparoscopic instruments, and can be considered a potential alternative for traditional laparoscopic nephrectomy.

Transumbilical laparoscopic urological surgery: are special devices strictly necessary?

OBJECTIVE: To evaluate the safety and feasibility of transumbilical laparoscopic surgery using conventional laparoscopic instruments and ports. PATIENTS AND METHODS: Since January 2008 we have been using laparoscopic transumbilical procedures. Patient selection was determined by any situation, pathological or not, for which laparoscopy was deemed appropriate as the standard of care in our practice. Exclusion criteria included patients who had undergone multiple abdominal procedures. The Veress needle was placed through the umbilicus, to allow insufflation with carbon dioxide. A 10-mm trocar was placed in the peri-umbilical site for the laparoscope, followed by placing two additional 5-mm peri-umbilical trocars. The entire procedure was done using conventional laparoscopic instruments. At the end of surgery the trocars were removed and all three peri-umbilical skin incisions were united for specimen retrieval. Patients undergoing surgery using this approach were evaluated prospectively and data were collected during and after surgery for analysis. RESULTS: Six procedures were performed using this technique (three nephrectomies, one adrenalectomy, one ureterolithotomy and one retroperitoneal mass resection). The mean operative duration and blood loss were 70.5 min and 108.3 mL, respectively. There were no complications during surgery and no patients needed a blood transfusion. Analgesia comprised metamizole (1 g intravenous every 6 h) and ketoprofen (100 mg intravenous every 12 h). The time to first oral intake was 8 h and the mean hospital stay was 28 h. CONCLUSION: Laparoscopic transumbilical surgery seems to be feasible and safe even using conventional laparoscopic instruments, and can be considered a potential alternative for traditional laparoscopic urological procedures.

Transvaginal endoscopic tubal sterilization.

BACKGROUND: Tubal sterilization is one of the most widely used options for female contraception. It can be performed by laparotomy, minilaparotomy, colpotomy, laparoscopy, and hysteroscopy. In this paper, we report the use of the transvaginal endoscopic approach to perform tubal ligation. CASE: The access to the abdomen was obtained by a 1.5-cm colpotomy. The flexible endoscope was introduced into the peritoneal cavity, and carbon dioxide was instilled to get the pneumoperitoneum. Fallopian tubes were identified and electrocauterized with a 40-W coagulation current. Total procedure time was 45 minutes. A single dose of intravenous dypirone was administered for pain. She was discharged 10 hours after the procedure. CONCLUSION: Transvaginal endoscopic tubal ligation is feasible and can be considered an alternative approach to perform female sterilization.

Laparoscopic renal biopsy.

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Total and partial laparoscopic adrenalectomy.

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Total and partial laparoscopic adrenalectomy

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Laparoscopic renal biopsy

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

A census of laparoscopic and robotic urological practice: a survey of minimally invasive surgery department of the Brazilian Society of Urology

ABSTRACT Minimally invasive urologic surgery has been developing in Brazil and now is a routine part of care in many regions and patients with different conditions benefit from it. Training in laparoscopic and robotic surgery has evolved and concerns exist both over the quality of surgical training and the practical effect on results of the urological training. This is an unprecedented study which undertook a census to determinate the current state of laparoscopic and robotic urological practice and to know the mains barriers to adequate practice in Brazil. In august 2017, surveys, consisting of an anonymous questionnaire with 15 questions, were sent via internet to the mailing list of the Brazilian Society of Urology (SBU). With these data, activities related to laparoscopy and robotic surgery of our urologists and the mains difficulties and barriers to practice laparoscopy and robotic surgery were evaluated. In our survey, 413 questionnaires were completed. Majority of the responders were currently working in the southeast region of Brazil (52.1%) and 75.5% of the surgeons performed laparoscopic surgery while, only 12.8%, robotic surgery. The lack of experience on the technique and the lack of equipment were the mains barriers and difficulties for not executing laparoscopic and robotic surgeries, respectively. Proper longitudinal training and access to good equipment in minimally invasive surgery are still barriers for urologists in our country.

Laparoendoscopic single-site surgery in urology: worldwide multi-institutional analysis of 1076 cases.

BACKGROUND: Laparoendoscopic single-site surgery (LESS) has gained popularity in urology over the last few years. OBJECTIVE: To report a large multi-institutional worldwide series of LESS in urology. DESIGN, SETTING, AND PARTICIPANTS: Consecutive cases of LESS done between August 2007 and November 2010 at 18 participating institutions were included in this retrospective analysis. INTERVENTION: Each group performed a variety of LESS procedures according to its own protocols, entry criteria, and techniques. MEASUREMENTS: Demographic data, main perioperative outcome parameters, and information related to the surgical technique were gathered and analyzed. Conversions to reduced-port laparoscopy, conventional laparoscopy, or open surgery were evaluated, as were intraoperative and postoperative complications. RESULTS AND LIMITATIONS: Overall, 1076 patients were included in the analysis. The most common procedures were extirpative or ablative operations in the upper urinary tract. The da Vinci robot was used to operate on 143 patients (13%). A single-port technique was most commonly used and the umbilicus represented the most common access site. Overall, operative time was 160±93 min and estimated blood loss was 148±234 ml. Skin incision length at closure was 3.5±1.5 cm. Mean hospital stay was 3.6±2.7 d with a visual analog pain score at discharge of 1.5±1.4. An additional port was used in 23% of cases. The overall conversion rate was 20.8%; 15.8% of patients were converted to reduced-port laparoscopy, 4% to conventional laparoscopy/robotic surgery, and 1% to open surgery. The intraoperative complication rate was 3.3%. Postoperative complications, mostly low grade, were encountered in 9.5% of cases. CONCLUSIONS: This study provides a global view of the evolution of LESS in the field of minimally invasive urologic surgery. A broad range of procedures have been effectively performed, primarily in the academic setting, within diverse health care systems around the world. Since LESS is performed by experienced laparoscopic surgeons, the risk of complications remains low when stringent patient-selection criteria are applied.

Bilateral retroperitoneoscopic lumbar sympathectomy by unilateral access for plantar hyperhidrosis in women.

OBJECTIVES: Primary focal hyperhidrosis is a disorder of excessive, bilateral, and relatively symmetric sweating occurring in the axillae, palms, soles, or craniofacial region. Armpits are affected in 51% of patients, feet in 29%, palms in 25%, and the face in 20%. There is a wide range of nonsurgical and surgical treatments available for patients with focal hyperhidrosis. Surgical treatments for plantar hyperhidrosis include thoracic and/or lumbar sympathectomy. In this article, we report on a new technique of bilateral retroperitoneoscopic lumbar sympathectomy by unilateral access for plantar hyperidrosis. MATERIALS AND METHODS: The sample consisted of female patients who presented with plantar hyperhidrosis at the time of surgery and received bilateral retroperitoneoscopic lumbar sympathectomy by a unilateral access technique at our hospital. All patients had already been submitted to a previous thoracic sympathectomy with no improvement of the plantar hyperhidrosis. RESULTS: Five procedures were performed successfully from January through March 2009. Mean operative time and mean estimated blood loss were 59 minutes and 54 cc, respectively. We had no intraoperative complications, and patients were discharged home 12.8 hours after surgery. Immediate warming of the feet was observed at the end of all procedures. On follow-up consultations, all patients referred a complete resolution of the plantar hyperhidrosis and 1 case of compensative hyperhidrosis on the back. CONCLUSIONS: Retroperitoneoscopic lumbar sympathectomy by unilateral access seems to be feasible when performed by a surgeon with experience on advanced laparoscopy. Larger series comparing unilateral to bilateral access are necessary to establish the real benefits and potential disadvantages of this new technique.

A comparison of hand-assisted and pure laparoscopic techniques in live donor nephrectomy.

PURPOSE: To compare hand-assisted laparoscopic donor nephrectomy and pure laparoscopic live donor nephrectomy techniques in live donor nephrectomy. METHODS: In this retrospective study, we included all patients submitted to hand-assisted laparoscopic donor nephrectomy and pure laparoscopic live donor nephrectomy between May 2002 and December 2007. The operative data and post-operative courses were reviewed. Information was collected on the operative time, warm ischemia time, estimated blood loss, intra-operative complications, time to first oral intake, length of hospital stay, and post-operative complications. The data were analyzed using Student's t -tests and Fisher exact tests as appropriate, with statistical significance defined as p < 0.05. RESULTS: The means of the operative duration, warm ischemia time and intra-operative bleeding were 83 min, 3.6 min and 130.9 cc, respectively, for hand-assisted laparoscopic donor nephrectomy, and 78.4 min, 2.5 min and 98.9 cc, respectively, for pure laparoscopic live donor nephrectomy (p=0.29, p<0.0001 and p=0.08, respectively). Intra-operative complications occurred in 6% of patients submitted to hand-assisted laparoscopic donor nephrectomy and in 4.5% of those submitted to pure laparoscopic live donor nephrectomy (p=0.68). Only one patient from each group required conversion to open surgery; one person receiving hand-assisted laparoscopic donor nephrectomy had bleeding and one person receiving pure laparoscopic live donor nephrectomy had low carbon dioxide levels during the warm ischemia period. Compared with patients receiving hand-assisted laparoscopic donor nephrectomy, patients submitted to pure laparoscopic live donor nephrectomy were able to take their first meal earlier (12.5 vs. 9.2 hours, p=0.046), were discharged home sooner (2.8 vs. 1.4 days, p<0.0001) and had fewer post-operative complications (7.5% vs. 0.6%, p=0.04). CONCLUSIONS: Pure laparoscopic live donor nephrectomy had some advantages over hand-assisted laparoscopic donor nephrectomy in terms of the warm ischemia time, time to first oral intake, length of hospital stay, and post-operative donor complications.