Laparoscopic vs percutaneous cryoablation for the small renal mass: 15-year experience at a single center.

OBJECTIVE: To analyze our 15-year experience with small renal masses ablation and present oncologic and functional outcomes of laparoscopic cryoablation (LCA) and percutaneous cryoablation (PCA). MATERIALS AND METHODS: We identified patients who underwent LCA (n = 275) or PCA (n = 137) for small renal masses between 1997 and 2012. Differences in overall survival (OS) and recurrence-free survival (RFS) were analyzed using a log-rank test. Cox proportional hazard ratios model was used to determine factors that predicted OS. Fit proportional hazard risk ratios were also calculated to determine if there were any factors that affected tumor recurrence. RESULTS: Tumor sizes were equal between the 2 groups; however, tumors in the PCA group were more complex. The overall (7.27% and 7.29%) and major complications (0.7% and 3.6%) were similar. The estimated probability of 5-year OS for LCA and PCA was 89% and 82%, respectively. The estimated probability of the 5-year RFS for LCA and PCA was 79% and 80%, respectively. Heart disease (hazard ratio, 2.15; 95% confidence interval, 1.35-3.41; P = .001) and history of disease recurrence (hazard ratio, 2.49; 95% confidence interval, 1.60-3.86; P = .001; P <.0001) were predictors of death. The median follow-up time for the LCA group (4.41 years [1.67-6.91 years]) was longer than the PCA group (3.15 years [1.37-4.08 years]; P = .0001). CONCLUSION: We found no significant difference in OS or RFS at 5 years between the 2 groups. Tumor size and anterior location affected local recurrence rates, and these factors should be taken into consideration when choosing the appropriate treatment plan. RENAL nephrometry score or type of cryoablation was not associated with tumor recurrence.

Augmented-reality-based skills training for robot-assisted urethrovesical anastomosis: a multi-institutional randomised controlled trial.

OBJECTIVE: To validate robot-assisted surgery skills acquisition using an augmented reality (AR)-based module for urethrovesical anastomosis (UVA). METHODS: Participants at three institutions were randomised to a Hands-on Surgical Training (HoST) technology group or a control group. The HoST group was given procedure-based training for UVA within the haptic-enabled AR-based HoST environment. The control group did not receive any training. After completing the task, the control group was offered to cross over to the HoST group (cross-over group). A questionnaire administered after HoST determined the feasibility and acceptability of the technology. Performance of UVA using an inanimate model on the daVinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) was assessed using a UVA evaluation score and a Global Evaluative Assessment of Robotic Skills (GEARS) score. Participants completed the National Aeronautics and Space Administration Task Load Index (NASA TLX) questionnaire for cognitive assessment, as outcome measures. A Wilcoxon rank-sum test was used to compare outcomes among the groups (HoST group vs control group and control group vs cross-over group). RESULTS: A total of 52 individuals participated in the study. UVA evaluation scores showed significant differences in needle driving (3.0 vs 2.3; P = 0.042), needle positioning (3.0 vs 2.4; P = 0.033) and suture placement (3.4 vs 2.6; P = 0.014) in the HoST vs the control group. The HoST group obtained significantly higher scores (14.4 vs 11.9; P 0.012) on the GEARS. The NASA TLX indicated lower temporal demand and effort in the HoST group (5.9 vs 9.3; P = 0.001 and 5.8 vs 11.9; P = 0.035, respectively). In all, 70% of participants found that HoST was similar to the real surgical procedure, and 75% believed that HoST could improve confidence for carrying out the real intervention. CONCLUSION: Training in UVA in an AR environment improves technical skill acquisition with minimal cognitive demand.

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.

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 ...

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.

Robotic-assisted laparoscopic approaches to the ureter: Pyeloplasty and ureteral reimplantation.

INTRODUCTION AND OBJECTIVES: The benefits of robotic surgery when compared to standard laparoscopy have been well established, especially when it comes to reconstructive procedures. The application of robotic technology to laparoscopic pyeloplasty has reduced the steep learning curve associated with the procedure. Consequently, this has allowed surgeons who are less experienced with laparoscopy to offer this treatment to their patients, instead of referring them to centers of excellence. Robotic pyeloplasty has also proved useful for repairing secondary UPJO, a procedure which is considered extremely difficult using a conventional laparoscopic approach. Finally, the pursuit of scarless surgery has seen the development of laparoendoscopic single site (LESS) procedures. The application of robotics to LESS (R-LESS) has also reduced the difficulty in performing conventional LESS pyeloplasty. Herein we present a literature review with regards to robotic-assisted laparoscopic pyeloplasty. We also discuss the benefits of robotic surgery with regards to reconstruction of the lower urinary tract. MATERIALS AND METHODS: A systematic literature review was performed using PubMed to identify relevant studies. There were no time restrictions applied to the search, but only studies in English were included. We utilized the following search terms: Ureteropelvic junction obstruction and laparoscopy; laparoscopic pyeloplasty; robotic pyeloplasty; robotic ureteric reimplantation; robotic ureteroneocystostomy; robotic boari flap; robotic psoas hitch. RESULTS: There has been considerable experience in the literature with robotic pyeloplasty. Unfortunately, no prospective randomized studies have been conducted, however there are a number of meta analyses and systematic reviews. While there are no clear benefits when it comes to surgical and functional outcomes when compared to standard laparoscopic pyeloplasty, it is clear that robotics makes the operation easier to perform. There is also a benefit to the robotic approach when performing a redo-pyeloplasty. Robotic pyeloplasty has also been applied to the pediatric population, and there may be a benefit in older children while in very young patients, retroperitoneal open pyeloplasty is still the gold standard. In the field of single incision surgery R-LESS is technically easier to perform than conventional LESS. However, the design of the current robotic platform is not completely suited for this application, limiting its utility and often requiring a larger incision. Optimized R-LESS specific technology is awaited. What is clear, from a number of analyses, is that robotic pyeloplasty is considerably more expensive than the laparoscopic approach, largely due to costs of instrumentation and the capital expense of the robot. Until cheaper robotic technology is available, this technique will continue to be expensive, and a cost-benefit analysis must be undertaken by each hospital planning to undertake this surgery. Finally, the benefits of upper tract reconstruction apply equally to the lower tract although there is considerably less experience. However, there have been a number of studies demonstrating the technical feasibility of ureteral reimplantation. CONCLUSIONS: Robotic-assisted laparoscopic pyeloplasty is gaining popularity, likely due to the shorter learning curve, greater surgeon comfort, and easier intracorporeal suturing. This has allowed more surgeons to perform the procedure, improving accessibility. Robotic technology is also beneficial in the field of LESS. Nevertheless, the procedure still is not as cost-effective as the conventional laparoscopic approach, and until more affordable robotic technology is available, it will not be universally offered.

Robotic single port surgery: Current status and future considerations.

INTRODUCTION AND OBJECTIVES: It has been established that robotic-assisted laparoscopic surgery has several advantages when compared with standard laparoscopic surgery. Optics, ergonomics, dexterity and precision are all enhanced with the use of a robotic platform. For these reasons, it was postulated that the application of robotics to laparoendoscopic single-site surgery (LESS) could overcome some of the constraints seen with the conventional laparoscopic approach. Issues such as instrument clashing, inability to achieve effective triangulation for dissection and difficulties with intracorporeal suturing have limited the widespread adoption of conventional LESS. The application of robotics has eliminated many of the constraints experienced with conventional LESS; however, challenges still remain. MATERIALS AND METHODS: A systematic literature review was performed using PubMed to identify relevant studies. There were no time restrictions applied to the search, but only studies in English were included. We used the following search terms: Robotic single site surgery, robotic single port surgery, robotic single incision surgery and robotic laparoendoscopic single site surgery. RESULTS: A number of centers have published their experience with robotic-laparoendoscopic single-site surgery (R-LESS); however, no prospective studies exist. What is clear is that R-LESS minimizes several of the difficulties experienced with conventional LESS, including intracorporeal suturing and triangulation during dissection. Outcomes are comparable to standard robotic surgery, with a trend toward improved cosmesis and reduced pain. However, a significant advantage with regard to these two factors has yet to be demonstrated. CONCLUSIONS: R-LESS is technically feasible and the benefits of robotic surgery eliminate many of the challenges seen with conventional LESS. However, despite the advantages of the robotic platform, R-LESS is not free of challenges. Instrument clashing remains an issue due to the bulky profile of the current robotic system. Other issues include lack of space for the assistant at the bedside, inability to incorporate the 4(th) robotic arm for retraction and difficulties with triangulation. Although solutions for some of these issues are currently under development, R-LESS is still very much in its infancy.

Robotic partial nephrectomy with intracorporeal renal hypothermia using ice slush.

OBJECTIVE: To outline our technique for intracorporeal cooling with ice slush during robotic partial nephrectomy (RPN), with real-time parenchymal temperature monitoring. MATERIALS AND METHODS: Eleven consecutive patients with enhancing solid renal masses suitable for treatment with RPN between September 2013 and January 2014 were included in the analysis. Institutional review board approval and informed consent were obtained. Preoperative patient characteristics, intraoperative surgical parameters including patient body temperature and ipsilateral kidney temperature with real-time monitoring, and short-term functional outcomes were analyzed. RESULTS: Median age was 55 years (range, 39-75 years) and American Society of Anesthesiologists score was 3 (range, 2-4). Median tumor size was 4 cm (range, 2.3-7.1) and RENAL nephrometry score was 9 (range, 5-11). One patient had a solitary kidney. During cooling, the lowest median renal parenchymal temperature was 17.05°C (range, 11°C-26°C) and cold ischemia time was 27.17 minutes (range, 18-49 minutes). Median time to latest postoperative estimated glomerular filtration rate was 12 days (range, 2-30 days). Median glomerular filtration rate preservation was 81% (range, 47.9%-126%). There was one positive margin. There were no postoperative complications, and no patients experienced a prolonged ileus. The limitations of this study include a small number of patients and short-term follow-up. CONCLUSION: RPN with renal hypothermia using intracorporeal ice slush is technically feasible. Our simplified method of introducing the ice slush was free of complications and highly reproducible. The use of a needle temperature probe allowed us to monitor in real time cooling of the renal parenchyma.

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.

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.

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 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.

Robotic nephroureterectomy: a simplified approach requiring no patient repositioning or robot redocking.

BACKGROUND: Robotic technology is increasingly adopted in urologic surgery and a variety of techniques has been described for minimally invasive treatment of upper tract urothelial cancer (UTUC). OBJECTIVE: To describe a simplified surgical technique of robot-assisted nephroureterectomy (RANU) and to report our single-center surgical outcomes. DESIGN, SETTING, AND PARTICIPANTS: Patients with history of UTUC treated with this modality between April 2010 and August 2013 were included in the analysis. Institutional review board approval was obtained. Informed consent was signed by all patients. SURGICAL PROCEDURE: A simplified single-step RANU not requiring repositioning or robot redocking. Lymph node dissection was performed selectively. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Descriptive analysis of patients' characteristics, perioperative outcomes, histopathology, and short-term follow-up data was performed. RESULTS AND LIMITATIONS: The analysis included 31 patients (mean age: 72.4±10.6 yr; mean body mass index: 26.6±5.1kg/m(2)). Twenty-six of 30 tumors (86%) were high grade. Mean tumor size was 3.1±1.8cm. Of the 31 patients, 13 (42%) had pT3 stage disease. One periureteric positive margin was noted in a patient with bulky T3 disease. The mean number of lymph nodes removed was 9.4 (standard deviation: 5.6; range: 3-21). Two of 14 patients (14%) had positive lymph nodes on final histology. No patients required a blood transfusion. Six patients experienced complications postoperatively, with only one being a high grade (Clavien 3b) complication. Median hospital stay was 5 d. Within the follow-up period, seven patients experienced bladder recurrences and four patients developed metastatic disease. CONCLUSIONS: Our RANU technique eliminates the need for patient repositioning or robot redocking. This technique can be safely reproduced, with surgical outcomes comparable to other established techniques. PATIENT SUMMARY: We describe a surgical technique using the da Vinci robot for a minimally invasive treatment of patients presenting with upper tract urothelial cancer. This technique can be safely implemented with good surgical outcomes.

Robotic ileal ureter: a completely intracorporeal technique.

INTRODUCTION: The first laparoscopic case of ileal interposition was reported in 2000, proving the feasibility of the procedure in a minimally invasive fashion by duplicating the principles of open surgery. Robotic applications in urology are expanding worldwide, given the unique features of the robotic platform, which facilitates more advanced laparoscopic procedures. In this study, we report a case of completely intracorporeal robotic ileal ureter and thoroughly describe our technique for this complex minimally invasive procedure. TECHNICAL CONSIDERATIONS: A 50-year-old gentleman with a history of right renal stones underwent multiple right ureteroscopies and thereafter developed 2 proximal ureteral strictures of 5 mm. Preoperative estimated glomerular filtration rate was 71 mL/min/1.73 m(2). Renal scan showed preserved function. The treatment options were discussed, and the patient elected to undergo a robotic ileal ureter interposition. Total operative time was 7 hours, the estimated blood loss was approximately 50 mL, and the patient progressed to regular diet on postoperative day 4 without any problem, being discharged without complications. On the postoperative day 12, a cystogram demonstrated no extravasation, and the Foley catheter was removed. After 1 month, renal scan showed the left kidney with 60.1% and the right kidney with 39.9% of total renal function. At 2 years follow-up, his serum creatinine was 1.14 and estimated glomerular filtration rate was 70 mL/min/1.73 m(2). CONCLUSION: Robot-assisted laparaoscopic ileal ureter with a completely intracorporeal technique is feasible and appears to be safe. A larger number of procedures using this technique and longer follow-up are needed to further define its role in the treatment of ureteral strictures.

30-day hospital readmission after robotic partial nephrectomy--are we prepared for Medicare readmission reduction program?

PURPOSE: After CMS introduced the concept of the Hospital Readmissions Reduction Program, hospitals and health care centers became financially penalized for exceeding specific readmission rates. MATERIALS AND METHODS: We retrospectively reviewed our institutional review board approved database of patients undergoing robotic partial nephrectomy at our institution and included in our analysis patients who were readmitted to any hospital as an inpatient stay within 30 days from discharge home after robotic partial nephrectomy. RESULTS: From March 2006 to March 2013 a total of 627 patients underwent robotic partial nephrectomy at our center and 28 (4.46%) were readmitted within 30 days of surgery. Postoperative bleeding was responsible for 8 (28.5%) readmissions. Pulmonary embolism was reported in 3 cases and retroperitoneal abscess was diagnosed in 2. Urinary leak requiring surgical intervention developed in 2 patients, pneumonia was diagnosed in 2 and 2 patients were readmitted for chest pain. Overall 9 (32.1%) patients presented with major complications requiring intervention. On multivariable analysis Charlson comorbidity index score was the only factor significantly associated with a higher 30-day readmission rate (p = 0.03). If the Charlson score was 5 or greater the chance of hospital readmission would be 2.7 times higher. CONCLUSIONS: Increased comorbidity, specifically a Charlson score of 5 or greater, was the only significant predictor of a higher incidence of 30-day readmission. This information can be useful in counseling patients regarding robotic partial nephrectomy and in determining baseline rates if CMS expands the number of conditions they evaluate for excess 30-day readmissions.

Robot-assisted laparoscopic renal artery aneurysm repair with selective arterial clamping.

Renal artery aneurysms represent a rare clinical entity, and most are managed with endovascular techniques when treatment is indicated. Laparoscopic and robot-assisted repair of renal artery aneurysms has been described; however, few reports exist in the literature. We describe our experience with the surgical management of a 1.6-cm right-sided renal artery aneurysms in a 35-year-old man who presented with flank pain. Using the DaVinci Si surgical platform (Intuitive, Sunnyvale, CA, USA), the aneurysm was resected and the renal artery was reconstructed. Segmental branches of the renal artery were dissected and selectively clamped during resection, allowing for regional rather than global renal ischemia. Operative time was 240 min, with an estimated blood loss of 200 cc. Warm ischemia time was only regional, for a duration of 44 min. Follow-up functional analysis showed preserved renal function in the right kidney. We describe our technique and show the technical feasibility of robot-assisted renal artery aneurysm repair. Furthermore, use of the DaVinci Si system facilitates segmental artery dissection, and allows for selective clamping during reconstruction. This avoids global renal ischemia and optimizes functional preservation.

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.

Robot-assisted laparoscopic retroperitoneal lymph node dissection for left clinical stage I non-seminomatous germ cell testicular cancer: focus on port placement and surgical technique.

The aim of our report was to describe the feasibility of robotic retroperitoneal lymph node dissection in the contemporary era. We suggest the linear port location and 90° robotic docking as the main key to minimizing instrument clashing and improving the range of surgical accessibility.