Can Perioperative Antibiotic Choice Impact Rates of Infectious Complications After Percutaneous Nephrolithotomy? A Single-Blind, Prospective Randomized Trial.

Objective: National guidelines recommend periprocedural antibiotics before percutaneous nephrolithotomy (PCNL), yet it is not clear which is superior. We conducted a randomized trial to compare two guideline-recommended antibiotics: ciprofloxacin (cipro) vs cefazolin, on PCNL outcomes, focusing on the development of systemic inflammatory response syndrome (SIRS) criteria. Methods: Adult patients who were not considered high risk for surgical or infectious complications and undergoing PCNL were randomized to receive either cipro or cefazolin perioperatively. All had negative preoperative urine cultures. Demographic and perioperative data were collected, including SIRS criteria, intraoperative urine culture, duration of hospitalization, and need for intensive care. SIRS is defined by ≥2 of the following: body temperature <96.8°F or >100.4°F, heart rate >90 bpm, respiratory rate >20 per minute, and white blood cell count <4000 or >12,000 cells/mm3. Results: One hundred forty-seven patients were enrolled and randomized (79 cefazolin and 68 cipro). All preoperative characteristics were similar (p > 0.05), except for mean age, which was higher in the cipro group (64 vs 57 years, p = 0.03). Intra- and postoperative findings were similar, with no difference between groups (p > 0.05), except a longer mean hospital stay in the cefazolin group (2 hours longer, p = 0.02). There was no difference between SIRS episodes in both univariate and multivariate analyses. Conclusions: Despite the relatively broader coverage for urinary tract pathogens with ciprofloxacin, this prospective randomized trial did not show superiority over cefazolin. Our findings therefore support two appropriate options for perioperative antibiotic prophylaxis in patients undergoing PCNL who are nonhigh risk for infectious complications.

IsoPSA® Reduces Provider Recommendations for Biopsy and Magnetic Resonance Imaging in Men with Total Prostate Specific Antigen ≥4 ng/ml: A Real-World Observational Clinical Utility Study.

INTRODUCTION: We assessed the impact of the IsoPSA® test for prostate cancer risk assessment on provider patient management decisions in a real-world clinical setting. METHODS: A total of 38 providers, including advanced practice providers, fellowship trained oncologists and general urologists in the Cleveland Clinic health system including both community-based practices and academic locations, enrolled 900 men being evaluated for prostate cancer; 734 met inclusion criteria (age ≥50 years, total serum prostate specific antigen [PSA] ≥4 and <100 ng/ml and no history of prostate cancer) and IsoPSA indication for use. A standard template was used to document biopsy recommendation prior to and after receiving IsoPSA results. The primary outcome was the number of biopsy and magnetic resonance imaging recommendation changes occurring after IsoPSA testing. RESULTS: IsoPSA testing resulted in a 55% (284 vs 638) net reduction in recommendations for prostate biopsy for men with total PSA ≥4 ng/ml. Additionally, a 9% reduction in recommendations for magnetic resonance imaging was observed. There was strong concordance between IsoPSA results and provider recommendations for prostate biopsy, with 87% of patients with an IsoPSA index above the threshold recommended for biopsy and 92% of patients with an IsoPSA index below the threshold not recommended for biopsy. CONCLUSIONS: In a real-world clinical setting, providers from diverse training backgrounds and practice settings readily adopted IsoPSA with substantial reductions in the rate of recommended prostate biopsies in patients with elevated PSA values (≥4 ng/ml). There was a high concordance between recommendation for or against prostate biopsy and the IsoPSA result.

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

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

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

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

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.

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.

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.

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.

Robotic real-time near infrared targeted fluorescence imaging in a murine model of prostate cancer: a feasibility study.

OBJECTIVE: To evaluate the detection of near-infrared fluorescence from prostate tumors stained with a prostate-specific membrane antigen (PSMA)-targeted tracer developed in our institution with a novel robotic imaging system. METHODS: Prostate cancer cell lines PC3-pip (PSMA positive) and PC3-flu (PSMA negative) were implanted subcutaneously into 6 immunodeficient mice. When tumors reached 5 mm, a PSMA-targeted fluorescent conjugate was injected intravenously. The first 3 mice underwent near-infrared imaging immediately and hourly up to 4 hours after injection to determine the time necessary to obtain peak fluorescence and were killed. The last 3 mice were imaged once preoperatively and were euthanized 120 minutes later. Excision of the tumors was performed by using a novel robotic imaging system to detect near-infrared fluorescence in real time. Specimens were submitted for pathology. RESULTS: In the first 3 mice, we found 120 minutes as the time needed to observe peak fluorescence from the PSMA-positive tumors. We identified discrete near-infrared fluorescence from 2 of 3 PSMA-positive tumors with the robotic imaging system. Surgical margins were negative for all excised specimens except for one PSMA-negative tumor. CONCLUSIONS: Real-time near-infrared fluorescence imaging of prostate cancer is feasible with a novel robotic imaging system. Further research is needed to optimize the signal intensity detectable from prostate cancer with our tracer. Toxicologic studies are needed before its clinical use.

Single institutional cost analysis of 325 robotic, laparoscopic, and open partial nephrectomies.

OBJECTIVE: To compare costs associated with partial nephrectomy (PN) using robotic, laparoscopic (LPN), and open (OPN) approaches. METHODS: An Investigational Review Board-approved prospectively maintained database was reviewed for 325 patients who underwent PN at our institution from January 2009 to December 2010. Costs for each surgical technique were itemized, including hospitalization, operating room (OR), anesthesia, medication, laboratory and pathology, professional fees, and blood bank. Continuous variables were analyzed with Kruskal-Wallis and Wilcoxon tests, and categoric variables were analyzed with χ(2) and Fisher exact tests. RESULTS: Median costs of RPN were higher than LPN ($632, P = .005), but not significantly higher than OPN ($313, P = .14). The major cause of this difference was OR instrumentation and supplies. OR costs for LPN and OPN were equivalent (P = .11). The cost associated with anesthesia was significantly lower for RPN and LPN than for OPN (P = .002). RPN and LPN had lower hospitalization costs than OPN (P <.0001), which was largely due to the shorter hospital stay (P <.0001) and lower laboratory cost (P <.0001). Pharmacy costs and blood bank costs were not significantly different among groups (P = .09 and P = .48, respectively). CONCLUSION: RPN had higher operating room costs than LPN and OPN, primarily due to instrumentation and supplies. This higher cost was offset by decreased cost of hospitalization in compared with the OPN group. Modification of practices aimed at lowering RPN instrumentation and supply costs may enable cost equivalence.

Utility of intraoperative frozen section during robot-assisted partial nephrectomy: a single institution experience.

BACKGROUND AND PURPOSE: Intraoperative frozen section (FS) analysis has been regarded as a paramount tool for immediate evaluation of tumor margin status during partial nephrectomy procedures. The aim of this study was to assess the utility of FS during robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS: A retrospective review of our Institutional Review Board-approved prospectively maintained minimally invasive partial nephrectomy database yielded 342 consecutive RAPN procedures from June 2007 to September 2011. Of these, the initial 128 cases underwent FS evaluation, whereas the following 214 cases did not. Patient demographics, perioperative outcomes, and final pathology results were analyzed and compared between the two groups. RESULTS: Body mass index, Charleson Comorbidity Index, tumor size, renal score, preoperative creatinine level, and estimated glomerular filtration rate (eGFR) were similar between both groups. Operative time was significantly longer in the no-FS group (193 vs 180 min; P=0.04). Warm ischemia time (median 19 vs 19 min), estimated blood loss (150 vs 200 mL), postoperative creatinine level (1.0 vs 1.1 mg/dL), and postoperative eGFR (75.6 vs 75.9) were similar between the no-FS group and FS group, respectively. Complications occurred in 32 (15.0%) and 31 (24.2%) cases in no-FS and FS, respectively (P=0.06). Final pathology results demonstrated seven cases of positive margins, 1 (1%), in the FS group and 6 (3%) in the no-FS group (P=0.19). Of the cases with positive margins at final pathology analysis, a R.E.N.A.L. score of 3/3 was found on closeness to renal sinus. Overall, three intraoperative positive margins were noted in the FS group (2.3%): One patient underwent radical nephrectomy and one reresection; one case was managed with observation only. CONCLUSION: Routine application of FS analysis during RAPN seems to provide a limited benefit. FS might be advisable for tumors with sinus invasion because they seem to carry a higher likelihood of positive surgical margin at final pathology determination.

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.

Correlation of the RENAL nephrometry score with warm ischemia time after robotic partial nephrectomy.

PURPOSE: The RENAL nephrometry score (RNS) was developed to quantify complexity of renal tumors in a reproducible manner. We aim to determine whether individual categories of the RNS have different impact on the warm ischemia time (WIT) for patients undergoing robotic partial nephrectomy (RPN). METHODS: In a retrospective analysis of a prospectively maintained database, we identified 251 consecutive patients who underwent RPN between January 2007 and June 2010. RNS was determined in 187 with available imaging. Univariable analysis and multivariable linear regression analysis were performed to identify which factors were more significantly associated with WIT. RESULTS: Overall RNS was of low (4-6), moderate (7-9), and high complexity (10-12) in 84 (45 %), 80 (43 %), and 23 (12 %) patients, respectively. There was no association between gender (p = 0.6), BMI (p = 0.3), or anterior/posterior location (A) (p = 0.8), and WIT. On univariable analysis, longer WIT was associated with size (R) >4 cm (p < 0.0001), entirely endophytic properties (E) (p = 0.005), tumor <4 mm from the collecting system/sinus (N) (p < 0.0001), and location between the polar lines (L) (p = 0.004). Total RNS and WIT were highly correlated (Spearman correlation coefficient = 0.54, p < 0.0001). There was a significant trend of higher WIT with increased tumor complexity (p for trend <0.0001). After multivariable analysis, only R (p = 0.0003), E (p = 0.003), and N (p = 0.00002) components of the RNS were significantly associated with WIT. CONCLUSIONS: The A and L subcategories of the RNS have no significant impact on the WIT of patients undergoing RPN. WIT is significantly dependent upon the other subcategories, as well as the overall RNS. These findings can be used to preoperatively predict which tumor characteristics will likely affect WIT and may be useful in preoperative counseling as well as planning of approach.

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.

The impact of body mass index on surgical outcomes of robotic partial nephrectomy.

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. "What's known on the subject?" and "What does the study add?" Obesity is associated with higher incidence of renal cell carcinoma. Laparoscopic and robotic partial nephrectomy (RPN) was shown to be technically feasible in the obese population. In the present study we evaluated the impact of obesity on outcome of RPN, in a large cohort of patients. In the present study, obese patients had a higher American Society of Anesthesiologists score and larger tumour size. We evaluated obesity as a categorical and a continuous variable, and we adjusted for confounding factors. We categorized obesity based according to the WHO classification of obesity. We described our technical modifications to overcome difficulties that can be encountered during the surgery. Obese patients had a higher estimated blood loss, but no difference in blood transfusion rate, operation duration or warm ischaemia time. OBJECTIVE: • To assess the impact of body mass index (BMI) on the surgical outcomes of robotic partial nephrectomy (RPN). PATIENTS AND METHODS: • Medical charts of 250 consecutive patients who underwent RPN at our institution between 2006 and 2010 were reviewed. • Patients were categorized based on their BMI into four groups per international classification of obesity into: normal (BMI < 25 kg/m(2)), overweight (25-29.9), obese (30-39.9) and morbidly obese (≥ 40). • Preoperative characteristics as well as perioperative and postoperative outcomes were analysed and compared between the groups. RESULTS: • Of the 250 patients, 43 (17.2% of the entire cohort) were non-obese, 104 (41.6%) were overweight, 75 (30%) were obese, and 28 (11.2%) were morbidly obese. • Groups were similar in terms of age, gender, history of previous surgery and nephrometry score (P = 0.5). • Patients with higher BMI had a higher American Society of Anesthesiologists (ASA) score (median 3 for obese and morbidly obese groups vs 2 for non-obese groups; P = 0.002) and tumour size (median 3.6, 2.9, 2.5 and 2.3 cm in those who were morbidly obese, obese, overweight and with normal BMI, respectively; P = 0.005). • Patients within the morbidly obese group had a higher estimated blood loss (median 250 mL) than other groups (median: 200, 200, 150 mL, respectively) (P = 0.03). • No significant difference was detected between the groups in terms of operation duration, warm ischaemia time, transfusion rate and postoperative complications. CONCLUSION: • Robotic partial nephrectomy represents an effective treatment modality for renal tumours providing equivalent surgical outcomes even for patients with BMI up to 60 kg/m(2).

LESS pyeloplasty & other reconstructive procedures.

OBJECTIVES: To review and synthesize the evidence available in the literature on laparoendoscopic single-site (LESS) pyeloplasty and other reconstructive procedures. METHODS: A literature search was performed to capture original articles related to LESS urological reconstructive procedures. We outlined the differences in technique and clinical outcomes related to their safety and efficacy. RESULTS: We found 28 retrospective studies, with a total of 146 patients. Procedures included pyeloplasty (91), ureterolithotomy (44), sacrocolpopexy (4), bladder diverticulectomy (4), partial cystectomy (2), one of which associated to augmentation cystoplasty, ureteroneocystostomy (1), ileal ureter (1), and retrocaval ureter (1). Mean operative time was 215 minutes for LESS pyeloplasty and 186 minutes for LESS ureterolithotomy. The mean estimated blood loss was 73 milliliters for pyeloplasty and 108 milliliters for ureterolithotomy. Mean length of stay was 2.7 days for pyeloplasty and 3.8 days for ureterolithotomy. CONCLUSION: Urological LESS reconstructive surgery is feasible and safe for different procedures. A solid laparoscopic experience is strongly advised prior attempting LESS reconstructive procedures due to its technical complexity. Future studies should prioritize prospective and randomized designs comparing LESS with standard laparoscopy.

Pieloplastia LESS y otros procedimiento reconstructivos / Less pyeloplasty & other reconstructive procedures

OBJECTIVES: To review and synthesize the evidence available in the literature on laparoendoscopic single-site (LESS) pyeloplasty and other reconstructive procedures. METHODS: A literature search was performed to capture original articles related to LESS urological reconstructive procedures. We outlined the differences in technique and clinical outcomes related to their safety and efficacy. RESULTS: We found 28 retrospective studies, with a total of 146 patients. Procedures included pyeloplasty (91), ureterolithotomy (44), sacrocolpopexy (4), bladder diverticulectomy (4), partial cystectomy (2), one of which associated to augmentation cystoplasty, ureteroneocystostomy (1), ileal ureter (1), and retrocaval ureter (1). Mean operative time was 215 minutes for LESS pyeloplasty and 186 minutes for LESS ureterolithotomy.The mean estimated blood loss was 73 milliliters for pyeloplasty and 108 milliliters for ureterolithotomy. Mean length of stay was 2.7 days for pyeloplasty and 3.8 days for ureterolithotomy. CONCLUSION: Urological LESS reconstructive surgery is feasible and safe for different procedures. A solid laparoscopic experience is strongly advised prior attempting LESS reconstructive procedures due to its technical complexity. Future studies should prioritize prospective and randomized designs comparing LESS with standard laparoscopy(AU)

OBJETIVO: Revisar y sintetizar la evidencia disponible en la literatura sobre pieloplastia laparoscópica por puerto único (LESS) y otros procedimientos reconstructivos. MÉTODOS: Realizamos una búsqueda bibliográfica para obtener artículos originales relacionados con operaciones urológicas reconstructivas por puerto único. Resumimos las diferencias en técnica y resultados clínicos relacionados con su seguridad y eficacia. RESULTADOS: Encontramos 28 estudios retrospectivos, con un total de 146 pacientes. Las operaciones incluían pieloplastia (91), ureterolitectomía (44), colposacropexia (4), diverticulectomía vesical (4), cistectomía parcial (2), una de ellas asociada con cistoplastia de aumento, ureteroneocistostomía (1), uréter ileal (1) y uréter retrocava (1). El tiempo medio operatorio fue 215 minutos para la pieloplastia LESS y 186 minutos para la ureterolitotomía. El sangrado estimado medio fue de 73 mililitros en la pieloplastia y 108 ml en la ureterolitectomía. La estancia media fue de 2,7 días para la pieloplastia y 3,8 días para la ureterolitectomía. CONCLUSION: La cirugía urológica reconstructiva por puerto único es factible y segura en diferentes operaciones. Antes de intentar procedimientos reconstructivos LESS es altamente recomendable una sólida experiencia laparoscópica debido a su complejidad técnica, Los estudios futuros deberían dar prioridad a diseños prospectivos aleatorizados que comparen LESS con laparoscopia estándar(AU)

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.