Alternative use of endocavitary probe to guide minimally invasive partial nephrectomy: is it reasonable?

Purpose: To describe the use of endocavitary ultrasound probe as an auxiliary tool when performing partial nephrectomy in cases of endophytic renal tumors, to standardize the method, and to report the preliminary results achieved with this technique. Methods: Fifteen patients diagnosed with completely endophytic underwent partial nephrectomy with the use of an endocavitary ultrasound probe. This article describes the technique involved in partial nephrectomy and details the preparation of the endocavitary ultrasound probe to ensure its safe use. Results: All the patients had a RENAL score between 8 and 11. The median time of warm ischemia was 26 and 18 minutes for laparoscopic or robot-assisted surgery, respectively. The median duration of surgery was 150 minutes, and the median console time was 145 minutes for the laparoscopic and robot-assisted surgery groups, respectively. The median estimate of blood loss was 200 mL. Only three patients in the laparoscopic group had focal positive surgical margins. There were no cases of infection at the site of probe entry. Conclusions: Intraoperative use of an endocavitary ultrasound probe for partial nephrectomy is possible and a safe alternative to the excision of endophytic tumors when neither robotic probes nor laparoscopic probes are available.

Endovascular Stapler Complications During Minimally Invasive Nephrectomy: An Updated Review of the FDA MAUDE Database From 2009-2019.

OBJECTIVE: To characterize the rates of endovascular stapler complications during hilar ligation in minimally invasive radical nephrectomy over the last 10 years. MATERIAL AND METHODS: We reviewed the Food and Drug Administration Manufacturer and User Facility Device Experience database from January 1, 2009 to August 1, 2019. Staplers were categorized according to type, namely Ethicon Inc. endocutters (Johnson & Johnson, New Brunswick NJ); Endo-GIA (Medtronic, Minneapolis MN); and Endo-TA (Medtronic, Minneapolis MN). RESULTS: There were 383 cases of complications involving staplers, 63% with Ethicon endocutters; 28% with GIA; and 9% with TA. 22 deaths (5.7% of total complications) were attributed to staplers. No deaths or reoperations occurred due to TA staplers. TA staplers were also associated with a reduced incidence of conversion to open as compared to Ethicon and GIA staplers. Apart from one device, manufacturer evaluation of returned devices either showed no abnormalities or attributed fault to improper use of staplers. DISCUSSION: We characterized stapler complications during a 10-year period for minimally invasive radical nephrectomy. No deaths or reoperations occurred due to TA staplers, perhaps due to cutting and stapling occurring in separate steps. Based on manufacturer evaluation attributing stapling malfunctions to human errors, training of operating room staff on proper use of these devices is critical to prevent potentially significant complications from occurring.

Comparison of the Safety and Efficacy of Valveless and Standard Insufflation During Robotic Partial Nephrectomy: A Prospective, Randomized, Multi-institutional Trial.

OBJECTIVE: To use a randomized, prospective, multi-institutional study to compare the safety and efficacy of conventional insufflation (CIS) and valveless insufflation (AirSeal Insufflation - AIS) at the conventional pressure of 15 mm Hg in robot-assisted partial nephrectomy - a surgery where AIS has gained popularity for maintaining visualization despite suction. This study was also powered to evaluate the effect of decreasing pneumoperitoneum by 20% in the valveless system. MATERIALS AND METHODS: Three high-volume institutions randomized subjects into CIS 15, AIS 15, and AIS 12 mm Hg cohorts. Endpoints included rates of subcutaneous emphysema (SCE), pneumothorax (PTX), pneumomediastinum (PMS), intraoperative end-tidal carbon dioxide (ET CO2), and peak airway pressure (PAP), as well as hospital stay, post-operative pain, and complications. Given the substantial proportion of retroperitoneal surgery, a secondary analysis evaluated the effect of surgical approach. RESULTS: Two hundred and two patients were accrued. SCE was decreased in the AIS 12 mm Hg group (p=0.003). PTX and PMS rates were not statistically significantly different across the 3 insufflation groups. Higher rates of SCE and PMS, although not PTX, were noted in all retroperitoneal surgery groups - with lower SCE rates for AIS 12 mm Hg regardless of surgical approach. CONCLUSION: AIS is often preferred for complex procedures including retroperitoneal and transperitoneal robotic-assisted partial nephrectomy, for its maintenance of pneumoperitoneum despite continuous suction necessary for visualization. This study shows that AIS is safe when compared to CIS at 15 mm Hg, and shows improvement in outcomes when pneumoperitoneum pressure is reduced by 20% to 12 mmHg.

Single Port Robotic Surgery in Urology.

PURPOSE: To provide a comprehensive review on the new da Vinci SP (single port) robotic surgical system. The published literature to date within urology and a description of the new system will be discussed. FINDINGS: There are currently no high-quality published studies with the SP robotic system. All studies are case series, many with 10 or fewer patients. However, all studies have found the SP system to be safe and feasible in performing most urological procedures. Renal and pelvic surgery using the SP robotic system is safe and feasible in the hands of expert robotic surgeons. Long-term, high-quality data is lacking. While the current high price and the learning curve will limit the SP systems' use in many health care systems, new updates and the release of robotic surgical systems from other developers may help drive down costs and encourage uptake.

Clips Can be Safely Used for Vascular Control of the Renal Vessels During Laparoscopic Donor Nephrectomy.

OBJECTIVE: To review our experience using clips to control the renal vessels during laparoscopic donor nephrectomy (LDN) and determine the safety of this practice. METHODS: We performed a retrospective review of patients who underwent LDN at our centre January 1, 2007-September 17, 2019. The primary outcome was the rate of complication associated with vascular control of the renal vessels, which included (1) conversion to open to manage bleeding, (2) additional procedures for bleeding, and (3) major bleeding requiring blood transfusion. Secondary outcomes included the rate of renal artery/vein clip dislodgement or crossing, change in hemoglobin, warm ischemia time and the incidence of intra-operative complications and postoperative in-hospital complications. RESULTS: We included 503 patients who underwent LDN, of which 497 were left sided. The main renal artery was controlled with 3 titanium clips in 489 (97%) cases. The main renal vein was controlled with 2 polymer-locking clips in 478 (95%) cases. For our primary outcome, there were no conversions to open to manage bleeding, no secondary procedures due to bleeding and no major bleeding requiring blood transfusion. Additionally, there were no donor deaths. Regarding our secondary outcomes, there were 5 intraoperative events related to the titanium clips being placed on the renal artery and 1 intraoperative event related to the polymer-locking clips on the renal vein, none of which resulted in any morbidity. CONCLUSION: Using 3 titanium clips on the renal artery and 2 polymer-locking clips on the renal vein during left LDN is safe and provides excellent vascular control.

5G ultra-remote robot-assisted laparoscopic surgery in China.

BACKGROUND: 5G communication technology has been applied to several fields in telemedicine, but its effectiveness, safety, and stability in remote laparoscopic telesurgery have not been established. Here, we conducted four ultra-remote laparoscopic surgeries on a swine model under the 5G network. The aim of the study was to investigate the effectiveness, safety, and stability of the 5G network in remote laparoscopic telesurgery. METHODS: Four ultra-remote laparoscopic surgeries (network communication distance of nearly 3000 km), including left nephrectomy, partial hepatectomy, cholecystectomy, and cystectomy, were performed on a swine model with a 5G wireless network connection using a domestically produced "MicroHand" surgical robot. The average network delay, operative time, blood loss, and intraoperative complications were recorded. RESULTS: Four laparoscopic telesurgeries were safely performed through a 5G network, with an average network delay of 264 ms (including a mean round-trip transporting delay of 114 ms and a 1.20% data packet loss ratio). The total operation time was 2 h. The total blood loss was 25 ml, and no complications occurred during the procedures. CONCLUSIONS: Ultra-remote laparoscopic surgery can be performed safely and smoothly with 5G wireless network connection using domestically produced equipment. More importantly, our model can provide insights for promoting the future development of telesurgery, especially in areas where Internet cables are difficult to lay or cannot be laid.

Ex vivo and animal study of the blue diode laser, Tm fiber laser, and their combination for laparoscopic partial nephrectomy.

BACKGROUND AND OBJECTIVES: To evaluate the feasibility of using a novel blue diode laser (blue laser), a thulium fiber laser (Tm laser), and their combination as a directed-energy surgical tool in laparoscopic partial nephrectomy (LPN). STUDY DESIGN/MATERIALS AND METHODS: The blue laser emitting at 442 nm, the Tm laser emitting at 1,940 nm wavelengths, and the combination of them were tested. First, cutting and coagulative abilities of the lasers were characterized ex vivo on porcine kidney in air and CO2 . Histological staining was performed to assess the efficiency of ablation and coagulation. Next, experimental LPN was performed on a porcine model at zero ischemia. Upper and lower segments of both kidneys were resected. Total operation time and resection time were measured; bleeding and carbonization were evaluated. RESULTS: Ex vivo data show that laser-induced ablation and coagulation processes do not differ substantially between CO2 and air environments. Histological analysis of ex vivo incisions demonstrates that the blue laser produced deep ablation with relatively narrow coagulation zone, whereas Tm laser was less efficient in terms of ablation but possessed excellent coagulative properties. Experimental LPN revealed that the blue laser provided fast cutting with minimal carbonization, whereas Tm laser induced slow cutting with strong carbonization. The combination of the blue and Tm lasers provided the most promising results demonstrating the highest resection rate, almost carbonization free resection surface and clinically acceptable hemostasis enabling LPN without the need for vessel clamping. CONCLUSIONS: The blue laser can be efficiently utilized in LPN. Furthermore, the combination of the blue and Tm lasers into a single modality may be beneficial for further development of successful laser-assisted LPN. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

True Single-Site Partial Nephrectomy Using the SP Surgical System: Feasibility, Comparison with the Xi Single-Site Platform, and Step-By-Step Procedure Guide.

Background: Robotic laparoendoscopic single-site (LESS) partial nephrectomy is not widely used because of its limitations, and true single-site surgery has not previously been possible. To investigate the feasibility of partial nephrectomy using the novel SP surgical system, compare perioperative outcomes using this system and the previous Xi single-site platform (XiSSP), and describe how true single-site partial nephrectomy is possible with the SP system. Methods: Retrospective chart review of patients undergoing robotic partial nephrectomy by a single surgeon using the SP surgical system or XiSSP from December 14, 2016 to June 14, 2019. For the SP system, a GelPOINT access platform was placed through a single periumbilical incision. A 25-mm multichannel robotic port and assistant's ports were placed in the GelSeal cap. No additional incisions were required for the assistant or liver traction. The primary outcomes were intraoperative and postoperative complications. Results: Fourteen patients underwent single-site partial nephrectomy with the SP surgical system (n = 9) or XiSSP (n = 5). No limitations were noted for accessing tumors in the upper aspect of the kidney using the SP system. One case of tumor fracture occurred with the SP system, and one case of conversion to multiport robotic surgery occurred with the XiSSP. The postoperative course was uneventful in all patients; only Clavien-Dindo 1 complications occurred. Conclusions: True single-site partial nephrectomy was performed safely with the SP surgical system. The SP system resolved many limitations associated with LESS and the XiSSP.

Nonischemic or Ischemic Laparoscopic Partial Nephrectomy Using a Newly Developed Hybrid Energy Device in a Porcine Model.

Purpose: To compare the efficacy of a newly developed hybrid pencil-type energy device (HD) generating simultaneously monopolar high-frequency electric energy and ultrasonic energy with that of a conventional device (CD) during laparoscopic partial nephrectomy (LPN). Materials and Methods: A total of 16 female pigs (32 kidneys) were divided into 4 groups of 4 animals (8 kidneys) each: nonischemic and ischemic HD-LPN groups, and nonischemic and ischemic CD-LPN groups. We performed bilateral LPN for each pig. HD alone was used in the HD-LPN group, whereas commercially available monopolar scissors and a soft coagulation system were used in the CD-LPN group. After observing the postoperative course for 14 days, we euthanized the animals and harvested the kidneys for histopathological observations. Results: We completed an LPN on a total of 32 kidneys. There were no cases of conversion to open surgery, nor were there any deaths or complications requiring treatment. For nonischemic LPN, LPN time was significantly shorter in the HD-LPN group than in the CD-LPN group (11.4 ± 4.8 vs 17.7 ± 5.3 minutes, p = 0.027). The decrease in postoperative hemoglobin was equally low in both groups. However, the frequency of TachoSil® use was significantly higher in the CD-LPN group than in the HD-LPN group (6/8 [75%] vs 0/8 [0%], p = 0.007). For ischemic LPN, we found no significant differences in parameters such as LPN time and using TachoSil between the two groups. The depth of thermal injury was the most superficial in the nonischemic HD-LPN group in comparison with the other three groups. Conclusions: The application of an HD allowed nonischemic LPN to be performed safely in a short time with less blood loss and less thermal injury to the kidney in the porcine model. Additional clinical investigations of human kidneys are required.

Robotic-assisted laparoscopic resection of a primary renal neuroendocrine carcinoma.

Primary renal neuroendocrine carcinomas (RNC) are extremely rare urological neoplasms, with fewer than 100 cases reported in the literature. There are no established protocols concerning diagnosis and treatment, and there is no definitive data on prognosis. Here, we report the findings of a 54-year-old woman who presented with intermittent back pain due to a large mass, which was initially suspected to be a renal cell or upper tract urothelial carcinoma. The patient underwent robotic-assisted laparoscopic nephrectomy and lymph node dissection without complications. Pathology revealed an RNC with local metastases to para-aortic lymph nodes without evidence of another primary origin. Subsequent surveillance showed no evidence of disease until 48-month follow-up imaging revealed a liver lesion suspicious for possible metastatic cancer. This report represents the second documented usage of robot-assisted laparoscopic nephrectomy for RNC and the longest follow-up in the literature. We review the diagnosis, treatment and follow-up of patients with RNC.

Effect of 3-Dimensional Virtual Reality Models for Surgical Planning of Robotic-Assisted Partial Nephrectomy on Surgical Outcomes: A Randomized Clinical Trial.

Importance: Planning complex operations such as robotic-assisted partial nephrectomy requires surgeons to review 2-dimensional computed tomography or magnetic resonance images to understand 3-dimensional (3-D), patient-specific anatomy. Objective: To determine surgical outcomes for robotic-assisted partial nephrectomy when surgeons reviewed 3-D virtual reality (VR) models during operative planning. Design, Setting, and Participants: A single-blind randomized clinical trial was performed. Ninety-two patients undergoing robotic-assisted partial nephrectomy performed by 1 of 11 surgeons at 6 large teaching hospitals were prospectively enrolled and randomized. Enrollment and data collection occurred from October 2017 through December 2018, and data analysis was performed from December 2018 through March 2019. Interventions: Patients were assigned to either a control group undergoing usual preoperative planning with computed tomography and/or magnetic resonance imaging only or an intervention group where imaging was supplemented with a 3-D VR model. This model was viewed on the surgeon's smartphone in regular 3-D format and in VR using a VR headset. Main Outcomes and Measures: The primary outcome measure was operative time. It was hypothesized that the operations performed using the 3-D VR models would have shorter operative time than those performed without the models. Secondary outcomes included clamp time, estimated blood loss, and length of hospital stay. Results: Ninety-two patients (58 men [63%]) with a mean (SD) age of 60.9 (11.6) years were analyzed. The analysis included 48 patients randomized to the control group and 44 randomized to the intervention group. When controlling for case complexity and other covariates, patients whose surgical planning involved 3-D VR models showed differences in operative time (odds ratio [OR], 1.00; 95% CI, 0.37-2.70; estimated OR, 2.47), estimated blood loss (OR, 1.98; 95% CI, 1.04-3.78; estimated OR, 4.56), clamp time (OR, 1.60; 95% CI, 0.79-3.23; estimated OR, 11.22), and length of hospital stay (OR, 2.86; 95% CI, 1.59-5.14; estimated OR, 5.43). Estimated ORs were calculated using the parameter estimates from the generalized estimating equation model. Referent group values for each covariate and the corresponding nephrometry score were summed across the covariates and nephrometry score, and the sum was exponentiated to obtain the OR. A mean of the estimated OR weighted by sample size for each nephrometry score strata was then calculated. Conclusions and Relevance: This large, randomized clinical trial demonstrated that patients whose surgical planning involved 3-D VR models had reduced operative time, estimated blood loss, clamp time, and length of hospital stay. Trial Registration: ClinicalTrials.gov identifiers (1 registration per site): NCT03334344, NCT03421418, NCT03534206, NCT03542565, NCT03556943, and NCT03666104.

Experimental Studies of Nonabsorbable Polymeric Surgical Clips for Use in Urologic Laparoscopy.

Objective: This study aimed to compare the stability of the Click'aV® (Grena®), Click'aV plus (Grena), and Hem-o-lok® (Weck®, Teleflex®) polymer clips and the evaluation of the clips stability on a complete porcine artery. Materials and Methods: A dynamometer with a custom support and clamp unit was used. The crank gradually increased the tension force being applied on the clip via the suture. Different directions for the application of the force were tested. The highest force before the start of slipping the suture was noted. The procedure was repeated three times for each ligating clip. Results: For transverse stability, the "XL-size" Grena Click'aV Plus required preventing slippage at a greater force compared to the Hem-o-lok (p = 0.0071). No significant differences found statistically between the Grena Click'aV and Hem-o-lok clips (p = 0.1). For longitudinal stability, the Hem-o-lok required a significantly higher force to be opened compared to the Click'aV (p = 0.0036), but no statistically significant difference was found compared to the Click'aV Plus (p = 0.1). Concerning porcine artery stability, the artery slipped through the Click'aV clip in both measurements at a force of 10.2 and 9.4 N. In contrast, the arteries were cut in all measurements using the Click'aV Plus and the Hem-o-lok clips at forces of 11.8 and 12.8 N and 12.9 and 14.2 N, respectively. None of the clips leaked with up to 300 mm Hg of intra-arterial pressure applied to porcine renal arteries. Conclusions: The Grena Click'aV Plus clip has similar performance to the Hem-o-lok clip, and this clip can be equally useful for ligating vessels in laparoscopic urologic surgeries. We believe, from our findings in this study as well as those from other reports, that vascular clips applied properly by experienced surgeons provide a safe, reliable, and considerable cost-saving option for vascular control in urologic laparoscopic surgery.

Use of a Novel Articulating Laparoscopic Needle Driver for Partial nephrectomy: An Initial Experience.

OBJECTIVES: To demonstrate the clinical feasibility of an articulated laparoscopic needle driver to assist in the performance of laparoscopic partial nephrectomy (LPN). Previous studies have demonstrated under-utilization of minimally invasive techniques for patients undergoing partial nephrectomy (PN). METHODS: Consecutive patients with renal masses amenable to PN underwent LPN with an articulating laparoscopic needle driver. A consecutive cohort of patients who previously underwent robot assisted laparoscopic PN (RALPN) was selected as a comparison cohort. Preoperative, perioperative, and postoperative variables were retrospectively collected. RESULTS: A total of 20 patients underwent PN with 10 patients assigned to each of the LPN and RALPN cohorts. Median R.E.N.A.L. nephrometry scores assigned to the LPN and RALPN cohorts were 7 and 6 respectively (P= .31). Median warm ischemia time for patients in the LPN and RALPN groups was 25.5 and 18.5 minutes respectively (P= .36). Median estimated blood loss for LPN and RALPN was 200 and 50 mL (P= .03). Median operative time for LPN and RALPN was 203 and 194 minutes respectively (P= .76). Median Length of stay after LPN and RALPN was similar (3.0 vs 2.5 nights, P= .26). Following LPN, 3 patients required blood transfusion as compared to 2 patients in the RALPN cohort (P= .61). CONCLUSION: Our initial results demonstrated the clinical safety and feasibility of a new surgical device for performing LPN. Patients who underwent LPN with a novel articulating needle driver demonstrated equivalent results to RALPN across several key outcomes.

Experience and outcomes in living donor liver procurement using the water jet scalpel.

BACKGROUND: The aim of the present study was to clarify treatment outcomes of living donor liver procurement using the water jet scalpel (WJS). METHODS: This single-center, retrospective cohort study included 40 living donors who underwent liver procurement from January 2014 to December 2018. One living donor who underwent posterior segmentectomy was excluded. Clinical data and outcomes after surgery for 20 WJS donors and 19 Cavitron Ultrasonic Surgical Aspirator (CUSA) donors were compared. RESULTS: Preoperative and excised graft data did not differ significantly between the WJS and CUSA groups. Operation time (P = 0.025) and parenchymal transection time (P = 0.007) were significantly shorter in the WJS group. There was no difference between the groups in terms of short-term outcomes after surgery. Multivariate analysis revealed that WJS offered significant advantages over CUSA in terms of shortening parenchymal transection time (P = 0.017). CONCLUSION: Living donor liver procurement using WJS contributes to shortening of parenchymal transection time while maintaining the same level of safety as when using CUSA.

Percutaneous hook wire assistance during laparoscopic excision of an intrarenal mass.

Completely endophytic renal tumours pose challenges in laparoscopic nephron-sparing tumour excisions, with the use of intraoperative imaging techniques (e.g. ultrasound) being crucial when managing such tumours. The use of a percutaneous hookwire for tumour localisations are in use in several other surgical fields, such as breast surgery. An asymptomatic 52-year-old man presented with an incidental small right sided solid 33-mm interpolar renal mass identified on computed tomography. A guided insertion of a percutaneous localisation wire was carried out prior to a laparoscopic partial nephrectomy to assist in intraoperative tumour landmark/margins identification. Operative time was 210 minutes with zero ischaemia time, with an estimated blood loss of 200 ml. No perioperative complications were observed and the patient was discharged two days postoperatively. Histology revealed the mass to be a Fuhrman grade 2 clear-cell carcinoma with a 2-mm clear surgical margin. The patient remained free of recurrence at 16 months of follow-up. We have reported our first experience of wire localisation prior to laparoscopic partial nephrectomy for an intrarenal mass, which to our knowledge could be the first of its kind in renal surgery. Percutaneous wire localisation of endophytic renal tumours is potentially safe and effective and can allow nephron-sparing surgery where laparoscopic ultrasound is not available. Longer-term and further evidence should be encouraged.

On-clamp versus off-clamp robotic partial nephrectomy: A systematic review and meta-analysis.

BACKGROUND: The debate on the pros and cons of robot-assisted partial nephrectomy performed with (on-clamp) or without (off-clamp) renal artery clamping is ongoing. The aim of this meta-analysis is to summarize the available evidence on the comparative studies assessing the outcomes of these two approaches. MATERIAL AND METHODS: A systematic review of the literature on PubMed, ScienceDirect®, and Embase® was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement (PRISMA). Only comparative and case-control studies were submitted to full-text assessment and meta-analysis. RevMan 5.3 software was used. RESULTS: From the initial retrieval of 1937 studies, 15 fulfilling inclusion criteria were selected and provided 2075 patients for analysis (702 off-clamp, 1373 on-clamp). Baseline tumor's features showed a significant difference in size (weighted mean difference: -0.58 cm; 95% confidence interval: [-1.06, -0.10]; p = 0.02) and R.E.N.A.L. score (weighted mean difference: -0.53; 95% confidence interval: [-0.81, -0.25]; p = 0.0002), but not in the exophytic property, the location, and the PADUA score. Pooled analysis revealed shorter operative time (p = 0.02) and higher estimated blood loss (p = 0.0002) for the off-clamp group. Overall complication and transfusion rates were similar, while higher major complication rate was observed in the on-clamp approach (5.6% vs 1.9%, p = 0.03). No differences in oncological outcomes were found. Finally, functional outcomes (assessed by estimated glomerular filtration rate at early postoperative, 3 month, 6 month, and last available follow-up) were not statistically different. CONCLUSION: This meta-analysis shows that off-clamp robot-assisted partial nephrectomy is reserved to smaller renal masses. Under such conditions, no differences with the on-clamp approach emerged.

Laparoendoscopic single-site nephrectomy with the aid of intraabdominal retractors.

OBJECTIVES: To evaluate the feasibility and clinical efficacy of a novel intraabdominal retractor device in laparoendoscopic single-site nephrectomy(LESS-N). METHODS: Between February 2012 and February 2017, 98 patients underwent LESS-N in our institution, including 38 patients with benign renal disease and 60 patients with malignant renal disease. 39 were performed conventional LESS-N(C-LESS-N) and 59 were performed intraabdominal retractor-assisted LESS-N(IAR-LESS-N). Demographic data, and perioperative and postoperative data were collected and analyzed retrospectively. RESULTS: All the procedures were completed successfully. In C-LESS-N group, four patients were added one 5-mm additional trocar and two patients were converted to open surgery. In IAR-LESS-N group, no patients required additional trocars or conversion to open surgery. The mean operative time was lower in IAR-LESS-N group than that in C-LESS-N group (94.2 min vs 127.4 min, P < 0.05). The mean renal vascular management time declined from 25.4 min in C-LESS-N group to 18.4 min in IAR-LESS-N group (P < 0.05). The mean estimated blood loss was 128.6 ml in C-LESS-N group and 102.3 ml in IAR-LESS-N group (P < 0.05). Two patients in C-LESS-N group required blood transfusion, while none of the patients in IAR-LESS-N group did. No severe postoperative complications occurred in both groups. Study limitations included retrospective study, short follow-up, and accumulated surgical experience and skills. CONCLUSIONS: Intraabdominal retractors allow performance of LESS-N with improved working space, quicker renal hilar management, and shortened total operative time. It is expected that the application of intraabdominal retractors, along with the new robotic platform might revive LESS and translate into a renewed future interest of LESS.

Evolution of Robot-assisted Partial Nephrectomy: Techniques and Outcomes from the Transatlantic Robotic Nephron-sparing Surgery Study Group.

BACKGROUND: Robot-assisted partial nephrectomy (RAPN) is considered a feasible minimally invasive alternative to open partial nephrectomy (OPN) for the surgical treatment of renal tumors. OBJECTIVE: To provide further evidence supporting the effectiveness of RAPN in a contemporary patient population treated at one of three tertiary care centers for robotic surgery and to describe the evolution of RAPN-based technical improvements. DESIGN, SETTING, AND PARTICIPANTS: The Transatlantic Robotic Nephron-sparing Surgery (TRoNeS) study group prospectively collected data from 635 patients subjected to RAPN for clinically localized kidney cancer between 2010 and 2016 at three high-volume tertiary care centers. SURGICAL PROCEDURE: RAPN was performed using methods outlined in the supplementary video using either the da Vinci Si or Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA). MEASUREMENTS: Clinical data were collected within a prospectively maintained multi-institutional database. Intra- and postoperative data as well as surgical outcomes were assessed. Descriptive statistical analysis was performed and multivariable logistic regression models were fitted to determine the predictors of surgical outcomes. RESULTS AND LIMITATIONS: Mean patient age was 60.7yr and mean preoperative tumor size was 33mm. According to the PADUA score, 202 (31.8%) patients had a low-, 235 (37.0%) had an intermediate-, and 198 (31.2%) had a high-complexity tumor. In the majority of patients, a transperitoneal approach was used (n=447; 70.4%). Mean operative time was 156.3min and mean estimated blood loss was 171ml. Overall, 25 (3.9%) patients experienced a significant (Clavien-Dindo >2) complication after surgery. No statistically significant differences between pre- and postoperative creatinine values were observed (p≤0.823). Finally, optimal surgical outcomes defined according to the margin, ischemia, and complication score were achieved in 459 (72.3%) individuals. At a mean follow-up of 26mo, only two local and two distant recurrences of the disease were observed. Finally, in multivariable logistic regression models, tumor complexity was associated with the risk of not achieving optimal surgical outcomes. CONCLUSIONS: RAPN represents an effective minimally invasive alternative to OPN in the treatment of clinically localized renal tumors. PATIENT SUMMARY: We reported contemporary experience with RAPN for the treatment of kidney cancer. RAPN appears to be a safe and effective procedure, resulting in optimal outcomes in the majority of individuals despite tumor complexity.

Retroperitoneoscopic partial nephrectomy in children: a multicentric international comparative study between lateral versus prone approach.

BACKGROUND: Very limited informations are currently available about the best approach to perform retroperitoneoscopic surgery. This multicentric international study aimed to compare the outcome of lateral versus prone approach for retroperitoneoscopic partial nephrectomy (RPN) in children. METHODS: The records of 164 patients underwent RPN in 7 international centers of pediatric surgery over the last 5 years were retrospectively reviewed. Sixty-one patients (42 girls and 19 boys, average age 3.8 years) were operated using lateral approach (G1), whereas 103 patients (66 girls and 37 boys, average age 3.0 years) underwent prone RPN (G2). The two groups were compared in regard to operative time, postoperative outcome, postoperative complications, and re-operations. RESULTS: The average operative time was significantly shorter in G2 (99 min) compared to G1 (160 min) (p = 0.001). Only 2 lateral RPN required conversion to open surgery. There was no significant difference between the two groups as for intraoperative complications (G1:2/61, 3.3%; G2:6/103, 5.8%; p = 0.48), postoperative complications (G1:9/61, 14.7%; G2:17/103, 16.5%; p = 0.80), and re-operations (G1:2/61, 3.3%; G2:4/103, 3.8%; p = 0.85). Regarding postoperative complications, the incidence of symptomatic residual distal ureteric stumps (RDUS) was significantly higher in G2 (7/103, 6.8%) compared to G1 (1/61, 1.6%) (p = 0.001). Most re-operations (4/6, 66.6%) were performed to remove a RDUS . CONCLUSIONS: Both lateral and prone approach are feasible and reasonably safe to perform RPN in children but the superiority of one approach over another is not still confirmed. Although prone technique resulted faster compared to lateral approach, the choice of the technique remains dependent on the surgeon's personal preference and experience. Our results would suggest that the lateral approach should be preferred to the prone technique when a longer ureterectomy is required, for example in cases of vesico-ureteral reflux into the affected kidney moiety, in order to avoid to leave a long ureteric stump that could become symptomatic and require a re-intervention.