A transition to laparoendoscopic single-site surgery (LESS) radical prostatectomy: human cadaver experimental and initial clinical experience.

BACKGROUND AND PURPOSE: Laparoendoscopic single-site surgery (LESS) represents a novel approach to abdominal surgery. Several applications have already been described. Drawbacks include limited range of motion and need for articulated instruments. Robotic technology could overcome such technical difficulties. We report our experience with LESS radical prostatectomy (LESS-RP) in a cadaver and LESS robot-assisted radical prostatectomy (LESS-RARP) in a human patient. MATERIAL AND METHODS: Standard laparoscopic instruments (SLI) and articulated laparoscopic instruments were used in the cadaveric LESS-RP. The da Vinci system was used in the LESS-RARP. Both procedures reproduced standard extraperitoneal laparoscopic prostatectomy as performed at Institut Montsouris. Control of the dorsal venous complex (DVC) and urethrovesical anastomosis (UVA) were key elements evaluated for feasibility. RESULTS: Cadaveric model: Total operative time (TOT) was 160 minutes, with 5 minutes for the DVC (one stitch) and 35 minutes for the UVA (six stitches). Although articulated instruments were helpful in the operation, SLI remained essential for the procedure. Clinical experience: LESS-RARP was performed for T(1c) prostate cancer. TOT was 150 minutes, including 5 minutes for the DVC (one figure-of-eight stitch) and 30 minutes for the UVA (six interrupted stitches). Blood loss was 500 mL. Bilateral neurovascular preservation was performed, and results of final pathologic examination showed negative surgical margins. CONCLUSIONS: The human cadaver is an adequate model for LESS-RP, and LESS-RARP is feasible to be performed in the clinical arena. The synergy of robotic technology and LESS represents a new generation of surgery.

The current status of laparoscopic sacrocolpopexy: a review.

CONTEXT: Pelvic organ prolapse (POP) is a common problem in women that causes morbidity and a decreased quality of life. Sacrocolpopexy can treat women with vaginal vault prolapse (VVP), multicompartmental POP, and/or a history of failed prolapse procedures. Abdominal sacrocolpopexy (ASC) is the gold standard for VVP and is superior to vaginal sacrocolpopexy, with fewer recurrent prolapses and less dyspareunia. Vaginal prolapse repairs, however, are often faster and offer patients a shorter recovery time. Laparoscopic sacrocolpopexy (LSC) aims to bridge this gap and to provide the outcomes of ASC with decreased morbidity. OBJECTIVE: This review evaluates the recent literature on LSC as a therapy for POP. EVIDENCE ACQUISITION: A PubMed search of the available English literature on LSC was performed. The reference lists of selected articles were reviewed, and additional on-topic articles were included. Some 50 articles were screened, 22 articles were selected, and the reported outcomes from 11 series are presented in this review. EVIDENCE SYNTHESIS: Laparoscopic experience with POP has advanced tremendously, and LSC results from >1000 patients in 11 series support this. Conversion rates and operative times have decreased with increased experience. Mean operative time was 158 min (range: 96-286 min) with a 2.7% conversion rate (range: 0-11%) and a 1.6% early reoperation rate (range: 0-3.9%). With a mean follow-up of 24.6 mo (range: 11.4-66 mo), there was, on average, a 94.4% satisfaction rate, a 6.2% prolapse reoperation rate, and a 2.7% mesh erosion rate. Several centers have demonstrated that excellent outcomes with LSC are reproducible in terms of operative parameters, durable results, minimal complications, and high levels of patient satisfaction. CONCLUSIONS: LSC upholds the outcomes of the gold standard ASC with minimal morbidity. Longer prospective and randomized trials are needed to confirm these results.

The management of malignant ureteral obstruction treated with ureteral stents.

PURPOSE: We developed an algorithm for the management of ureteral obstruction due to malignant extrinsic compression. MATERIALS AND METHODS: We retrospectively reviewed all ureteral stents placed for noncalculous reasons at our institution from January 1, 1990 to January 1, 2004. Further clinical information was gathered from 157 patients with malignant extrinsic ureteral compression. Failure was defined as recurrent ureteral obstruction or an inability to place stents cystoscopically. RESULTS: A total of 157 patients underwent retrograde ureteral stent attempt for malignant extrinsic ureteral obstruction. Mean patient age was 54.7 years (range 23 to 83) and average followup was 13.6 months. Of our patients 61% were women, and the most common cancer diagnoses were ovarian cancer (in 26), lymphoma (17) and cervical cancer (16). A total of 24 patients required immediate percutaneous nephrostomy (PCN) referral. There were 32 patients who experienced a late failure and required PCN (average 180 days after initial stent), and 83 patients in our series (52.9%) who experienced 110 major complications. Type of cancer did not predict need for PCN. However, when invasion into the bladder was noted on cystoscopy, 55.9% (19 of 34, p = 0.008) progressed to PCN referral. A total of 77 patients underwent stent replacement on average 2.8 times and with an interval of 95 days. CONCLUSIONS: In our series patients with malignant extrinsic ureteral compression presenting for ureteral stent(s) experienced a failure rate of 35.7% (56 of 157). Invasion at cystoscopy had a significant predictive value for progression to PCN. We present an algorithm on the management of extrinsic malignant ureteral obstruction.