A Comparison of Outcomes Between Robotic-Assisted, Single-Site Laparoscopy Versus Laparoendoscopic Single Site for Benign Hysterectomy.

STUDY OBJECTIVE: To compare the perioperative outcomes, including estimated blood loss, conversion to open laparotomy, length of stay, and total operative time of hysterectomies using robotic-assisted, single-site laparoscopy with laparoendoscopic single site (LESS) for benign indications. DESIGN: A retrospective cohort study (Canadian Task Force classification Level II-2. SETTING: Multicenter (private hospitals). PATIENTS: Gynecologic patients who underwent a hysterectomy for benign indications via robotic-assisted, single-site laparoscopy (n = 50) versus LESS (n = 50). INTERVENTIONS: Observational study. MEASUREMENTS AND MAIN RESULTS: Continuous outcomes were analyzed using multiple linear regression, whereas the dichotomous outcome of conversion was analyzed using a multiple log-binomial regression model. Linear and log-binomial regression coefficients were adjusted for the ages of the patients and other clinical factors. A total of 100 consecutive patient records were available for analysis: 50 for robotic-assisted, single-site laparoscopy and 50 for LESS. Univariate analyses revealed that both groups were similar in mean age (robotic, 46.0 years; LESS, 45.4 years; p = .75), but not mean body mass index (robotic, 25.9 kg/m(2); LESS, 28.8 kg/m(2); p = .02). There was no difference in the unadjusted (crude) risk of conversion to a multiport procedure between the robotic and laparoscopic groups (p = .37). There were only 2 major complications (cystotomy and vaginal dehiscence) in the LESS arm and 1 vaginal dehiscence in the robotic-assisted, single-site arm. After adjusting for 7 potential confounders, no relationship was detected between the type of approach (robotic vs laparoscopic) and the outcome of a major complication (exact odds ratio, 0.55; exact p = 1.0). A multivariate linear regression analysis that compared the 2 groups (robotic-assisted single site vs LESS) revealed no differences in estimated blood loss. On average, the robotic-assisted, single-site group had a length of stay that was 8.12 hours shorter than the LESS group (p = .003) after adjusting for patient characteristics. Total operative time was an average of 24.9 min longer in the robotic-assisted, single-site group (p = .002) after adjustment. A plot of total operative time in minutes by chronological case number and procedural approach was analyzed to estimate a learning curve. This plot showed a steeper learning curve with the robotic-assisted, single-site approach. CONCLUSIONS: This preliminary observational study found that the robotic-assisted, single-site group had a statistically significant decrease in length of hospital stay, but also experienced an increase in total operative time. There were no conversions to open laparotomies.

Ergonomic principles and techniques in facilitating advanced laparoendoscopic single site (LESS) urinary tract reconstruction with conventional laparoscopic instruments.

BACKGROUND/PURPOSE: The technical and ergonomic details of laparoendoscopic single site (LESS) reconstruction have not been reported. In this study, we explored the feasibility and safety of performing advanced LESS upper urinary tract reconstruction with conventional laparoscopic instruments. METHODS: Between September 2010 and March 2011, we retrospectively reviewed prospectively collected data from five patients who underwent LESS urinary tract reconstruction. The LESS reconstruction included pyeloureterostomy (N = 1), dismembered pyeloplasty (N = 2), ureteroneocystostomy (N = 1), and ureteroplasty for bifid blind ending ureter (N = 1). The perioperative and postoperative parameters were collected for analysis. The ergonomic principles and techniques are detailed. RESULTS: All reconstructive LESS procedures were completed successfully without open conversion or laparoscopic conversion. Ancillary ports or ancillary instruments were not applied in any of the patients. The mean patient age was 40.4 years. The mean operative time was 213 ± 69 minutes, the estimated blood loss ranged from minimal to 50 mL, and the mean hospital stay was 4.4 ± 4 days. No operation-related complication occurred. CONCLUSION: Based on our ergonomic principles and suturing/knotting techniques, conventional laparoscopic instruments are feasible and safe for LESS urinary reconstructive procedures.

Laparoendoscopic single-site (LESS) robot-assisted partial nephrectomy (RAPN) reduces postoperative wound pain without a rise in complication rates.

OBJECTIVE: To compare long-term functional outcomes and pain scale scores of patients who underwent laparoendoscopic single-site (LESS)- robot-assisted partial nephrectomy (RAPN) to those who underwent conventional RAPN (C-RAPN), as LESS surgery is increasingly being adopted by urologists worldwide to reduce morbidities and scarring associated with surgical interventions. PATIENTS AND METHODS: In all, 167 consecutive patients who had RAPN were identified from our Institutional Review Board-approved computerised database between October 2006 to July 2012. Patients were stratified into two groups: 80 patients who underwent C-RAPN and 79 who underwent LESS-RAPN. RESULTS: The LESS-RAPN group had a longer warm ischaemia time [WIT, mean (sd) 26.5 (10.5) vs 19.8 (13.1) min; P = 0.001] and total operation time [TOT, mean (sd) 210.3 (83.4) vs 183.1 (76.1) min; P = 0.033] when compared with the C-RAPN group. While, the LESS-RAPN group and C-RAPN group were not significantly different for the number of patients with negative surgical margins [77 (96.2%) vs 73 (91.4%); P = 0.194), absolute change in postoperative renal function [mean (sd) -6.5 (16.7)% vs -7.6 (16.7)%; P = 0.738) and postoperative complications rate [12 (15.0%) vs 10 (12.6%); P = 0.279). Furthermore, the LESS-RAPN group had lower visual analogue pain scale (VAPS) scores at discharge [mean (sd) 2.1 (1.3) vs 1.7 (1.0); P = 0.048]. CONCLUSIONS: Despite a significantly longer WIT and TOT, the functional outcomes of LESS-RAPN were comparable to those of C-RAPN for tumours of similar mean sizes and complexities, without any detriments in oncological and complications outcomes. On discharge, patients who underwent LESS-RAPN also reported lower pain levels as one of the advantages of minimally invasive surgery. With the development of instrumentation specifically designed for single-site surgery, LESS could be more easily conducted in patients who are interested in improved quality of life outcomes.

Laparoendoscopic single-site (LESS) robot-assisted nephroureterectomy: comparison with conventional multiport technique in the management of upper urinary tract urothelial carcinoma.

OBJECTIVE: To compare the peri-operative, pathological and oncological outcomes of laparoendoscopic single-site (LESS) robot-assisted nephroureterectomy (LESS-RALNU) with those of multiport robot-asssisted nephroureterectomy (M-RALNU). PATIENTS AND METHODS: A total of 38 patients with upper urinary tract urothelial carcinoma underwent LESS-RALNU (n = 17) or M-RALNU (n = 21) by a single surgeon at a tertiary institution. Data were obtained from a prospectively maintained database. RESULTS: Patients' demographics and tumour characteristics were similar between the M-RALNU and LESS-RALNU groups. The mean follow-up was 48.4 months for M-RALNU and 30.9 months for LESS-RALNU (P = 0). The mean operating time, estimated blood loss and length of hospitalization for M-RALNU and LESS-RALNU were 251 min, 192 mL, 6.5 days and 247 min, 376 mL and 5.4 days, respectively (P > 0.05). Overall, there were no significant differences in complication rates, although three patients in the LESS-RALNU group required blood transfusion, whereas no patient in the M-RALNU group did (P = 0.081). The proportion of patients with bladder recurrence, local recurrence and distant metastases was similar between the two groups. There were no significant differences in the recurrence-free survival, cancer-specific survival and overall survival rates between the two groups. CONCLUSIONS: Although the oncological and peri-operative outcomes of patients who underwent LESS-RALNU compared well with those who underwent M-RALNU and with series of other surgical approaches, LESS-RALNU might result in greater intra-operative blood loss. We suggest careful selection of patient for this technique.

The Transumbilical Laparoendoscopic Single-Site Extraperitoneal Approach for Pelvic and Para-Aortic Lymphadenectomy: A Technique Note and Feasibility Study.

Background: Nowadays, lymphadenectomy could be performed by the transperitoneal or extraperitoneal approach. Nevertheless, each approach has its own advantages and disadvantages. Under these circumstances, we developed a transumbilical laparoendoscopic single-site (TU-LESS) extraperitoneal approach for lymphadenectomy. In this research, the primary goal is to demonstrate the feasibility of the novel approach in systematic lymphadenectomy and present the surgical process step-by-step. Methods: Between May 2020 and June 2021, patients who had the indications of systematic lymphadenectomy underwent lymphadenectomy via the TU-LESS extraperitoneal approach. This new approach was described in detail, and the clinical characteristics and surgical outcomes were collected and analyzed. Results: Eight patients with gynecological carcinoma were included in the research, including four with high-risk endometrial cancer and four with early-stage ovarian cancer. The TU-LESS extraperitoneal approach for pelvic and para-aortic lymphadenectomy was successfully performed in all patients without conversion. In all, a median of 26.5 pelvic lymph nodes (range 18-35) and 18.0 para-aortic lymph nodes (range 7-43) were retrieved. There was a median of 166.5 min of surgical time (range 123-205). Patients had speedy recoveries without complications. All patients had positive pain responses after surgery, as well as satisfactory cosmetic and body image outcomes. Conclusion: Our initial experience showed that it is feasible to perform systematic lymphadenectomy with the TU-LESS extraperitoneal approach. And this new approach may provide a new measure or a beneficial supplement for lymphadenectomy in gynecologic cancer.

Single incision prone retroperitoneoscopic paediatric nephrectomy.

OBJECTIVE: We have previously reported our early experience (2 patients) of single-incision nephrectomy via the retroperitoneal prone route using an advanced access platform (GelPOINT Mini). Here, we review our series to date and also present a detailed video demonstrating the technique. METHOD: In the prone position, a single transverse incision was made at the midpoint on a line along the lateral border of erector spinae bounded by the lower border of the 12th rib and iliac crest. Posterior abdominal muscles were split and the deep lumbodorsal fascia incised. The Alexis retractor was positioned and the Gel-Seal cap with low-profile sleeves locked in place. Hilar vessels were divided by endoclip application or harmonic scalpel. The kidney was retrieved directly or via an endobag. The Alexis retractor was removed and wound closed with absorbable sutures. RESULTS: Between July 2013 and March 2015, we have used this approach to perform 10 nephrectomies in nine patients (4 male and 5 female). The median age at nephrectomy was 10.9 years (range 2.7-15.9 years). The median kidney length was 7.5 cm (range 3.7-11.5 cm). No complications occurred and none converted to open procedure. CONCLUSION: Single incision retroperitoneal nephrectomy is feasible, safe, and provides excellent cosmesis.

Accessibility and surgical outcomes of transumbilical single-port laparoscopy using straight instruments for hysterectomy in difficult conditions.

OBJECTIVES: To evaluate the accessibility of transumbilical single-port laparoscopy for hysterectomy in difficult conditions. MATERIALS AND METHODS: This prospective observational study recruited patients with benign diseases who were scheduled for laparoscopic hysterectomy between March 2010 and October 2011 to undergo the transumbilical single-port approach with straight instruments and a laparoscope. RESULTS: In total, 109 patients were included with a mean [± standard error of the mean (SEM)] age of 45.9 ± 0.4 years and mean body mass index of 23.9 ± 0.3 kg/m(2). The yielded mean uterine weight was 403.4 ± 25.3 g, with 28 (25.7%) weighing ≥500 g, including four specimens >1000 g, and 44 (40.4%) needed concurrent adhesiolysis. The operative time was 117.2 ± 4.2 minutes, estimated blood loss was 270.3 ± 22.9 mL, and the postoperative hospital stay was 2.8 ± 0.1 days. Patients with a uterus weighing ≥500 g had a higher intraoperative blood loss in comparison with those with a uterus weighing <500 g (375.4 ± 55.3 mL vs. 234.0 ± 23.0 mL; p < 0.05) and a higher incidence of blood transfusion (17.9% and 6.2%, respectively). The single-port approach was abandoned in four (3.7%) patients with severe pelvic adhesion--an additional port was opened for extensive adhesiolysis. None of the patients with a voluminous uterus needed an additional port. There were no major intraoperative or postoperative complications. CONCLUSION: The single-port approach using straight, conventional laparoscopic instruments was feasible and safe in the majority of the patients undergoing hysterectomy, and was found to be accessible even in cases with a large uterus. The patients benefitted from this approach and had less abdominal wounds. However, patients with a voluminous uterus tended to have more intraoperative blood loss, and in some cases with severe adhesions, additional port(s) were required for surgical effectiveness.