No ischemia technique, parenchymal preservation and age are the most important determinants of renal function after partial nephrectomy.

OBJECTIVE: The aim of the present study was to compare the outcomes of Off-Clamp to On -Clamp approach during robot-assisted partial nephrectomy (RAPN). MATERIEL AND METHODS: Retrospective study of 940 patients who underwent a RAPN between 2007 and 2015 for cT1a tumors using On-Clamp or Off-Clamp approaches. Patient with solitary kidney or multifocal were excluded. Overall, 103 patients underwent Off-Clamp approach and 37 patients On-Clamp approach. We matched the patients in terms of tumor size, Charlson comorbidity index and R.E.N.A.L. score. At all, 309 patients from the On-Clamp were matched to the Off-Clamp group. We compared the clinic-pathological characteristics, perioperative morbidity and late functional outcomes between the 2 propensity score matched groups. Limitation included retrospective analysis. RESULTS: After matching, there were no difference in clinic-pathological characteristics in terms of gender, age, race, body mass index, Charlson comorbidity index, American Society of Anesthesiologists score, baseline estimated glomerular filtration rate (e-GFR), tumor size, R.E.N.A.L. score complexity, hilar (H) location between the 2 groups. Regarding perioperative outcomes; while operative time (P=0,4), estimated blood loss (P=0,28), Clavien grade III-IV complications (P=0,8) surgical reoperation (P=1), 30-day readmission (P=1), positive surgical margin (5,5% vs. 5,8%, P=0,9) were comparable between the 2 groups, there were significant difference in excisional volume loss (median, 7,08 vs. 3,51cm3, P<0,01), e-GFR decline (median, -9,7 vs. -2,2ml/min/1,73 m2, P<0,01), percent of e-GFR preservation (median, 87% vs. 97%, P<0,01), and CKD upstaging (36,5% vs. 23,3%, P=0,01), Off-Clamp approach (P=0,01), and age (P=0,02) were predictors of renal function preservation, whereas excisional volume loss (OR=1,035, CI 95% (1,015-1,06), P<0,01) predicted upstaging. CONCLUSION: RAPN for selected renal mass using Off-Clamp approach offered renal functional advantage over On-Clamp, without adding morbidities. While no ischemia technique was associated with less excisional volume loss, Off-Clamp approach, and age were independent predictors of renal function preservation. Clinical significance of these findings in various clinical settings will require further investigation.

Perioperative morbidity, oncological outcomes and predictors of pT3a upstaging for patients undergoing partial nephrectomy for cT1 tumors.

OBJECTIVES: To evaluate perioperative morbidity, oncological outcome and predictors of pT3a upstaging after partial nephrectomy (PN). MATERIALS AND METHODS: Retrospective study of 1042 patients who underwent PN for cT1N0M0 renal cell carcinoma between 2007 and 2015. A total of 113 cT1 patients were upstaged to pT3a, while 929 were staged as pT1. Demographic, perioperative and pathological variables were reviewed. We compared the clinico-pathological characteristics, perioperative morbidity and oncological outcomes between pT3a and pT1 groups. Multivariate regression evaluates variables associated with T3a upstaging. Recurrence-free survival (RFS) and overall survival analyses were performed. Survival curves were compared using log-rank test. RESULTS: The pT3a tumors were high complexity tumors (median RENAL score 8 vs. 7, p < 0.01), higher hilar (h) location (27.5 vs. 14.8%, p < 0.01), higher grade (57.5 vs. 38.2%, p < 0.01), and higher positive surgical margins (18.6 vs. 5.8%, p < 0.01. Patients with pT3a had a higher estimated blood loss, transfusion rate, ischemia time and overall complications, though there were no differences in median e-GFR decline and major (Grade III-V) complications. Five-year RFS was 78.5% for pT3a group vs. 94.6% for pT1 group (log-rank p < 0.01). Male gender (OR 2.2, p < 0.01), and R.E.N.A.L. score (OR 2.3, p = 0.01) were preoperative predictors of upstaging. We acknowledge limitations in our study, most are inherent problems of retrospective studies. CONCLUSION: Perioperative morbidity, after partial nephrectomy, is acceptable in cT1/pT3 tumors in comparison to cT1/pT1; however, upstaged patients had a worse oncological outcome. cT1/pT3a tumors are associated with adverse clinico-pathological features. Preoperative risk predictors of upstaging were higher R.E.N.A.L. score and male gender.

Perioperative factors associated with acute kidney injury after partial nephrectomy.

BACKGROUND: Partial nephrectomy is performed with the aim to preserve renal function. But the occurrence of postoperative acute kidney injury (AKI) can interfere with this goal. Our primary aim was to evaluate associations between pre-specified modifiable factors and estimated glomerular filtration rate after partial nephrectomy. Our secondary aims were to evaluate associations between pre-specified modifiable factors and both serum creatinine concentration and type of nephrectomy. METHODS: The records of 1955 patients who underwent partial nephrectomy were collected. Postoperative estimated glomerular filtration rate (eGFR) was used as the primary outcome measure. Twenty modifiable risk factors were studied. A repeated-measures linear model with autoregressive within-subject correlation structure was used. The interaction between all the factors and type of nephrectomy was also studied. RESULTS: A total of 1187 (61%) patients had no kidney injury, 647 (33%) had stage I, 80 (4%) had stage II, and 41 (2%) had stage III injury. The mean eGFR increased an estimated 0.83 (99.76% CI 0.79-0.88) ml min(-1) 1.73 m(-2) for a unit increase in baseline eGFR. Mean eGFR was 2.65 (99.76% CI: 0.13, 5.18) ml min(-1) 1.73 m(-2) lower in patients with hypertension. Mean eGFR decreased 0.42 (99.76% CI: 0.22, 0.62) ml min(-1) 1.73 m(-2) for a 10-minute longer in duration of procedure and decreased 2.09 (99.76% CI: 1.39, 2.80) ml min(-1) 1.73 m(-2) for a 10-minute longer in ischemia time. It was 3.53 (99.76% CI: 0.83, 6.23) ml min(-1) 1.73 m(-2) lower for patients who received warm ischemia as compared to cold ischemia. CONCLUSION: Potentially modifiable factors associated with AKI in the postoperative period were identified as baseline renal function, preoperative hypertension, longer duration of surgical time and ischaemia time, and warm ischaemia.

Comparison of lateral flank approach and low anterior access for single port (SP) retroperitoneal partial nephrectomy: an analysis from the single port advanced research consortium (SPARC).

Single Port (SP) robotic partial nephrectomy (RPN) can be performed via retroperitoneal and transperitoneal approach. We aim to compare outcomes of two commonly described incisions for retroperitoneal SP RPN: lateral flank approach (LFA) and low anterior access (LAA). We performed a retrospective study of patients who underwent SP retroperitoneal RPN from 2018 to 2023 as part of a large multi-institute collaboration (SPARC). Baseline demographic, clinical, tumor-specific characteristics, and perioperative outcomes were compared using χ2, t test, Fisher exact test, and Mann-Whitney U test. Multivariable analyses were conducted using robust and logistic regressions. A total of 70 patients underwent SP retroperitoneal RPN, with 44 undergoing LAA. Overall, there were no significant differences in baseline characteristics between the two groups. The LAA group exhibited significantly lower median RENAL scores (8 vs. 5, p < 0.001) and more varied tumor locations (p = 0.002). In the bivariate analysis, there were no statistically significant differences in ischemia time, estimated blood loss, or complication rates between the groups. However, the LAA group had longer operative times (101 vs. 134 min, p < 0.001), but was more likely to undergo a same-day discharge (p < 0.001). When controlling for other variables, LAA was associated with shorter ischemia time (p = 0.005), but there was no significant difference in operative time (p = 0.348) and length of stay (p = 0.122). Both LFA and LAA are acceptable approaches for SP retroperitoneal RPN with comparable perioperative outcomes. This early data suggests the LAA is more versatile for varying tumor locations; however, larger cohort studies are needed to ascertain whether there is an overall difference in patient recovery.

[Robotic partial nephrectomy: five years retrospective analysis at a single center]. / Néphrectomie partielle laparoscopique assistée par robot : analyse monocentrique et rétrospective sur cinq ans.

INTRODUCTION: The aim of this study is to assess perioperative outcomes in a large series of robotic partial nephrectomy. PATIENTS AND METHODS: We performed a retrospective analysis of 413 patients undergoing a robotic partial nephrectomy in a single center between June 2006 and December 2011. We analyzed demographic characteristics, operative and postoperative outcomes. RESULTS: Mean age was 58.6±11.9 years, body mass index was 30.5±7.1 kg/m2 and median ASA score 3. Mean tumor size was 3.2±1.66 cm and was divided in low, moderate and high RENAL nephrometry score respectively in 40%, 44% and 16%. Operative time and warm ischemia time were respectively 191 and 21min. Mean estimated blood loss was 200 mL and there were 4.3% major complications (Clavien-Dindo System). Mean length of stay was 3.6 days. The latest estimated glomerular filtration rate (eGFR) was 74.84 mL/min×1.73 m2 with a mean decrease of 8.6%. In multivariate analysis, Charlson comorbidity index (P=0.005), preoperative eGFR (P<0.001) and warm ischemia time (P=0.0025) were found to be independent predictors of latest postoperative renal function. CONCLUSION: Robotic partial nephrectomy is feasible and safe in experienced hands. In our study preoperative renal function, Charlson comorbidity index and warm ischemia time were independent predictors of latest eGFR.

Robotic-assisted laparoscopic partial nephrectomy for a 7-cm mass in a renal allograft.

Treatment options for a suspicious renal mass in a renal allograft include radical nephrectomy or nephron-sparing surgery (NSS). To our knowledge robotic-assisted laparoscopic partial nephrectomy (RPN) as treatment for a renal mass in a transplant kidney has not been previously reported. We report the case of RPN for a 7-cm renal mass in a transplanted kidney. A 35-year-old female with reflux nephropathy received a living-related donor kidney transplant in 1986. At 24 years after transplantation she had a 7-cm Bosniak III cystic mass of the allograft detected on computerized tomography (CT) scan. Preoperative creatinine was 2.2 mg/dL with an estimated glomerular filtration rate (eGFR) of 25 mL/min/1.73 m(2) . RPN was performed with bulldog clamping of the renal vessels, the graft was left in situ and immunosuppression was maintained postoperatively. Tumor diameter was 7.3 cm with a nephrometry score of 10a. Warm ischemia time (WIT) was 26.5 min. Estimated blood loss was 100 mL. There was no change between pre- and postoperative eGFR. There were no operative complications. Histology was papillary renal cell carcinoma type 1, nuclear grade 2. Margins were negative. RPN is a technically feasible treatment option for a suspicious renal mass in renal allografts.

Minimizing minimally invasive surgery: Current status of the single-port robotic surgery in Urology.

BACKGROUND: The novel da Vinci Single-Port (SP) robotic platform received the US FDA approval in 2018. The device, specifically conceived for single-site approach, is pushing through the limits of minimally invasive surgery. We sought to provide a comprehensive overview of the current status of the clinical experiences accomplished by the da Vinci SP in urology, and to discuss future perspectives. METHODS: A non-systematic literature review was performed focusing on single port articles in urological surgery using Medline/PubMed and Embase search electronic engines. The authors analyzed findings and a brief report of the clinical experience for surgical procedures completed by the SP platform was described. RESULTS: The current data available from single-port robotic established the safety and feasibility of urologic procedures using this novel platform. However, the results come from single-center case series, small cohorts and retrospective studies that need to be cautiously interpreted. Additional evidence is required to determine the asset of the SP platform in the urological community. CONCLUSIONS: The SP robotic system opens new frontiers on the surgical scenery facilitating the completion of urological surgeries through a single incision. Further comparative studies will be required to assess perioperative and long-term oncological and functional outcomes among SP, multi-arm robotic and open approaches.

[Single-port in urology]. / Single-port en urologie.

UNLABELLED: Single-port transumbilical laparoscopy has emerged as an attempt to further enhance cosmetic benefits and reduce morbidity of minimally invasive surgery. Within a short span, several clinical reports have emerged in the urologic literature. As this field is poised to move forward, a complete understanding of its evolution and current status seems imperative. We have summarized and reviewed the history of Single-Port across surgical disciplines. This review emphasizes nomenclature, surgical technique, instrumentation, and perioperative outcomes. EVIDENCE ACQUISITION: Using the National Library of Medicine database, the English language literature was reviewed for the past 40 years. Keyword searches included scarless, scar free, single-port/trocar/incision, laparoendoscopic single site surgery intraumbilical, and transumbilical. Within the bibliography of selected references, additional sources were retrieved. EVIDENCE SYNTHESIS: The major findings and surgical techniques described in these papers, are summarized in a chronological and subject-grouped manner. CONCLUSIONS: Single-port has made its initial forays into laparoscopic surgery. Ongoing refinement in technique and instrumentation is likely to expand its future role.

Multiquadrant Combined Robotic Radical Prostatectomy And Left Partial Nephrectomy: A Combined procedure by A Single Approach. / Cirugía robótica multicuadrante concomitante para prostatectomía radical y nefrectomía parcial izquierda. Dos procedimientos mediante un solo abordaje.

INTRODUCTION: To present the first case of a concomitant robotic radical prostatectomy and a left robotic partial nephrectomy performed by a single-port approach using the SP® da Vinci surgical system (Intuitive Surgical, Sunnyvale CA, EE.UU.). PATIENT AND METHODS: A 66-year-old male diagnosed with localized prostate cancer and a left kidney renal mass incidentally found on computed tomography (CT) scan during prostate cancer evaluation. Procedures were performed using a single supra-umbilical 3cm incision, plus one additional laparoscopic port, utilizing a standard Gelpoint® (Applied Medical, Rancho Santa Margarita, CA, EE.UU.) and replicating the technique previously described for single-port transperitoneal radical prostatectomy and partial nephrectomy with the use of the SP® robotic platform. RESULTS: Total operative time was 256minutes (min) with a console time of 108min for radical prostatectomy, and 101min for the partial nephrectomy respectively, including a warm ischemia time of 26min. Estimated blood loss was 250cc. Blood transfusion was not needed. Final pathology for prostate was adenocarcinoma Gleason 7 (4+3) and for the kidney lesion was renal cell carcinoma. After two months of follow-up, PSA was undetectable and no complications or recurrence were detected. CONCLUSIONS: The single-port approach has advantages as easier surgical planning and transition for combined and multi-quadrants surgeries: faster recovery, minimal postoperative pain and need for opioids, and excellent cosmetic outcome. We suggest that combined procedures should be performed only in high volume institutions by surgeons with vast experience in robotic surgery in selected patients.

Single-Port Percutaneous Transvesical Simple Prostatectomy Using the SP Robotic System: Initial Clinical Experience.

OBJECTIVE: To present our initial experience with single-port percutaneous transvesical simple prostatectomy using the novel SP robotic surgical system. METHODS: Ten patients underwent single-port transvesical simple prostatectomy between February and November 2019. Percutaneous access to the bladder dome was made and all SP instruments were inserted through the SP multichannel cannula directly into the bladder. Prostate adenoma enucleation, hemostasis and trigonization were done according to the principles of open simple prostatectomy technique. Demographics and perioperative outcomes were prospectively collected and analyzed. RESULTS: All procedures were performed successfully without the need for conversion to open surgery. Median preoperative estimated prostate size was 159 (Interquartile range (IQR) 108-223) grams. No intraoperative complications occurred. Median operative time and estimated blood loss were 190 (IQR 146-203) minutes and 100 (IQR 68-175) ml, respectively. Mean postoperative specimen weight was 84.3 ± 34 grams. Median length of hospital stay was 19 (IQR 17-28) hours. All patients were satisfied with their urinary flow after catheter removal without any episode of acute urinary retention 1-6 months, postoperatively. CONCLUSION: Single-port transvesical simple prostatectomy can be offered as an alternative treatment option for surgical management of lower urinary tract symptoms associated with large prostate adenoma. Sparing the peritoneal cavity, minimum dissection of the bladder, excellent visualization of the prostate fossa can be some of the potential advantages of this minimally invasive approach. Comparative studies with standard techniques are advisable to evaluate the surgical outcome and postoperative morbidity of each treatment modality.

Single-port laparoscopy in colorectal surgery.

PURPOSE: Laparoscopy is the approach of choice for the majority of colorectal disorders that require a minimally invasive abdominal operation. As the emphasis on minimizing the technique continues, natural orifice surgery is quickly evolving. The authors utilized an embryologic natural orifice, the umbilicus, as sole access to the abdomen to perform a colorectal procedure. Herein, we present our initial experience of single-port laparoscopic colorectal surgery using a Uni-X Single-Port Access Laparoscopic System (Pnavel Systems, Morganville, New Jersey, USA) with a multi-channel cannula and specially designed curved laparoscopic instrumentation. METHOD: The abdomen was approached through a 3.5 cm incision via the umbilicus and a single-port access device was utilized to perform a right hemicolectomy on a patient with an unresectable caecal polyp and a body mass index of 35. Ligation of the ileocolic artery was done with a LigaSure Device (Covidien Ltd, Norwalk, Connecticut, USA), and was followed by colonic mobilization, extraction and extracorporeal ileocolic anastomosis. RESULTS: The total operative time was 115 min with minimal blood loss. Hospital stay was 4 days with no undue sequelae. CONCLUSION: Single-port laparoscopic surgery may allow common colorectal laparoscopic operations to be performed entirely through the patient's umbilicus and enable an essentially scarless procedure. Additional experience and continued investigation are warranted.

Robot-assisted laparoscopic excision of prostatic utricle in a 3-year old.

Prostatic utricles have traditionally been excised via the open approach or laparoscopically. Recently, the robot-assisted laparoscopic approach has been described in a 19-year-old male. the case of a 3-year-old male with a disorder of sex development (mosaic 45X/46 XY), with multiple associated anomalies, who presented with recurrent UTI is presented. Renal/bladder ultrasound revealed normal bilateral kidneys, and a 4.3 × 2.8 × 3.3 cm cystic mass in the midline posterior to the bladder. Voiding cystourethrogram demonstrated a large cystic mass behind the bladder, concerning for large prostatic utricle. The patient was brought to the operating room and placed in lithotomy. The urethra was examined cystoscopically. The os of the utricle was identified, an open-ended catheter was advanced, the cystoscope was removed, and a Foley was placed. The camera port was introduced supraumbilically, and robotic ports were introduced inferolaterally. Irrigation of the catheter and distension of the utricle allowed manipulation of the utricle to facilitate identification of a plane of dissection. The neck of the utricle was identified and incised. The catheter was removed, transection was completed, and the stump was oversewn. CONCLUSION: Combined cystoscopic and robotic approach to prostatic utricle excision is feasible, safe, and effective in this patient population.

Minimally invasive management of renal cancer.

In the last two decades, the diagnosis and treatment of renal cancer were influenced by new technologies and surgical techniques. The new radiologic methods had a major impact in detecting smaller and asymptomatic tumors, while the minimally invasive options have offered a low-morbidity and high-efficacy individualized treatments to the patients, based on tumor characteristics and associated comorbidities. Herein we present a contemporary review of the minimally invasive approaches to the renal cancer, supported by the large experience with these therapeutic methods at the Cleveland Clinic.

Laparoscopic radical cystoprostatectomy with ileal conduit performed completely intracorporeally: the initial 2 cases.

OBJECTIVES: To present the initial 2 patients who underwent laparoscopic radical cystoprostatectomy, bilateral pelvic lymphadenectomy, and ileal conduit urinary diversion, with the entire procedure performed exclusively by intracorporeal laparoscopic techniques. METHODS: Two male patients, 78 and 70 years old, with muscle-invasive, organ-confined, transitional cell carcinoma of the urinary bladder underwent the procedure. The entire procedure, including radical cystoprostatectomy, pelvic node dissection, isolation of the ileal loop, restoration of bowel continuity with stapled side-to-side ileoileal anastomosis, retroperitoneal transfer of the left ureter to the right side, and bilateral stented ileoureteral anastomoses were all performed exclusively by intracorporeal laparoscopic techniques. Free-hand laparoscopic suturing and in situ knot-tying techniques were used exclusively. RESULTS: The surgical time was 11.5 hours in the first patient and 10 hours in the second. The respective blood loss was 1200 mL and 1000 mL. In both patients, ambulation resumed on postoperative day 2, bowel sounds on day 3, and oral intake on day 4; the hospital stay was 6 days. Narcotic analgesia comprised 108.3 mg and 16.5 mg of morphine sulfate equivalent, respectively. Pathologic examination revealed pT4N0M0 (prostate) and pT2bN0M0 transitional cell carcinoma of the bladder with the surgical margins negative for cancer in both patients. No intraoperative or postoperative complications occurred in either patient. CONCLUSIONS: To our knowledge, this is the initial report of laparoscopic radical cystoprostatectomy with intracorporeal ileal conduit urinary diversion. We believe that with further experience and refinement in the operative technique, laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion may become an attractive treatment option for selected candidates with localized muscle-invasive bladder cancer.

Retroperitoneal laparoscopic nephroureterectomy and management options for the distal ureter.

Radical nephroureterectomy, including en bloc excision of the ureter with a bladder cuff, is the standard treatment for upper tract transitional-cell carcinoma (TCC). This procedure requires either a flank and lower abdominal incision or an extended flank incision. Laparoscopic surgery for TCC has been used at several medical centers; the most challenging and controversial aspect is the oncologically correct management of the distal ureter. We believe that the Cleveland Clinic technique of securing the distal bladder cuff intravesically while simultaneously occluding the distal ureter prevents tumor spillage and allows accurate and complete resection of the targeted ureter in a manner mirroring the open procedure.

Laparoscopic renal autotransplantation.

BACKGROUND AND PURPOSE: Renal autotransplantation is an extensive open surgical operation consisting of two distinct procedures, live-donor nephrectomy and autotransplantation, and requiring two large skin incisions. Herein, we analyze the feasibility of performing the entire procedure laparoscopically. MATERIALS AND METHODS: Renal autotransplantation was performed entirely laparoscopically in six female farm pigs. Following a left donor nephrectomy, intracorporeal renal hypothermia was achieved by intra-arterial perfusion of ice-cold solution through a 4F balloon catheter. During autotransplantation, the renal vessels were anastomosed intracorporeally to the previously prepared ipsilateral common iliac vessels in an end-to-side fashion. Laparoscopic freehand suturing (5-0 Prolene) and knot-tying techniques were employed exclusively. A staged contralateral native nephrectomy was performed in five animals. Postoperative follow-up included serial creatinine measurements, intravenous urography, aortography, and renal histologic examination. RESULTS: The mean operating time was 6.2 hours (range 5.3-7.9 hours), the venous anastomosis time was 33 minutes (range 22-46 minutes), the arterial anastomosis time was 31 minutes (range 27-35 minutes), and the total iliac clamping time was 77 minutes (range 62-88 minutes). The total renal ischemia time was 68.7 minutes: warm ischemia 5.1 minutes, cold ischemia 33 minutes and rewarming 31 minutes. Serum creatinine concentrations remained stable: baseline 1.3 mg/dL, after autotransplantation 1.1 mg/dL, and after contralateral nephrectomy 1.6 mg/dL. Intravenous urography and aortography prior to euthanasia (N = 5) demonstrated prompt contrast uptake and excretion by the autotransplanted kidneys and patent arterial anastomoses, respectively. Histopathologic examination of the autograft demonstrated normal renal architecture. CONCLUSIONS: Renal autotransplantation can be performed utilizing laparoscopic techniques exclusively. This study may form the basis for performance of complex urologic vascular procedures laparoscopically.

Laparoscopic orthotopic ileal neobladder.

BACKGROUND AND PURPOSE: Orthotopic ileal neobladder is currently the preferred continent urinary diversion in suitable patients undergoing radical cystectomy for muscle-invasive bladder cancer. To our knowledge, presented herein is the initial report of laparoscopic orthotopic ileal neobladder following cystectomy that was performed completely intracorporeally in a porcine model. MATERIALS AND METHODS: The laparoscopic technique was developed in seven pigs. Subsequently, a long-term survival study was performed in 12 consecutive animals. Laparoscopic cystectomy was performed, preserving the urethral sphincter. An ileal segment of 35 cm (first three animals), 45 cm (next four), or 55 cm (final five animals) with adequate mesentery was isolated; and ileal continuity was restored intracorporeally by a stapled anastomosis. Ileal detubularization for construction of an ileal neobladder, urethroileal anastomosis, and bilateral stented ileoureteral anastomoses to a tubular Studer limb extension were all created completely intracorporeally using only laparoscopic free-hand suturing and knot-tying. Biochemical data (preoperative and serial postoperative hemoglobin, renal panel, blood gases), radiologic studies (intravenous urogram, retrograde pouchgram), functional measures (neobladder urodynamics, Whitaker pressure-flow study of both ureters), and microscopic evaluation of the neobladder and ureteroileal and urethroileal anastomotic sites were obtained to evaluate the long-term functional and anatomic outcome. RESULTS: Completely intracorporeal laparoscopic construction of an ileal orthotopic neobladder was successful in all 12 animals without intraoperative or early postoperative complications or open conversion. The mean operating time was 5.4 hours (range 4.5-6.5 hours), and the blood loss was minimal. All study pigs survived their predetermined follow-up period, ranging from 1 to 3 months. Late complications occurred in three animals: one port-site abscess and two cases of E. coli pyelonephritis and azotemia, leading to one death at 2 months. The mean serum creatinine concentrations were 1.33 mg/dL, 1.61 mg/dL, and 1.55 mg/dL at 1, 2, and 3 months, respectively. The mean neobladder capacity was 420 mL (range 250-700 mL) with pressures < or = 20 cm H2O (range 17-20 cm H2O). Pre-euthanasia Whitaker testing confirmed excellent drainage in all 24 ureters. No ileoureteral or ileourethral anastomotic strictures or leaks were noted on intravenous urography, retrograde pouchgram, or postmortem physical calibration of the anastomotic sites. Histologic examination confirmed excellent healing without obvious fibrosis. CONCLUSION: Laparoscopic construction of an orthotopic neobladder is feasible. The anatomic and functional outcome is excellent and comparable to that of open surgery. Clinical application is imminent.