Low-cost reusable instrumentation for laparoendoscopic single-site nephrectomy: assessment in a porcine model

PURPOSE: To test different sets of prebent instruments and a new reusable access device for laparoendoscopic single-site (LESS) surgery. MATERIALS AND METHODS: Three surgeons with previous experience in LESS performed 12 nephrectomies in six pigs. In all procedures, a multichannel access device (X-CONE) and a 5-mm extra-long telescope were used. Four sets of prebent instruments with different profiles (S-portal) were tested: Standard (one straight scissors and one curved grasper), Cuschieri, Carus, and Leroy set (each of them consisting of two curved instruments with different configurations). Assessment was performed based on both objective (procedure time; time to manage the pedicle; time to free kidney) and subjective parameters (entry/exit of instruments; triangulation; dissection up/down; dissection lateral; retraction; interdependence). The subjective assessment tool used was a Likert type scale (1 = easy to 5 = prohibitive). The access device was assessed by using objective (time to complete insertion of device after skin incision) and subjective (significant air leakage, movement constraint) parameters. RESULTS: Time to insertion of the X-CONE was <1 minute in all the cases. Surgeons reported significant insufflant leakage in 58% of cases. The procedure was completed in 10/12 (83%) cases. Mean operative time was 8.3 ± 4.2 minutes, being lower for the Carus group (4.5 min) and higher for the standard group (13 min). Among the different sets, the standard one obtained the best mean scores for all subjective parameters. CONCLUSIONS: X-CONE allows easy abdominal access, and its reusable properties represent cost savings for LESS compared with disposable devices. Prebent instruments might also represent attractive low-cost tools for LESS

Low-cost reusable instrumentation for laparoendoscopic single-site nephrectomy: assessment in a porcine model

PURPOSE: To test different sets of prebent instruments and a new reusable access device for laparoendoscopic single-site (LESS) surgery. MATERIALS AND METHODS: Three surgeons with previous experience in LESS performed 12 nephrectomies in six pigs. In all procedures, a multichannel access device (X-CONE) and a 5-mm extra-long telescope were used. Four sets of prebent instruments with different profiles (S-portal) were tested: Standard (one straight scissors and one curved grasper), Cuschieri, Carus, and Leroy set (each of them consisting of two curved instruments with different configurations). Assessment was performed based on both objective (procedure time; time to manage the pedicle; time to free kidney) and subjective parameters (entry/exit of instruments; triangulation; dissection up/down; dissection lateral; retraction; interdependence). The subjective assessment tool used was a Likert type scale (1 = easy to 5 = prohibitive). The access device was assessed by using objective (time to complete insertion of device after skin incision) and subjective (significant air leakage, movement constraint) parameters. RESULTS: Time to insertion of the X-CONE was <1 minute in all the cases. Surgeons reported significant insufflant leakage in 58% of cases. The procedure was completed in 10/12 (83%) cases. Mean operative time was 8.3 ± 4.2 minutes, being lower for the Carus group (4.5 min) and higher for the standard group (13 min). Among the different sets, the standard one obtained the best mean scores for all subjective parameters. CONCLUSIONS: X-CONE allows easy abdominal access, and its reusable properties represent cost savings for LESS compared with disposable devices. Prebent instruments might also represent attractive low-cost tools for LESS

Consensus statement on natural orifice transluminal endoscopic surgery and single-incision laparoscopic surgery: heralding a new era in urology?

[Excerpt] For decades, urologists have implemented technologies that provide effective treatment while limiting morbidity. In many instances, this has been achieved by operating via natural body openings (eg, cystoscopy, transurethral resection, and ureteroscopy) [1,2]. Urologists have also pioneered novel techniques to address clinical situations where access through natural body openings was impossible, such as percutaneous stone surgery, laparoscopy, and robotics [3–5].[...

Head to Head Impact of Margin, Ischemia, Complications, Score Versus a Novel Trifecta Score on Oncologic and Functional Outcomes After Robotic-assisted Partial Nephrectomy: Results of a Multicenter Series

BACKGROUND: There is a paucity of data describing the ability of margin, ischemia, complications, score (MIC) and trifecta in predicting long-term outcomes of robotic-assisted partial nephrectomy (RAPN).OBJECTIVE: To compare a novel trifecta (negative margins, no significant complications, and perioperative estimated glomerular filtration rate [eGFR] decrease 6430%) versus standard MIC as predictors of oncologic and functional results in a large series of RAPNs.DESIGN, SETTING, AND PARTICIPANTS: Between 2009 and 2019, a multicenter dataset was queried for patients with nonmetastatic renal masses who underwent RAPN at eight participating institutions.INTERVENTION: RAPN.OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: MIC and trifecta achievement were determined for the overall cohort and a subgroup undergoing off-clamp RAPN (ocRAPN), respectively. The overall survival (OS), recurrence-free survival (RFS), and new onset of end-stage renal disease (ESRD; defined as eGFR &lt;30 ml/min) probabilities were assessed by the Kaplan-Meier method. Cox regression analyses were used to identify predictors of OS, RFS, and ESRD. For all analyses, two-sided p &lt; 0.05 was considered significant.RESULTS AND LIMITATIONS: Out of 1807 patients, MIC and trifecta were achieved in 71.1% (n = 1285) and 82.6% (n = 1492), respectively, and once restricted to the ocRAPN cohort, in 95.6% (n = 625) and 81.6% (n = 534), respectively. On Kaplan-Meier analysis, both MIC and trifecta achievement predicted higher OS and lower ESRD probabilities (all p &lt; 0.014), while only trifecta achievement was a predictor of RFS probabilities (p = 0.009). On multivariable Cox regression, MIC did not predict any of the endpoints independently, while trifecta achievement was an independent predictor of higher OS (hazard ratio [HR] 0.4, 95% confidence interval [CI] 0.18-0.86; p = 0.019) and lower ESRD development probabilities (HR 0.32, 95% CI 0.15-0.72; p = 0.005).CONCLUSIONS: Trifecta, initially described as comprehensive measures of perioperative outcomes, needs to stand the test of time. Compared with MIC, the recent trifecta was an independent predictor of clinically significant endpoints, namely, survival and ESRD development probabilities.PATIENT SUMMARY: Our novel trifecta represents a reliable method for estimating survival and development of end-stage renal disease after robotic-assisted partial nephrectomy

Outcomes and predictors of benign histology in patients undergoing robotic partial or radical nephrectomy for renal masses: A multicenter study

Introduction Theaim of this study was to assess preoperative factors associated with benign histology in patients undergoing surgical removal of a renal mass and to analyze outcomes of robotic partial nephrectomy (PN) and radical nephrectomy (RN) for these masses. Material and methods Overall, 2,944 cases (543 benign and 2,401 malignant) who underwent robotic PN and RN between 2003–2018 at 10 institutions worldwide were included. The assessment of the predictors of benign histology was made at the final surgical pathology report. Descriptive statistics, Mann-Whitney U, Pearson’s χ2, and logistic regression analysis were used. Results Patients in the benign group were mostly female (61 vs. 33%; p <0.001), with lower body mass index (BMI) (26.0 vs. 27.1 kg/m2; p <0.001). The benign group presented smaller tumor size (2.8 vs. 3.5 cm; p <0.001), R.E.N.A.L. score (6.0 vs. 7.0; p <0.001). There was a lower rate of hilar (11 vs.18%; p = 0.001), cT≥3 (1 vs. 4.5%; p <0.001) tumors in the benign group. There was a statistically significant higher rate of PN in the benign group (97 vs. 86%; p <0.001) as well as a statistically significant lower 30-day re-admission rate (2 vs. 5%; p = 0.081). Multivariable analysis showed male gender (OR: 0.52; p <0.001), BMI (OR: 0.95; p <0.001), and cT3a (OR: 0.22; p = 0.005) to be inversely associated to benign histology. Conclusions In 18% of cases, a benign histologic type was found. Only 3% of these tumors were treated with RN. Female gender, lower BMI, and higher T staging showed to be independent predictors of benign histology

Initial experience of transumbilical laparoendoscopic single-site surgery of partial adrenalectomy in patient with aldosterone-producing adenoma

<p>Abstract</p> <p>Background</p> <p>Laparoscopic single-site surgery has recently emerged in the field of urology and this minimally-invasive surgery has resulted in a further reduction in morbidity compared with traditional laparoscopy. We present our initial experience with laparoendoscopic single-site surgery of partial adrenalectomy (LESS-PA) to treat aldosterone-producing adenomas.</p> <p>Case presentation</p> <p>A 60-year-old woman was diagnosed with aldosterone-producing macroadenomas in the left adrenal and aldosterone-producing microadenomas in the right adrenal. A two-step operation was planned. The first step involved transumbilical LESS-PA for the left adrenal tumors. A multichannel port was inserted through the center of the umbilicus and the left adrenal gland was approached using bent instruments according to standard traditional laparoscopic procedures. The tumors were resected using an ultrasonic scalpel, and the resected site was coagulated using a vessel sealing instrument and then sealed with fibrin glue. Operative time was 123 minutes and blood loss was minimal. The patient was discharged from hospital within 72 hours. Her right adrenal microadenomas will be treated in the next several months.</p> <p>Conclusions</p> <p>Although our experience is limited, LESS-PA appears to be safe and feasible for treating aldosterone-producing adenomas. More cases and comparisons with the multiport technique are needed before drawing any definite conclusions concerning the technique.</p