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SINGLE INCISION TRANS - URETERAL (SITU) LAPAROSCOPIC NEPHRECTOMY
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THE JOURNAL OF UROLOGY®
METHODS: A retrospective review of single port robotic surgery was performed. Patient demographics, peri-operative data, pain assessment and operative times were obtained. Single port robotic surgery was performed in patients suitable for standard laparoscopy. Exclusion criteria included patients with advanced malignancy, multiple abdominal or renal surgeries and those with a solitary kidney. Single port access was achieved via a commercially available multi-channel port. The daVinci-S® surgical platform using pediatric instruments were used. RESULTS: Nine single port robotic procedures were completed without complicatons or use of additional ports. Surgeries included radical prostatectomy (n = 1), radical nephrectomy (n = 1), ureteral reimplantation (n = 1), dismembered pyeloplasty (n = 2), partial nephrectomy (n = 2), sacrocolpopexy (n = 1), and nephroureterectomy (n = 1). Control of the renal artery and vein during radical nephrectomy was achieved using Hem-O-Lok clips. Suture ligation of the dorsal venous complex was completed intracorporeally. The urethral-vesical and uretero-pelvic anastamoses were completed without additional ports using a running suture technique. During partial nephrectomy under normal renal perfusion, renal tumor excision was performed using a Harmonic scalpel. Surgical margins for all cancer-related procedures were negative. No evidence of pelvic organ prolapse has been noted at 4 month followup. CONCLUSIONS: Application of the robotic platform during single port surgery may represent the next step in its evolution. The improved articulation offered by robotics may expand and disseminate the role and reproducibility of single port surgery. Source of Funding: None
1202 LAPROENDOSCOPIC SINGLE SITE(LESS) LIVE DONOR NEPHRECTOMY:A SINGLE CENTRE EXPERIENCE Arvind P Ganpule*, Abraham Kurien, Divya R Dhawan, Ravindra B Sabnis, Veeramani Muthu, Mahesh R Desai, Nadiad, India INTRODUCTION AND OBJECTIVES:We present our experience of 10 patients ,who underwent Laproendoscopic single site (LESS) live donor nephrectomy (LDN). We describe technical considerations and modifications . METHODS: Pneumoperitoneum was established via a 2 mm Veress needle port in 1 case and in rest by open technique. A single access tri/ quadri - lumen R-port (Advanced Medical concepts, Dublin, Ireland) was inserted through an umbilical incision. In all standard laparoscopic instruments were used. 9 cases had single and one had double vessel. Donor kidney was pre-positioned near the umbilical extraction site for easy retrieval by hand. RESULTS: Mean age was 46.11 + 17.71 yrs, BMI was 23.18 + 4.6 kg/m2 (range 17.9 - 29.78 kg/m2). Mean operating time was 240 + 19.67 min (range 90 - 240 min), blood loss was 144.44 + 85.87 cc (range 50 - 300 cc), Warm ischemia time was 6.94 + 1.88 minutes (range 4 - 10 min) and hospital stay was 5 + 1.99 days (range 3 - 5 days). Right LESS donor nephrectomy was done in one case. Mean length of renal artery was 3.71 cm (range 3 - 4.3 cm), renal vein 3.8 cm and ureter lenght was14.56 (range 13 - 16 cm). Mean retrieval incision length was 5.3 cm. Except for a small 3 mm upper polar tear in right LDN, no intraoperative complication was noticed. All allografts functioned immediately. Donor visual analog pain scores were 0/10 at 2 weeks. CONCLUSIONS: LESS donor nephrectomy is safe, efficient and feasible. Apart from enhanced cosmesis, LESS donor Nephrectomy offers the patient reduced pain. LESS LDN on right side and in donors with double vessels is technically feasible. Source of Funding: None
Vol. 181, No. 4, Supplement, Monday, April 27, 2009
1203 SINGLE INCISION TRANS - URETERAL (SITU) LAPAROSCOPIC NEPHRECTOMY Andrei Nadu*, Oscar Schatloff, Jacob Ramon, Tel Hashomer, Israel INTRODUCTION AND OBJECTIVES: NOTES (Natural Orifices Transluminal Endoscopic Surgery) and single incision surgery have been recently reported as feasible approaches to laparoscopic nephrectomy. We present a novel, hybrid technique that combines single incision laparoscopic nephrectomy with NOTES principles by using the ureteral stump as a natural orifice. METHODS: Six renal units were operated in a non survival study on female pigs by using a hybrid approach that combines a single umbilical incision with the natural orifice provided by the divided ipsilateral ureter. A transurethral 16 F Amplatz sleeve inserted in the ureter under cystoscopic guidance became a natural orifice port after transection of the ureter. Two adjacent ports (5 and 12 mm) were introduced through a single umbilical incision. The camera was placed in one of the umbilical ports and two operating instruments were introduced through the additional umbilical port and the “natural orifice port” respectively. Operative time, blood loss, complications were recorded. RESULTS: Right and left laparoscopic nephrectomy were successfully performed. No complications occurred except one case of a periureteral hematoma due to the dilation of the ureter. The hylar blood vessels were thoroughly dissected and controlled by either clips or vascular staplers. The blood loss was under 50 cc in all cases. The operative time decreased from 140 minutes in the first procedure to 70 minutes in the last (median 85 minutes). The learning curve was short as basic principles of laparoscopy like correct instrument angulation could be achieved through the inferior, natural orifice port. CONCLUSIONS: Laparoscopic nephrectomy combining a single umbilical incision with a natural orifice provided by the ipsilateral ureter is technically feasible. The divided ureter seems to provide a useful natural orifice. Further experience together with assessment of advantages over classic laparoscopic nephrectomy are needed. Source of Funding: None
1204 NOTES TRANS-GASTRIC PARTIAL CYSTECTOMY Irma J Lengu*, Matthew L Steinway, Mark D Sawyer, Joseph A Trunzo, Edward E Cherullo, Lee E Ponsky, Cleveland, OH INTRODUCTION AND OBJECTIVES: Partial cystectomy is indicated for solitary muscle invasive bladder tumors involving the dome or located in a bladder diverticulum, as well as non-invasive bladder tumors, which are not amendable to trans-urethral resection. We investigated the feasibility of performing trans-gastric partial cystectomy in a porcine model. METHODS: Peritoneum was accessed through a gastrotomy incision using an Olympus R Gastroscope. A bladder lesion was created in a trans-urethral fashion at the time of the operation. The bladder was accessed ultimately with a 22F Rigid cystoscope. A pre-marked 2cm flexible tip wire was used to make a 2x2cm lesion, using cautery with needle knife at 4 corners. It was observed transgastrically to avoid bowel injury. The same wire was used to make 2cm margins at each corner. At the margins, methylene blue was injected in the bladder wall, which was visualized transgastrically. An endoloop was applied through the gastroscope and secured slightly passed the marked margins. A second loop was placed distally to the first. A needle knife was used to cauterize between the two loops. Endoclips were applied in full thickness to close the cystotomy. The cystoscope was exchanged for Council-tip catheter. The closure was tested and observed transgastrically for a leak. If a leak was noted, additional clips were applied. The specimen was extracted with the gastrosope, using an endocatch bag. The gastrostomy was closed with clips. Bladder lesion size and margins were recorded. The swine were survived for 14 days. A cystogram was performed on day 14. Necropsy was performed. RESULTS: The procedure was performed successfully in 5 female
THE JOURNAL OF UROLOGY®
METHODS: A retrospective review of single port robotic surgery was performed. Patient demographics, peri-operative data, pain assessment and operative times were obtained. Single port robotic surgery was performed in patients suitable for standard laparoscopy. Exclusion criteria included patients with advanced malignancy, multiple abdominal or renal surgeries and those with a solitary kidney. Single port access was achieved via a commercially available multi-channel port. The daVinci-S® surgical platform using pediatric instruments were used. RESULTS: Nine single port robotic procedures were completed without complicatons or use of additional ports. Surgeries included radical prostatectomy (n = 1), radical nephrectomy (n = 1), ureteral reimplantation (n = 1), dismembered pyeloplasty (n = 2), partial nephrectomy (n = 2), sacrocolpopexy (n = 1), and nephroureterectomy (n = 1). Control of the renal artery and vein during radical nephrectomy was achieved using Hem-O-Lok clips. Suture ligation of the dorsal venous complex was completed intracorporeally. The urethral-vesical and uretero-pelvic anastamoses were completed without additional ports using a running suture technique. During partial nephrectomy under normal renal perfusion, renal tumor excision was performed using a Harmonic scalpel. Surgical margins for all cancer-related procedures were negative. No evidence of pelvic organ prolapse has been noted at 4 month followup. CONCLUSIONS: Application of the robotic platform during single port surgery may represent the next step in its evolution. The improved articulation offered by robotics may expand and disseminate the role and reproducibility of single port surgery. Source of Funding: None
1202 LAPROENDOSCOPIC SINGLE SITE(LESS) LIVE DONOR NEPHRECTOMY:A SINGLE CENTRE EXPERIENCE Arvind P Ganpule*, Abraham Kurien, Divya R Dhawan, Ravindra B Sabnis, Veeramani Muthu, Mahesh R Desai, Nadiad, India INTRODUCTION AND OBJECTIVES:We present our experience of 10 patients ,who underwent Laproendoscopic single site (LESS) live donor nephrectomy (LDN). We describe technical considerations and modifications . METHODS: Pneumoperitoneum was established via a 2 mm Veress needle port in 1 case and in rest by open technique. A single access tri/ quadri - lumen R-port (Advanced Medical concepts, Dublin, Ireland) was inserted through an umbilical incision. In all standard laparoscopic instruments were used. 9 cases had single and one had double vessel. Donor kidney was pre-positioned near the umbilical extraction site for easy retrieval by hand. RESULTS: Mean age was 46.11 + 17.71 yrs, BMI was 23.18 + 4.6 kg/m2 (range 17.9 - 29.78 kg/m2). Mean operating time was 240 + 19.67 min (range 90 - 240 min), blood loss was 144.44 + 85.87 cc (range 50 - 300 cc), Warm ischemia time was 6.94 + 1.88 minutes (range 4 - 10 min) and hospital stay was 5 + 1.99 days (range 3 - 5 days). Right LESS donor nephrectomy was done in one case. Mean length of renal artery was 3.71 cm (range 3 - 4.3 cm), renal vein 3.8 cm and ureter lenght was14.56 (range 13 - 16 cm). Mean retrieval incision length was 5.3 cm. Except for a small 3 mm upper polar tear in right LDN, no intraoperative complication was noticed. All allografts functioned immediately. Donor visual analog pain scores were 0/10 at 2 weeks. CONCLUSIONS: LESS donor nephrectomy is safe, efficient and feasible. Apart from enhanced cosmesis, LESS donor Nephrectomy offers the patient reduced pain. LESS LDN on right side and in donors with double vessels is technically feasible. Source of Funding: None
Vol. 181, No. 4, Supplement, Monday, April 27, 2009
1203 SINGLE INCISION TRANS - URETERAL (SITU) LAPAROSCOPIC NEPHRECTOMY Andrei Nadu*, Oscar Schatloff, Jacob Ramon, Tel Hashomer, Israel INTRODUCTION AND OBJECTIVES: NOTES (Natural Orifices Transluminal Endoscopic Surgery) and single incision surgery have been recently reported as feasible approaches to laparoscopic nephrectomy. We present a novel, hybrid technique that combines single incision laparoscopic nephrectomy with NOTES principles by using the ureteral stump as a natural orifice. METHODS: Six renal units were operated in a non survival study on female pigs by using a hybrid approach that combines a single umbilical incision with the natural orifice provided by the divided ipsilateral ureter. A transurethral 16 F Amplatz sleeve inserted in the ureter under cystoscopic guidance became a natural orifice port after transection of the ureter. Two adjacent ports (5 and 12 mm) were introduced through a single umbilical incision. The camera was placed in one of the umbilical ports and two operating instruments were introduced through the additional umbilical port and the “natural orifice port” respectively. Operative time, blood loss, complications were recorded. RESULTS: Right and left laparoscopic nephrectomy were successfully performed. No complications occurred except one case of a periureteral hematoma due to the dilation of the ureter. The hylar blood vessels were thoroughly dissected and controlled by either clips or vascular staplers. The blood loss was under 50 cc in all cases. The operative time decreased from 140 minutes in the first procedure to 70 minutes in the last (median 85 minutes). The learning curve was short as basic principles of laparoscopy like correct instrument angulation could be achieved through the inferior, natural orifice port. CONCLUSIONS: Laparoscopic nephrectomy combining a single umbilical incision with a natural orifice provided by the ipsilateral ureter is technically feasible. The divided ureter seems to provide a useful natural orifice. Further experience together with assessment of advantages over classic laparoscopic nephrectomy are needed. Source of Funding: None
1204 NOTES TRANS-GASTRIC PARTIAL CYSTECTOMY Irma J Lengu*, Matthew L Steinway, Mark D Sawyer, Joseph A Trunzo, Edward E Cherullo, Lee E Ponsky, Cleveland, OH INTRODUCTION AND OBJECTIVES: Partial cystectomy is indicated for solitary muscle invasive bladder tumors involving the dome or located in a bladder diverticulum, as well as non-invasive bladder tumors, which are not amendable to trans-urethral resection. We investigated the feasibility of performing trans-gastric partial cystectomy in a porcine model. METHODS: Peritoneum was accessed through a gastrotomy incision using an Olympus R Gastroscope. A bladder lesion was created in a trans-urethral fashion at the time of the operation. The bladder was accessed ultimately with a 22F Rigid cystoscope. A pre-marked 2cm flexible tip wire was used to make a 2x2cm lesion, using cautery with needle knife at 4 corners. It was observed transgastrically to avoid bowel injury. The same wire was used to make 2cm margins at each corner. At the margins, methylene blue was injected in the bladder wall, which was visualized transgastrically. An endoloop was applied through the gastroscope and secured slightly passed the marked margins. A second loop was placed distally to the first. A needle knife was used to cauterize between the two loops. Endoclips were applied in full thickness to close the cystotomy. The cystoscope was exchanged for Council-tip catheter. The closure was tested and observed transgastrically for a leak. If a leak was noted, additional clips were applied. The specimen was extracted with the gastrosope, using an endocatch bag. The gastrostomy was closed with clips. Bladder lesion size and margins were recorded. The swine were survived for 14 days. A cystogram was performed on day 14. Necropsy was performed. RESULTS: The procedure was performed successfully in 5 female