Robot-assisted, Single-site, Dismembered Pyeloplasty for Ureteropelvic Junction Obstruction with the New da Vinci Platform: A Stage 2a Study

Comparison of the safety and efficacy of laparoscopic single-incision triangulated umbilical surgery pyeloplasty with traditional three-hole surgery in a pediatric tertiary center

OBJECTIVE

To report the application of laparoscopic single-incision triangulated umbilical surgery (SITUS) pyeloplasty in children with ureteropelvic junction obstruction (UPJO) and compare its feasibility and efficacy with traditional three-hole laparoscopic pyeloplasty.

METHODS

Data from children with UPJO who underwent SITUS between July 2018 and August 2021 were included in this retrospective study and patients who were treated with traditional laparoscopic pyeloplasty were chosen for comparison. Thirty-two patients from SITUS group and 72 patients from traditional group were reviewed. The clinical characteristics, complications, and follow-up results were collected and compared.

RESULTS

The preoperative demographic data and imaging parameters, including sex, surgical side, age, BMI, and preoperative anterior-posterior pelvic diameter (APD), showed no significant differences between the two groups. The median surgical time was 135 min (IQR: 119.75-160.5) in SITUS group, while 163.5 min (IQR: 141.25-187.5) in the traditional group (p = 0.0008). Two Clavien-Dindo III complications (6.25%) in SITUS group and 11 (15.3%) in the traditional group were recorded (p = 0.335). The success rate was 100% (32/32) in SITUS group and 94% (68/72) in the traditional group (p = 0.309).

CONCLUSION

SITUS pyeloplasty is a feasible and effective laparo-endoscopic single-site (LESS) technique for pediatric patients with excellent cosmetic results comparable to the conventional laparoscopic pyeloplasty. More cases and longer follow-up periods are needed to determine the exact outcomes of the modified LESS technique.

Robotic reconstruction for benign upper urinary tract obstruction: a review of the current literature

The field of reconstructive urology has seen a paradigm shift in the surgical approach for intra-abdominal cases, resulting in an increased preference for minimally invasive techniques. The introduction of the surgical robot has led to exponential growth in innovative approaches, reflecting the ongoing efforts to improve patient outcomes and address the limitations of open and laparoscopic surgery. This review article summarizes the knowledge gained in the last 10 years about adult robotic ureteral reconstruction. A non-systematic literature review was conducted on February 18, 2024 using Medline, PubMed, Web of Science, and Embase libraries. Studies published in English since 2014 reporting at least five robotic ureteral reconstructive cases for the management of benign ureteral obstruction in adults were included. A narrative review focusing on robotic ureteral reconstructive techniques, their associated success and complication rates, and how the robotic approach compares to open and laparoscopic reconstruction was performed. The current literature demonstrates increased utilization of the robotic platform in reconstructive urological procedures. Robotic surgery has been shown to be associated with shorter learning curves, lower surgeon fatigue, better visualization and equivalent results to those seen with laparoscopic surgery. While the literature is limited by a lack of comparative data, well-designed randomized controlled trials, and standardized criteria for defining and measuring success, this review demonstrates the safety, feasibility, and efficacy of robotic ureteral reconstruction for managing benign ureteral strictures, confirming it as a viable alternative to open and laparoscopic surgery.

Robot-assisted radical nephroureterectomy using the KangDuo Surgical Robot-01 System versus the da Vinci System: a multicenter prospective randomized controlled trial

INTRODUCTION

We aim to compare the safety and effectiveness of the KangDuo (KD)-Surgical Robot-01 (KD-SR-01) system and the da Vinci (DV) system for robot-assisted radical nephroureterectomy (RARNU).

MATERIALS AND METHODS

This multicenter prospective randomized controlled trial was conducted between March 2022 and September 2023. Group 1 included 29 patients undergoing KD-RARNU. Group 2 included 29 patients undergoing DV-RARNU. Patient demographic and clinical characteristics, perioperative data, and follow-up outcomes were collected prospectively and compared between the two groups.

RESULTS

There were no significant differences in patient baseline demographic and preoperative characteristics between the two groups. The success rates in both groups were 100% without conversion to open or laparoscopic surgery or positive surgical margins. No significant difference was observed in docking time [242 (120-951) s vs 253 (62-498) s, P = 0.780], console time [137 (55-290) min vs 105 (62-220) min, P = 0.114], operative time [207 (121-460) min vs 185 (96-305) min, P = 0.091], EBL [50 (10-600) mL vs 50 (10-700) mL, P = 0.507], National Aeronautics and Space Administration Task Load Index scores, and postoperative serum creatinine levels between the two groups. None of the patients showed evidence of distant metastasis, local recurrence, or equipment-related adverse events during the four-week follow-up. One (3.4%) patient in Group 2 experienced postoperative enterovaginal and enterovesical fistulas (Clavien-Dindo grade III).

CONCLUSIONS

The KD-SR-01 system is safe and effective for RARNU compared to the DV Si or Xi system. Further randomized controlled studies with larger sample sizes and longer durations are required.

Development of the European Laparoscopic Intermediate Urological Skills LUSs2 Curriculum: A Delphi Consensus from the European School of Urology

Background and objective

While programmes such as the European Basic Laparoscopic Urological Skills have made strides in foundational training, a significant gap exists for intermediate and advanced laparoscopy education. Our objective is to develop and validate the European laparoscopic intermediate urological skills (LUSs2) curriculum, which will establish uniformity in the training of urological laparoscopic procedures and facilitate proficiency among practitioners.

Methods

The study combines a literature review, cognitive task analysis development by a steering group, and a two-round Delphi survey involving international experts in urological laparoscopy. Consensus was defined as agreement of ≥70% among experts. The survey included statements on various laparoscopic procedures, assessed on a Likert scale from 1 (strongly disagree) to 9 (strongly agree).

Key findings and limitations

The Delphi process achieved consensus on 85% (235/275) of statements, indicating a strong agreement on the curriculum's content. Areas covered include renal hilum dissection, major vessel injury management, enucleation and renorrhaphy, vesicourethral anastomosis, and pyeloplasty. Limitations include the nonsystematic nature of the literature review and potential biases inherent in expert-based consensus methods.

Conclusions and clinical implications

The LUSs2 curriculum significantly advances the standardised training of laparoscopic urological skills. It offers a detailed, consensus-validated framework that addresses the need for uniformity in surgical education and aims to enhance surgical proficiency and patient care.

Patient summary

This study presents the development of a new standardised training curriculum for urological laparoscopic surgery. We intend this curriculum to improve the quality of surgical training and ensure high-quality patient care.

Outcomes of single-port robotic ureteral reconstruction using the da Vinci SP® system

PURPOSE

The da Vinci SP^® robotic system enables three double-jointed wristed instruments and a fully wristed three-dimensional camera to be placed through a single port. This study presents our experience with robot-assisted ureteral reconstruction using the SP system and reports its outcomes.

MATERIALS AND METHODS

Between December 2018 and April 2022, a single surgeon performed robotic ureteral reconstruction using the SP system in 39 patients: 18 underwent pyeloplasty and 21 received ureteral reimplantation. Demographic and perioperative patient data were collected and analyzed. Radiographic and symptomatic improvements were assessed 3 months after surgery.

RESULTS

In pyeloplasty group, 12 patients (66.7%) were female and two patients (11.1%) had undergone previous surgery for ureteral obstruction. The median operative time was 152 minutes, the median blood loss was 8 mL, and the median length of stay in hospital was 3 days. There was one case of a complication involving postoperative percutaneous nephrostomy (PCN). In ureteral reimplantation group, 19 patients (90.5%) were female and ten patients (47.6%) had undergone gynecological surgery that caused ureteral obstruction. The median operative time was 152 minutes, the median blood loss was 10 mL, and the median length of stay in hospital was 4 days. We observed one case of open conversion and two cases of complications (colonic serosal tearing and postoperative PCN after ileal ureter replacement). The radiographic results and symptoms successfully improved following both surgeries.

CONCLUSIONS

Despite adhesion-related complications, the SP system appears to be safe and effective for use in robot-assisted ureteral reconstruction.

Robot-assisted Partial Nephrectomy with the Newly Developed KangDuo Surgical Robot Versus the da Vinci Si Surgical System: A Double-center Prospective Randomized Controlled Noninferiority Trial

BACKGROUND

The KangDuo surgical robot (KD-SR) was recently developed in China.

OBJECTIVE

To compare the safety and efficacy of the KD-SR versus the da Vinci Si Surgical System (DV-SS-Si) for robot-assisted partial nephrectomy (RAPN).

DESIGN, SETTING, AND PARTICIPANTS

A double-center prospective randomized controlled noninferiority trial of patients aged 18-75 yr with a suspicion of T1a N0M0 renal cancer (RENAL nephrometry score ≤9) was conducted.

INTERVENTION

RAPN with the KD-SR versus the DV-SS-Si.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was the success rate of operation. The operation was successful if (1) there was no open or laparoscopic conversion, (2) the warm ischemia time was <30 min for RENAL nephrometry scores of 4-6 or 40 min for RENAL nephrometry scores of 7-9, and (3) the pathological margin was negative. The secondary endpoint was the estimated glomerular filtration rate (eGFR). A threshold of 10% was set to demonstrate noninferiority.

RESULTS AND LIMITATIONS

From September 2020 to March 2021, 100 participants were enrolled, of whom 99 (49 in the KD-SR group and 50 in the DV-SS-Si group) were finally included in the full analysis set and 98 (49 in the KD-SR group and -49 in the DV-SS-Si group) in the per-protocol set. Baseline demographic and clinical characteristics were similar between the two groups. All surgeries were completed successfully. The eGFR at postoperative weeks 4-12 and adverse events were similar between the two groups. The docking time and suture time per stitch were longer in the KD-SR group. The main limitation was that a negative margin was considered as the primary outcome rather than survival.

CONCLUSIONS

The KD-SR achieved noninferior outcomes as compared with the DV-SS-Si regarding safety and efficacy for T1a tumors.

PATIENT SUMMARY

The first trial comparing the KangDuo surgical robot (KD-SR) versus the da Vinci Si Surgical System for robot-assisted partial nephrectomy showed that the KD-SR is a viable option for minimally invasive treatment of T1a renal tumors.

Initial Experience with the Comprehensive Modified Laparoscopic Pyeloplasty Technique Based on Membrane Anatomy for Treating Ureteropelvic Junction Obstruction

OBJECTIVE

The aim of the objective was to present our initial experience and evaluate the feasibility of the novel comprehensive modified laparoscopic pyeloplasty (CMLP) technique based on membrane anatomy.

MATERIALS AND METHODS

Forty-eight patients underwent CMLP from February 2016 to October 2020. CMLP involves the following: dissection of the ureter was based on the fascia or fusion fascia formed by embryonic development. The ureter was separated from the ureteral sheath, and the pelvis and ureter were incised with incomplete amputation. The first stitch was placed between the lower point of the spatulated ureter and the lowest corner of the renal pelvis to ensure correct orientation of the anastomosis; anastomosis of the renal pelvis and ureter was performed using the touchless technique.

RESULTS

All CMLPs were completed successfully without conversion. The mean overall operating time was 230.96 min. The median estimated blood loss was 50.00 (interquartile range 20.00-57.50) mL. The average postoperative hospital stay was 9.31 days. The average follow-up time was 24.73 months. No major complications occurred. In 1 case, revision laparoscopic pyeloplasty was performed, but the obstruction persisted after double J stent removal, so ultimately, the double J stent required regular replacement. Another asymptomatic patient with hydronephrosis experienced failed treatment and is still under follow-up. The overall success rate was 95.83% (46/48). The success rate in patients with recurrent ureteropelvic junction obstruction (UPJO) was 87.5% (7/8).

CONCLUSIONS

CMLP is a practical and effective treatment option for UPJO with a high success rate. An advantage of CMLP is the clear surgical field.

Single-Port Robot-Assisted Dismembered Pyeloplasty With Mini-Pfannenstiel or Peri-Umbilical Access: Initial Experience in a Single Center

OBJECTIVE

To assess the feasibility and describe the surgical technique for single-port robotic-assisted laparoscopic pyeloplasty using the new da Vinci SP surgical platform (Intuitive Surgical Inc., Sunnyvale, CA), and to describe the approach through a mini-pfannenstiel incision.

METHODS

Data from a prospectively maintained single-institution database on all patients undergoing single-port robotic-assisted pyeloplasty between November 2018 and November 2019 were reviewed. Pyeloplasty was performed with the da Vinci SP system through a pure single site approach (except for the first patient). The initial procedures were performed through a midline incision and the technique evolved to a mini-pfannenstiel incision. Patient demographics, intraoperative data, post-operative data and surgical outcomes were collected.

RESULTS

Overall, 10 patients were included and underwent the procedure without intraoperative complications or conversion to an alternate approach. The patients' ages ranged between 11 and 75 years. Mean operative time was 166 minutes (interquartile range [IQR] 146-181) and EBL was minimal. Pfannenstiel incision was performed for 6 patients and 4 patients had a vertical midline incision. The only complication recorded was a postoperative urinary tract infection treated with antibiotics. The median postoperative hospital stay was 21 hours (7-24). Postoperative pain management after discharge was managed exclusively with non-opioid medication. Overall success rate defined as the absence of pain and renal obstruction on post-operative imaging at 3 months after surgery was 100%.

CONCLUSION

Single-port robotic-assisted laparoscopic pyeloplasty is a safe and feasible procedure through a mini-pfannenstiel incision.

Robotic Single-Port Platform in General, Urologic, and Gynecologic Surgeries: A Systematic Review of the Literature and Meta-analysis

BACKGROUND

Robotic platforms have recently acquired progressive importance in different surgical fields, such as urology, gynecology, and general surgery. Through the years, new surgical robots have become available as single-port robotic platform. The study is aimed to value the single-port robotic platform characteristics in different surgical specialties.

METHODS

The terms "LESS" OR "single port" OR "single site" AND "robot" OR "robotic" were systematically used to search the PubMed and Scopus databases. A total of 57 studies were considered eligible for the present review. The articles included were divided according to the surgical field in which the study was conducted: General surgery (29 articles), Gynecology (18 articles), Urology (10 articles).

RESULTS

Most part of the articles showed the feasibility of robotic single-port surgical procedures and described advantages in terms of cosmetic, hospital stay, and in some series even cost reduction. A meta-analysis was conducted, showing a significant increment of complications using RSP if compared with SLPS and a trend (P = 0.008) when RSP was compared with LESS. The comparison of different techniques in terms of conversion to laparotomy did not show any significant difference.

CONCLUSION

Robotic single port potentially furnishes an important surgical and post-operatory improvement; however, some limits still prolong the surgical time and complication rate.

Is secondary robotic pyeloplasty safe and effective as primary robotic pyeloplasty? A systematic review and meta-analysis

Robot-assisted laparoscopic pyeloplasty (RLP) has excellent surgical safety and efficacy in primary pyeloplasty. In recent, the application of robotics has explored to more complex surgical conditions such as failed pyeloplasty. This meta-analysis aimed to evaluate the surgical and clinical outcomes of secondary RLP compared with primary RLP. Following PRISMA guidelines, we carried out an extensive literature search in the PubMed, Web of Science, Cochrane Library, Scopus, and Google Scholar to extract the published articles comparing primary vs. secondary RLP up to April 2019. Interested surgical and clinical outcomes were extracted from each study and then used RevMan 5.3 Software for meta-analysis comparison. Furthermore, the quality of each study was assessed using the Modified Newcastle-Ottawa Scale for cohort studies. Our search has yielded seven studies that met our inclusion criteria. These studies contained 613 vs. 107 patients in primary vs. secondary RLP, respectively. Using random effect model, the analysis showed no statistical difference between the groups in the presence of a crossing vessel, complications, length of hospital stays (LOS), and follow-up period. However, the operative time, estimated blood loss (EBL), and recurrence rate were significantly higher in the secondary RLP compared with primary RLP (p = 0.004), (p = 0.01), and (p = 0.04), respectively. Our results indicate that secondary RLP is associated with significantly increased operative time and EBL and higher recurrence rates compared with primary RLP. We believe that our findings might help surgeon's decision making in patient selection and consultation during redo pyeloplasty surgical planning.

Recent advances in urologic surgical techniques for pyeloplasty

Pyeloplasty is one of the most common urological reconstructive interventions. Since the presentation of the first open pyeloplasty by Anderson and Hynes in 1949, the management of ureteropelvic junction obstruction has dramatically developed. The most immense progress was made in the 1990s with the introduction of laparoscopy. A multitude of new minimal surgical techniques have been introduced since then. In the last few years, the innovations were based on refinement of already-existing techniques and technology. With this aim, single-port surgery, three-dimensional vision for laparoscopy, robotic technology, and alternative techniques for creating the anastomosis-like fibrin glue have been introduced. This unsystematic review is timely, and the scientific interest is to present and discuss some of the latest advances in surgical techniques and different approaches for the intra- and post-operative management in pyeloplasty. To the best of our knowledge, this is the only review looking at the recent advances in urological surgical techniques for pyeloplasty during the last few years with a focus on new technology and surgical techniques.

Use of the IDEAL framework in the urological literature: where are we in 2018?

OBJECTIVES

To assess uptake and application of the IDEAL principles in original surgical procedure- or device-related clinical research studies, as well as its reported relevance as characterized by secondary publications, editorials and reviews.

MATERIALS AND METHODS

IDEAL (Idea, Development, Exploration, Assessment, Long-term study) is a framework that provides stage-specific guidance for surgical innovation and represented a major advance towards raising evidential standards. We performed a comprehensive literature search of all urology-related publications citing one or more of seven key publications on IDEAL in The Lancet and BMJ using multiple databases up to 31 December 2017.

RESULTS

We identified a total of 150 urology-related manuscripts citing IDEAL, of which 83 (55.3%) were original research and 67 (44.7%) were secondary publications. Among the original research articles, 40 (48.2%) did not explicitly apply IDEAL principles or were not surgical innovation studies. The IDEAL phases of the 43 (51.8%) remaining original research studies were IDEAL, in nine (20.9%), 27 (62.8%), four (9.3%), 0 (0%), and three publications (7.0%), respectively. Across IDEAL stages, 30 (75.0%) studies were prospective, 29 (85.3%) reported ethical oversight, and 39 (90.7%) captured treatment-related harms. None of the studies collected information on physician experience.

CONCLUSIONS

The IDEAL framework has found widespread adoption in the urology literature as witnessed by a large number of original manuscripts and secondary publications citing IDEAL; however, its application is largely limited to the early stages of surgical innovation, frequently with inappropriate and incomplete implementation. Further efforts are needed to guide investigators in the optimal use of the IDEAL framework as it relates to surgical innovation in urology.

Robotic surgery in pediatric urology: Current status

Robot-assisted laparoscopic surgery (RALS) has been increasingly embraced in the fields of adult and pediatric urology, especially in North America and Europe. The advantages of a stable magnified 3-D view, tremor filtering, and motion scaling allow for precise intracorporeal exposure and suturing. Because most surgeries are performed as reconstructive rather than excision procedures, the robotic platform is particularly feasible for the field of pediatric urology. In this review, we summarize the recent viewpoints on RALS, such as pyeloplasty, ureteral reimplantation, bladder neck reconstruction, bladder neck sling, appendicovesicostomy, bladder diverticulectomy, and treatments for ureterocele or ectopic ureters, and we also critically summarize the current status of the literature. Based on our initial experience, RALS is technically feasible for pediatric patients and may be achieved with comparable surgical outcomes. RALS is also associated with reduced morbidity compared to open surgery to conventional laparoscopic surgery. This evolution will offer an alternative in the treatment pediatric patients, along with improved care and patient quality of life. Further large case series and randomized controlled trials that investigate the robotic platform's technological improvements will help to expand indications of RALS in the field of pediatric urology.

Minimally invasive vertical versus conventional tooth extraction: An interrupted time series study

BACKGROUND

Minimally invasive vertical tooth extraction techniques have evolved in light of the limitations of conventional tooth extraction techniques and flap surgery in preserving the alveolar bone. The authors conducted a study to obtain data on the performance of a vertical extraction system. This included comparing the need for flap surgery using the vertical extraction system versus conventional tooth extraction techniques for the extraction of anterior teeth and premolars not suitable for forceps extraction.

METHODS

The authors conducted a prospective observational clinical study of the vertical extraction system versus conventional tooth extraction techniques using an interrupted time series in line with the Idea, Development, Exploration, Assessment, Long-term Follow-up collaboration framework for surgical innovation.

RESULTS

Overall, 276 of 323 teeth (85.4%) in 240 patients were successfully extracted using the vertical extraction system. Of the 47 failures in the vertical tooth extraction cohort, 18 required flap surgery, resulting in an overall incidence of flap surgery of 5.6% (95% confidence interval [CI], 3.2% to 8.7%). During the routine care period, of the 94 anterior teeth and premolars in 78 patients, 21 teeth could not be extracted using conventional techniques and required flap surgery, leading to an incidence of flap surgery of 22% (95% CI, 14% to 32%).

CONCLUSIONS

The results suggest that the vertical extraction system may be used with a high success rate for extraction of severely destroyed teeth, and its use may lead to a marked reduction in the need for flap surgery. Randomized clinical trials are needed to confirm the findings.

PRACTICAL IMPLICATIONS

The use of a vertical extraction system may lower the incidence of flap surgery.

Current status of robotic surgery in urology

As a result of ergonomics, optimal magnification of the operative field, surgeon dexterity, and precision of surgical manipulation, robotic technology has been shown to overcome many difficulties associated with pure laparoscopy. With the recent expansion of robot-assisted surgery in the field of urology and following the success of robot-assisted prostatectomy and robot-assisted partial nephrectomy, robot-assisted surgery is being applied to treat many other genitourinary diseases, such as bladder cancer and ureteropelvic junction obstruction. The aim of the present review is to discuss the role of robotic surgery in urology and summarize recent developments in the field of urologic robotic surgery.

Initial experience with the new da Vinci single-port robot-assisted platform

OBJECTIVE

To describe our experience in the first cases of urological surgeries performed with the da Vinci single-port robot-assisted platform.

MATERIAL AND METHODS

We performed 5 single-port robot-assisted surgeries (R-LESS) between May and October 2014. We performed 3 ureteral reimplant surgeries, one ureteropyeloplasty in an inverted kidney and 1 partial nephrectomy. The perioperative and postoperative results were collected, as well as a report of the complications according to the Clavien classification system.

RESULTS

Of the 5 procedures, 4 were performed completely by LESS, while 1 procedure was reconverted to multiport robot-assisted surgery. There were no intraoperative complications. We observed perioperative complications in 4 patients, all of which were grade 1 or 2. The mean surgical time was 262minutes (range, 230-300).

DISCUSSION

In our initial experience with the da Vinci device, R-LESS surgery was feasible and safe. There are still a number of limitations in its use, which require new and improved R-LESS platforms.

Current status of robotic single-port surgery

Robotic-assisted laparoscopic surgery in urology is an ever progressing field, and boundaries are constantly broken with the aid of new technology. Advancements in instrumentation have given birth to the era of robotic laparoendoscopic single-site technique (R-LESS). R-LESS however, has not gained widespread acceptance due to technical hurdles such as adequate triangulation, robotic arm clashing, decreased access for the bedside assistant, lack of wrist articulation, continued need for an axillary/accessory port, lack of robust retraction, and ergonomic discomfort. Many innovations have been explored to counter such limitations. We aim to give a brief overview of a history and development of R-LESS urologic surgery and outline the latest advancements in the realm of urologic R-LESS. By searching PubMed selectively for relevant articles, we concluded a literature review. We searched using the keywords: robotic laparoscopic single incision, robotic laparoendoscopic single-site, single incision robotic surgery, and R-LESS. We selected all relevant articles in that pertained to single-site robotic surgery in urology. We selected all relevant articles that pertained to single-site robotic surgery in urology in a table encompassed within this article. The development of the R-LESS procedures, instrumentations, and platforms has been an evolution in progress. Our results showed the history and evolution toward a purpose-built single-port robotic platform that addresses previous limitations to R-LESS. Even though previous studies have shown feasibility with R-LESS, the future of R-LESS depends on the availability of purpose-built robotic platforms. The larger concern is the demonstration of the definitive advantage of single-site over the conventional multiport surgery.

Da Vinci single site© surgical platform in clinical practice: a systematic review

BACKGROUND

The Da Vinci single-site© surgical platform (DVSSP) is a set of single-site instruments and accessories specifically dedicated to robot-assisted single-site surgery.

METHODS

The PubMed database from inception to June 2015 was searched for English literature on the clinical use of DVSSP in general surgery, urology and gynecology.

RESULTS

Twenty-nine articles involving the clinical application of DVSSP were identified; 15 articles on general surgery (561 procedures), four articles on urology (48 procedures) and 10 articles on gynecology (212 procedures). All studies have proven the safety and feasibility of the use of DVSSP. The principal reported advantage is the restoration of intra-abdominal triangulation, while the main reported limitation is the lack of the endowrist.

CONCLUSIONS

Da Vinci systems have proven to be valuable assets in single-site surgery, owing to the combination of robot use with the dedicated single-incision platform. However, case-control or prospective trials are warranted to draw more definitive conc lusions. Copyright © 2015 John Wiley & Sons, Ltd.

A modified technique of paraumbilical three-port laparoscopic dismembered pyeloplasty for infants and children

BACKGROUND

Common causes of complications of laparoscopic pyeloplasty in children include anastomotic stricture, poor drainage due to high ureteropelvic anastomosis, and torsion of ureter. Herewith, we described our modified technique of paraumbilical three-port laparoscopic dismembered pyeloplasty (PTLDP) to minimize these complications.

PATIENTS AND METHODS

Data from 62 patients (age: 1-180 months, median: 12 months) with ureteropelvic junction obstruction (UPJO) who underwent pyeloplasty using our modified technique of PTLDP between February 2014 and September 2014 at our institution were reviewed. The key steps of our modified method involve identifying the lowest point of the renal pelvis and the lateral aspect of the ureter to guarantee a low pelviureteric and correct orientation anastomosis, and using a 4-0 silk for assistant suturing to avoid crushing of the anastomotic tissue.

RESULTS

All surgeries were successfully completed without conversion. Three patients required an accessory port for the anastomosis. All the patients achieved complete clinical or radiologic resolution after the operation. The mean operative time was 103.4 min, and mean estimated blood loss was 14.4 mL. Mean postoperative differential function of affected kidney was 43.0 ± 16.3 % (range 24-100 %), increased from 39.7 ± 18.0 % (range 18-100 %), preoperatively (p < 0.001). The success rate was 100 % at a mean follow-up of 18.3 ± 2.9 (range 13-25) months.

CONCLUSIONS

Our modified technique of PTLDP is safe and feasible and to allow high success rate for the treatment of pelviureteric junction obstruction in children.

First Canadian experience with robotic single-incision pyeloplasty: Comparison with multi-incision technique

INTRODUCTION

We compared the outcomes of single-incision, robot-assisted laparoscopic pyeloplasty vs. multiple-incision pyeloplasty using the da Vinci robotic system.

METHODS

We reviewed all consecutive robotic pyeloplasties by a single surgeon from January 2011 to August 2015. A total of 30 procedures were performed (16 single:14 multi-port). Two different single-port devices were compared: the GelPort (Applied Medical, Rancho Santa Margarita, CA) and the Intuitive single-site access port (Intuitive Surgical, Sunnyvale, CA).

RESULTS

Patient demographics were similar between the two groups. Mean operating time was similar among the single and multi-port groups (225.2 min vs. 198.9 minutes [p=0.33]). There was no significant difference in length of hospital stay in either group (86.2 hr vs. 93.2 hr [p=0.76]). There was no difference in success rates or postoperative complications among groups.

CONCLUSIONS

Single-port robotic pyeloplasty is non-inferior to multiple-incision robotic surgery in terms of operative times, hospitalization time, success rates, and complications. Verifying these results with larger cohorts is required prior to the wide adoption of this technique. Ongoing objective measurements of cosmesis and patient satisfaction are being evaluated.

Robot-assisted renal surgery: current status and future directions

This paper examines the current role of robot-assisted renal surgery as complex and partial nephrectomies, including vena cava thrombus, combined nephroureterectomies, living donor nephrectomy, autotransplantation, and difficult anatomy as in patients with obesity or adhesions. Indications for robot-assisted renal surgery are comparable to those of conventional laparoscopic approaches. A reduction in the learning curve leads to a stabilization of the procedure and further increases the number of minimally invasive procedures performed. A Medline literature search for publications on the field of robotic kidney surgery has been performed using the MeSH terms: robotic surgical procedures and kidney. Future directions include progress in robotic technology and instrumentation with further miniaturization of robotic procedures as laparoendoscopic single-site interventions and progress in image-guided robotic surgery.

[Robotic surgery in urology: the Italian contribution]

The introduction of robotic technology has given a major boost to the urologic surgery by expanding the indications of minimally-invasive surgery. The Italian urological community has played a major role in this revolution, by contributing to the development and dissemination of technological innovation in urology, with several key publications stemming from this research. The most important revolution has been observed in radical prostatectomy, with robotic technology allowing to achieve better functional results. Nephron-sparing surgery has also been expanded, and leading Italian centers are being involved in international research groups focused on these topics. Major impact has been observed for pyeloplasty, where Italy has been a leader in the field with the introduction of robot-assisted single-site technique. In summary, the advent of robotics has improved collaborations between Italy and other Countries, with increased scientific activity, continuous improvement of surgical techniques and effective training of young urologists.

[The added value of robotic surgery]

Robotic surgery has recently emerged as a feasible alternative to open and laparoscopic procedures for the treatment of many urological diseases. The use of robotics allows the surgeon to overcome the limitations of standard laparoscopy while maintaining the advantages of a minimally invasive approach. Robotic-assisted radical prostatectomy is the most frequent surgery performed robotically, resulting in better functional outcomes and comparable oncological results with respect to open surgery. Given its advantages, the indications for robotic surgery have progressively extended to different fields, and there is increasing evidence for its effectiveness in high-risk prostate cancer, bladder cancer, kidney cancer, and adrenal disease. Based on the available evidence in the literature, robotic surgery should be considered a viable option for the treatment of many urological conditions, with the final aim of optimizing patients' outcomes.

One-trocar-assisted pyeloplasty: An attractive alternative to open pyeloplasty

BACKGROUND

To survey the effects of one-trocar-assisted pyeloplasty (OTAP) in the treatment of ureteropelvic junction obstruction (UPJO) in kids.

MATERIALS AND METHODS

Forty-four children (±3.5 years) were submitted to OTAP procedure. A flank incision under the XII rib was made, the Gerota's fascia was achieved and a balloon Hasson trocar with an operative telescope inserted for retroperitoneal access. The renal pelvis and ureter were isolated and exteriorised. Forty-two patients underwent Anderson-Hynes dismembered and one Fenger pyeloplasty . One patient was converted to an open procedure. Two patients presented an aberrant crossing vessel. In all patients, a double J stent was positioned. The operative time and length of stay (LOS) were evaluated. Renal scan and ultrasound (US) were utilised to evaluate the results from 6 to 12 months.

RESULTS

OTAP was successful in all but 1 patient. Mean operative time and LOS were 128 min and 3,5 days. We had four operative complications (9.09%). The US and a nuclear scan confirmed the resolution of the UPJO in all patients except one with the Fenger pyeloplasty who had an open Anderson-Hynes.

CONCLUSIONS

The combination of retroperitoneoscopic and open procedures for dismembered pyeloplasty offers a simple, time-saving method in a minimally invasive fashion with low morbidity for patients with UPJO.

Current status of robotic laparoendoscopic single-site partial nephrectomy

Robotic laparoendoscopic single-site partial nephrectomy is increasingly carried out in an attempt to improve the cosmetic outcome of minimally-invasive procedures. However, the actual role of this novel technique remains to be determined. The present article reviews evidence and examines updates of robotic laparoendoscopic single-site partial nephrectomy outcomes reported in more contemporary studies. A comprehensive online systematic search of PubMed, Scopus and Web of Science databases according to Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria recommendations was carried out in January 2014, identifying data from 2008 to 2014 regarding robotic laparoendoscopic single-site partial nephrectomy. The majority of medical evidence to date is based on case reports or retrospective studies. Current studies show that robotic laparoendoscopic single-site partial nephrectomy is a feasible procedure carried out in an acceptable length of operative time, and resulting in a desirable cosmetic outcome and less postoperative pain. However, comparable studies show that robotic laparoendoscopic single-site partial nephrectomy is inferior to the conventional approach, especially with regard to warm ischemia time. Furthermore, the numerous limitations that exist with the utilization of the current commercial single-site devices make robotic laparoendoscopic single-site PN more challenging and more complicated for surgeons compared with conventional procedures. Further significant improvements, along with more studies, are required in order to develop the ideal robotic laparoendoscopic single-site robotic platform and overcome the current limitations. For the time being, robotic laparoendoscopic single-site partial nephrectomy procedures could be applicable in patients with low tumor size and complexity, and should not be routinely applied in all cases.

Robot-assisted laparoendoscopic single-site partial nephrectomy with the novel da vinci single-site platform: initial experience

Purpose

To report our initial clinical cases of robotic laparoendoscopic single-site (R-LESS) partial nephrectomy (PN) performed with the use of the novel Da Vinci R-LESS platform.

Materials and Methods

Three patients underwent R-LESS PN from November 2013 through February 2014. Perioperative and postoperative outcomes were collected and intraoperative difficulties were noted.

Results

Operative time and estimated blood loss volume ranged between 100 and 110 minutes and between 50 and 500 mL, respectively. None of the patients was transfused. All cases were completed with the off-clamp technique, whereas one case required conversion to the conventional (multiport) approach because of difficulty in creating the appropriate scope for safe tumor resection. No major postoperative complications occurred, and all tumors were resected in safe margins. Length of hospital stay ranged between 3 and 7 days. The lack of EndoWrist movements, the external collisions, and the bed assistant's limited working space were noticed to be the main drawbacks of this surgical method.

Conclusions

Our initial experience with R-LESS PN with the novel Da Vinci platform shows that even though the procedure is feasible, it should be applied in only appropriately selected patients. However, further improvement is needed to overcome the existing limitations.