Laparoscopic Surgery in Urologic Oncology

Prognostic indices of perioperative outcome following transperitoneal laparoscopic adrenalectomy

OBJECTIVES

We sought to identify preoperative patient and tumor characteristics that may be useful prognostic indicators of postsurgical outcome in patients undergoing laparoscopic adrenalectomy (LA).

SUBJECTS AND METHODS

Data from 92 patients who underwent 93 transabdominal LA procedures between 2006-2012 were retrieved. Patients were stratified based on estimated blood loss (EBL), length of stay (LOS), and perioperative complications. Interdependencies between surgical outcome and patient demographics, tumor characteristics, comorbidities, and Charlson Comorbidity Index (CCI) were statistically analyzed. The predictive capacity of each index was assessed using receiver operating characteristic curves.

RESULTS

Neither age, gender, tumor laterality, body mass index, American Society of Anesthesiologists (ASA) score, nor CCI predicted the occurrence of perioperative complications. EBL was significantly associated with increased age, tumor size, ASA score, and CCI, whereas prolonged LOS was associated with higher ASA score. Tumor size was related, although not significantly, to LOS and perioperative complications. Tumors ≥7.5 cm in diameter were significantly associated with worse perioperative outcomes.

CONCLUSIONS

LA for adrenal lesions demonstrated reasonable complication rates and perioperative outcomes. Tumor size, CCI, and ASA score are predictive of increased EBL and LOS.

Oncologic outcomes obtained after laparoscopic, robotic and/or single port nephroureterectomy for upper urinary tract tumours

INTRODUCTION

Open surgery (ONU) is still considered to be the gold standard approach for nephroureterectomy (NU); however, with the introduction of laparoscopic surgery, minimally invasive techniques have been applied to surgical therapy of upper urinary tract tumours (UUT-UC) and they are gaining adepts. However, several concerns still exist about the safety of laparoscopic nephroureterectomy (LNU) in the treatment of UUT-UC, and different authors suggest that, although it could be equivalent to open surgery, this equivalence is not accomplished in all UUT-UC, suggesting that more advanced disease should undergo open surgery. More controversial still is the application of robotic surgery (RALNU) or really novel minimally invasive techniques, such as laparoendoscopic single-site surgery (LESSNU), for the treatment of UUT-UC. Although all these techniques seem feasible, their influence on oncologic results is still a matter of concern.

METHODOLOGY

We present a review on the oncologic outcomes of minimally invasive laparoscopic techniques in the treatment of UUT-UC. We focus our analysis on oncologic outcomes and we also analyze the different techniques proposed for the treatment of the distal ureter during minimally invasive surgery for UUT-UC. In the absence of prospective randomized studies with large patient samples, we must base our conclusions on retrospective studies and longer follow-up.

CONCLUSION

Given the evidence accumulated so far, LNU has proven to be equivalent or non-inferior, in terms of recurrence-free survival (RFS) and cancer-specific survival (CSS) to ONU. Nevertheless, comparative studies are needed with longer follow-up before determining the equivalence of LNU in advanced tumours.

Ex-vivo training model for laparoendoscopic single-site surgery

BACKGROUND:

Laparoendoscopic single-site surgery (LESS) has recently been applied successfully in the performance of a host of surgical procedures. Preliminary consensus from the experts is that this mode of surgery is technically challenging and requires expertise. The transition from trainee to practicing surgeon, especially in complex procedures with challenging learning curves, takes time and mentor-guided nurturing. However, the trainee needs to use platforms of training to gain the skills that are deemed necessary for undertaking the live human case.

OBJECTIVE:

This article aims to demonstrate a step-by-step means of how to acquire the necessary instrumentation and build a training model for practicing steeplechase exercises in LESS for urological surgeons and trainees. The tool built as a result of this could set the platform for performance of basic and advanced skills uptake using conventional, bent and articulated instruments. A preliminary construct validity of the platform was conducted.

MATERIALS AND METHODS:

A box model was fitted with an R-Port^™ and camera. Articulated and conventional instruments were used to demonstrate basic exercises (e.g. glove pattern cutting, loop stacking and suturing) and advanced exercises (e.g. pyeloplasty). The validation included medical students (M), final year laparoscopic fellows (F) and experienced consultant laparoscopic surgeons (C) with at least 50 LESS cases experience in total, were tested on eight basic skill tasks (S) including manipulation of the flexible cystoscope (S1), hand eye coordination (S2), cutting with flexible scissors (S3), grasping with flexible needle holders (S4), two-handed maneuvers (S5), object translocation (S6), cross hand suturing with flexible instruments (S7) and conduction of an ex-vivo pyeloplasty.

RESULTS:

The successful application of the box model was demonstrated by trainee based exercises. The cost of the kit with circulated materials was less than £150 (Pounds Sterling). The noncamera handling skills (S2–S8) of the ex-vivo training model for LESS can distinguish between laparoscopically naïve fellows and experienced consultants in LESS. S4–S8 showed the highest level of construct validity, by accurately differentiating among the M, F and C groups.

CONCLUSION:

LESS requires a significant amount of skill and has an inherent steep learning curve. The ex-vivo model described provides a cost-effective means that a trainee or training unit can build for optimising preliminary skill acquisition in LESS for urological trainees. It has construct validity in several tasks. Such platform models should be tested further with an emphasis on rapid sequence uptake of optimal skills, prior to undertaking the live human case.

Devices for laparoendoscopic single-site surgery in urology

The quest to make minimally invasive techniques even more 'minimal' has generated a drive within the surgical community to explore novel ways of achieving this. This has led to surgeons attempting to either decrease the number of trocars placed through the abdominal wall or eliminate them completely. This led to the evolution of several approaches, including natural orifice translumenal endoscopic surgery (NOTES), single incision laparoscopic surgery (SILS), single port access surgery and one port umbilical surgery (OPUS) or E-NOTES. The most recent consensus on nomenclature involves the term laparoendoscopic single-site surgery (LESS). The transition from multiple port access surgery to single port access surgery represents a paradigm shift in reconstructive and extirpative surgery and is a testament to the recent advances in surgical technology. Successful LESS involves the use of articulating or bent instrumentation via a single large-caliber trocar or small, adjacent trocars. Advances in technology have led to the development of new laparoscopic access ports (R-Port and Quadriport by Advanced Surgical Concepts, Wicklow, Ireland; and Uni-X Single Port, PNavel Systems, Cleveland, OH, USA) capable of permitting several instruments to be inserted through multiple channels incorporated in, and as part of, a larger single port. The development of articulating and bent instrumentation permits triangulation intracorporeally despite the close proximity of several instruments via a single port. Currently, commercially available instruments can be broadly divided into articulating laparoscopic graspers and shears (Real Hand, Novare Surgical Systems, Cupertino, CA, USA; and Autonomy Laparo-angle, Cambridge Endo, Framingham, MA, USA), endoshears (Cambridge Endo), and laparoscopic needle drivers (Cambridge Endo). Despite the preliminary optimistic results in the outcomes of LESS, an experienced laparoscopic skill set is essential for the safe and effective completion of surgery.

A fast method to identify renal vessels during retroperitoneal laparoscopic nephrectomy

PURPOSE

To evaluate a fast method to identify renal vessels during retroperitoneal laparoscopic nephrectomy.

METHODS

One hundred fifty retroperitoneal laparoscopic nephrectomies were performed from October 2003 to June 2006. The renal arteries were identified by following five steps: location, pulling, apophysis, pulsation,and fibrin. Then the renal arteries were severed or ligatured with a linear cutter or Hem-o-lok clips. The renal veins were exposed by dissecting toward the abdominal side under the renal arteries. The management for the renal veins was the same with that of the renal arteries. The fast method to identify the renal vessels during retroperitoneal laparoscopic nephrectomy were evaluated.

RESULTS

All 150 procedures were successfully completed, and the renal vessels could be identified in short time. The average time to operation was 90 min (range 45-120 min) with average blood loss of 105 mL (range 10-510 mL). The average specimen weight was 494 g (range 140-890 g). Intake of usual diet and walking were allowed within 3 days for all patients. Drains were removed within 2-4 postoperative days. No patient was converted into an open surgery and blood transfusion. Minor complications were found in 12 cases (8%), and no severe complication occurred in any of the 150 cases. The median time to hospitalization was 6.3 days. Following the five steps, the renal vessels could be identified quickly and easily. The duration of the operations, the risk of conversion to the open surgery, and the vessel injury were decreased.

CONCLUSIONS

Renal vessels could be identified quickly by the following the five steps during retroperitoneal laparoscopic nephrectomy: location, pulling, apophysis, pulsation, and fibrin. It proved to be a useful method suitable for clinic application.