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Purpose: We present our cumulative experience with robotic laparoendoscopic single site urological surgery at a single institution.Materials and Methods: Medical records of patients undergoing robotic laparoendoscopic single site procedures between May 2008 and December 2010 were analyzed. The da Vinci® S or Si systems and 3 different multichannel single port devices were used. Demographic, intraoperative and postoperative data were assessed.Results: Overall, 50 patients were scheduled to undergo robotic laparoendoscopic single site urological surgery during the study period, representing 36% of the total patients undergoing laparoendoscopic single site surgery at our institution. Mean ± SD patient age was 60.2 ± 13.6 years. Mean body mass index was 27.0 ± 4.5 kg/m2. Specifically, 24 patients underwent robotic laparoendoscopic single site renal surgery and the same method was used in 26 patients undergoing pelvic surgery. Mean operative time was 207 ± 74 minutes and mean estimated blood loss was 140 ± 111...

To compare elderly patients undergoing robotic assisted partial nephrectomy (RAPN) with a match cohort of younger patients. Investigating the benefits of minimally invasive RAPN including faster convalescence and decreased postoperative narcotic use make this an attractive option in patients with advanced age and numerous comorbidities.A retrospective review of 250 consecutive patients who underwent robotic-assisted partial nephrectomy (RAPN) for a solitary renal tumor from June 2006 to May 2010 at our institution was performed. Thirty-seven patients ≥ 70 years (G70) who underwent 38 robotic partial nephrectomy (RPN) procedures were identified. This group was matched with 38 patients70 years (L70) who underwent 38 RPN procedures at our institution. Functional, perioperative, and oncological outcomes of RAPN in patients ≥ 70 years old were analyzed.Overall, the median tumor size was 2.65 cm. Tumor characteristics, renal function, nephrometry score, and incidence of renal cancer in lesions were similar between the L70 and G70 groups. The two groups showed no differences in American Society of Anesthesiologists scores of 1-4 or Charlson comorbidity index score. Perioperative and postoperative outcomes showed no variation between L70 and G70 patients. Postoperative complications rate of 21% and 31.6% in the L70 and G70 groups, respectively, showed no difference (P.48). There were 5 deaths, 3 of which occurred in the G70 group (8.1%) at a median of 22 months after surgery.RAPN for small renal masses offers a safe alternative for patients70 years of age, with no increase in perioperative and postoperative morbidity and mortality. Age may not be predictive of perioperative complications.

Despite numerous retrospective series of laparoendoscopic single site surgery, cohorts have generally been small and followup largely short-term. Therefore, we report intermediate term outcomes for patients undergoing reconstructive laparoendoscopic single site procedures at a single institution.Upon review of our prospectively maintained laparoendoscopic single site urological database of 185 cases, 32 reconstructive procedures were identified including pyeloplasty (25), ileal interposition (3), ureteroneocystostomy (3) and retrocaval ureter repair (1). Perioperative data were reviewed, and clinical and radiographic success was noted.Median followup was 24.4 months for pyeloplasty, 35 months for ileal interposition, 29.4 months for ureteroneocystostomy and 20 months for retrocaval ureter repair. At last followup 24 of 25 patients treated with pyeloplasty, 2 of 3 with ileal ureter, 3 of 3 with ureteroneocystostomy and 1 of 1 with retrocaval ureter reported being asymptomatic or improved after the procedure. Delayed incisional hernia repair was required in 1 patient. One death occurred during the followup period, remote from the date of surgery. No other complications were noted.Intermediate term results after laparoendoscopic single site reconstructive procedures remain promising. Further followup of this patient population is required to ensure the durability of results. Prospective evaluation is also needed to assess if advantages exist for laparoendoscopic single site reconstructive procedures compared to standard minimally invasive approaches.

Background The aim of this study was to evaluate a novel ultrasound probe specifically developed for robotic surgery by determining its efficiency in identifying renal tumors. Methods The study was carried out using the Da Vinci™ surgical system in one female pig. Renal tumor targets were created by percutaneous injection of a tumor mimic mixture. Single-port and standard robotic partial nephrectomy were performed. Intraoperative ultrasound was performed using both standard laparoscopic probe and the new ProART™ Robotic probe. Probe maneuverability and ease of handling for tumor localization were recorded. Results The standard laparoscopic probe was guided by the assistant. Significant clashing with robotic arms was noted during the single-port procedure. The novel robotic probe was easily introduced through the assistant trocar, and held by the console surgeon using the robotic Prograsp™ with no registered clashing in the external operative field. The average time for grasping the new robotic probe was less than 10 s. Once inserted and grasped, no limitation was found in terms of instrument clashing during the single-port procedure. Conclusions This novel ultrasound probe developed for robotic surgery was noted to be user-friendly when performing porcine standard and especially single-port robotic partial nephrectomy. Copyright © 2011 John Wiley & Sons, Ltd.

Objective: To describe the evolution of robotic partial nephrectomy (PN) technique and to analyze the surgical outcomes in a large single institution experience. Materials and Methods: Retrospective review of our institutional review boardapproved, prospectively maintained, minimally invasive PN database yielded 252 robotic partial nephrectomy (RPN) procedures from June 2007 to October 2010. Our initial experience, adopted from our laparoscopic PN approach included a standard interrupted bolstered renorrhaphy, whereas our contemporary experience included a nonbolstered continuous horizontal mattress stitch for the capsular closure. Perioperative results were evaluated depending on renorrhaphy technique, length of warm ischemia time, and nephrometry scores. Results: Overall, mean tumor size was 3.1 ± 1.6 cm, operative time 190 ± 56 minutes, warm ischemia time 18.2 ± 9.4 minutes, and estimated blood loss 267 ± 275 mL. Significantly better outcomes were noted in the contemporary experience in terms of transfusion rate (8.2% vs 21.9%, P

Objective To compare the intraoperative and early postoperative outcomes of robotic partial nephrectomy (RPN) with those of laparoscopic partial nephrectomy (LPN) outcomes in patients with bilateral synchronous renal tumors. RPN is emerging as an attractive minimally invasive nephron-sparing approach for renal tumors. Methods Our ongoing institutional review board-approved, prospectively maintained, kidney cancer database was used to identify the study population. The medical records of patients who underwent minimally invasive nephron-sparing surgery at our institution from January 2001 to March 2010 were used. A cohort of 9 patients undergoing bilateral RPN was identified and compared with 17 consecutive patients who underwent sequential bilateral LPN. The demographic, intraoperative, postoperative, and short-term renal functional data were retrospectively compared between the 2 groups. Results A total of 18 procedures were performed in the RPN group and 32 in the LPN group. The median warm ischemia time was shorter in the RPN group than in the LPN group (19 vs 37 minutes, respectively; P = .059). The median tumor size was 2.85 and 2.7 cm in the RPN and LPN group, respectively ( P = .03). The final median postoperative glomerular filtration rate was 68.7 mL/min/1.73 m 2 (interquartile range 14-73) and 26.9 mL/min/1.73 m 2 (interquartile range 20-70) in the RPN and LPN groups, respectively ( P = .004). No difference was found in the complications in the RPN group (n = 2) compared with the LPN group (n = 4). Conclusion RPN is a safe and effective minimally invasive nephron-sparing treatment of bilateral synchronous kidney tumors. A trend was seen toward a shorter warm ischemia time and less effects on postoperative renal function compared with the laparoscopic approach.

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.

What's known on the subject? and What does the study add? LESS is a surgical technique that is utilized in many urological surgeries. The recent fusion of robotics and conventional LESS has significant implications for the future direction of LESS. This study is a review of LESS surgery, with a discussion about emerging technologies and the future directions of LESS surgery. • Laparoendoscopic single-site surgery (LESS) is a term that covers a spectrum of surgical techniques that perform laparoscopic surgery by consolidating all ports into one surgical incision. • In recent years, there has been an expansion of LESS surgical techniques with a wide spectrum of urological procedures being performed using LESS surgery. • Paralleling the clinical expansion of LESS are efforts to improve the instrumentation and access devices as well as incorporation of robotic platforms to the LESS arena. • This expansion in technology has generated the essential question: is robotics the future of LESS?

OBJECTIVE To report our short-term results of robot-assisted partial nephrectomy for treating sporadic multiple ipsilateral renal tumours. METHODS Over a 3-year period, eight patients with two or more ipsilateral renal masses underwent nine robotic partial nephrectomies in our institution. We evaluated the PADUA and R.E.N.A.L. nephrometry scores, intraoperative outcomes, histopathological characteristics, complications according to Clavien classification and renal function outcomes. RESULTS In total, 19 tumours were removed from eight patients in nine procedures. Mean operative time was 199 ± 47 min (median 200; range 150-300). Mean size of the dominant lesion was 3.0 ± 1.1 cm (2.7; 1.6-4.8) and overall mean tumour size was 2.2 ± 1.2 cm (1.9; 0.4-4.8). Mean number of tumours removed per patient was 2.4. Median PADUA and R.E.N.A.L. scores were 7 and 6 (with the predominance of an anterior, non-hilar position), respectively. Excluding the six off-clamp resected tumours, the mean warm ischaemia time was 21 ± 9.2 min (21; 10-35). Mean estimated blood loss was 250 ± 154 mL (200; 100-500) and no patient required transfusion. There were no intraoperative complications or conversion to open surgery. One patient had atrial fibrillation, resolved with anti-arrhythmic drugs. Mean length of stay was 4.2 ± 0.97 days. Sixteen of the nineteen tumours were malignant, most of papillary type and Fuhrman grade II. The mean decrease in glomerular filtration rate was 4%, with a mean follow-up of 14 months. CONCLUSIONS Robotic partial nephrectomy for sporadic ipsilateral multifocal renal tumours is feasible and safe. Off-clamp resection of multiple tumours can also be safely performed in carefully selected lesions.

Laparoendoscopic single-site surgery (LESS) is a novel technique that aims to perform abdominal surgery through a single incision. Various access techniques and ports exist. This review will attempt to describe the currently available ports as well as highlight their advantages and disadvantages.

LaparoEndoscopic Single-Site (LESS) surgery presents many technical and ergonomic obstacles. The solution to these current limitations may lie within emerging technologies, primarily the daVinci robotic platform. The purpose of this review was to examine the available literature as it pertains to robotic laparoendoscopic single-site surgery (R-LESS) and detail our experience with this approach at our institution.An electronic literature search was conducted using the Medline database to identify all publications relating to R-LESS and/Mor robotic single port surgery in urology. Additionally, a retrospective review of our single center experience was completed.Fifteen original articles and two abstracts were identified in the literature and included dry lab investigation, animal experiments, single case reports, cumulative series, and two retrospective comparative analyses. Most detailed technique, perioperative outcomes, and associated procedural nuances.R-LESS urologic surgery is feasible and can be performed using several approaches. R-LESS reduces difficulties encountered with conventional LESS urologic surgery. An ideal robotic system is needed and would be task specific, deployable through a single incision, possess articulating instruments, and have reduced external housings.

Treatment options for a suspicious renal mass in a re-nal allograft include radical nephrectomy or nephron-sparing surgery (NSS). To our knowledge robotic-assisted laparoscopic partial nephrectomy (RPN) astreatment for a renal mass in a transplant kidney hasnot been previously reported. We report the case ofRPN for a 7-cm renal mass in a transplanted kidney. A35-year-old female with reflux nephropathy receiveda living-related donor kidney transplant in 1986. At24 years after transplantation she had a 7-cm BosniakIII cystic mass of the allograft detected on comput-erized tomography (CT) scan. Preoperative creatininewas 2.2 mg/dL with an estimated glomerular filtrationrate (eGFR) of 25 mL/min/1.73 m

The RENAL nephrometry score (RNS) was developed to quantify complexity of renal tumors in a reproducible manner. We aim to determine whether individual categories of the RNS have different impact on the warm ischemia time (WIT) for patients undergoing robotic partial nephrectomy (RPN). In a retrospective analysis of a prospectively maintained database, we identified 251 consecutive patients who underwent RPN between January 2007 and June 2010. RNS was determined in 187 with available imaging. Univariable analysis and multivariable linear regression analysis were performed to identify which factors were more significantly associated with WIT. Overall RNS was of low (4–6), moderate (7–9), and high complexity (10–12) in 84 (45 %), 80 (43 %), and 23 (12 %) patients, respectively. There was no association between gender (p = 0.6), BMI (p = 0.3), or anterior/posterior location (A) (p = 0.8), and WIT. On univariable analysis, longer WIT was associated with size (R) >4 cm (p

The desire to decrease morbidity from multiple port sites and progress toward a natural orifice approach has stimulated interest in laparoendoscopic single-site (LESS) surgery. Limitations, however, including clashing of instruments and loss of triangulation, have prevented widespread dissemination of LESS. To overcome these problems, the advantages of the robotic platform have been applied to single-site surgery. The objective of this article is to review our experience and summarize the current literature pertaining to robot-assisted LESS renal surgery.Twenty-eight robot-assisted LESS kidney procedures were identified from our prospectively maintained LESS database. These included 11 radical nephrectomies, 5 partial nephrectomies, 3 nephroureterectomies, 7 pyeloplasties, 1 simple nephrectomy, and 1 renal cyst decortication. Perioperative and postoperative data were analyzed.Of 28 cases, 4 conversions occurred. The remaining procedures were performed with no extraincisional trocars. Mean follow-up was 11.3 months for radical nephrectomy, 21.3 months for partial nephrectomy, 17.8 months for nephroureterectomy, 12.9 months for pyeloplasty, 4 months for simple nephrectomy, and 1.6 months for renal cyst decortication. Patients who underwent radical nephrectomy, partial nephrectomy, and nephroureterectomy all had negative surgical margins and have remained disease free during the follow-up period. Six of seven patients who underwent pyeloplasty reported complete resolution of symptoms while the seventh reports significant improvement.We present a large experience with robot-assisted LESS kidney surgery demonstrating the wide variety of procedures that can be performed. Further follow-up of this patient population is needed to document continued oncologic efficacy and durability of results.

The aim of this study was to evaluate a novel ultrasound probe specifically developed for robotic surgery by determining its efficiency in identifying renal tumors.The study was carried out using the Da Vinci™ surgical system in one female pig. Renal tumor targets were created by percutaneous injection of a tumor mimic mixture. Single-port and standard robotic partial nephrectomy were performed. Intraoperative ultrasound was performed using both standard laparoscopic probe and the new ProART™ Robotic probe. Probe maneuverability and ease of handling for tumor localization were recorded.The standard laparoscopic probe was guided by the assistant. Significant clashing with robotic arms was noted during the single-port procedure. The novel robotic probe was easily introduced through the assistant trocar, and held by the console surgeon using the robotic Prograsp™ with no registered clashing in the external operative field. The average time for grasping the new robotic probe was less than 10 s. Once inserted and grasped, no limitation was found in terms of instrument clashing during the single-port procedure.This novel ultrasound probe developed for robotic surgery was noted to be user-friendly when performing porcine standard and especially single-port robotic partial nephrectomy.

• Laparoendoscopic single-site surgery (LESS) is a term that covers a spectrum of surgical techniques that perform laparoscopic surgery by consolidating all ports into one surgical incision. • In recent years, there has been an expansion of LESS surgical techniques with a wide spectrum of urological procedures being performed using LESS surgery. • Paralleling the clinical expansion of LESS are efforts to improve the instrumentation and access devices as well as incorporation of robotic platforms to the LESS arena. • This expansion in technology has generated the essential question: is robotics the future of LESS?

To report our short-term results of robot-assisted partial nephrectomy for treating sporadic multiple ipsilateral renal tumours.Over a 3-year period, eight patients with two or more ipsilateral renal masses underwent nine robotic partial nephrectomies in our institution. We evaluated the PADUA and R.E.N.A.L. nephrometry scores, intraoperative outcomes, histopathological characteristics, complications according to Clavien classification and renal function outcomes.In total, 19 tumours were removed from eight patients in nine procedures. Mean operative time was 199 ± 47 min (median 200; range 150-300). Mean size of the dominant lesion was 3.0 ± 1.1 cm (2.7; 1.6-4.8) and overall mean tumour size was 2.2 ± 1.2 cm (1.9; 0.4-4.8). Mean number of tumours removed per patient was 2.4. Median PADUA and R.E.N.A.L. scores were 7 and 6 (with the predominance of an anterior, non-hilar position), respectively. Excluding the six off-clamp resected tumours, the mean warm ischaemia time was 21 ± 9.2 min (21; 10-35). Mean estimated blood loss was 250 ± 154 mL (200; 100-500) and no patient required transfusion. There were no intraoperative complications or conversion to open surgery. One patient had atrial fibrillation, resolved with anti-arrhythmic drugs. Mean length of stay was 4.2 ± 0.97 days. Sixteen of the nineteen tumours were malignant, most of papillary type and Fuhrman grade II. The mean decrease in glomerular filtration rate was 4%, with a mean follow-up of 14 months.Robotic partial nephrectomy for sporadic ipsilateral multifocal renal tumours is feasible and safe. Off-clamp resection of multiple tumours can also be safely performed in carefully selected lesions.

Nephron-sparing surgery is currently considered the gold standard treatment for T1 renal tumors. As laparoscopic partial nephrectomy (LPN) represents a technically challenging procedure, robotic surgery has been increasingly used during the last few years in the field of nephron-sparing surgery. The aim of this review is to analyze the techniques and outcomes of robotic partial nephrectomy (RPN). Currently available evidence shows that RPN is a feasible and safe procedure for small localized renal tumors and also for selected complex renal tumors. Early comparative studies have demonstrated similar perioperative outcomes between RPN and LPN, with a trend towards a shorter ischemia time for RPN. However, oncological follow-up remains limited and further prospective trials are awaited to confirm the benefits of robotic approach for partial nephrectomy.

Background Recent reports have suggested that robotic laparoendoscopic single-site surgery (R-LESS) is feasible, yet comparative studies to conventional laparoscopy are lacking. Objective To report our early experience with R-LESS radical nephrectomy (RN). Design, setting, and participants A retrospective review of R-LESS RN data was performed between May 2008 and November 2010. A total of 10 procedures were performed and subsequently matched to 10 conventional laparoscopic RN procedures (controls). The control group was matched with respect to patient age, body mass index (BMI), American Society of Anesthesiologists score, surgical indication, and tumor size. Surgical procedure R-LESS RN was performed using methods outlined in the manuscript and supplemental video material. All patients underwent R-LESS RN by a single surgeon. Single-port access was achieved via two commercially available multichannel ports, and robotic trocars were inserted either through separate fascial stabs or through the port, depending on the type used. The da Vinci S and da Vinci-Si Surgical Systems (Intuitive Surgical, Sunnyvale, CA, USA) with pediatric and standard instruments were used. Measurements Preoperative, perioperative, pathologic, and functional outcomes data were analyzed. Results and limitations The mean patient age was 64.0 yr of age for both groups, and BMI was 29.2kg/m 2 . There was no difference between R-LESS and conventional laparoscopy cases in median operative time, estimated blood loss, visual analogue scale, or complication rate. The R-LESS group had a lower median narcotic requirement during hospital admission (25.3 morphine equivalents vs 37.5 morphine equivalents; p =0.049) and a shorter length of stay (2.5 d vs 3.0 d; p =0.03). Study limitations include the small sample size, short follow-up period, and all the inherent biases introduced by a retrospective study design. Conclusions R-LESS RN offers comparable perioperative outcomes to conventional laparoscopic RN. Prospective comparison is needed to definitively establish the position of R-LESS in minimally invasive urologic surgery.

We evaluated the incidence of perioperative complications after robotic partial nephrectomy.We retrospectively reviewed the records of patients treated with robotic assisted partial nephrectomy across the 4 participating institutions. Demographic, blood loss, warm ischemia time, and intraoperative and postoperative complication data were collected. All complications were graded according to the Clavien classification system.A total of 450 consecutive robotic assisted partial nephrectomies were done between June 2006 and May 2009. Overall 71 patients (15.8%) had a complication, including intraoperative and postoperative complications in 8 (1.8%) and 65 (14.4%), respectively. Hemorrhage developed in 2 patients (0.2%) intraoperatively and in 22 (4.9%) postoperatively. Seven patients (1.6%) had urine leakage. As classified by the Clavien system, complications were grade I-II in 76.1% of cases and grade III-IV in 23.9%. Robotic assisted partial nephrectomy was converted to open or conventional laparoscopic surgery in 3 patients (0.7%) and to radical nephrectomy in 7 (1.6%). There were no deaths.Current data indicate that robotic assisted partial nephrectomy is safe. Most postoperative complications are Clavien grade I or II, or can be managed conservatively.

We evaluated the oncological and functional outcomes of computerized tomography guided percutaneous cryotherapy or radio frequency ablation of kidney tumors in patients with a solitary kidney.We reviewed the medical charts of patients with a solitary kidney who underwent percutaneous probe ablation for renal masses at our institution from April 2002 through March 2010. Followup consisted of computerized tomography or magnetic resonance imaging 1 day postoperatively, at 3, 6 and 12 months, and annually thereafter. Serum creatinine and estimated glomerular filtration rate were used to measure renal function. The cryotherapy and radio frequency ablation groups were compared for demographics, the 2-year actuarial survival rate and renal function.Overall 65 patients were included in this retrospective analysis, of whom 29 (44.6%) underwent cryotherapy and 36 (55.4%) underwent radio frequency ablation. Median followup was 15.1 (IQR 4.4 to 32.9) and 38.8 months (13.8 to 50.7), respectively. The 2 groups were comparable in median age, body mass index, American Society of Anesthesiologists score, tumor size and preoperative estimated glomerular filtration rate. The 3 primary treatment failures, including 1 after cryotherapy and 2 after radio frequency ablation, were successfully re-treated with thermal ablation. There were 14 recurrences after radio frequency ablation and 3 after cryotherapy. Two-year actuarial overall, cancer specific, recurrence-free and metastasis-free survival rates for cryotherapy vs radio frequency ablation were 89% vs 93%, 100% vs 96%, 69% vs 58% and 86% vs 91%, respectively. For each group no significant decrease in renal functional parameters was found at the latest followup visit.Computerized tomography guided percutaneous probe ablation represents a safe treatment option in surgical patients at high risk with a solitary kidney. It provides low morbidity, acceptable short-term cancer control and minimal clinical impact on postoperative renal function.