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Single-port (SP) robotic surgery is a relatively new technology that is expected to become available on the European market within a year. We investigated the current expectations of robotic surgery experts and opinion leaders practicing in Europe. A 17-item online questionnaire was sent to 120 participants identified as “experts” on the basis of their general contributions to the field of robotic surgery. Overall, 90 responses were registered, with a response rate of 75%. Italy (30%), France (15%), and the UK (12%) provided the most participants, who worked mainly in academic—either public (60%) or private (20%)—hospitals. Most respondents (79%) had no previous experience with “single site” surgery, and attendance at scientific meetings (79%) and perusal of the literature (65%) were the sources of SP knowledge most frequently reported. The perceived advantages of SP robotic surgery included lower invasiveness (61%), easier access to the retroperitoneal or extraperitoneal space (53%), better cosmetic results (44%), and lower postoperative pain (44%). The most “appealing” SP procedures were retroperitoneal partial nephrectomy via an anterior approach (43%) and transvesical simple prostatectomy (43%). Within the limitations of this type of analysis, our findings suggest high interest and a positive attitude towards SP technology overall. Patient summary: Technology for single-port (SP) robotic surgery, in which just one skin incision is made in the abdomen to perform the operation, will soon be available in Europe. We conducted a survey on SP surgery among European experts in urological robotic surgery. The results show that there is high interest in and a positive attitude to SP surgery. The SP approach could result in better cosmetic results and lower postoperative pain for patients.

Objective: To describe the surgical technique and report the early outcomes of the transvesical (TV) approach to single-port (SP) robot-assisted radical prostatectomy. Methods: All procedures were performed at a single center by one surgeon. We identified the first 100 consecutive patients with clinically localized prostate cancer that underwent SP TV robot-assisted radical prostatectomy using the da Vinci SP robotic surgical system. Data were collected prospectively and analyzed with descriptive statistics. The primary outcomes assessed were postoperative urinary continence, rate of biochemical recurrence, and sexual function. Results: All procedures were performed without extra ports or conversion. The median age was 62.1 years and 49.0% of the patients had abdominal surgery history. The preoperative median prostate-specific antigen value and prostate volume were 5.0 ng/mL and 33.0 mL, respectively. There were no intraoperative complications. The median operative time and estimated blood loss were 212.5 min and 100.0 mL, respectively. A total of 92.0% of patients were discharged within 24.0 h, with an overall median length of stay of 5.6 h. Only 4.0% of patients required opioid prescriptions at discharge. The median Foley catheter duration was 3 days. Positive margins were present in 15.0% of cases. Median follow-up was 10.4 months. Continence rate was immediate after Foley removal in 49.0% of cases, 65.0% at 2 weeks, 77.4% at 6 weeks, 94.1% at 6 months, and 98.9% at 1 year. One case of biochemical recurrence (1.0%) was noted 3 months after surgery. Conclusion: The SP TV approach for radical prostatectomy cases is a safe and feasible technique for patients with clinically localized prostate cancer. This technique offers advantages of short hospital stay, minimal narcotic use postoperatively, and promising early return of urinary continence, without compromising oncologic outcomes.

Background: Partial nephrectomy (PN) is preferred for a renal mass in a solitary kidney (RMSK), although tumors with high complexity can be challenging. Objective: To evaluate the evolution of RMSK management with a focus on achievement of PN. Design, setting, and participants: Patients with nonmetastatic RMSK (n = 499) were retrospectively reviewed; 133 had high tumor complexity, including 80 in the pre-tyrosine kinase inhibitor (TKI) era (1999–2008) and 53 in the TKI era (2009–2022). After 2009, 23/53 patients received neoadjuvant TKI and 30/53 had immediate-surgery. Outcome measurements and statistical analysis: Functional outcomes, adverse events and complications, dialysis-free survival, and recurrence-free survival (RFS) were the measures evaluated. Mann-Whitney and χ2 tests were used to compare cohorts, and the log-rank test was applied for survival analyses. Results and limitations: Overall, the median RENAL score was 10 and the median tumor diameter was 5.2 cm. Demographic characteristics, tumor diameter, and RENAL scores were similar between the pre-TKI-era and TKI-era groups. In the TKI era, 23/53 patients (43%) with clear-cell histology were selected for neoadjuvant TKI. These 23 patients had a greater median tumor diameter (7.1 vs 4.4 cm; p = 0.02) and RENAL score (11 vs 10; p = 0.07). After TKI treatment, the median tumor diameter decreased to 5.6 cm and the RENAL score to 9, and tumor volume was reduced by 59% (all p

Context: The resection technique used to excise tumor during robotic partial nephrectomy (RPN) is of paramount importance in achieving optimal clinical outcomes. Objective: To provide an overview of the different resection techniques used during RPN, and a pooled analysis of comparative studies. Evidence acquisition: The systematic review was conducted according to established principles (PROSPERO: CRD42022371640) on November 7, 2022. A population (P: adult patients undergoing RPN), intervention (I: enucleation), comparator (C: enucleoresection or wedge resection), outcome (O: outcome measurements of interest), and study design (S) framework was prespecified to assess study eligibility. Studies reporting a detailed description of resection techniques and/or evaluating the impact of resection technique on outcomes of surgery were included. Evidence synthesis: Resection techniques used during RPN can be broadly classified as resection (non-anatomic) or enucleation (anatomic). A standardized definition for these is lacking. Out of 20 studies retrieved, nine compared “standard” resection versus enucleation. A pooled analysis did not reveal significant differences in terms of operative time, ischemia time, blood loss, transfusions, or positive margins. Significant differences favoring enucleation were found for clamping management (odds ratio [OR] for renal artery clamping 3.51, 95% confidence interval [CI] 1.13–10.88; p = 0.03), overall complications (OR for occurrence 0.55, 95% CI 0.34–0.87; p = 0.01) major complications (OR for occurrence 0.39, 95% CI 0.19–0.79; p = 0.009), length of stay (weighted mean difference [WMD] −0.72 d, 95% CI −0.99 to −0.45; p

In 2018, the da Vinci Single Port (SP) robotic system was approved by the US Food and Drug Administration for urologic procedures. Available studies for the application of SP to prostate cancer surgery are limited. The aim of our study is to summarize the current evidence on the techniques and outcomes of SP robot-assisted radical prostatectomy (SP-RARLP) procedures. A narrative review of the literature was performed in January 2023. Preliminary results suggest that SP-RALP is safe and feasible, and it can offer comparable outcomes to the standard multiport RALP. Extraperitoneal and transvesical SP-RALP appear to be the two most promising approaches, as they offer decreased invasiveness, potentially shorter length of stay, and better pain control. Long-term, high-quality data are missing and further validation with prospective studies across different sites is required.

Small renal masses (SRM) are defined as contrast-enhancing solid masses detected on diagnostic imaging, with a size of less than or equal to 4cm, corresponding to renal cell carcinoma stage T1a. These tumours are mainly benign, with an indolent nature and rare metastatic potential. Given the size and nature of these tumours, there has been a significant evolution and in management modalities of these tumours. These range from conventional radical approaches such as radical nephrectomy, partial nephrectomy, to more conservative approaches such as active surveillance, and some novel emerging management strategies such as various thermal ablation techniques. The treatment decision depends on patient factors such as age and co-morbidity, and tumour factor on radiological imaging, such as tumour size, location, growth rate and biopsy result. In this review, we aim to provide the latest updates on approaching SRM and various management modalities.

Over the past 20 years, the field of robotic surgery has largely been dominated by the da Vinci robotic platform. Nevertheless, numerous novel multiport robotic surgical systems have been developed over the past decade, and some have recently been introduced into clinical practice. This nonsystematic review aims to describe novel surgical robotic systems, their individual designs, and their reported uses and clinical outcomes within the field of urologic surgery. Specifically, we performed a comprehensive review of the literature regarding the use of the Senhance robotic system, the CMR-Versius robotic system, and the Hugo RAS in urologic procedures. Systems with fewer published uses are also described, including the Avatera, Hintori, and Dexter. Notable features of each system are compared, with a particular emphasis on factors differentiating each system from the da Vinci robotic system.

Objective: The novel single-port (SP) platform offers an alternative way to perform robot-assisted radical prostatectomy (RARP). The SP platform allows operating in small anatomical spaces. Using this benefit, we adopted the extraperitoneal approach to RARP. Herein, we aim to describe our technique to perform SP extraperitoneal RARP.Patients and Surgical Procedure: We demonstrate the video of a 55-year-old man with a PSA of 4.4 ng/ml. Biopsy showed 5/13 cores positive for Gleason 3+3 prostate cancer. Preoperative prostate MRI showed a 43 g prostate and a right to midline anterior 1.8 cm PI-RADS 5 lesion, with possible extracapsular extension. We performed an extraperitoneal SP RARP and bilateral pelvic lymph node dissection.Results: The case was completed in 3 hours and 11 minutes. Estimated blood loss was 100 ml. Patient was discharged 8 hours after surgery. Pathology revealed pT2N0 stage and Gleason 3+4 prostate cancer. At 3 months follow up, PSA was undetectable and patient was continent. We performed 212 cases using this approach. Surgery was successfully completed in all patients without any need for additional port placement. Median length of stay was 4 hours, and 62 patients were admitted for observation. 50.5% of patients did not require opioid analgesics after discharge. Among patients with available one year follow data, 92.2% were continent and 85.9% had undetectable PSA.Conclusion: Extraperitoneal SP RARP can be safely performed using the novel SP surgical platform.

Objective: To describe the surgical steps of single-port robotic radical prostatectomy through the transvesical approach. Methods: Through a 3 cm suprapubic midline incision, the bladder was entered and the Da Vinci Single-Port Access Kit was used for access. Through the access kit, the dedicated multichannel port, an 8 mm assistant port, and the remotely operated suction irrigation system were introduced. The surgical steps for transvesical radical prostatectomy were performed in the following order. (1) Posterior bladder neck dissection, (2) Vas deferens and seminal vesicle dissection, (3) Posterior dissection, (4) Anterior bladder neck and prostate dissection, (5) Pedicle and neurovascular bundle dissection, (6) Posterior Reconstruction and Urethrovesical Anostomosis, (7) removal of the prostate through a single incision and bladder closure. Results: The mean patients’ age was 62 years and the mean preoperative prostate-specific antigen (PSA) was 6.8 ng/mL. Single port robotic transvesical radical prostatectomy was performed successfully in 83 patients without the need for additional port placement or open conversions. The average operative time was 212 min. The mean estimated blood loss was 115 mL. The median length of stay was 4 h. Median time with a Foley catheter after surgery was 4 days. 56% of the patients had immediate continence after Foley removal. The continence rate was 96.7% at postoperative 3 months. Conclusion: SP transvesical robotic radical prostatectomy is a novel approach that provides advantages including a single incision, no additional ports, minimal opioid use, immediate continence, and same-day discharge without compromising intraoperative and oncological outcomes.

Objective: To describe in a video format the surgical steps and contemporary technique of robotic partial nephrectomy for hilar tumors. Methods: A 37-year-old female patient with a 2.5 cm heterogeneous mass in the left renal hilum was selected for this publication. The surgical steps and techniques of this procedure were recorded. Patients are positioned in a modified flank position at approximately 60 to 75 degrees. Bowel mobilization is performed in the standard fashion. After elevation of the gonadal vein and ureter on the left side and ureter on the right side, dissection continues toward the hilum until we meet the renal vein. The renal artery is identified posterior to the renal vein and is dissected off the surrounding tissue. Gerota's fascia is incised and dissected off the kidney like a clamshell. An intraoperative ultrasound probe is used to identify and mark the margins of the tumor. The renal artery is then clamped. Cold scissors are used to incise renal parenchyma and dissect around the mass. In hilar lesions, vessels feeding the tumor are clipped and divided. Renorrhaphy is performed in 2 layers. Early unclamping is performed after completing the deep renorrhaphy. The tumor is placed in a specimen retrieval bag. Gerota's fascia is reapproximated and the specimen is removed. Results: Partial nephrectomy was completed successfully without any complications. Warm ischemia time was 28 minutes. 90% of kidney volume was preserved. The estimated blood loss was 50 mL. Foley catheter and drain were removed on postoperative days 1 and 2 respectively. The patient was discharged home on postoperative day 2. Final pathology revealed a clear cell renal cell carcinoma, pT3a, with the International Society of Urologic Pathologists (ISUP) grade of 3. Surgical margins were negative. Conclusion: We demonstrated steps and the contemporary technique of the robotic partial nephrectomy for hilar tumors.

Objective: We are presenting a novel technique to perform single-port (SP) extraperitoneal dismembered pyeloplasty using a modified mini-Pfannenstiel incision. Patients and methods: Our case is a 31 year-old female with history of right sided flank pain and recurrent urinary tract infections. Her flank pain required consistent use of analgesic medication. Preoperative MAG-3 scan demonstrated 30% function of the right kidney and there was no response to furosemide administration on the right side. Patient underwent right ureteral J stent placement prior to referral and her pain improved significantly with ureteral stent placement. The decision was made to treat the patient with SP extraperitoneal right robotic dismembered pyeloplasty. The access was made through a 3.5 cm modified Pfannenstiel incision and with blunt dissection, the extraperitoneal space was created. Da Vinci SP access kit was used to insert an 8 mm assistant port, and the remotely operated suction irrigation system was used. After access, surgical steps in order were 1) Ureteral Dissection, 2) Renal pelvis dissection, 3) Excision of strictured segment, 4) Spatulation of ureter and pelvis, 5) Anastomosis. Results: Surgery was completed successfully without any need for additional port placement. Operative time was 175 minutes and estimated blood loss was 20 ml. Patient was discharged home the day of surgery. She did not require opioid analgesics after discharge. Ureteral J stent was removed 4 weeks after surgery and the patient has been without right flank pain since ureteral stent removal. Postoperative MAG-3 scan showed resolution of obstruction. Conclusions: Retroperitoneal SP dismembered pyeloplasty is safe and feasible using a modified mini-Pfannenstiel incision. This approach is applicable to any patient without a past history of pelvic surgery.

Objective: To describe in a video format the surgical steps and techniques of single-port robot-assisted extraperitoneal kidney transplantation using the SP da Vinci platform. Methods: We recorded the surgical steps and techniques of this procedure. After induction of anesthesia, and positioning the patient, a 5-cm peri or infra-umbilical incision is made and the extraperitoneal space is developed. GelPOINT access platform is placed and the robot is docked. The external iliac artery and vein are carefully dissected. The bench is performed using a LigaSure™ device to dissect the vessels. A ureteral stent is placed and the posterior surfaces of the artery and the vein are marked. The kidney is then wrapped with a blue surgical glove. After introducing some ice and the kidney into the extraperitoneal space, the robot is redocked, and venous and then arterial anastomoses are performed using 6–0 GORE-TEXⓇ sutures. After repositioning the kidney, ureteroneocystostomy is done. Nephropexy is then performed. The robot is undocked and the wound is closed. Results: Single-port robot-assisted kidney transplantation has been performed for 12 patients with end-stage renal disease. Allograft kidneys were from living and deceased donors in 9 and 3 patients respectively. Surgery was completed successfully in all patients without any complications. Median (IQR) vein and artery anastomosis times were 26 (24–28) and 37 (33–40) minutes, respectively. All grafts were perfused well on the color Doppler ultrasonography. Mean (SD) follow- up and creatinine were 11.25 (6.3) months, and 1.26 (1.16) mg/dL respectively. Conclusion: Extraperitoneal single-port robot-assisted kidney transplantation better duplicates open kidney transplantation and is associated with less number of overall incisions compared to the alternative robotic approaches.

Objectives: To present the updated technique and evaluate the perioperative outcomes of Single-port Robotic-assisted transvesical simple prostatectomy (SP RASP) Patients and methods: Forty-two consecutive patients with BPH indicated for surgery underwent SP RASP in a single institution. The procedure was performed in the following steps: 1- The Patient was placed in a supine position. 2- A 3-3.5 cm suprapubic midline incision is made, and a 2 cm vertical cystotomy was performed after bladder identification. 3- After insertion of the access port, the single-port (SP) robot was docked. 4- Identification of the ureteral orifices. 5- Prostatic enucleation was performed using the prostatic capsule as a landmark. 6- Then a complete vesicourethral mucosal advancement flap was accomplished. Results: All procedures were successfully performed with no conversion, additional port placement, or intraoperative complication. The median prostatic volume was 170cc. 95% of the patients did not require opioid analgesia after discharge. 65% of the last consecutive patients were discharged a few hours after the surgery and had their Foley catheter removed 2-3 days later. The Median IPSS score decreased from 23 before the surgery to 2.5 after the surgery. All patients had a significant postoperative improvement in maximum flow rate with a 200% improvement over baseline (19 vs. 6.5 mL/sec). Conclusion: In our initial series, SP RASP allows for favorable perioperative and early postoperative outcomes including low complication same-day discharge, short Foley catheter stay, minimal opioids use, and quick recovery.

Abstract Background Although pathological factors remain the main determinate of survival for patients with bladder cancer, quality of surgical care is crucial for satisfactory outcomes. Using a validated quality score, we investigated the impact of surgical factors on the overall survival (OS), recurrence-free survival (RFS) and disease-specific survival (DSS) in patients with locally advanced and organ-confined disease (OCD). Retrospective review of IRCC database includes 2460 patients from 29 institutions across 11 countries. The final cohort included 1343 patients who underwent RARCs between 2005 and 2016. Patients with locally advanced disease (LAD) (> pT2 and/or N +) were compared with OCD (≤ pT2/N0). Validated Quality Cystectomy Score (QCS) based on four sets of quality metrics was used to compare surgical performance. Kaplan–Meier method was used to compute RFS, CSS and OS rates. Multivariable stepwise logistic regression was used to evaluate variables associated with RFS, DSS and OS. Results 48% had LAD. When compared to patients with OCD, they received neobladders less frequently (17% vs. 28%, p

We compared perioperative outcomes after on-clamp versus off-clamp robot-assisted partial nephrectomy (RAPN) for >7 cm renal masses. A multicenter dataset was queried for patients who had undergone RAPN for a cT2cN0cM0 kidney tumor from July 2007 to February 2022. The Trifecta achievement (negative surgical margins, no severe complications, and ≤ 30% postoperative estimated glomerular filtration rate (eGFR) reduction) was considered a surrogate of surgical quality. Overall, 316 cases were included in the analysis, and 58% achieved the Trifecta. A propensity-score-matched analysis generated two cohorts of 89 patients homogeneous for age, ASA score, preoperative eGFR, and RENAL score (all p > 0.21). Compared to the on-clamp approach, OT was significantly shorter in the off-clamp group (80 vs. 190 min; p < 0.001), the incidence of sRFD was lower (22% vs. 40%; p = 0.01), and the Trifecta rate higher (66% vs. 46%; p = 0.01). In a crude analysis, >20 min of hilar clamping was associated with a significantly higher risk of sRFD (OR: 2.30; 95%CI: 1.13–4.64; p = 0.02) and with reduced probabilities of achieving the Trifecta (OR: 0.46; 95%CI: 0.27–0.79; p = 0.004). Purely off-clamp RAPN seems to be a safe and viable option to treat cT2 renal masses and may outperform the on-clamp approach regarding perioperative surgical outcomes.

Introduction: Robotic-assisted radical prostatectomy in patients with a history artificial urinary sphincter (AUS) placement has not been previously described. We describe the technique of extraperitoneal single-port robotic-assisted radical prostatectomy in a patient with a preexisting functional AUS, with emphasis on critical technical details of the procedure to prevent injury to the AUS components. Methods: The patient was a 69-year-old male with history of total urinary incontinence after transurethral resection of the prostate managed with AUS placement in 2011. He was diagnosed with multifocal intermediate risk Gleason 3 + 4 prostate cancer and scheduled for robotic assisted radical prostatectomy (RARP) with bilateral pelvic lymph node dissection (PLND). Results: Extraperitoneal robotic-assisted radical prostatectomy and bilateral pelvic lymph node dissection were performed with a pure single-site approach using the da Vinci SP® surgical system. There were no intraoperative complications. There was no damage to the adjacent organs or the AUS components. Operative time was 180 min with negligible blood loss. The Foley catheter was removed on postoperative day 7 and the AUS was reactivated afterwards. Patient could void without any difficulty and was pad free when AUS was active. Histopathological examination of the specimen showed prostate adenocarcinoma with Gleason score 3 + 4 disease and unilateral extra prostatic extension (pT3a) with focally positive margins. Three-month postoperative nadir prostate specific antigen (PSA) was undetectable and the patient remained pad-free during the same period. Conclusion: Extra-peritoneal robotic-assisted RP in a patient with preexisting AUS by using a single-port robotic platform is safe and feasible. When compared to multi-port robotic instrumentation, the single-port robotic arms enter from the same incision, which may result in decreased out-of-field instrument contact with the AUS hardware.

ABSTRACT

We aimed to review studies comparing the outcomes of the laparoendoscopic single site (LESS) pyeloplasty with those of conventional laparoscopic pyeloplasty (CLP). A systematic review of the literature was performed according to the PRISMA (preferred reporting items for systematic reviews and meta-analysis) criteria. The methodological quality of the studies was rated according validated scales. The level of evidence (LE) was reported as described by the Oxford criteria. Preoperative demographic parameters and perioperative outcomes between the two surgical techniques were assessed. A meta-analysis of the included studies was performed. A total of 5 studies were elected for the analysis, including 164 cases, 70 (42.6%) of them being LESS and 94 (57.4%) being CLP. Four studies were observational retrospective comparative studies (LE: 3a-4); one was a prospective randomized controlled trial (LE: 2b). There was no significant difference in age, body mass index, gender, side and presence of the crossing vessel, between the groups. There was no significant difference regarding the operative time (weight mean difference [WMD]: −7.02; 95% confidence interval [CI]: −71.82-57.79; P = 0.83) and length of hospital stay (WMD: 0.04; 95% CI: −0.11-0.20; P = 0.58), whereas the estimated blood loss was statistically lower for LESS (WMD: −16.83; 95% CI: −31.79-−1.87; P = 0.03). The postoperative use of analgesic favored the LESS group but without reaching statistical significance (WMD: −7.52; 95% CI: −17.56-2.53; P = 0.14). In conclusion, LESS pyeloplasty offers comparable surgical and functional outcomes to CLP while providing the potential advantages of less blood loss and lower analgesic requirement. Thus, despite being more technically challenging, LESS pyeloplasty can be regarded as a minimally invasive approach for patients seeking fewer incisional scars.

PURPOSE: To report the 5-year oncological outcomes of patients undergoing laparoscopic radical nephrectomy for renal cancer compared to a cohort of patients undergoing open radical nephrectomy. METHODS: We retrospectively analyzed the data of 88 patients undergoing radical nephrectomy for renal cell carcinoma prior to January 2000. Of these, 45 patients underwent laparoscopic radical nephrectomy, and 43 patients underwent open radical nephrectomy. Inclusion criteria comprised clinically organ-confined tumors of 15 cm or less in size without concomitant lymphadenopathy or vena cava thrombus. Oncological follow-up data were obtained from charts, radiological reports, and phone calls to patients or their families, and were calculated from the date of surgery to the date of last appointment with physician or date of death. RESULTS: All laparoscopic procedures were completed without open conversion. On comparing the laparoscopic radical nephrectomy and open radical nephrectomy groups, mean tumor size was 5. 8 vs 6.2 cm (P = . 44), mean blood loss was 183 vs 461 mL (P = . 004), and mean operative time was 2.8 vs 3.7 hrs (P < . 001). Over a mean follow-up of 5 years in the laparoscopic radical nephrectomy group and 6 years in the open radical nephrectomy group, the overall survival was 81% vs 79% (P = . 47), and cancer-specific survival was 90% vs 92% (P = . 70) , respectively. CONCLUSIONS: Laparoscopic radical nephrectomy for renal cancer confers equivalent 5-year oncological outcomes to those of open surgery.OBJETIVO: Relatar os resultados oncológicos após 5 anos de seguimento em pacientes submetidos a nefrectomia radical laparoscópica para tratamento do câncer renal, comparando esses com os resultados obtidos com um grupo de pacientes submetidos a nefrectomia radical aberta. MÉTODOS: Foram analisadas retrospectivamente as informações obtidas de 88 pacientes submetidos a nefrectomia radical para o tratamento do carcinoma renal realizadas previamente a Janeiro de 2000. Destes pacientes, 45 foram tratados com nefrectomia radical laparoscópica e 43 com nefrectomia radical aberta. Foram incluídos pacientes com tumores localizados com tamanho máximo de 15 cm, sem adenopatia ou sinal de envolvimento de veia renal na avaliação radiologica pré-operatória. As informações sobre o seguimento dos pacientes foram obtidas a partir de prontuários, laudos de exames radiológicos e ligações telefônicas para pacientes e/ou familiares. O seguimento foi calculado desde a data da cirurgia até a última consulta médica ou data de falecimento. RESULTADOS: Todos os procedimentos laparoscópicos foram realizados sem conversão para a técnica aberta. O tamanho médio tumoral foi de 5.8 e. 6.2 cm (P=0.44), perda sanguínea estimada de 183 e. 461 mL (P=0.004), e tempo operatório de 2.8 e. 3.7 horas (P

ABSTRACT Introduction Minimally invasive surgery has recently gained interest for kidney transplantation. We aimed to describe the step-by-step technique for single-port robotic transperitoneal kidney transplantation using the SP® surgical system (Intuitive Surgical, Sunnyvale, Ca) in a pre-clinical model. Materials and Methods A male fresh cadaver model was placed in a lithotomy position. A 3cm midline incision was made 4cm cephalad to the belly button. An advanced access platform (GelPOINT, Rancho Margarita, California, USA) was inserted into the abdominal cavity through the incision. A left kidney was obtained for the local procurement organization. Bench preparation of the kidney was performed. Thereafter, the organ was introduced transperitoneal through the Alexis® wound retractor. The SP® robotic platform was docked and the pelvic fossa was targeted. The standardized steps of robotic multi-arm kidney transplant were duplicated. Primary outcomes such as intraoperative complications, rate of conversion to standard technique and operative times were recorded. Results The procedure was technically completed using the SP® robotic system without conversion or the need for additional ports. There were no intraoperative complications. The total operative time was 182 minutes, with 35 minutes spent for bench kidney. Conclusions Robotic Single-Port kidney transplantation using the SP® surgical platform is feasible in a pre-clinical model. The platform could be particularly interesting for multi-quadrant surgery such as auto-transplantation, potentially reducing the time for redocking. Further clinical studies in humans and comparison with standard surgical techniques are warranted.

ABSTRACT Introduction and Objectives: Robotic assisted radical cystectomy (RARC) is an alternative to open radical cystectomy. As experience is gained with the RARC approach the technique is being applied to more complex surgical cases. We describe here our technique for RARC with intracorporeal ileal conduit urinary diversion for a renal transplant recipient. Materials and Methods: The patient is a 60-year old man with high-grade muscle invasive bladder cancer. He has a history of renal failure due to polycystic kidney disease and received a deceased donor renal transplant in 2008. His hospital course at time of transplant was complicated by low-level BK virus viremia. Interestingly his trans-urethral bladder tumor resection specimen at time of bladder cancer diagnosis stained positive for SV40. His native kidneys were anuric so bilateral laparoscopic nephrectomy was performed in a staged fashion 2 weeks prior to RARC. Our surgical technique utilizes 6 trocars, of note a 12-mm assistant trocar is placed 1 cm superior to the pubic symphysis, and this trocar is solely used to pass a laparoscopic stapler to facilitate the excision of the ileal segment and the stapled enteric anastomosis. Surgical steps include: identification of native ureters bilaterally (removed en bloc with the bladder specimen); identification of the transplanted ureter at the right bladder dome; posterior bladder and prostate dissection along Denonvilliers’ fascia; development of the space of Retzius; ligation and transection of the bladder and prostate vascular bundles; apical prostate dissection and transection of urethra; left pelvic lymphadenectomy; ilium resection for creation of the ileal conduit; stapled enteric anastomosis; ureteroileal anastomosis; maturation of the ileal conduit stoma. Results: The surgery had no intraoperative complications. Operative time was 443 minutes (7.4 hours). Estimated blood loss was 250 cc. Length of hospital stay was 5 days. The patient did not experience any postoperative complications. The patient maintained good renal graft function with no decline in eGFR to date. Conclusions: As surgeon comfort and experience with robotic assisted surgery grows, robotic surgery can successfully be applied to less frequently performed procedures. Here we successfully performed a robotic assisted radical cystoprostatectomy with intracorporeal ileal conduit urinary diversion for a renal transplant recipient.

ABSTRACT Introduction: Augmentation ileocystoplasty is a common treatment in adults with low capacity bladders due to neurogenic bladder dysfunction. We describe here our technique for robotic assisted laparoscopic augmentation ileocystoplasty in an adult with a low capacity bladder due to neurogenic bladder dysfunction. Materials and Methods: The patient is a 35 years-old man with neurogenic bladder due to a C6 spinal cord injury in 2004. Cystometrogram shows a maximum capacity of 96cc and Pdet at maximum capacity of 97cmH2O. He manages his bladder with intermittent catheterization and experiences multiple episodes of incontinence between catheterizations. He experiences severe autonomic dysreflexia symptoms with indwelling urethral catheter. He has previously failed non operative management options of his bladder dysfunction. Our surgical technique utilizes 6 trocars, of note a 12mm assistant trocar is placed 1cm superior to the pubic symphysis, and this trocar is solely used to pass a laparoscopic stapler to facilitate the excision of the ileal segment and the enteric anastomosis. Surgical steps include: development of the space of Retzius/dropping the bladder; opening the bladder from the anterior to posterior bladder neck; excision of a segment of ileum; enteric anastomosis; detubularizing the ileal segment; suturing the ileal segment to the incised bladder edge. Results: The surgery had no intraoperative complications. Operative time was 286 minutes (4.8 hours). Estimated blood loss was 50cc. Length of hospital stay was 8 days. He did experience a postoperative complication on hospital day 3 of hematemesis, which did not require blood transfusion. Cystometrogram at 22 days post operatively showed a maximum bladder capacity of 165cc with a Pdet at maximum capacity of 10cmH2O. Conclusions: As surgeon comfort and experience with robotic assisted surgery grows, robotic surgery can successfully be applied to less frequently performed procedures. In this case we successfully performed a robotic assisted laparoscopic augmentation ileocystoplasty displaying improvement in measurable functional outcomes.