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Objective: To evaluate the feasibility and functional outcomes in porcine models of a novel robotic surgical technique for the treatment of complex ureteral injuries and strictures. Materials and methods: Six pigs underwent robotic ureteral reconstruction using a long tabularized peritoneal flap and followed for 6–9 weeks after the surgery. Ureteral flap vascularity, intra-renal pressure, patency of the conduct, endoscopic aspect of the flap, renal function and histopathology were evaluated. Results: All animals successfully underwent ureteral reconstruction using a tubularized peritoneal flap. Median operative time was 223 min (162–360). Flap tubularization suture took 31 min (19–47), and proximal anastomosis took 20 min (15–38). Bladder mobilization with psoas hitch and distal anastomosis took 9 min (7–12) and 23 min (13–46), respectively. On follow-up, significant shrinkage of the ureteral flap in both length and width was observed. Antegrade pyelograms confirmed dilation and tortuosity of the proximal ureter, dilation of the renal pelvis, and major and minor calyxes without any definitive strictures. Microscopically, focal urothelial lining was seen in the neoureter. Creatinine level was significantly higher at the end of the follow-up period (p = 0.003). Conclusions: Robot-assisted ureteral reconstruction using a tubularized peritoneum flap is technically feasible and reproducible. The flap sustained abundant vascular supply after different intervals of follow-up and the peritoneal mesenchymal cells differentiated into urothelium and myofibroblasts. Further studies are needed to address the issue of functional obstruction to improve long-term renal function outcomes.

To determine the impacts of clamping the main renal artery vs individually clamping presegmental or segmental arteries at the time of global renal ischemia on the surgical and functional outcomes of robot-assisted partial nephrectomy (RAPN).Patients who underwent RAPN at our center from 2009 to September 2013 were assessed for details of intraoperative renal arterial anatomy. Cases were divided into two groups according to the type of global renal ischemia: Group 1 consisted of cases where one main renal artery (or hilum) was clamped; group 2 included cases where multiple arteries or multiple branches of arteries were individually clamped. Patient demographics, tumor characteristics, perioperative data, functional outcomes (as well as pathology findings) were assessed for both groups. Univariable and multivariable analyses were performed for identifying factors predicting early (at day 3) estimated glomerular filtration rate (eGFR) preservation postoperatively.Group 1 and group 2 included 468 and 111 patients, respectively. Estimated blood loss and warm ischemia time (WIT) were comparable between the two groups. A higher proportion of combined arterial and venous clamping was observed in group 1 (76.2% vs 52.3%; P=0.0001). On postoperative day 3, eGFR preservation was not significantly different between the two groups (P=0.87). On multivariable analysis, WIT and preoperative eGFR remained the only significant predictors of early eGFR preservation. The number of arterial vessels clamped during the procedure or simultaneous arterial/vein clamping were not predictors of early eGFR preservation.Perioperative outcomes of RAPN are not influenced by clamping the main renal artery compared with clamping multiple branches of the renal artery for achievement of global renal ischemia. WIT and baseline eGFR were confirmed to be significant predictors of postoperative renal function preservation after RAPN.

To evaluate the effect of warm ischemia time (WIT) on late renal function in patients undergoing robotic partial nephrectomy (RPN).From January 2009 to June 2013, patients with tumors ≤7 cm (cT1) undergoing RPN at our center with at least 1-year renal function data were included. Patients with deterioration of renal function due to coexisting medical conditions and patients with a solitary kidney were excluded from the analysis. We compared our cohort based on three WIT groups, namely, zero ischemia (WIT=0 minutes), limited ischemia (WIT ≤30 minutes), and extended ischemia (WIT30 minutes).From the 665 patients undergoing RPN, 266 met our inclusion criteria. Median follow up for evaluation of estimated glomerular filtration rate (eGFR) was 24 months. Zero ischemia group had the highest percentage of renal function preservation (92.9%) followed by WIT ≤30 group (89.2%) and WIT30 group (83.2%). On univariable analysis, pre-existing eGFR, tumor size, RENAL score, and WIT were significant predictors of degree of late eGFR preservation. On multivariable analysis, tumor size, pre-existing eGFR, and WIT grouping remained the only significant predictors of late renal function. There was no statistical significance in degree of late eGFR preservation between zero ischemia and WIT ≤30 groups. However, WIT30 minutes was a negative predictor of late eGFR preservation when compared to WIT ≤30 minutes.WIT30 minutes, preoperative eGFR, and tumor size were independent predictors of late eGFR deterioration after RPN in our series. With increase in the use of RPN in more complex tumors, the prolonged WIT associated with resection and reconstruction of such tumors needs to be mitigated.

Background The aim of this study is to report our single center experience with robotic partial nephrectomy (RPN) in patients with history of previous abdominal surgery (PAS). Methods Medical records of patients who underwent RPN for a single renal mass in our center from 2006 to 2013 were reviewed. Patients were divided in two groups: those who had history of PAS and those without history of PAS. Within the PAS group, four sub-groups were considered: (a) remote site of PAS in relation to RPN; (b) PAS in the proximity of RPN site; (c) previous umbilical hernia/abdominal hernia mesh repair; (d) major PAS. Results In total 627 patients were analyzed, and of these 321 patients had history of PAS (51.2%). On univariable and multivariable analyses, only Charlson Comorbidity Index, estimated blood loss, and tumor size were the significant predictors of complications. Conclusions RPN can be safely performed in patients with history of PAS with surgical outcomes comparable with those obtained in patients without history of PAS. Copyright © 2015 John Wiley & Sons, Ltd.

Purpose: To evaluate the feasibility of perineal robot-assisted laparoscopic radical prostatectomy (P-RALP) in the cadaver model.Methods: The prostate was assessed by ultrasonography and cystoscopy in the lithotomy position. After incision and subcutaneous dissection, a single-port device was placed and the robot was docked. The rectourethralis muscle was divided and the levator ani fibers were split. The Denonvilliers fascia was incised and the posterior prostate and seminal vesicles were dissected. The apex was dissected and the urethra was transected. The anterior and lateral planes were dissected and the prostate pedicles were clipped. The prostate was freed from the bladder neck and the vesicourethral anastomosis was performed. The robot was undocked and the wound was sutured in layers. Cystoscopy confirmed integrity of the anastomosis. The specimen was sent for histopathology examination.Results: Nerve-sparing P-RALP was successfully completed in three cadavers. Median time for setting was 23 minutes. Time for posterior dissection was 15 minutes. Dissection of the apex and section of the urethra took 9 minutes. Time for anterolateral dissection was 14 minutes. Time for bladder neck dissection was 7 minutes. Vesicourethral anastomosis took 8 minutes. Total operative time was 89 minutes. The prostate capsule was grossly intact and histopathology examination was negative for prostatic tissue in all distal urethral sections and in two of three bladder neck sections.Conclusions: P-RALP is feasible in the cadaver. Future studies should evaluate the feasibility of lymph node dissection through the same incision, clinical feasibility, and prospective comparisons with standard techniques.

Background Recent evidence supports the use of robotic surgery for the minimally invasive surgical management of adrenal masses. Objective To describe a contemporary step-by-step technique of robotic adrenalectomy (RA), to provide tips and tricks to help ensure a safe and effective implementation of the procedure, and to compare its outcomes with those of laparoscopic adrenalectomy (LA). Design, setting, and participants We retrospectively reviewed the medical charts of consecutive patients who underwent RA performed by a single surgeon between April 2010 and October 2013. LA cases performed by the same surgeon between January 2004 and May 2010 were considered the control group. Surgical procedure The main steps of our current surgical technique for RA are described in this video tutorial: patient positioning, port placement, and robot docking; exposure of the adrenal gland; identification and control of the adrenal vein; circumferential dissection of the adrenal gland; and specimen retrieval and closure. Outcome measurements and statistical analysis Demographic parameters and main surgical outcomes were assessed. Results and limitations A total of 76 cases (RA: 30; LA: 46) were included in the analysis. Median tumor size on computed tomography (CT) was significantly larger in the LA group (3cm [interquartile range (IQR): 3] vs 4cm [IQR: 3]; p =0.002). A significantly lower median estimated blood loss was recorded for the robotic group (50ml [IQR: 50] vs 100ml [IQR: 288]; p =0.02). The RA group presented five minor complications (16.7%) and one major (Clavien 3b) complication (3.3%), whereas four minor complications (8.7%) and one major (Clavien 3b) complication (2.3%) were observed in the LA group. No significant difference was noted between groups in terms of malignant histology ( p =0.66) and positive margin rate ( p =0.60). Distribution of pheochromocytomas in the LA group was significantly higher than in the RA group (43.5% vs 16.7%; p =0.02). Conclusions The standardization of each surgical step optimizes the RA procedure. The robotic approach can be applied for a wide range of adrenal indications, recapitulating the safety and effectiveness of open surgery and potentially improving the outcomes of standard laparoscopy. Patient summary In this report we detail our surgical technique for robotic removal of adrenal masses. This procedure has been standardized and can be offered to patients, with excellent outcomes.

Background Robotic technology is increasingly adopted in urologic surgery and a variety of techniques has been described for minimally invasive treatment of upper tract urothelial cancer (UTUC). Objective To describe a simplified surgical technique of robot-assisted nephroureterectomy (RANU) and to report our single-center surgical outcomes. Design, setting, and participants Patients with history of UTUC treated with this modality between April 2010 and August 2013 were included in the analysis. Institutional review board approval was obtained. Informed consent was signed by all patients. Surgical procedure A simplified single-step RANU not requiring repositioning or robot redocking. Lymph node dissection was performed selectively. Outcome measurements and statistical analysis Descriptive analysis of patients' characteristics, perioperative outcomes, histopathology, and short-term follow-up data was performed. Results and limitations The analysis included 31 patients (mean age: 72.4±10.6 yr; mean body mass index: 26.6±5.1kg/m 2 ). Twenty-six of 30 tumors (86%) were high grade. Mean tumor size was 3.1±1.8cm. Of the 31 patients, 13 (42%) had pT3 stage disease. One periureteric positive margin was noted in a patient with bulky T3 disease. The mean number of lymph nodes removed was 9.4 (standard deviation: 5.6; range: 3–21). Two of 14 patients (14%) had positive lymph nodes on final histology. No patients required a blood transfusion. Six patients experienced complications postoperatively, with only one being a high grade (Clavien 3b) complication. Median hospital stay was 5 d. Within the follow-up period, seven patients experienced bladder recurrences and four patients developed metastatic disease. Conclusions Our RANU technique eliminates the need for patient repositioning or robot redocking. This technique can be safely reproduced, with surgical outcomes comparable to other established techniques. Patient summary We describe a surgical technique using the da Vinci robot for a minimally invasive treatment of patients presenting with upper tract urothelial cancer. This technique can be safely implemented with good surgical outcomes.

Background The aim of this study was to describe experience with robotic assisted hemi-nephrectomy (RAHN) for the management of duplicated renal collecting system. Methods The authors’ institutional database was queried to identify patients who underwent RAHN from 2007 to 2013 for the management of a duplicated system. Patient demographics, indications and surgical outcomes were reviewed and analyzed. Results Five patients were identified with a duplicated system of which all had a history of pain and recurrent infection. Three patients underwent hemi-nephrectomy for a poorly functioning lower pole and two for an abnormal upper pole moiety. All operations were completed successfully using a robotic approach. There were only two minor (Clavien grade 1–2) complications. Conclusions RAHN is a viable option for the surgical treatment of an atrophic, chronically infected duplicated system. The unique features of robotic technology offer enhanced dexterity and vision facilitating the management of complex vascular and ureteral anatomy. Copyright © 2014 John Wiley & Sons, Ltd.

The aim of this study is to examine the role of robotic partial nephrectomy (RPN) in the management of caliceal diverticula by assessing our single-center outcomes. Between July 2007 and July 2013, 7 of 670 patients underwent RPN procedures as a reason of caliceal diverticula. The indications for RPN in all cases were recurrent urinary tract infection and pain attributed to the diverticulum in addition to failed management by endourologic or extracorporeal shockwave lithotripsy (SWL) treatments. One patient with a calcified diverticulum and another with an unsuccessful SWL treatment underwent RPN without further endourologic intervention. The other five patients had a history of unsuccessful percutaneous nephrolithotomy (one case), ureteroscopy (URS) (two cases), and a combination of SWL+URS (two cases). No intraoperative or postoperative complications were observed. No patient was readmitted postoperatively. Unique features of the robotic platform facilitate the excision of diverticulum and subsequent kidney reconstruction for this benign, but complex pathology.

The aim of this study was to provide a systematic review and meta-analysis of reports comparing laparoendoscopic single-site (LESS) living-donor nephrectomy (LDN) vs standard laparoscopic LDN (LLDN). A systematic review of the literature was performed in September 2013 using PubMed, Scopus, Ovid and The Cochrane library databases. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Weighted mean differences (WMDs) were used to measure continuous variables and odds ratios (ORs) to measure categorical ones. Nine publications meeting eligibility criteria were identified, including 461 LESS LDN and 1006 LLDN cases. There were more left-side cases in the LESS LDN group (96.5% vs 88.6%, P < 0.001). Meta-analysis of extractable data showed that LLDN had a shorter operative time (WMD 15.06 min, 95% confidence interval [CI] 4.9-25.1; P = 0.003), without a significant difference in warm ischaemia time (WMD 0.41 min, 95% CI -0.02 to 0.84; P = 0.06). Estimated blood loss was lower for LESS LDN (WMD -22.09 mL, 95% CI -29.5 to -14.6; P < 0.001); however, this difference was not clinically significant. There was a greater likelihood of conversion for LESS LDN (OR 13.21, 95% CI 4.65-37.53; P < 0.001). Hospital stay was similar (WMD -0.11 days, 95% CI -0.33 to 0.12; P = 0.35), as well as the visual analogue pain score at discharge (WMD -0.31, 95% CI -0.96 to 0.35; P = 0.36), but the analgesic requirement was lower for LESS LDN (WMD -2.58 mg, 95% CI -5.01 to -0.15; P = 0.04). Moreover, there was no difference in the postoperative complication rate (OR 1.00, 95% CI 0.65-1.54; P = 0.99). Renal function of the recipient, as based on creatinine levels at 1 month, showed similar outcomes between groups (WMD 0.10 mg/dL, -0.09 to 0.29; P = 0.29). In conclusion, LESS LDN represents an emerging option for living kidney donation. This procedure offers comparable surgical and early functional outcomes to the conventional LLDN, with a lower analgesic requirement. However, it is more technically challenging than LLDN, as shown by a greater likelihood of conversion. The role of LESS LDN remains to be defined.

Objective To compare the outcomes of robotic partial nephrectomy (RPN) for cystic and solid renal neoplasms. Methods Our RPN database was queried to identify consecutive patients who underwent RPN for cystic and solid renal masses in the period between July 2007 and July 2013. Cystic renal masses were diagnosed on cross-sectional imaging (computed tomography or magnetic resonance imaging). Matching was done between the patients with cystic renal masses and patients with solid renal masses (1:1 matching) by age, gender, tumor size, and nephrometry score. Results Of 647 cases, 55 patients with cystic masses (group 1) were matched with 55 patients with solid tumors (group 2). There was no cyst rupture or positive surgical margin observed in group 1. The volume of resected rim of healthy renal parenchyma surrounding the tumor was the same for both groups (P = .9). There was no difference between the groups in terms of percentage of glomerular filtration rate preservation postoperatively (85% vs 86%; P = .94). There was no difference in term of overall complications between the 2 groups. Thirty patients (54.5%) in group 1 and 47 patients (85.5%) in group 2 had renal cell carcinoma (P = .0001). Conclusion RPN can be safely and effectively performed when treating a suspicious cystic renal neoplasm with outcomes resembling those obtained for solid masses. Thus, when a cystic renal mass in encountered, nephron-sparing surgery can be offered and RPN represents an effective tool for this approach.

CONTEXT: Over the last decade, robot-assisted adrenalectomy has been included in the surgical armamentarium for the management of adrenal masses. OBJECTIVE: To critically analyze the available evidence of studies comparing laparoscopic and robotic adrenalectomy. EVIDENCE ACQUISITION: A systematic literature review was performed in August 2013 using PubMed, Scopus, and Web of Science electronic search engines. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria. EVIDENCE SYNTHESIS: Nine studies were selected for the analysis including 600 patients who underwent minimally invasive adrenalectomy (277 robot assisted and 323 laparoscopic). Only one of the studies was a randomized clinical trial (RCT) but of low quality according to the Jadad scale. However, the methodological quality of included nonrandomized studies was relatively high. Body mass index was higher for the laparoscopic group (weighted mean difference [WMD]: -2.37; 95% confidence interval [CI], - 3.01 to -1.74; p

The aim of this study was to provide a systematic review and meta‐analysis of reports comparing laparoendoscopic single‐site (LESS) living‐donor nephrectomy (LDN) vs standard laparoscopic LDN (LLDN). A systematic review of the literature was performed in September 2013 using PubMed, Scopus, Ovid and The Cochrane library databases. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta‐analyses criteria. Weighted mean differences (WMDs) were used to measure continuous variables and odds ratios (ORs) to measure categorical ones. Nine publications meeting eligibility criteria were identified, including 461 LESS LDN and 1006 LLDN cases. There were more left‐side cases in the LESS LDN group (96.5% vs 88.6%, P < 0.001). Meta‐analysis of extractable data showed that LLDN had a shorter operative time (WMD 15.06 min, 95% confidence interval [CI] 4.9–25.1; P = 0.003), without a significant difference in warm ischaemia time (WMD 0.41 min, 95% CI –0.02 to 0.84; P = 0.06). Estimated blood loss was lower for LESS LDN (WMD −22.09 mL, 95% CI –29.5 to –14.6; P < 0.001); however, this difference was not clinically significant. There was a greater likelihood of conversion for LESS LDN (OR 13.21, 95% CI 4.65–37.53; P < 0.001). Hospital stay was similar (WMD –0.11 days, 95% CI –0.33 to 0.12; P = 0.35), as well as the visual analogue pain score at discharge (WMD –0.31, 95% CI –0.96 to 0.35; P = 0.36), but the analgesic requirement was lower for LESS LDN (WMD –2.58 mg, 95% CI –5.01 to –0.15; P = 0.04). Moreover, there was no difference in the postoperative complication rate (OR 1.00, 95% CI 0.65–1.54; P = 0.99). Renal function of the recipient, as based on creatinine levels at 1 month, showed similar outcomes between groups (WMD 0.10 mg/dL, –0.09 to 0.29; P = 0.29). In conclusion, LESS LDN represents an emerging option for living kidney donation. This procedure offers comparable surgical and early functional outcomes to the conventional LLDN, with a lower analgesic requirement. However, it is more technically challenging than LLDN, as shown by a greater likelihood of conversion. The role of LESS LDN remains to be defined.

Over the last 20–30 years, the urology operating suite has undergone significant changes with the incorporation of new technologies, instruments, and innovative techniques aiming to decrease the invasiveness of surgical procedures. After the pioneering work of Clayman et al. in early 1990s, laparoscopic surgery spread quickly in the urological field. Since the early 2000s, robot-assisted surgery has also been increasingly adopted and even replaced standard laparoscopy in some instances. Laparoendoscopic single-site surgery (LESS) was developed with the goal to reproduce the same operative steps of laparoscopic surgery through a single incision, maximizing the cosmetic results and potentially causing less pain. More than 1,000 LESS urological procedures have been reported worldwide, encompassing almost the whole spectrum of urological surgery. With appropriate case selection, the safety of this approach appears to be similar to standard laparoscopy.

Laparoscopic and robotic pyeloplasty can be performed effectively and reproducibly by using approaches and techniques as we describe herein. Availability of robotics may be especially useful to obviate the need to perfect complex suturing technique and for more technically challenging procedures such as secondary pyeloplasty.

Objective: To evaluate contemporary international trends in the implementation of minimally invasive adrenalectomy and to assess contemporary outcomes of different minimally invasive techniques performed at urologic centers worldwide. Methods: A retrospective multinational multicenter study of patients who underwent minimally invasive adrenalectomy from 2008 to 2013 at 14 urology institutions worldwide was included in the analysis. Cases were categorized based on the minimally invasive adrenalectomy technique: conventional laparoscopy (CL), robot-assisted laparoscopy (RAL), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML). The rates of the four treatment modalities were determined according to the year of surgery, and a regression analysis was performed for trends in all surgical modalities. Results: Overall, a total of 737 adrenalectomies were performed across participating institutions and included in this analysis: 337 CL (46 % of cases), 57 ML (8 %), 263 LESS (36 %), and 80 RA (11 %). Overall, 204 (28 %) operations were performed with a retroperitoneal approach. The overall number of adrenalectomies increased from 2008 to 2013 (p = 0.05). A transperitoneal approach was preferred in all but the ML group (pÂ

WOS: 000360379300005 PubMed ID: 26328206 Objective: To explore the feasibility of laparoscopic trans-rectal Natural Orifice Transluminal Endoscopic Surgery (NOTES) radical prostatectomy in a cadaveric model and to define anatomical landmarks of this surgical route. Material and methods: After the ethical clearance, the study was conducted in Turkish Council of Forensic Medicine. With the cadaver in an exaggerated lithotomy position, a full thickness incision was made on the anterior wall of the rectum. The anteriorly visible Denonvilliers' fascia was incised sharply, exposing the posterior surface of the prostate. A single-port device (GelPOINT (R) Path) was inserted trans-anally passing the incision on the anterior wall of the rectum, into the bluntly created space between rectum and prostate. Three, 10 mm ports were placed through the GelPOINT (R) Path, at 3, 6, and 9 o'clock positions. A 5 mm, 0 degrees degree lens was introduced at 6 o'clock position; followed by laparoscopic scissors and laparoscopic grasper. Prostatic and periprostatic anatomy was defined as encountered during each step of the procedure. Results: Exposure of the posterior surface of the prostate and seminal vesicles was easily achieved. No additional openings of the rectal wall were made. Surgical specimen was extracted keeping its integrity. Conclusion: Transrectal radical prostatectomy is technically feasible in the cadaver model, being facilitated by previous experience with perineal surgery. Anatomical observations during the present experimental study suggest that the transrectal NOTES route provides good exposure of the operative field and easy access to the posterior surface of prostate, Future experimental endeavors should focus on reproducibility of this approach and feasibility of lymph node dissection using trans-rectal route.

Objective To objectively assess ipsilateral renal function (IRF) preservation and factors influencing it after robot-assisted partial nephrectomy (RAPN). Patients and Methods Our database was queried to identify patients who had undergone RAPN from 2007 to 2013 and had complete pre- and postoperative mercapto-acetyltriglycine (MAG3) renal scan assessment. The estimated glomerular filtration rate (eGFR) for the operated kidney was calculated by multiplying the percentage of contribution from the renal scan by the total eGFR. IRF preservation was defined as a ratio of the postoperative eGFR for the operated kidney to the preoperative eGFR for the operated kidney. The percentage of total eGFR preservation was calculated in the same manner (postoperative eGFR/preoperative eGFR × 100). The amount of healthy rim of renal parenchyma removed was assessed by deducting the volume of tumour from the volume of the PN specimen assessed on pathology. Multivariable linear regression was used for analysis. Results In all, 99 patients were included in the analysis. The overall median (interquartile range) total eGFR preservation and IRF preservation for the operated kidney was 83.83 (75.2-94.1)% and 72 (60.3-81)%, respectively (P < 0.01). On multivariable analysis, volume of healthy rim of renal parenchyma removed, warm ischaemia time (WIT) > 30-min, body mass index (BMI) and operated kidney preoperative eGFR were predictive of IRF preservation. Conclusions Using total eGFR tends to overestimate the degree of renal function preservation after RAPN. This is particularly relevant when studying factors affecting functional outcomes after nephron-sparing surgery. IRF may be a more precise assessment method in this setting. Operated kidney baseline renal function, BMI, WIT >30-min, and amount of resected healthy renal parenchyma represent the factors with a significant impact on the IRF preservation. RAPN provides significant preservation of renal function as shown by objective assessment criteria.

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 investigate risk factors for urine leak in patients undergoing minimally invasive partial nephrectomy (MIPN) and to determine the role of intraoperative ureteral catheterization in preventing this postoperative complication. Materials and Methods MIPN procedures done from September 1999 to July 2012 at our Center were reviewed from our IRB-approved database. Patient and tumor characteristics, operative techniques and outcomes were analyzed. Patients with evidence of urine leak were identified. Outcomes were compared between patients with preoperative ureteral catheterization (C-group) and those without (NC-group). Univariable and multivariable analyses were performed to identify factors predicting postoperative urine leak. Results A total of 1,019 cases were included (452 robotic partial nephrectomy cases and 567 laparoscopic partial nephrectomy cases). Five hundred twenty eight patients (51.8%) were in the C-group, whereas 491 of them (48.2%) in the NC-group. Urine leak occurred in 31(3%) cases, 4.6% in the C-group and 1.4% in the NC-group (p

To evaluate the feasibility of perineal robot-assisted laparoscopic radical prostatectomy (P-RALP) in the cadaver model.The prostate was assessed by ultrasonography and cystoscopy in the lithotomy position. After incision and subcutaneous dissection, a single-port device was placed and the robot was docked. The rectourethralis muscle was divided and the levator ani fibers were split. The Denonvilliers fascia was incised and the posterior prostate and seminal vesicles were dissected. The apex was dissected and the urethra was transected. The anterior and lateral planes were dissected and the prostate pedicles were clipped. The prostate was freed from the bladder neck and the vesicourethral anastomosis was performed. The robot was undocked and the wound was sutured in layers. Cystoscopy confirmed integrity of the anastomosis. The specimen was sent for histopathology examination.Nerve-sparing P-RALP was successfully completed in three cadavers. Median time for setting was 23 minutes. Time for posterior dissection was 15 minutes. Dissection of the apex and section of the urethra took 9 minutes. Time for anterolateral dissection was 14 minutes. Time for bladder neck dissection was 7 minutes. Vesicourethral anastomosis took 8 minutes. Total operative time was 89 minutes. The prostate capsule was grossly intact and histopathology examination was negative for prostatic tissue in all distal urethral sections and in two of three bladder neck sections.P-RALP is feasible in the cadaver. Future studies should evaluate the feasibility of lymph node dissection through the same incision, clinical feasibility, and prospective comparisons with standard techniques.

clamp. In our experience with hilar lesions, only the renal artery is clamped while the renal vein remains open throughout the procedure. Reconstruction of the kidney is performed with care not to obstruct the renal pelvis post operatively. CONCLUSIONS: Robotic-assisted laparoscopic partial nephrectomy is a safe and feasible option for the treatment of complex renal masses including hilar tumors.

Hak Lee*, Ithaar Derweesh, Song Wang, Ramzi Jabaji, Kyle Gilis, La Jolla, CA; Riccardo Autorino, Luis Brandao, S. Jeff Chueh, Jihad Kaouk, Cleveland, OH; Yinghao Sun, Bo Yang, Guo Fei, Shanghai, China, People’s Republic of; Deok Hyun, Byong Chang Jeong, Seoul, Korea, Republic of; Francesco Greco, Vincenzo Altieri, Rocca di Neto, Italy; Paolo Fornara, Halle Saale, Germany; Luca Cindolo, Francesco Berardinelli, Luigi Schips, Vasto, Italy; Christian Fiori, Francesco Porpiglia, Orbassano, Italy; Xiang Chen, Zhi Chen, Yao He, Changsha, China, People’s Republic of; Anibal Branco, Curitiba, Brazil; Chun-Hou Liao, Taipei, Taiwan; Iason Kyriazis, Evangelos Liatsikos, Patra, Greece; Akira Miyajima, Mototsugu Oya, Tokyo, Japan

several years (Hexvix) and has recently been approved in the US (Cysview) and is being used by select centers. In the video we demonstrate use of Cysview for detection of NMIBC. METHODS: From August 2012 to August 2013, 96 patients scheduled for TURBT at our institution have undergone instillation of Cysview and cystoscopy under blue light. Several cases are highlighted in the video demonstrating cystosocpic view under normal and blue light with pathology results. RESULTS: Use of Cysview to detect NIMBC is demonstrated in 2 select cases as seen in figure 1. The top images are under normal cystoscopy and the bottom images demonstrate the same view under blue light cystoscopy following administration of Cysview. The fluorescent areas were biopsied and revealed high-grade pT1 in the patient on the left and high grade pT1 and CIS in the patient on the right. CONCLUSIONS: Use of Cysview can help with the detection of NMIBC as well as CIS in patients undergoing TURBT for bladder cancer.

INTRODUCTION AND OBJECTIVES: Since 2009, Centers for Medicare and Medicaid Services (CMS) began publishing 30-day readmission data for selected medical diseases. The Readmission Reduction Program went into effect on October 1st, 2012 and hospitals are now financially penalized for excess readmissions. The purpose of this study is to identify factors associated with 30-day readmission after robotic partial nephrectomy (RPN). METHODS: We retrospectively reviewed our Institutional ReviewBoard approveddatabase of RPN.Demographics and perioperative parameters were analyzed. Comparisons between both groups were evaluated using Wilcoxon rank-sum test for continuous variables, while chi-square test, or Fisher’s exact test (if events number were small) were used for categorical variables. Simple or multivariable logistic regression analysis was applied to identify factors associated with readmission. Results were considered significant when p value was

We thank our colleagues for having found time in their busy schedule to perform such an in-depth methodological assessment of our systematic review and meta-analysis [1]. We would like to address the issues that were raised in their letter to the editor. The first step in our studywas a systematic review of the available studies, which was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines to minimize the risk of missing pertinent studies. One of our criteria for exclusion was studies in which the ZEUS robotic system—rather than the daVinci robotic system—was used. The ZEUS system— as our colleagues certainly know—represents an outdated technology and is no longer commercially available. Thus, we preferred not to include such studies, as clearly indicated in the text and the PRISMA diagram, and this was the case for the study byWu et al [2]. Another criterion for exclusion—again, as pointed out in the PRISMA diagram and in the text—was studies that did not include a laparoscopic/retroperitoneoscopic (control) arm. This was the case for the study by Dickson et al [3], who reported outcomes for a series of 30 retroperitoneoscopic robotic cases without any comparison to standard retroperitoneoscopy. Thus, importantly, those two studies were actually screened but deemed to be ineligible. Regarding the study by Agcaoglu et al [4], it is not possible to determine from reading the study methodology whether there was any an overlap with another study by the same group. Thus, we felt it was more appropriate to include the study. Another issue pointed out by our colleagues is the use of standard errors versus standard deviations, which are two different statistical measures [5]. We recognize that this was erroneously done and apologize for this inaccuracy.We calculated corrected values for standard deviations based on the standard error values (Supplementary Table 1). We

Introduction Partial nephrectomy is the standard of care for localized renal tumors. However, bleeding and warm ischemia time are still controversial when laparoscopic surgeries are carried out. Herein, we aim to compare the outcomes from laparoscopic partial nephrectomy with and without the use of biological glue with purified bovine albumin and glutaraldehyde (BioGlue®). Materials and Methods Twenty-four kidneys of 12 pigs were used in this study. A pre-determined lower pole segment was resected (3 cm x 1 cm) and one of two different hemostatic techniques was performed. In one kidney, hemostatic “U suture” (poliglecaprone 3.0) was performed and in the contra-lateral kidney, only the biological glue was applied. Data recorded was comprised of warm ischemia time (seconds) and estimated blood loss (mL) for each procedure. In cases of bleeding after glue administration, a complementary suture was done. Results Mean warm ischemia time was 492.9±113.1 (351-665) seconds and 746±185.3 (409-1125) seconds for biological glue and suture groups, respectively. There was a positive significant difference in terms of warm ischemia favoring the biological glue group over the suture group (p

Purpose After CMS introduced the concept of the Hospital Readmissions Reduction Program, hospitals and health care centers became financially penalized for exceeding specific readmission rates. Materials and Methods We retrospectively reviewed our institutional review board approved database of patients undergoing robotic partial nephrectomy at our institution and included in our analysis patients who were readmitted to any hospital as an inpatient stay within 30 days from discharge home after robotic partial nephrectomy. Results From March 2006 to March 2013 a total of 627 patients underwent robotic partial nephrectomy at our center and 28 (4.46%) were readmitted within 30 days of surgery. Postoperative bleeding was responsible for 8 (28.5%) readmissions. Pulmonary embolism was reported in 3 cases and retroperitoneal abscess was diagnosed in 2. Urinary leak requiring surgical intervention developed in 2 patients, pneumonia was diagnosed in 2 and 2 patients were readmitted for chest pain. Overall 9 (32.1%) patients presented with major complications requiring intervention. On multivariable analysis Charlson comorbidity index score was the only factor significantly associated with a higher 30-day readmission rate (p = 0.03). If the Charlson score was 5 or greater the chance of hospital readmission would be 2.7 times higher. Conclusions Increased comorbidity, specifically a Charlson score of 5 or greater, was the only significant predictor of a higher incidence of 30-day readmission. This information can be useful in counseling patients regarding robotic partial nephrectomy and in determining baseline rates if CMS expands the number of conditions they evaluate for excess 30-day readmissions. © 2014 by American Urological Association Education and Research, Inc.

Introduction A duplicated renal collecting system is a relatively common congenital anomaly rarely presenting in adults. Aim In this video we demonstrate our step-by-step technique of Robotic heminephrectomy in a patient with non-functioning upper pole moiety. Materials and Methods Following cystoscopy and ureteral catheter insertion the patient was placed in 600 modified flank position with the ipsilateral arm positioned at the side of the patient. A straight-line, three arm robotic port configuration was employed. The robot was docked at a 90-degree angle, perpendicular to the patient. Following mobilization the colon and identifying both ureters of the duplicated system, the ureters were followed cephalically toward, hilar vessels where the hilar anatomy was identified. The nonfunctioning pole vasculature was ligated using hem-o-lok clips. The ureter was sharply divided and the proximal ureteral stump was passed posterior the renal hilum. Ureteral stump was used as for retraction and heminephrectomy is completed along the line demarcating the upper and lower pole moieties. Renorrhaphy was performed using 0-Vicryl suture with a CT-1 needle. The nonfunctioning pole ureter was then dissected caudally toward the bladder hiatus, ligated using clips, and transected. Results The operating time was 240 minutes and blood loss was 100 cc. There was no complication post-operatively. Conclusions Wrist articulation and degree of freedom offered by robotic platform facilitates successful performance of minimally invasive heminephrectomy in the setting of an atrophic and symptomatic renal segment.

Objective To present our robotic partial nephrectomy (RPN) experience for renal masses ≥7 cm and compare the surgical outcomes in this cohort with those obtained for small (≤4 cm) renal masses. Materials and Methods We retrospectively reviewed our institutional review board-approved RPN database and identified patients undergoing RPN for tumors ≥7 cm. Surgical technique, renal function, oncologic, and pathologic data were analyzed and compared with the RPN for renal masses ≤4 cm. Results Overall, 441 patients were identified for the purpose of this study, including 29 cases and 412 controls. Median operative time (200 vs 180 min; P =.005), warm ischemia time (26.5 vs 19 min; P

Introduction The first laparoscopic case of ileal interposition was reported in 2000, proving the feasibility of the procedure in a minimally invasive fashion by duplicating the principles of open surgery. Robotic applications in urology are expanding worldwide, given the unique features of the robotic platform, which facilitates more advanced laparoscopic procedures. In this study, we report a case of completely intracorporeal robotic ileal ureter and thoroughly describe our technique for this complex minimally invasive procedure. Technical Considerations A 50-year-old gentleman with a history of right renal stones underwent multiple right ureteroscopies and thereafter developed 2 proximal ureteral strictures of 5 mm. Preoperative estimated glomerular filtration rate was 71 mL/min/1.73 m2. Renal scan showed preserved function. The treatment options were discussed, and the patient elected to undergo a robotic ileal ureter interposition. Total operative time was 7 hours, the estimated blood loss was approximately 50 mL, and the patient progressed to regular diet on postoperative day 4 without any problem, being discharged without complications. On the postoperative day 12, a cystogram demonstrated no extravasation, and the Foley catheter was removed. After 1 month, renal scan showed the left kidney with 60.1% and the right kidney with 39.9% of total renal function. At 2 years follow-up, his serum creatinine was 1.14 and estimated glomerular filtration rate was 70 mL/min/1.73 m2. Conclusion Robot-assisted laparaoscopic ileal ureter with a completely intracorporeal technique is feasible and appears to be safe. A larger number of procedures using this technique and longer follow-up are needed to further define its role in the treatment of ureteral strictures.