Clinical Research Of Laparoendoscopic Single-Site Surgery Technique Application In Urology

Objectives1.To present the first case of transperitoneal laparoendoscopic Single-site live donornephrectomy (LESS-DN) in the mailland of China and assess its safety, feasibility.2.To present the first clinical case series of retroperitoneal laparoendoscopicsingle-site(LESS) renal cryoablation in the mailland of China and assess its safety, feasibility.3.To determine whether the transumbilical LESS radical nephrectomy shows anyobjective advantage in comparison with standard laparoscopy.4To present our cumulative experience with first100cases of urologiealLaparoEndoscopic Single-site Surgery(LESS).Methods1.Donor, female,59-year-old, BMI21.6kg/m. Preoperative serum creatinine levelwas45umol/L. Using Tc99m-DTPA to determine the glomeruli ifltration rate (GFR), thepreoperative unilateral renal function was determined to be50mL/min (left side)^id56mL/min (right side). Recipient, male,41-year-old, BMI19.5kg/m2? with preoperative serumcreatinine level of1446umol/L. On Nov.9th2011, one case of LESS-DN was performed viaa multi-channel TriPort?(Advanced Surgical Concepts, Wicklow, Ireland) through a5cmskin incision at our institute. No extra skin incisions were made whatsoever. The dissection ofthe kidney was facilitated with the stand^d laparoscopic instruments at all the steps. Therenal artery and the renal vein were skeletonized atfer the adrenal vein and the lumber vein, ifany, were clipped. The ureterogonadal packet was letf en bloc and transected at the level of itscrossing with the common iliac vessels. The kidney was entrapped, and the mouth of the bagloosely cinched around the intact renal artery and vein. The renal artery and the renal veinwere divided. The pre-entrapped kidney was extracted through the original incision aftergenerous crmiial and caudal extension of the rectus fascia incision.2.Two patients with an enchancing radiographic small renal mass underwentretroperitoneal laparoendoscopic single-site renal cryoablation by a single urologic surgicalteam at14-Mar-2012and19-Mm*-2012in our institution. The salient patient demographics and tumor characteristics, inlcuding age, gender, body mass index, Charlson Co-morbidityIndex (Age-weighted), tunor laterality, diameter, R.E.N.A.L.nephrometry score andpreoperative eGFR (mL/min/1.73m2) were:79/43, male/female,27.0/25.0,4/3, letf/letf,2.7/2.6,2+2+3+p+3二lOp/l+l+l+a+2二5a^61.5/187.8. A2-cm longitudinal skin incision wasmade at the mid-point between the iliac crest and the inferior margin of12th rib at the level ofmidaxillary line. With the renal mass fully dissected and exposed, two2-mm cryoprobes werepercutaneously introduced and placed into the tumor under laparoscopic visualization. Twofreeze-thaw cryoablation cycles were performed according to the instructions of EndoCareCryo-Care Surgery System.3.Between September2008and January2011, a total of105transperitoneallaparoscopic radical nephrectomies (RN) were performed by a single urologist at our center,of which there were21consecutive transumbilical LESS RN (Group A). This group wassubsequently matched to21standard lap^oscopic RN procedures (Group B). Perioperativeoutcomes and follow-up information, including scores of cosmetic satisfaction, wereretrospectively analyzed. The control group was matched with respect to patient age, bodymass index, tumor size and location, and surgical indication (Tl stage).4.Between December2008and May2011， an observational cohort of98patients whowere performed with a total of100T?riPort LESS urologic surgeries for various indications,of which2patients underwent a synchronous bilateral surgery. These included radicalnephrectomy (N=24), partial nephrectomy (N=3), simple nephrectomy (N=10), kidney cystexcision (N=21), adrenlectomy (N=12)? transvesical simple prostatectomy (N=9)?ureterolithotomy (N=6), and others (N=15). Demographics and perioperative outcomes andfollow-up data were prospectively recorded.Results1. The procedure was smoothly completed without any extra skin incision. Theoperating time210min, estimated blood loss was50ml, warm ischemia time was3.8min.The length of harvested renal artery, vein and ureter was3.6cm,4.5cm and13cm,respectively. The length of skin incision at closure was5cm. Allogratf functionedimmediately on trmisplantation. Donor Visual Analog Pain Scores were2.5/10，1/10,0/10atpostoperative day1，2and3. The recovery of the donor was uneventful and discharged at4thpostoperative day. Postoperative serum creatinine level of the at12h,24h，2d,3d,4d,5d,6d, 7d, discharge day was475,282,148,145,117,100,103,98,80umol/L, respectively. And thelength of postoperative day of the recipient was10days.2.The two procedures were smoothly completed without any extra skin incision.Operative duration, cyroablation time and estimated blood loss was185min/170min,30min/30min,50ml/30ml, respectively. Postoperative pain measured by the visual analog painscale (VASP) at dayl,day2，day3was2/1，1/1,0/0, respectively. The two patients underwentan uncomplicated recovery and were discharged at day5， and day6atfer surgery. Pathologicex謹inaztion revealed clem*cell renal cell carcinoma of both patients with Fuhrman grade IIand I. The eGFR of both patients tested at1-month follow-up postoperativly was60.2/144.3(mL/min/1.73m2). No evidence of contrast-enhancing at the cyroablative region by renalcontrasted CT scan performed1week and1month atfer surgery, indicating there was notumor remanet and free of recurrence.3.The LESS group had significmitly (p <0.05) quicker bowel function recovery(31.6士17.98vs.42.3士19.94, hours), lower postoperative pain score (3.5士0.84vs.4.1士1.06),and a better cosmetic satisfaction (8.2士0.71vs.7.3士0.85). Notably, there was statisticaldifference between the two groups in memi operative time for the first10cases of each group,while not for the last10cases or overall. With a mean respective follow-up of8.4士4.41and20.0士3.95(P二0.000) months, all patients of both groups remained symptom-free and noevidence of recurrence was detected.4.Of100surgeries,87were smoothly completed. An5-mm ancillary trocar wasrequired in9cases. Conversion to standard laparoscopy and open surgery were needed in1and3patients, respectively. The overall rate of complication was15%with6%intraoperatively and9%postoperatively. The complication rate was5%of the first50casesand10%of the subsequent50cases. At the latest follow-up, all patients remained clinicallyhealthy with a delighted hidden scar. No evidence of recurrence or metastasis was detected inpatients performed with tumor resection.Conclusions1、 The initial experience shows the laparoendoscopic Single-site live donornephrectomy is a safe, feasible and eiffcacious procedure. It may exhibit clinical benefits forpatients in terms of pain control, convalescence and cosmesis, with encouraging future.2、 The initial experience shows the laparoendoscopic single-site renal cryoablation is a safe, feasible and efficacious procedure. It may exhibit clinical benefits for patients in termsof pain control, preservation of renal function, convalescence and cosmesis, with an attractiveoption for patients with significant comorbidities and an intensitive treatment intention.3、 The transumbilical LESS radical nephrectomy offers comparable perioperativeoutcomes to standard laparoscopy, with better postoperative pain control, quicker recovery ofbowel function, and better cosmetic satisfaction. In addition, the leaning curve of thisprocedure appears to be not so steep for an experienced laparoscopist following a strictspecialized training course. However, prospective randomized control trials and long-termfollow-up m*e awaited for further conclusions.4、 The LESS urologieal surgery is safe and technically feasible with further minimalinvasiveness and better cosmesis. Great emphasis should be attached on the patient selectionand indication criteria. Ongoing refinement in instrumentation, further clinical practice, andwell-designed multi-center prospective clinical control trials will make a greater role of theLESS surgery in the treatment of urologic diseases.