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Robot-assisted surgery (RAS) has been integrated into clinical practice to overcome several limitations of conventional open or laparoscopic surgery. After the expiration of the long key patent period of Intuitive Surgical, various robotic systems (RSs) have been developed aiming at improving certain characteristics of the first robotic platform, the Da Vinci RS. This narrative review provides an overview of the current RSs used in urology along with the initial results from their application in urologic procedures. Nine robotic platforms are being analyzed regarding their unique characteristics as well as their efficacy, safety, feasibility, and outcomes in urologic, oncological, or non-oncological operations. The main barrier to the wide application of RAS has been the increased cost that refers to both acquisition and maintenance costs. Besides, the health inequality resulting from the lack of expert robotic surgeons and the difficulty of performing robot-assisted procedures in provincial hospitals should be overcome. However, large properly designed comparative studies are required to establish the role of newly introduced RSs. In addition, urologists should keep abreast of new developments and research in robot-assisted urologic procedures.

Purpose: To investigate the learning curve in four basic surgical skills in laparoscopic and robotic surgeries, and evaluate the approximate time needed to reach sufficient expertise in performing these tasks with the avatera® system., Methods: Twenty urology residents with no previous experience in dry-lab and robotic surgery were asked to complete four basic laparoscopic tasks (peg transfer, circle cutting, needle guidance, and suturing) laparoscopically and robotically. All participants were asked to complete the tasks first after watching the Uroweb educational material and, second, after undertaking a 2-hour training in robotic and laparoscopic dry-lab. Thereafter, all trainees continued to undertake 2-hour training programs until being able to complete the tasks with the avatera® robot at the desired time. Paired t test and one-way ANOVA test were used to analyze time differences between the groups., Results: Time needed to complete all tasks either robotically or laparoscopically was significantly less in the second compared to the first attempt for all Groups in each Task. In the robotic dry-lab, time needed to complete the tasks was significantly less than in the laparoscopic dry-lab. A significant effect of previous laparoscopic experience of the participants on the training time needed to achieve most of the goal times was detected., Conclusion: The results of the study highlight the role of previous laparoscopic experience in the training time needed to achieve the performance time goals and demonstrate that the learning curve of basic surgical skills using the avatera® system is steeper than the laparoscopic one., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Robot-assisted radical prostatectomy is a minimally invasive, safe procedure preferred in the management of localized prostate cancer. In this study, we present our initial experience with the avatera ™ system (avateramedical GmbH, Jena, Germany) in robot-assisted radical prostatectomy., Methods: A total of fourteen patients underwent robot-assisted radical prostatectomy using this newly introduced system in our department from June 2022 to October 2022. The primary endpoints of the study were the time and the successful completion of the operation, the hemoglobin drop and the presence of complications. The pathologic tumor stage and the presence of positive surgical margins were also recorded. Follow-up of the patients for the functional outcomes over a period of 3 months took place., Results: The completion of all the surgeries was successful. The median draping and docking times were 9.5 minutes (7-13) and 10 minutes (5-40), respectively. The median console time was 103.5 minutes (90-121). No conversion to laparoscopic or open prostatectomy was necessary. The median hemoglobin drop was 1.95 g/dL (0.3-2.7), while positive surgical margins were present in two patients postoperatively. No major complications or need for transfusion were noticed. Six months after the procedure, 78.6% of the participants were continent while 77.7% of the nerve-sparing patients reported erections adequate for intercourse., Conclusions: All the operations were completed successfully without major complications or significant blood loss. The functional outcomes were acceptable according to the literature. Based on the early outcomes, robot-assisted radical prostatectomy with the avatera ™ system (avateramedical GmbH) could be considered feasible, safe, and efficient.

Objective: To evaluate retrospectively the feasibility of Florence robotic intracorporeal neobladder technique in laparoscopic radical cystectomy., Methods: Fourteen patients with muscle-invasive bladder cancer underwent laparoscopic radical cystectomy and Florence robotic intracorporeal neobladder between September 2021 and February 2023. Patients' characteristics, pathology data, perioperative outcomes, postoperative complications, and follow-up data were collected., Results: All operations were successfully completed laparoscopically. The median total operative time was 343 minutes, and the median estimated blood loss was 169.5 mL. No intraoperative complications were observed. The median hospitalization time was 7days, while the median time to regular diet was 3days. Clavien Dindo Grade < III complications appeared in five patients within 30days postoperation. No other complications were noted over the 90days follow-up. Organ-confined disease was confirmed in 11 patients and locally advanced disease in three patients. At 3months follow-up, eight and four patients were daytime and night-time continent, respectively., Conclusion: Replicating Florence robotic intracorporeal neobladder in laparoscopic radical cystectomy is safe, feasible, and repeatable, based on the encouraging perioperative, oncological, and functional outcomes of our study. However, further prospective studies on a larger scale are required to prove its long-term results., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the safety and feasibility of partial nephrectomy with the use of the novel robotic system in an in vivo animal model., Methods: Right partial nephrectomy was performed in female pigs by a surgical team consisting of one surgeon and one bedside assistant. Both were experienced in laparoscopic surgery and trained in the use of the novel robotic system. The partial nephrectomies were performed using four trocars (three trocars for the robotic arms and one as an assistant trocar). The completion of the operations, set-up time, operation time, warm ischemia time (WIT) and complication events were recorded. The decrease in all variables between the first and last operation was calculated., Results: In total, eight partial nephrectomies were performed in eight female pigs. All operations were successfully completed. The median set-up time was 19.5 (range, 15-30) minutes, while the estimated median operative time was 80.5 minutes (range, 59-114). The median WIT was 23.5 minutes (range, 17-32) and intra- or postoperative complications were not observed. All variables decreased in consecutive operations. More precisely, the decrease in the set-up time was calculated to 15 minutes between the first and third attempts. The operative time was reduced by 55 minutes between the first and last operation, while the WIT was decreased by 15 minutes during the consecutive attempts. No complications were noticed in any operation., Conclusions: Using the newly introduced robotic system, all the advantages of robotic surgery are optimized and incorporated, and partial nephrectomies can be performed in a safe and effective manner.

Purpose: This pilot study was designed to interpret the technically specific features of the avatera robotic system and present our initial experience with this novel platform in robot-assisted pyeloplasty (RAP)., Methods: A single-center prospective study was conducted including all patients who underwent RAP with the avatera robotic system from June 2022 to October 2022 in our Department. Transperitoneal robot-assisted dismembered pyeloplasty was performed in all cases. The trocar placement and the surgical technique were similar in all patients. The successful completion of the procedures, operation time (including draping, docking and console time), decrease in hemoglobin postoperatively, and presence of any complications were the study's primary endpoints., Results: In total, nine patients underwent RAP using the avatera system. All procedures were successfully completed. The draping of the robotic unit was completed in a median time of 10 min (range 7-15), while the median docking time was 17 min (range 10-24). The median console time was 88 min (range 78-116) and no complications were noticed. The median hemoglobin drop was calculated to 0.7 g/dL (range 0.4-1). During the mean follow-up of 9.33 ± 2.78 months, no late postoperative complications were noticed., Conclusion: The early outcomes of the use of the novel avatera system in RAP are presented. All operations were successfully completed with safety and efficacy, without complications or significant blood loss., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To evaluate the feasibility and intraoperative technical parameters of the new robot-assisted surgical system Avatera by performing bilateral nephrectomy in a live porcine model. Materials and Methods: Six pigs underwent bilateral robot-assisted radical nephrectomy using the Avatera robotic system (RS). The operations were performed by experienced open (Group 1) and laparoscopic (Group 2) surgeons. The operating time, docking time, set-up time, and console time were evaluated. Data regarding intraoperative complications (major or not), injury of adjacent organs, and technical difficulties during the operation were also recorded. Results: Robot-assisted bilateral nephrectomy was completed effectively in all sample pigs. The docking time and set-up time were similar among the two groups, whereas the console time and operating time were significantly longer for the open surgeon group. Two intraoperative minor complications occurred in the open surgeon's group. An inadvertent damage of the renal vein occurred in two cases and the bleeding was controlled effectively. Other than the initial two cases, the estimated blood loss was <50 mL in both groups. Injury of the adjacent organs was not noticed. Conclusions: The study demonstrated that radical nephrectomy using the Avatera robotic surgical system is technically feasible, safe, and valid in pigs. Our results warrant the application of the Avatera RS in other urologic procedures, collecting data for further clinical trials.

Objective: This study aimed to compare the stability of the Click'aV ® (Grena ® ), Click'aV plus (Grena), and Hem-o-lok ® (Weck ® , Teleflex ® ) polymer clips and the evaluation of the clips stability on a complete porcine artery. Materials and Methods: A dynamometer with a custom support and clamp unit was used. The crank gradually increased the tension force being applied on the clip via the suture. Different directions for the application of the force were tested. The highest force before the start of slipping the suture was noted. The procedure was repeated three times for each ligating clip. Results: For transverse stability, the "XL-size" Grena Click'aV Plus required preventing slippage at a greater force compared to the Hem-o-lok ( p  = 0.0071). No significant differences found statistically between the Grena Click'aV and Hem-o-lok clips ( p  = 0.1). For longitudinal stability, the Hem-o-lok required a significantly higher force to be opened compared to the Click'aV ( p  = 0.0036), but no statistically significant difference was found compared to the Click'aV Plus ( p  = 0.1). Concerning porcine artery stability, the artery slipped through the Click'aV clip in both measurements at a force of 10.2 and 9.4 N. In contrast, the arteries were cut in all measurements using the Click'aV Plus and the Hem-o-lok clips at forces of 11.8 and 12.8 N and 12.9 and 14.2 N, respectively. None of the clips leaked with up to 300 mm Hg of intra-arterial pressure applied to porcine renal arteries. Conclusions: The Grena Click'aV Plus clip has similar performance to the Hem-o-lok clip, and this clip can be equally useful for ligating vessels in laparoscopic urologic surgeries. We believe, from our findings in this study as well as those from other reports, that vascular clips applied properly by experienced surgeons provide a safe, reliable, and considerable cost-saving option for vascular control in urologic laparoscopic surgery.

Objectives: Literature regarding experience with three-dimensional (3D) laparoscopy in urology has remained scanty, and this might be also related to the parallel explosion of robot-assisted laparoscopic surgery. The study aim was to compare 3D vs two-dimensional (2D) laparoscopic approaches for urological procedures in perioperative outcomes in a subgroups analysis of studies reporting procedures requiring intracorporeal suturing., Materials and Methods: We searched EMBASE and Medline from database inception to September 22, 2017 for studies comparing patients undergoing 2D vs 3D laparoscopic approach for urological procedures. Two investigators independently selected studies for inclusion. Studies identification and selection was performed according to PRISMA criteria. Quality of the studies was assessed by the Newcastle-Ottawa and the Jadad scales for nonrandomized controlled trials (RCTs) and RCTs, respectively. For continuous variables, weighted mean difference was used for quantitative synthesis; for categorical variables, the odds ratio with confidence interval (95% CI) was used instead. A random-effect model was used for pooled estimates to account for heterogeneity. Statistical analyses were performed using RevMan 5.3 (Cochrane Collaboration, Oxford, United Kingdom)., Results: Eight comparative studies of interest published in English were found and considered for the quantitative synthesis. Among them, four were RCTs. Six studies regarded procedures requiring intracorporeal suturing and were considered for cumulative-analysis. Meta-analysis did not show any significant difference in operative time. Quantitative synthesis showed advantages for 3D laparoscopy in terms of operative time, blood losses, and length of stay. When limited to studies regarding radical prostatectomy, operative time significantly favored 3D approach (mean difference -35.00, 95% CI -41.34 to -28.67 minutes)., Conclusions: The present systematic review and cumulative-analysis indicated that 3D laparoscopy could offer some advantages in terms of operative time for more challenging procedures requiring intracorporeal suture.

The monopoly of robotic surgical devices of the last 15 years will end in 2019 when key patents of Intuitive Surgical expire. Thus, we can expect an interesting competitive situation in the coming years. Based on personal experience with robot-assisted surgery since 2001, we conducted a search of the current literature together with a search of relevant patents in this field. Finally, we visited the websites of manufacturers of existing and future robotic surgical devices with possible applications in urology. Such devices have to prove that they meet the high-quality standard of the current Da Vinci series (SI, X, XI). For this purpose, we propose to classify the main features of the different devices, such as type of console (closed/open), arrangement of robotic arms (single/multiple carts/attached to operating room table), type of three-dimensional videosystem (by mirror/ocular/using polarizing glasses) or degrees of freedom (DOF) of end effectors (5 vs. 7 DOF). In the meantime, there are also robotic systems used in endourology: Avicenna Roboflex® and the AquaBeam® system for robot-assisted aquablation therapy of the prostate. While Roboflex® improves the ergonomics of flexible ureteroscopy-similar to the Da Vinci robot, AquaBeam® may for the first time eliminate the surgeon, who might only be needed to manage severe postoperative bleeding.

Purpose: Live surgery (LS) is considered a useful teaching opportunity. The benefits must be balanced with patient safety concerns. To evaluate the rate of complications of a series of urologic LS performed by experts during the Congress Challenge in Laparoscopy and Robotics (CILR)., Methods: We present a large, multi-institution, multi-surgeon database that derives from 12 CILR events, from 2004 to 2015 with a total of 224 cases. Radical prostatectomy (RP) was the most common procedure and a selection of complex cases was noted. The primary measure was postoperative complications and use of a Postoperative Morbidity Index (PMI) to allow quantitative weighing of postoperative complications., Results: From 12 events, the number of cases increased from 11 in 2004 to 27 in 2015 and a total of 27 surgeons. Of 224 cases (164 laparoscopic and 60 robotic), there were 26 (11.6%) complications: 5 grade I, 5 grade II, 3 grade IIIa, 12 grade IIIb and 1 grade V, the latter from laparoscopic cystectomy. Analysis of PMI was 23 times higher from cystectomy compared to RP., Conclusions: In the setting of live surgery, the overall rate of complications is low considering the complexity of surgeries. The PMI is not higher in more complex procedures, whereas RP seems very safe.

Purpose: To look at the bibliometric publication trends on 'Urolithiasis' and aspects of treatment and training associated with it over a period of 16 years from 2000 to 2015. To this end, we conducted this study to look at the publication trends associated with urolithiasis, including the use of simulation, laser technology, and all types of interventions for it., Materials and Methods: We performed a systematic review of the literature using PubMed over the last 16 years, from January 2000 to December 2015 for all published papers on 'Urolithiasis'. While there were no language restrictions, English language articles and all non-English language papers with published English abstracts were also included. Case reports, animal and laboratory studies, and those studies that did not have a published abstract were excluded from our analysis. We also analyzed the data in two time periods, period-1 (2000-2007) and period-2 (2008-2015)., Results: During the last 16 years, a total of 5343 papers were published on 'Urolithiasis', including 4787 in English language and 556 in non-English language. This included papers on URS (n = 1200), PCNL (n = 1715), SWL (n = 887), open stone surgery (n = 87), laparoscopic stone surgery (n = 209), pyelolithotomy (n = 35), simulation in Endourology (n = 82), and use of laser for stone surgery (n = 406). When comparing the two time periods, during period 2, the change was +171% (p = 0.007), +279% (p < 0.001), and -17% (p = 0.2) for URS, PCNL, and SWL, respectively. While there was a rise in laparoscopic surgery (+116%), it decreased for open stone surgery (-11%) and pyelolithotomy (-47%). A total of 82 papers have been published on simulation for stone surgery including 48 papers for URS (67% rise in period-2, p = 0.007), and 34 papers for PCNL (480% rise in period-2, p < 0.001). A rising trend for the use of laser was also seen in period 2 (increase of 126%, p < 0.02, from 124 papers to 281 papers)., Conclusions: Published papers on intervention for Urolithiasis have risen over the last 16 years. While there has been a steep rise of URS and minimally invasive PCNL techniques, SWL and open surgery have shown a slight decline over this period. A similar increase has also been seen for the use of simulation and lasers in Endourology.

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 (p < 0.001). European centers mostly adopted CL and ML techniques, whereas those from Asia and South America reported the highest rate in LESS procedures, and RAL was adopted to larger extent in the USA. LESS had the fastest increase in utilization at 6 %/year. The rate of RAL procedures increased at slower rates (2.2 %/year), similar to ML (1.7 %/year). Limitations of this study are the retrospective design and the lack of a cost analysis., Conclusions: Several minimally invasive surgical techniques for the management of adrenal masses are successfully implemented in urology institutions worldwide. CL and LESS seem to represent the most commonly adopted techniques, whereas ML and RAL are growing at a slower rate. All the MIS techniques can be safely and effectively performed for a variety of adrenal disease.

Purpose: To evaluate the efficacy of mini-laparoscopic instruments in combination with laparoendoscopic single-site surgery (LESS) instruments for the performance of oncological urological surgery., Methods: Thirty-five patients underwent oncological hybrid LESS either mini-laparoscopic-assisted LESS partial nephrectomy (LESS-PN, n = 12) or mini-laparoscopic-assisted LESS radical nephrectomy (LESS-RN, n = 23). Perioperative data were prospectively collected. The patient and observer scar assessment scale (POSAS) was used for the evaluation of the cosmetic outcome., Results: Mean tumor size treated by LESS-PNs was 28.8 (IQR 20.5-37.3) mm. Average operative time and blood loss were 123 (IQR 112.5-145) min and 158.3 (IQR 100-200) ml, respectively. Renal artery clamping took place in seven cases. LESS-RN was performed in cases with a mean tumor size of 60 (IQR 48-71.5) mm. The average operative time was 116.8 (IQR 100-130) min. Average blood loss was 137 (IQR 100-150) ml. Complications were limited to grade II according to Clavien classification. The oncological outcome, including midterm results, was directly comparable to the literature. Patients reported low pain scores and high satisfaction in terms of postoperative scarring. The POSAS scores confirmed the excellent cosmetic outcome of hybrid LESS., Conclusion: The combination of mini-laparoscopic and LESS instrumentation as routine equipment of oncological surgery provided an efficient option for urologic surgery. The combination of mini-laparoscopic and LESS instruments improves the intraoperative ergonomics of LESS-PN and LESS-RN. The provided surgical and oncological outcome compares favorably to the LESS and conventional laparoscopic literature.

The demand for urological surgical treatment associated with better cosmesis, lower morbidity rates and shorter hospitalization constantly grows. The transvaginal route has been proposed in an attempt to avoid long abdominal incisions for the removal of the large laparoscopic specimens. Moreover, the transvaginal NOTES approach represents a promising evolution of laparoscopic surgery to a more "minimally invasive" alternative. The current review summarizes the available experience in the literature in transvaginal conventional laparoscopy and NOTES in urology, gynecology and general surgery. The clinical outcome is presented. The most important issues associated with the transvaginal approach are the complications and the postoperative sexual function. These issues are presented.

Objectives: To describe the progress being made in training for minimally invasive surgery (MIS) in urology., Methods: A group of experts in the field provided input to agree on recommendations for MIS training. A literature search was carried out to identify studies on MIS training, both in general and specifically for urological procedures., Results: The literature search showed the rapidly developing options for e-learning, box and virtual training, and suggested that box training is a relatively cheap and effective means of improving laparoscopic skills. Development of non-technical skills is an integral part of surgical skills training and should be included in training curricula. The application of modular training in surgical procedures showed more rapid skills acquisition. Training curricula for MIS in urology are being developed in both the USA and Europe., Conclusion: Training in MIS has shifted from 'see-one-do-one-teach-one' to a structured learning, from e-learning to skills laboratory and modular training settings., (© 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.)

Background and Purpose: Three-dimensional (3D) laparoscopy has been developed in an attempt to address one of the main limitations of laparoscopic surgery, which is two-dimensional (2D) vision. Still, data on the learning curve during adaptation of such technology in clinical practice are scarce. In this study, perioperative data from the initial operations performed by an experienced laparoscopic surgeon in a 3D laparoscopic setup are presented, aiming to document any difficulties faced during the integration of 3D vision to laparoscopy., Patients and Methods: In total, 15 consecutive, unselected cases were operated using 3D laparoscopy within a 30-day period. The cases included five laparoscopic extraperitoneal radical prostatectomies, three nephrectomies, three partial nephrectomies, one nephrouretectomy, one adrenalectomy, one ureterolithotomy, and one radical cystectomy with ureterocutaneostomies. Perioperative data were prospectively collected and analyzed., Results: The transition from 2D to 3D laparoscopy for the expert surgeon seemed to be very rapid without compromising the efficacy of the operation or patient safety. Perioperative outcomes and complications resembled the outcomes of our 2D experience., Conclusions: Our preliminary experience with 3D laparoscopy was favorable, and we definitely opt for 3D vision in future operations. Nevertheless, current systems are related to several technical limitations that should be addressed to make even more appealing the further development of this technology. Whether the visual comfort offered by 3D vision during laparoscopy can be translated into an improvement in clinical outcomes offered to patients remains to be addressed in the future.

Introduction: Laser-assisted partial nephrectomy (PN) can benefit from the excellent coagulative properties of lasers to provide a bloodless tumor excision without the necessity for renal artery clamping. In this review, we aim to determine the current clinical implementation of laser assistance during laparoscopic nephron-sparing surgery., Materials and Methods: An extensive literature evaluation on laser-assisted PN was performed. Experimental work on animals and review articles were excluded., Results: Current literature regarding laser-assisted PN is scarce. Available data consist mostly of small cohorts providing low level of evidence. Even though initial studies with currently available laser modalities demonstrated promising results, several drawbacks in each technique need to be addressed before being widely accepted as a standard care., Conclusions: Experience with laser-assisted laparoscopic PN is steadily increasing and uniformly documenting favorable results. As urologist became more familiar with laser technology by its implementation in other clinical entities and with the increasing interest in nephron-sparing management of renal tumors, the use of laser assistance during PN should be expected to play a major role in future.

Objective: To report on a large multi-institutional series of laparoendoscopic single-site (LESS) partial nephrectomy (PN) and analyse renal function and short-term oncological outcomes., Material and Methods: We conducted a retrospective analysis of consecutive cases of LESS-PN performed between November 2007 and March 2012 at 11 participating institutions. Demographic data and data on the main peri-operative outcomes and complications were gathered and analysed. Kidney function was evaluated by measuring serum creatinine concentration and estimated glomerular filtration rate (eGFR). Chronic kidney disease was defined in stages for each patient according to the National Kidney Foundation, Kidney Disease Outcomes Quality Initiative., Results: A total of 190 cases were included in this analysis. The mean renal tumour size was 2.6 cm, and the mean PADUA score was 7.2. The median operating time was 170 min with a median estimated blood loss of 150 mL. A clampless technique was used in 70 cases (36.8%) and the median warm ischaemia time (WIT) was 16.5 min. PADUA score independently predicted the length of WIT (low vs high score: odds ratio 5.11, CI 1.50-17.41, P = 0.009; intermediate vs high score: odds ratio 5.13, CI 1.56-16.88, P = 0.007). The overall postoperative complication rate was 14.7%. Where a clamping technique was used, a significant increase in serum creatinine concentration and a significant decrease in eGFR were observed postoperatively and at 6 months. On multivariate analysis PADUA score was the only predicting factor. Overall survival rates were 99, 97 and 88% at 12-, 24- and 36-month follow-up, respectively, while disease-free survival rates were 98% at 12-month and 97% at 24- and 36-month follow-up., Conclusion: The study showed that LESS-PN is effective in terms of renal function preservation and oncological control at short- and intermediate-term follow-up., (© 2013 The Authors. BJU International © 2013 BJU International.)

Purpose: Barbed self-retaining sutures (SRS) have been introduced as an advance in suture technology, facilitating reconstructive laparoscopic surgery. We present the experience of three centers performing laparoscopic pyeloplasty with the use of SRS., Methods: Preoperative, intraoperative and follow-up data were collected for 6 patients undergoing pyeloplasty using the Quill SRS (Angiotech, Vancouver, CAN) in three centers. Standard laparoscopic pyeloplasty technique was used and a knot-less continuous anastomosis between the spatulated ureter and the renal pelvis was created., Results: Knot-less uretero-pelvic anastomosis creation was feasible in all six cases. Peri-operative data were similar to standard pyeloplasty using conventional suture materials. A very high stricture recurrence rate (5/6 patients) was noted during follow-up. Further endourologic and open interventions were needed to address the recurrence of the strictures., Conclusions: Knotless intracorporeal laparoscopic suturing using SRS for the reconstruction of UPJ during laparoscopic pyeloplasty is associated with high rates of stricture recurrence at least in the initial cases of each surgeon. Until further investigations elucidate the cause of treatment failure, SRS should not be recommended for upper urinary tract reconstruction.

Laparoscopic surgery of the upper urinary tract has reduced the morbidity related to large abdominal incisions and has resulted in significant advantages over open surgery. Nevertheless, the pursuit for even more minimally invasive alternatives to laparoscopy has led to the concept of scarless surgery and the approach of laparoendoscopic single-site surgery (LESS). LESS is currently a feasible approach for the majority of kidney surgical procedures, and there is intense debate regarding its efficiency and advantages. In the present review of the literature, the current status of upper urinary LESS and its advantages and disadvantages, as well the technological and technical evolution, are presented.

Background: Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to further reduce the surgical trauma associated with conventional laparoscopy. Partial nephrectomy (PN) represents a challenging indication for LESS., Objective: To report a large multi-institutional series of LESS-PN and to analyze the predictors of outcomes after LESS-PN., Design, Setting, and Participants: Consecutive cases of LESS-PN done between November 2007 and March 2012 at 11 participating institutions were included in this retrospective analysis., Intervention: Each group performed LESS-PN according to its own protocols, entry criteria, and techniques., Outcome Measurements and Statistical Analysis: Demographic data, main perioperative outcome parameters, and perioperative complications were gathered and analyzed. A multivariable analysis was used to assess the factors predicting a short (≤ 20 min) warm ischemia time (WIT), the occurrence of postoperative complication of any grade, and a favorable outcome, arbitrarily defined as a combination of the following events: short WIT plus no perioperative complications plus negative surgical margins plus no conversion to open surgery or standard laparoscopy., Results and Limitations: A total of 190 cases were included in this analysis. Mean renal tumor size was 2.6, and PADUA score 7.2. Median operative time was 170 min, with median estimated blood loss (EBL) of 150 ml. A clampless technique was adopted in 70 cases (36.8%), and the median WIT was 16.5 min. PADUA score independently predicted length of WIT (low vs high score: odds ratio [OR]: 5.11 [95% confidence interval (CI), 1.50-17.41]; p=0.009; intermediate vs high score: OR: 5.13 [95% CI, 1.56-16.88]; p=0.007). The overall postoperative complication rate was 14.7%. The adoption of a robotic LESS technique versus conventional LESS (OR: 20.92 [95% CI, 2.66-164.64]; p=0.003) and the occurrence of lower (≤ 250 ml) EBL (OR: 3.60 [95% CI, 1.35-9.56]; p=0.010) were found to be independent predictors of no postoperative complications of any grade. A favorable outcome was obtained in 83 cases (43.68%). On multivariate analysis, the only predictive factor of a favorable outcome was the PADUA score (low vs high score: OR: 4.99 [95% CI, 1.98-12.59]; p<0.001). Limitations of the study were the retrospective design and different selection criteria for the participating centers., Conclusions: LESS-PN can be safely and effectively performed by experienced hands, given a high likelihood of a single additional port. Anatomic tumor characteristics as determined by the PADUA score are independent predictors of a favorable surgical outcome. Thus patients presenting tumors with low PADUA scores represent the best candidates for LESS-PN. The application of a robotic platform is likely to reduce the overall risk of postoperative complications., (Copyright © 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background and Purpose: Radical prostatectomy is the gold standard surgical treatment for organ-confined prostate cancer. There is no consensus on the impact of previous laparoscopic experience on the learning curve of robot-assisted laparoscopic prostatectomy (RALP). We compared the perioperative complications and early patient outcomes from our initial 100 cases of RALP with laparoscopic prostatectomy (LRP) cases performed well beyond the learning curve., Patients and Methods: Between July 2011 and January 2012, 110 RALP were performed by one of two surgeons, each with previous experience of more than 1000 LRP. The cases were pair matched from among the last 208 patients who had undergone LRP by the same surgeons at the same time. The clinical parameters, operative details, postoperative complications, and short-term outcomes from these patients, collected prospectively, were compared between the two groups., Results: The prostate-specific antigen (PSA) level and age of the two groups was similar. The operative time (128.4 vs 153.9 min; P=0.01) and blood loss (200 vs 254 mL; P=0.01) was significantly less for the LRP group, but the duration of catheterization was similar (5.89 vs 6.2 days). The complication rate was low. No procedures needed conversions, and no patient had a visceral injury or blood transfusion. Twenty-three patients in the LRP group and 33 patients in the RALP group had extraprostatic disease, and the positive margin rate was 14% and 19% for these respective groups. At 3 months, PSA level was undetectable in 94% of LRP and 92% RALP patients, while 56% and 65% (P=0.062) patients in these groups were using 0 to 2 pads per day., Conclusions: The initial results of the outcome of RALP are at least at par with those of LRP and with those of previously published RALP series. This suggests the lack of a steep learning curve for experienced laparoscopic surgeons in performing RALP.

Unlabelled: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Over the last few years, minimally invasive urological surgery has evolved towards less invasive, 'scarless' procedures. New surgical concepts, such as those of natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been introduced. Mini-laparoscopy has been rediscovered in an attempt to reduce the invasiveness of standard laparoscopy. This study is the first to compare the perception of surgeons when first facing three different scarless options for performing a porcine nephrectomy and when dealing with the constraints of each technique. The study findings suggest that: (i) when first approaching these techniques, surgeons tend to perform equally well under expert guidance in the porcine model; (ii) mini-laparoscopy is perceived as less difficult to perform; (iii) for all the techniques, surgeon's impressions are in line with their expectations., Objective: • To evaluate the perception and performance of urological surgeons when first applying scarless surgical techniques., Methods: • The study was conducted during the 2(nd) Minimally Invasive Urological Surgical Week annual course in Braga, Portugal. • Fourteen attendees performed three porcine nephrectomies by using each of the following techniques: mini-laparoscopy, laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES)-assisted laparoscopy. • Peri-operative data were recorded, and operating performance was scored by one experienced surgeon for each working station, using a global rating scale. • The surgeons' subjective perceptions of degree of difficulty were graded and their expectations before the procedures were recorded., Results: • Forty-two porcine nephrectomies were performed. • There were no differences in overall operating time, or time to dissect and manage the renal vascular hilum, whereas time to gain access was faster for LESS than for mini-laparoscopy or NOTES-assisted laparoscopy (mean [sd] 8 [6] min vs 10.2 [5.3] min vs 9.9 [5.3] min, respectively; P = 0.59). • A better visualization of the surgical field was obtained with mini-laparoscopy and there was a higher degree of difficulty of bimanual dexterity for LESS, but no significant differences were found among the three techniques for any variable (operating field view: P = 0.52; bimanual dexterity: P = 0.49; efficiency: P = 0.77; tissue handling: P = 0.61; autonomy: P = 0.2). • Subjective perception of the degree of difficulty trended in favour of mini-laparoscopy (P= 0.17), but no significant difference was found in terms of surgeons' impression as compared with their expectations (P = 0.34)., Conclusions: • When first approaching new scarless techniques, surgeons tend to perform equally well under expert guidance in the porcine model. • Mini-laparoscopy is perceived as less difficult to perform and, for all the techniques, surgeons' impressions are in line with their expectations., (© 2012 THE AUTHORS. BJU INTERNATIONAL © 2012 BJU INTERNATIONAL.)

Purpose: Laparoendoscopic single-site surgery (LESS) has emerged in the recent years as an alternative approach to conventional laparoscopic surgery which is accompanied by additional advantages over laparoscopy. In this work we attempt to review the current literature and to investigate the possible combination of LESS to other currently available approaches such as natural orifice transluminal endoscopic surgery (NOTES), needlescopic and robotic laparoscopic surgery., Methods: Extensive literature search on the topics of LESS, hybrid and pure NOTES, Needlescopic-assisted LESS and "Robot-assisted LESS" took place. Additionally, the accumulated experience from 118 LESSs performed in our departments is presented in an attempt to provide evidence regarding the mix of technique in LESS in urology., Results: The challenging nature of LESS limits the broader application and acceptance. Expanding experience in single-site surgery has currently provided tools such as transvaginal access, needlescopic instruments and robot assistance that can aid LESS and enhance its efficiency without compromising any of its advantages. A mix of these techniques with LESS could ease the stiff learning curve of the second and benefit not only its performance but also the adaptation of LESS as a standard practice., Conclusion: Pure LESS although feasible, remains a technical challenge for the surgeon, preventing the widespread application of the technique. The goal of urologists on LESS surgery should not be the purity of LESS approach, but the superiority against already established techniques. A mix of techniques could be a key for the documentation of the advantages of LESS over conventional laparoscopy.

Purpose: We analyzed the incidence of and risk factors for complications and conversions in a large contemporary series of patients treated with urological laparoendoscopic single site surgery., Materials and Methods: The study cohort consisted of consecutive patients treated with laparoendoscopic single site surgery between August 2007 and December 2010 at a total of 21 institutions. A logistic regression model was used to analyze the risks of conversion, and of any grade and only high grade postoperative complications., Results: Included in analysis were 1,163 cases. Intraoperatively complications occurred in 3.3% of cases. The overall conversion rate was 19.6% with 14.6%, 4% and 1.1% of procedures converted to reduced port laparoscopy, conventional laparoscopic/robotic surgery and open surgery, respectively. On multivariable analysis the factors significantly associated with the risk of conversion were oncological surgical indication (p=0.02), pelvic surgery (p<0.001), robotic approach (p<0.001), high difficulty score (p=0.004), extended operative time (p=0.03) and an intraoperative complication (p=0.001). A total of 120 postoperative complications occurred in 109 patients (9.4%) with major complications in only 2.4% of the entire cohort. Reconstructive procedure (p=0.03), high difficulty score (p=0.002) and extended operative time (p=0.02) predicted high grade complications., Conclusions: Urological laparoendoscopic single site surgery can be done with a low complication rate, resembling that in laparoscopic series. The conversion rate suggests that early adopters of the technique have adhered to the principles of careful patient selection and safety. Besides facilitating future comparisons across institutions, this analysis can be useful to counsel patients on the current risks of urological laparoendoscopic single site surgery., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Recent publications have failed to demonstrate significant differences in perioperative oncological and functional outcomes between laparoscopic radical prostatectomy (LRPE) and R-LRPE. Reports suggesting better functional results, in particular better potency rates for R-LRPE, are rare. However, to date no large prospective, randomized, multicenter studies have compared the two methods. With an experienced operator both methods produce comparably good results. The monopoly of the intuitive system with extremely high cost of purchase and maintenance are the major disadvantages of R-LRPE.

Laparoendoscopic single-site surgery (LESS) represents the next step of laparoscopic surgery and a major advancement towards scarless surgery. LESS radical nephrectomy is an evolving technique based on technological advancement of laparoscopic instruments as well as the refinement of existing techniques.The current report describes LESS nephrectomy technique, presents the experience with the technique in a series of 42 patients and reviews current literature in the field of LESS nephrectomy.

Background: Laparoendoscopic single-site surgery (LESS) has gained popularity in urology over the last few years., Objective: To report a large multi-institutional worldwide series of LESS in urology., Design, Setting, and Participants: Consecutive cases of LESS done between August 2007 and November 2010 at 18 participating institutions were included in this retrospective analysis., Intervention: Each group performed a variety of LESS procedures according to its own protocols, entry criteria, and techniques., Measurements: Demographic data, main perioperative outcome parameters, and information related to the surgical technique were gathered and analyzed. Conversions to reduced-port laparoscopy, conventional laparoscopy, or open surgery were evaluated, as were intraoperative and postoperative complications., Results and Limitations: Overall, 1076 patients were included in the analysis. The most common procedures were extirpative or ablative operations in the upper urinary tract. The da Vinci robot was used to operate on 143 patients (13%). A single-port technique was most commonly used and the umbilicus represented the most common access site. Overall, operative time was 160±93 min and estimated blood loss was 148±234 ml. Skin incision length at closure was 3.5±1.5 cm. Mean hospital stay was 3.6±2.7 d with a visual analog pain score at discharge of 1.5±1.4. An additional port was used in 23% of cases. The overall conversion rate was 20.8%; 15.8% of patients were converted to reduced-port laparoscopy, 4% to conventional laparoscopy/robotic surgery, and 1% to open surgery. The intraoperative complication rate was 3.3%. Postoperative complications, mostly low grade, were encountered in 9.5% of cases., Conclusions: This study provides a global view of the evolution of LESS in the field of minimally invasive urologic surgery. A broad range of procedures have been effectively performed, primarily in the academic setting, within diverse health care systems around the world. Since LESS is performed by experienced laparoscopic surgeons, the risk of complications remains low when stringent patient-selection criteria are applied., (Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background and Purpose: Recent technical advances and a trend toward laparoscopic single incision surgery have led us to explore the feasibility of laparoendoscopic single-site (LESS) hernia repair., Patients and Methods: We present our technique and initial experience with LESS extraperitoneal inguinal hernia repair in 10 consecutive men with unilateral inguinal hernias. Age range was 43.7 (28-64) years. Mean body mass index was 28 (range 24-30). Six were left inguinal hernias. There were six indirect and four direct hernias. Three patients had undergone previous open appendectomy. Incarcerated or bilateral hernias were excluded from our initial series. All cases were performed by three surgeons who were experienced in conventional totally extraperitoneal laparoscopic hernia repair as well as experienced in LESS. A literature review of current single-port inguinal hernia repair data is also presented., Results: The mean operative time was 53 minutes (range 45-65  min). The average length of skin incision was 2.8  cm (range 2.3-3.2  cm). No drain was necessary in any of the patients, while no recordable bleeding was observed. There were no intraoperative or immediate postoperative complications. Hospitalization period was 2 days for all patients. After a limited follow-up of 1 month, there have been no recurrences and no complaints of testicular pain. The results of the current series compare favorably with those found in a literature review., Conclusion: LESS extraperitoneal inguinal hernia repair is both feasible and safe, although more technically demanding than its conventional laparoscopic counterpart. Although the cosmetic result with the former approach may prove superior, there are standing questions regarding the complications and long-term outcome. Randomized and if possible blinded trials that compare conventional and single-incision laparoscopic hernia repair may help to distinguish the most advantageous technique.

Laparoscopy has gained a place in everyday surgical routine as an alternative surgical approach that decreases morbidity and postoperative hospitalization. Single port laparoscopic surgery has been introduced as a further development of laparoscopy. The feasibility and safety of single port laparoscopy is under extensive evaluation in specialized laparoscopic centers. Nevertheless, wide acceptance of the technique requires adequate documentation of the advantages of the approach over conventional laparoscopy and further refinement of surgical instrumentation to overcome intraoperative ergonomic problems.

Laparoendoscopic single-site surgery (LESS) probably represents the next evolutionary step in laparoscopic surgery. Although most urologic procedures are feasible by the LESS approach, significant challenges in terms of intraoperative ergonomics and requirement for laparoscopic skill are present. New, specially designed instruments and ports represent a solution for combating ergonomic problems during surgery. Documentation of the advantages of LESS over other approaches is currently lacking, as comparative clinical trials are scarce in the literature; in the absence of such information, the technique has been accepted at centers of laparoscopic expertise. Thus, further prospective randomized clinical trials are necessary to fully characterize the outcomes of LESS.

Objective: To assess the use of the Clavien classification system in documenting the complications related to open retropubic radical prostatectomy (RRP)., Patients and Methods: The medical records of 995 patients, who had open RRP during a period of 7 years, were reviewed retrospectively. Short- and long-term complications were classified according to the recently revised Clavien classification system. We also compared the results with a recently reported series of laparoscopic and robotic RRP., Results: The overall complication rate was 26.9%; Grade I, Id, II, IIIa, IIIb and V complications were recorded in 3.4%, 3.9%, 12.8%, 2.6%, 3.8% and 0.3% of cases, respectively. Rectal injuries (10) and postoperative wound infections (24) were included in the Grade I category. Anastomotic leakage was recorded in 39 patients and rated as Grade Id. Grade II included cases of deep vein thrombosis (11), urinary tract infections (42), lymphorrhoeas (22) and haemorrhage requiring transfusion (53). Anastomotic strictures (26) and incisional hernias (38) were included in Grade IIIa and IIIb, respectively. Pulmonary embolism was fatal for three patients (0.3%) of Grade IV and V., Conclusions: To avoid incoherence in reporting morbidity data, a reproducible and practical classification system is necessary. The Clavien system could provide, after refinement and validation, a common language among urologists.

Introduction: To evaluate the feasibility and efficacy of salvage endoscopic extraperitoneal radical prostatectomy (EERPE) in recurrent prostate cancer after failed high intensity focused ultrasound therapy (HIFU), external beam radiotherapy (EBT) and brachytherapy., Patients and Methods: Twelve patients with mean age 63.3 years (48-74), mean preoperative PSA 12.7 ng/ml and mean prostate weight 48.8 grams were treated with salvage EERPE with curative intent for biopsy proven locally recurrent prostate cancer. Our group was consisted of four patients who have been treated in the past with HIFU, six with EBT and two with brachytherapy. Operative time, estimated blood loss, conversion to open surgery rate, transfusion rate and transurethral catheter time were recorded. Also functional outcome and short term oncological outcome were reviewed., Results: Average operative time was 153 minutes. Mean blood loss was 238 ml. The procedure was completed in all cases with no difficulty and without intraoperative complications. There was no need for conversion to open surgery or transfusion. Mean total urethral catheterization time was 7.2 days. After mean follow-up of 20 months, 10 patients were completely continent, and 2 needed 1-2 pads per day. Three patients were potent before the surgical treatment, but no one reported potency postoperatively. Biochemical recurrence was observed in only one patient 12 months postoperatively., Discussion: In the initial experience, salvage EERPE in experienced hands has minimal perioperative morbidity. Short term oncological and functional outcomes are encouraging but further studies and longer follow-up are required in order to assess the long-term outcomes.

Objectives: To investigate the feasibility and efficacy of salvage endoscopic extraperitoneal radical prostatectomy (EERPE) in cases of recurrent prostate cancer after high-intensity focused ultrasound therapy (HIFU) or radiotherapy., Methods: Nine patients underwent salvage EERPE with curative intent for biopsy-proven, locally recurrent prostate cancer. Of these 9 patients, 3 had previously undergone HIFU and 6 radiotherapy. Perioperative parameters (operation time, estimated blood loss, conversion to open surgery rate, transfusion rate, transurethral catheter time), functional outcome, and short-term oncologic outcome were reviewed., Results: Mean patient age was 63.3 years (range 48 to 74 years). Mean preoperative PSA value was 12.64 ng/mL and mean prostate weight was 49.2 g. Mean blood loss was 238 mL. There was no need for conversion to open surgery or transfusion. Mean operation time was 148 minutes, and mean total transurethral catheter time was 6 days. No intraoperative complications were reported. There was no clear difference in operation difficulty between the post-HIFU and postradiotherapy EERPE. After a mean follow-up of 17 months, 7 patients were completely continent, and 2 needed 1 to 2 pads per day. Three patients were potent before the surgical treatment, but no patient reported potency postoperatively. In 1 patient a PSA relapse (1.20 ng/mL) was recognized 12 months postoperatively., Conclusions: Salvage EERPE after failed HIFU and radiation therapy is a safe and efficient method to treat locally recurrent prostate cancer. Short-term oncologic and functional outcomes are promising, but further study should be made on the long-term oncologic outcomes of this technique.

Relatively long learning curves and, therefore, initially longer operating times compared to conventional procedures are still a matter of debate. Today, there are numerous possibilities for learning laparoscopic techniques and establishing one's own laparoscopic programs, including various pelvitrainers and virtual reality computer programs. One useful and realistic way involves "wet lab" training programs for ablative and reconstructive procedures using the pig model. Today, laparoscopic urological surgery includes procedures with low (e.g. laparoscopy for undescended testicles), intermediate (laparoscopic pyeloplasty) and high level (laparoscopic/endoscopic prostatectomy) complexity. Therefore, laparoscopy should be an integral part of training in urology. A defined number of possibly multi-institutional training centers with well structured educational programs are needed. The main goal should be the standardization of surgical procedures as well as educational training programs in order to shorten individual learning curves and generate common quality standards.

Background and Objective: Minimally invasive surgery plays a definitive role in the management of complications associated with the horseshoe kidney (HK). Aberrant vessels, the renal isthmus, and renal ectopia are all unique features of this anomaly that make the laparoscopic approach a challenge. We report our experience with this technique in 2 patients., Methods: Two patients with an HK were evaluated for recurrent urinary tract infection. In both cases, the nonfunctioning renal moiety was demonstrated by renal scan. A transperitoneal laparoscopic heminephrectomy was performed. The Endostapler device was used to divide the renal isthmus., Results: The operative time was less than 3 hours. Blood loss was negligible. No intraoperative complications occurred. The hospital stay was 48 hours. Postoperative discomfort was minimal., Conclusion: Laparoscopic heminephrectomy is a safe and feasible approach for benign diseases of the HK. The Endostapler is a useful adjunct in the division of the renal isthmus.