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Purpose: To compare the intra- and postoperative outcomes of single-port robotic donor nephrectomies (SP RDNs) and laparoscopic donor nephrectomies (LDNs). Materials and Methods: We retrospectively reviewed our institutional database for patients who received LDN or SP RDN between September 2020 and December 2022. Donor baseline characteristics, intraoperative outcomes, postoperative outcomes, and recipient renal function were extracted and compared between LDN and SP RDN. SP RDN learning curve analysis based on operative time and graft extraction time was performed using cumulative sum analysis. Results: One hundred forty-four patients underwent LDN and 32 patients underwent SP RDN. LDN and SP RDN had similar operative times (LDN: 190.3 ± 28.0 minutes, SP RDN: 194.5 ± 35.1 minutes, p  = 0.3253). SP RDN patients had significantly greater extraction times (LDN: 83.2 ± 40.3 seconds, SP RDN: 204.1 ± 52.2 seconds, p  < 0.0001) and warm ischemia times (LDN: 145.1 ± 61.7 seconds, SP RDN: 275.4 ± 65.6 seconds, p  < 0.0001). There were no differences in patient subjective pain scores, inpatient opioid usage, or Clavien-Dindo II+ complications. Short- and medium-term postoperative donor and recipient renal function were also similar between the groups. SP RDN graft extraction time and total operative time learning curves were achieved at case 27 and 13, respectively. Conclusion: SP RDN is a safe and feasible alternative to LDN that minimizes postoperative abdominal incisional scars and has a short learning curve. Future randomized prospective clinical trials are needed to confirm the findings of this study and to identify other potential benefits and drawbacks of SP RDNs.

Introduction: The Levita™ Magnetic Surgical System (LMSS) is a new device that can provide retraction using magnets and can reduce the number of ports used during laparoscopic and robotic procedure. It is U.S. Food and Drug Administration (FDA) approved for laparoscopic cholecystectomy, bariatric operation, and robotic radical prostatectomy. Our objective was to evaluate the safety and feasibility of the magnetic surgical system during renal procedure. Methods: We performed a prospective, single-center, single-arm, open-label study to assess the safety and performance of the LMSS. The system includes a deployable, single-use magnetic grasper and a reusable external magnet. Selected patients undergoing either laparoscopic or robotic renal procedure from April 2019 to August 2019 were included. Robotic procedures were performed with the da Vinci Xi or single-port (SP) surgical platforms. Preoperative demographic, intraoperative data, and postoperative data were collected and analyzed. Results: Ten procedures were performed using the LMSS. Cases included Xi robotic partial nephrectomy ( n  = 3), Xi robotic radical nephrectomy ( n  = 2), SP robotic partial nephrectomy ( n  = 2), SP robotic pyeloplasty ( n  = 1), laparoscopic donor nephrectomy ( n  = 1), and laparoscopic radical nephrectomy ( n  = 1). No cases required conversion to an open procedure. Issues included one small liver capsular tear from the device jaws necessitating fulguration and occasional robotic "recoverable fault" errors when the external magnet was placed too close to the robotic arms. All patients were discharged home on postoperative day 1 or 2, and there were no readmissions within 30 days. Conclusions: This is the first report on the use of the LMSS for renal procedure. Its use for laparoscopic and robotic renal procedure appears safe and feasible. The grasper is especially useful for exposing the renal hilum during dissection and the ureteropelvic junction during SP robotic procedures, mimicking multiport techniques. Further study is required to optimize use of the LMSS and evaluate its cost effectiveness.

Introduction: The benefit and short-term safety of ketorolac have been established in previous studies however, the risk of bleeding and long-term renal impairment in patients undergoing donor nephrectomy remain unclear. We report our experience at a high-volume transplant center., Method: Between January 1996 and January 2014, 862 consecutive patients underwent laparoscopic donor nephrectomy. Exclusion criteria included nonsteroidal anti-inflammatory drug allergy, asthma, bleeding disorders, long-term opioid use, intraoperative blood loss >700 mL, peptic ulcer disease, bleeding diathesis, and baseline creatinine greater than 1.9 mg/dL. Intravenous ketorolac was administered within 30 minutes following the surgical procedure at a dose of 15 to 30 mg every 6 hours. Patients were categorized into 2 groups according to the administration of ketorolac after surgery. Differences between the groups were analyzed. Primary outcomes were changes in serum creatinine and hemoglobin levels. Poor outcome was defined as postsurgical complications., Results: During this time, 469 (55.3%) received ketorolac. The mean donor age was 39 years, and 360 (42.5%) were male. Left kidneys were procured in 82%. Operative time averaged 210 minutes and warm ischemia time117 seconds. Baseline demographic and operative outcomes were comparable in both groups. No statistically significant differences were found between the ketorolac group and the nonketorolac group in preoperative and postoperative hemoglobin levels and serum creatinine at 1 week, 1 year, and 5 years ( P = .6). Ketorolac use was not associated with increased perioperative morbidity ( P = NS)., Conclusion: The use of intravenous ketorolac in patients undergoing donor nephrectomy was not associated with an increased risk of bleeding or renal impairment.

Safety is of utmost importance in live donor nephrectomies. In this study, we describe our initial experience with robot-assisted laparoscopic donor nephrectomy (RDN) in comparison with the standard laparoscopic donor nephrectomy (LDN). We retrospectively reviewed 95 patients who either underwent RDN or LDN performed by a single surgeon from 2011 to 2016 at a tertiary institution. Donor perioperative course and postoperative outcome along with recipient outcomes were compared. Of the 95 cases, 73 were classified as LDN and 22 were classified as RDN. There were no significant differences between the two groups in age, sex, BMI, race, and ASA status. Operative times (p < 0.001) were longer in the RDN group, but eventually approached LDN times. Warm ischemia (p = 0.002) and extraction times (p = 0.05) were also longer in the RDN cohort. The donor length of hospital stay, complication rates, and postoperative change in eGFR from baseline were similar in both cohorts up to 1 year. Recipient outcomes, including delayed graft function, graft failure, and renal function up to 1 year, were also comparable. In this study, we compared the longest postoperative course so far in both donors and recipients between RDN and LDN. Up to 1 year, RDN does not negatively impact outcomes. Proficiency with RDN also quickly improved to match LDN, making it a suitable procedure for newer surgeons.

We report the case of a 30-year-old male patient undergoing a robotic-assisted laparoscopic left donor nephrectomy, where compression of the left renal vein between the superior mesenteric artery and aorta was noted on magnetic resonance angiography before the operation. The patient was diagnosed with nutcracker phenomenon and was noted to be asymptomatic at that time. This is the first reported case to date of a patient with nutcracker phenomenon who underwent a robotic-assisted laparoscopic donor nephrectomy. This article also reviews the current literature on nutcracker phenomenon and nutcracker syndrome.

The aim of the study was to compare the utilization trends and short-term outcomes of open, laparoscopic, and robotic partial nephrectomy in New York State since the introduction of the robotic modifier in October 2008. The Statewide Planning and Research Cooperative System database is an all-payer, administrative database covering all hospital discharges within New York State. All patients who underwent partial nephrectomy (ICD-9 55.4) for kidney cancer (189.0) from October 2008 to December 2012 were identified. Patients with a minimally invasive modifier (54.21, 54.51) without the robotic modifier (17.4x) were categorized in the laparoscopic cohort. Logistic regression was performed to assess outcomes by surgical approach. Of the 5107 patients, 57.9% (2959/5107) underwent open, 12.1% (617/5107) laparoscopic, and 30.0% (1531/5107) robotic partial nephrectomy. From 2009 to 2012, the percentage of robotic cases increased from 17.7 to 39.8%. In comparison to open patients, those undergoing laparoscopic and robotic approaches, respectively, were less likely to receive blood transfusion (OR 0.54, p < 0.0005 and OR 0.45, p < 0.0005) and to experience a prolonged length of stay (OR 0.52, p < 0.0005 and OR 0.30, p < 0.0005). Patients undergoing robotic approach were also less likely to have an inpatient complication (OR 0.74, p = 0.004) and be readmitted within one (OR 0.73, p = 0.005) and 3 months (OR 0.69, p < 0.0005), but were at higher risk of excess hospital charges (OR 1.216, p = 0.01). Robotic partial nephrectomy is the predominant minimally invasive approach in New York State. Minimally invasive partial nephrectomy has multiple short-term advantages over open, with the costlier robotic approach having additional advantages with less inpatient complication and readmission risk.

Background: Loss of a needle during laparoscopic surgery is a rare but potentially serious adverse event that can cause prolonged operative time and patient harm. Standard recovery techniques currently include instrument count, standard visual search, and plain abdominal x-rays. We developed a laparoscopic instrument to speed the retrieval of lost needles in the abdomen and pelvis., Study Design: We performed in vivo testing of a novel articulating laparoscopic magnet in a porcine model. Three experienced surgeons and 3 inexperienced surgeons conducted 116 needle-retrieval trials with the device and 58 trials with a standard visual approach. Surgeons were blind to the locations of randomly placed surgical needles within the abdominal cavity. Time to recovery was measured and capped at 15 minutes. Analysis was performed using univariate and multivariable methods., Results: The magnetic device was able to retrieve needles significantly faster than the standard approach (2.9 ± 4.0 minutes vs 8.0 ± 6.0 minutes; p < 0.0001). On multivariable analysis, faster recovery time remained independently significant when controlling for surgeon experience, needle size (small, medium, or large), and needle location (by quadrant) (p < 0.0001). There were 2 (2%) injuries to abdominal organs during the device trials and 4 (7%) injuries during the standard trials (p = 0.182)., Conclusions: Recovery of lost surgical needles during porcine laparoscopic surgery is safe and feasible with a simple articulating magnetic device. Our initial in vivo experience suggests that recovery is markedly faster using the magnetic device than the standard approach, even in the hands of experienced laparoscopic surgeons. This device will be particularly useful as minimally invasive robotic and single-site surgical techniques are adopted and, in the future, it should be integrated into the standard protocol for locating lost needles during surgery., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Laparoscopic donor nephrectomy is associated with a 10% chance of morbidity and a 0.03% mortality rate. We present a case of negative pressure pulmonary edema (NPPE) in a healthy subject immediately following a laparoscopic donor nephrectomy. In this report, we will use the case to review the complications of NPPE and to illustrate its management., Case Description: A healthy 19-y-old male presented at our institution as a living-related donor for left laparoscopic donor nephrectomy. Following the surgery, the patient was reintubated and kept in the intensive care unit secondary to NPPE. The patient experienced an uneventful postoperative course and was subsequently discharged., Discussion: Although a self-limiting phenomenon, mainstay NPPE therapy requires immediate re-establishment of the airway, adequate oxygenation, and application of positive airway pressure.

Background: Although the procedure is generally safe, significant morbidity and even mortality have occurred after laparoscopic donor nephrectomy (LDN). The learning curves for both surgeons and institutions with LDN have not been well delineated, and longterm donor data are not well reported., Study Design: A retrospective study of the initial 512 patients undergoing LDN performed at Mount Sinai Medical Center between October 1996 and March 2006 was performed. Intraoperative and immediate postoperative surgical outcomes were reviewed. Univariate analysis and multivariate logistic regressions were performed to identify predictors of outcomes, including the experience level of individual surgeons and of the institution. Longitudinal followup data of donor patients between 1 month and 9 years were obtained., Results: Mean donor age was 39.2 years, and 54.6% of patients were women. Left kidneys were procured in 84.0%. Operative time averaged 215.2 minutes, and warm ischemia time, 166.6 seconds. The conversion rate was 1.4%, and hand-assistance was used in 49.9%. The intraoperative complication rate was 5.5%, 30-day complication rate 9.4%, and 1.4% of patients required reoperation. Immediate graft survival was 97.1%, acute tubular necrosis occurred in 8.5%, and delayed graft function in 3.7%. At a mean followup of 37.2 months, delayed donor complications were infrequent, but included chronic pain, hypertension, incisional hernia, and small bowel obstruction. Although individual surgeons and our institution gained experience, operative and warm ischemia times decreased significantly, but complication rates were unchanged., Conclusions: Although a learning curve was discovered for operative time and warm ischemia time, excellent results can be achieved during the early experience of both surgeons and institutions with LDN, and maintained over time. Younger, female, and nonobese donors were associated with fewer complications. Longterm donor morbidity is uncommon, but mandates better followup.

Purpose: The introduction of the da Vinci Surgical System to perform complex reconstructive procedures, such as repair of ureteropelvic junction obstruction, has helped to overcome some of the technical challenges associated with laparoscopy. We review our large multi-institutional experience with long-term followup of robotic dismembered pyeloplasty., Materials and Methods: A total of 140 patients from 3 university medical centers underwent robotic dismembered pyeloplasty. An institutional review board approved retrospective chart review was performed to collect demographic, preoperative, operative and postoperative data. Patients were analyzed as an entire cohort and then divided into various subgroups., Results: Of the cases 117 (84.6%) were primary repairs and 23 (16.4%) were secondary repairs. There were 13 (9.3%) patients who underwent concomitant stone extraction and 5 (3.6%) procedures were performed on patients with solitary kidneys. A crossing vessel was found in 77 (55%) patients. Mean operative time was 217 minutes (range 80 to 510), estimated blood loss was 59.4 ml (range 10 to 600), mean length of hospital stay 2.1 days (range 0.75 to 7) and mean followup was 29 months (range 3 to 63). Radiographic resolution of obstruction on first postoperative diuretic renal scan or excretory urogram was noted in 134 patients (95.7%). There was a 7.1% major complication rate and a 2.9% minor complication rate. No statistically significant differences were found in any parameters among patients from the various cohorts., Conclusions: To our knowledge this review represents the largest multi-institutional experience of robotic dismembered pyeloplasty with long-term followup. Robotic pyeloplasty appears to be safe, durable and efficacious for primary and secondary ureteropelvic junction obstruction with or without concomitant stone extraction, and for patients with a solitary kidney.

Objective: We report our experience with hand-assisted laparoscopic nephroureterectomy (HALN) for upper urinary tract transitional cell carcinoma and compare our results with a contemporary series of open nephroureterectomy (ON) performed at our institution., Methods: Between August 1996 and May 2003, 90 patients underwent nephroureterectomy for upper-tract transitional cell carcinoma (TCC). Thirty-eight patients underwent HALN, while 52 had an ON. End-points of comparison included operative time, estimated blood loss (EBL), intraoperative and postoperative complications, length of hospital stay, pathologic grade and stage of tumor, and tumor recurrence., Results: The mean patient age was 72.3 and 70.6 years in the ON and HALN groups, respectively. Mean operative duration was 243 minutes (ON) and 244 minutes (HALN), with an EBL of 478mL in the open group versus 191 mL in the hand-assisted group (P<0.001). No intraoperative complications occurred, but postoperative complications occurred in 4% and 11% of the ON and HALN groups, respectively (P=0.21). The mean hospital duration was 7.1 days (ON) versus 4.6 days (HALN) (P<0.01). No difference existed in the pathologic grade or stage distribution of urothelial tumors between the 2 groups. The mean follow-up was 51.0 months in the ON group and 31.7 months in the HALN group. Recurrence of urothelial carcinoma occurred in 50% of patients who underwent ON and 40% treated by HALN (P=0.38) at a median interval of 9.1 and 7.7 months, respectively, after surgery., Conclusion: Hand-assisted laparoscopic nephroureterectomy is an effective modality for the treatment of upper urinary tract urothelial carcinoma. Patients benefited from less intraoperative blood loss and a shorter hospitalization with an equivalent intermediate-term oncologic outcome compared with that of the open approach.

Objective: To compare a contemporary series of laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) at one institution, to evaluate the size and types of tumour in each group and the early outcome after each procedure, as LPN is replacing open radical nephrectomy as the standard of care for uncomplicated renal tumours but partial nephrectomy remains significantly more difficult laparoscopically, especially if the goal is to duplicate the open surgical technique., Patients and Methods: We retrospectively analysed the records of all patients who underwent partial nephrectomy at our institution from January 2000 to April 2004, identifying 66 who had LPN and compared them with 59 who had OPN (mean age at LPN and OPN, 62.1 and 64.2 years, respectively; 70% men in each group). Variables analysed included operative time, blood loss, creatinine levels before and after partial nephrectomy, time to resuming clear liquids and regular diet, length of stay, tumour size, tumour pathological type and complications. Groups were compared using Student's t-test, with P < 0.05 taken to indicate significance., Results: Of those having LPN, 59% had right-sided tumours, vs 53% in the OPN group; the respective mean tumour size was 2.2 and 3.4 cm, the mean operative duration 144 and 239 min (both P < 0.001), and the mean estimated blood loss 236 and 363 mL (P = 0.09). Seven patients in the OPN group had obligatory partial nephrectomy for either a solitary kidney (two) or azotaemia (five). No patient in the LPN group required an obligatory partial nephrectomy. Serum creatinine levels were measured before and 1 and 2 days after surgery, and were 88, 88 and 97 micromol/L for the LPN group, and 97, 106 and 106 micromol/L for the OPN group. Clear fluids were started a mean of 41 h after surgery, a regular diet resumed 76 h after and discharge was 129 h after surgery in the OPN group; the respective values for the LPN group were 24 h (P = 0.01), 49 h (P = 0.2) and 82 h (P < 0.001). Complications were similar in both groups but the pathological subtypes differed., Conclusions: LPN offers early functional advantages over OPN in terms of earlier resumption of diet and slightly earlier discharge. However, the two groups of patients were clearly not evenly matched for size nor pathological subtypes, with larger, malignant subtypes more predominant in the OPN group. These results suggest that while LPN is a safe, effective treatment for small renal tumours, obligatory partial nephrectomy or large tumours continue to be performed using open techniques with good results.

Objective: Advanced laparoscopic skills limit the implementation of laparoscopic pyeloplasty to centers with extensive experience. The introduction of robotic technology into the field of minimally invasive surgery has facilitated complex surgical dissection and genitourinary reconstruction. We report our experience with robot-assisted laparoscopic pyeloplasty using the da Vinci Robotic Surgical System at 3 New York City medical centers., Methods: A review of all robot-assisted laparoscopic Anderson-Hynes dismembered pyeloplasty cases in 38 patients (21 females, 17 males) between April 2001 and January 2004 was performed. All patients had symptoms or radiographic evidence of ureteropelvic junction obstruction. Robotic assistance with the da Vinci Robotic Surgical System was used after preparation of the ureteropelvic junction with a standard laparoscopic approach., Results: The average patient age was 39.3 years (range, 15 to 69). The mean operative time and suturing time were 225.6+/-59.3 minutes and 64.2+/-14.6 minutes. The average estimated blood loss was minimal at 77.3+/-55.3 mL. The mean length of hospitalization was 69.6 hours (range, 28 to 310). The average use of intravenous morphine was 26.5 mg (range, 0 to 162). No intraoperative complications occurred, and open conversions were not necessary. A mean follow-up of 12.2 months revealed a success rate of 94.7% with 2/38 patients requiring further treatments., Conclusions: This combined multi-institutional series reveals that robot-assisted pyeloplasty with the da Vinci Surgical System is safe and reproducible. These intermediate results appear comparable to results with open and laparoscopic pyeloplasty repairs.

Background and Purpose: The need for advanced laparoscopic skills limits the implementation of laparoscopic pyeloplasty to centers with extensive experience. The introduction of robotic technology into the field of minimally invasive surgery has facilitated complex surgical dissection and genitourinary reconstruction. We report our experience with robot-assisted laparoscopic pyeloplasty using the daVinci Surgical System at three New York City medical centers., Patients and Methods: A retrospective review of all robot-assisted laparoscopic Anderson-Hynes dismembered pyeloplasty cases in 18 female and 17 male patients between April 2001 and January 2004 was performed. The average patient age was 39.0 years (range 15-69 years). All patients had symptoms or radiographic evidence of ureteropelvic junction (UPJ) obstruction. Robotic assistance with the daVinci Surgical System was employed after preparation of the UPJ with a standard laparoscopic approach., Results: The mean operative time and suturing time was 216.4 +/- 52.9 minutes and 63.0 +/- 14.2 minutes, respectively. The average estimated blood loss was minimal at 73.9 +/- 58.3 mL. The mean length of hospitalization was 69.4 hours (range 28-310 hours). The average use of intravenous morphine was 28.4 mg (range 0-162 mg). There were no intraoperative complications or open conversions. A mean follow-up of 7.9 months revealed a success rate of 94%, with two patients requiring further treatment., Conclusions: This combined multi-institutional series reveals that robot-assisted pyeloplasty with the daVinci Surgical System is safe and reproducible. These intermediate results appear comparable to those of open and laparoscopic pyeloplasty repairs.