Initial experience of laparoendoscopic single-site radical prostatectomy with a novel purpose-built robotic system

Objective This prospective single-arm clinical trial aimed to evaluated the feasibility and safety of the application of the SHURUI system(Beijing Surgerii Technology Co.,Ltd.,Beijing,China),a novel purpose-built robotic system,in single-port robotic radical prostatectomy.Methods Sixteen patients diagnosed with prostate cancer were prospectively enrolled in and underwent robotic radical prostatectomy from October 2021 to August 2022 by the SHURUI single-port robotic surgical system.The demographic and baseline data,surgical,oncological,and functional outcomes as well as follow-up data were recorded.Results The mean operative time was 226.3(standard deviation[SD]52.0)min,and the mean console time was 183.4(SD 48.3)min,with the mean estimated blood loss of 116.3(SD 90.0)mL.The mean length of postoperative hospital stay was 4.50(SD 0.97)days.Two patients had postoperative complications(Clavien-Dindo Grade II),and both patients improved after conservative treatment.All patients’postoperative prostate-specific antigen levels decreased to below 0.2 ng/mL 1 month after discharge.The mean prostate-specific antigen level further decreased to a mean of 0.0219(SD 0.0641)ng/mL 6 months after surgery.Thirty days postoperatively,12 out of 16 patients reported using no more than one urinary pad per day,and all patients reported satisfactory urinary control without the need for pads 6 months after surgery.Conclusion The SHURUI system is safe and feasible in performing radical prostatectomy via both transperitoneal and extraperitoneal approaches.Tumor control and urinary continence were satisfying for patients enrolled in.The next phase involves conducting a large-scale,multicenter randomized controlled trial to thoroughly assess the effectiveness and safety of the new technology in a broader population.

Laparoendoscopic single-site distal pancreatectomy in pigs

AIM:To explore the technique for laparoendoscopic single-site distal pancreatectomy.METHODS:Laparoendoscopic single-site spleenpreserving distal pancreatectomy was performed in pigs using a novel flexible multichannel port,a curved laparoscopic multifunctional operative device and a fish hook retractor,which provided a favorable operative field.RESULTS:Six pigs were involved in this study,and five survived the procedure.The first animal died following injury to the superior mesenteric vein and uncontrolledintraoperative bleeding.Except for this failure,the mean operative time was 155 min(range:102-236 min).A steep learning curve was observed in the study,with a mean operative time of 177 min in the first two operations vs 134 min in the last three operations.The mean blood loss was 50 mL,and the postoperative course was uneventful.The animals were sacrificed three weeks after the procedures,and no pancreatic leakage or abdominal infection was found macroscopically.CONCLUSION:Laparoendoscopic single-site distal pancreatectomy is a safe and feasible procedure and can be implemented in humans in selected cases at qualified surgical centers.

A Comparison between Laparoendoscopic Single-Site and Conventional Laparoscopic Renal Stone Removal Surgery: A Study of Application in Two Cases

Aim: To present our initial experience of applying laparoendoscopic single-site surgery (LESS) nephrolithotomy in the treatment of renal calculi. Methods: In August 2010 and April 2012, the LESS nephrolithotomy technique was applied to treat two patients with a renal calculus. One patient had a calculus measuring 5 × 3 cm, and the second patient's measured 3 × 3 cm. Both patients underwent general anesthesia. The operations were performed through a retroperitoneal approach with a single-port instrument inserted through the retroperitoneal incision. The standard laparoscopic retroperitoneal technique was performed, and the calculi were removed by incising the area of the thin renal cortex and the renal pelvis, respectively. The operating time, estimated blood loss, intraoperative complications, other complications, drainage time, and post-operative hospital stay were recorded. Results: Both procedures were completed successfully. No additional trocars were added. No conversion to standard laparoscopic or open surgery was needed. The operating times were 130 min and 120 min, and the estimated blood losses were 40 mL and 30 mL. There were no intraoperative complications. The wound drainage times were 3 d and 2 d, respectively and the post-operative hospital stays were 8 d and 7 d, respectively. There was no secondary bleeding or wound infection. Follow-up times were 2 years and 3 months, respectively. No incidence of hydronephrosis was recorded. Conclusions: LESS nephrolithotomy is safe and feasible for treating kidney calculi. It can be applied in patients with large renal calculi and regionally thin renal parenchyma.

Laparoendoscopic Single-Site Combined Hysterectomy and Nephrectomy in Deep Infiltrating Endometriosis

Within the advance ports and instruments, laparoendoscopic single-site (LESS) surgery has been increasingly used among gynaecologic surgeons. In addition, advanced port systems have enabled to perform concomitant surgical procedures via transumbilical incision. However, combined surgical operations are rarely reported in the literature, particularly in gynaecology. This case report presents a 42-year-old woman who undergo concomitant LESS hysterectomy and nephrectomy due to deep infiltrating endometriosis (DIE) and end stage renal disease. The operation is performed in approximately 3 hours without any complications, and the patient is discharged on postoperative third day. This case demonstrates that complex concomitant operations even in a patient with DIE can be performed using a LESS surgical approach.

Laparoendoscopic single site,laparoscopic or open surgery for adrenal tumors:Selecting the optimal approach

Numerous surgical modalities are available to treat adrenal lesions. Minimally-invasive approaches for adrenalectomy are indicated in most circumstances, and new evidence continues to be accumulated. In this context, current indications for open surgical adrenalectomy(OS-A), minimally-invasive adrenalectomy(MI-A), and laparoendoscopic single-site adrenalectomy(LESS-A) remain unclear. A comprehensive Englishlanguage literature review was performed using MEDLINE/Pub MED to identify articles and guidelines pertinent to the surgical management of adrenal tumors. A comprehensive chart review was performed for three illustrative cases. Clinical recommendations were generated based on relevant literature and the expertise of the investigator group. MI-A offers advantages over OS-A in properly selected patients, who experience fewer complications, lower blood loss, and shorter hospital stays. Robot-assisted laparoscopic and retroperitoneoscopic adrenalectomy may offer advantages over transperitoneal surgery, and LESS-A may be an even less-invasive option that will require further evaluation. MI-A remains the surgical treatment of choice for most adrenal lesions. Tumor size and stage are the primary indications for selecting alternative treatment modalities. OS-A remains the gold standard for large tumors(> 10 cm) and suspected or known advanced stage malignancy. LESS-A appears to be an appropriate initial approach for small tumors(< 4-5 cm), including pheochromocytoma and isolated adrenal metastases.

Single-site laparoscopic partial nephrectomy: Where are we going?

AIM:To review an evolution of laparoscopic surgery,there has been a growing interest in laparoendoscopic single-site surgery(LESS).METHODS:A comprehensive electronic literature search was conducted using PubM ed database to identify all publications relating to LESS-partial nephrectomy(PN).The research includes articles published from April 2008 to January 2014.We focused our attention only on articles in which were cited the single-site surgical technique(laparoscopic and robotic),tumour stage and grade,mean tumour size,intraoperative variables,blood loss and transfusion rate,length of postoperative stay and complication rates,Clavien classification,positive of surgical margins,pain assessment at discharge.RESULTS:A total of 9 studies were collected with 221patients included.The mean patients age was 62 years.The mean tumor size was 2.35 cm with a mean operative time of 181 min(range 111-270 min)and 58.3%were done by robot.The mean ischemia time was 23.6min.The 25.8%of patients underwent an unclamp LESS-PN.Mean estimated blood loss was 296 mL and median length of hospital stay was 4 d.The rate of severe post-operative complications(≥Clavien gradeⅢ)was 5.4%.Not all surgical series of LESS-PN or Robotic-LESS-PN shows conversion in Multiport Laparoscopic or Open Surgery.Regarding oncologic outcomes,surgical margins were positive 4%of patients(9/221),no distant or port-site metastases were recorded.CONCLUSION:LESS-PN and RLESS-PN are feasible and associated with reduced postoperative pain,shorter median hospital stay,shorter recovery time,and better cosmetic satisfaction without compromising surgical and oncological safety.

Comparison of surgical effect and postoperative patient experience between laparoendoscopic single-site and conventional laparoscopic varicocelectomy, a systematic.review and meta-analysis

The present meta-analysis was conducted to compare the clinical effect and patient experience of laparoendoscopic single-site varicocelectomy （LESSV） and conventional laparoscopic varicocelectomy. The candidate studies were included after literature search of database Cochrane Library, PubMed, EMBASE, and MEDLINE. Related information on essential data and outcome measures was extracted from the eligible studies by two independent authors, and a meta-analysis was conducted using STATA 12.0 software. Subgroup analyses were conducted by study design （RCT and non-RCT）. The odds ratio （OR） or standardized mean difference （SMD） and their 95% confidence intervals （95% CIs） were used to estimate the outcome measures. Seven articles were included in our meta-analysis. The results indicated that patient who had undergone LESSV had a shorter duration of back to work （overall： SMD = -1.454, 95% Ch -2.502m0.405, P= 0.007; non-RCT： SMD = -2.906, 95% Ch -3.796-2.017, P= 0.000; and RCT： SMD = -0.841, 95% Ch -1.393-0.289, P = 0.003） and less pain experience at 3 h or 6 h （SMD = -0.447, 95% Ch -0.754-0.139, P = 0.004）, day 1 （SMD = -0.477, 95% Ch -0.905-0.05, P = 0.029）, and day 2 （SMD = -0.612, 95% Ch -1.099-0.125, P= 0.014） postoperatively based on RCT studies. However, the meta-analyses based on operation time, clinical effect （improvement of semen quality and scrotal pain relief）, and complications （hydrocele and recurrence） yielded nonsignificant results. In conclusion, LESSV had a rapid recovery and less pain experience over conventional laparoscopic varicocelectomy. However, there was no statistically significant difference between the two varicocelectomy techniques in terms of the clinical effect and the incidence of hydrocele and varicocele recurrence. More high-quality studies are warranted for a comprehensive conclusion.

Transurethral assistant transumbilical laparoendoscopic single-site radical prostatectomy

The laparoendoscopic single-site （LESS） technique is the latest technical innovation in laparoscopic surgery to undergo exponential development in urology. This study undertaken to illustrate our initial experience LESS radical prostatectomy （RP） and analyze early outcomes. Nineteen patients diagnosed with prostate cancer underwent LESS-RP in our institute. The patients were divided into two groups： conventional LESS and transurethral assistant LESS. Preoperative, perioperative, postoperative, pathologic, and functional outcomes data were assessed. With the help of a transurethral assistant, the mean operation and anastomosis time were decreased markedly. No focal positive margins were encountered. No prostate-specific antigen recurrence was detected 1 month postoperatively. Complete continence recovery （no pad） was observed in 32% of the patients at 1 month after the operation. No intraoperative and postoperative complications were reported, LESS-RP is a feasible and effective surgical procedure for treatment of prostate cancer. Moreover, transurethral assistant LESS could reduce the difficulty of LESS-RP and shorten the operation time.

Laparoendoscopic single-site radical prostatectomy： technique and initial outcomes

Background Laparoendoscopic single-site surgery radical prostatectomy （LESS-RP） is a challenging urological procedure and needs to be further evaluated. This study was undertaken to illustrate the safety and initial results of pure LESS-RP with conventional available instruments.

Preliminary experience with transperitoneal laparoendoscopic single-site radical nephrectomy using a home-made single-port device in China

Background Laparoendoscopic single-site （LESS） surgery represents a technique to further reduce morbidity and scarring associated with surgery.We present our preliminary experience with transperitoneal LESS radical nephrectomy （RN） using a home-made single-port device in China.Methods From July 2010 to November 2011,eleven patients with renal tumor not greater than T2 underwent LESS-RN by an experienced laparoscopic surgeon.A home-made single-port device was used through a 5-cm umbilical incision.A combination of standard and articulating laparoscopic instruments was used.The sequence of steps of LESS-RN was similar to transperitoneal laparoscopic RN.Patient characteristics,perioperative variables and postoperative outcomes were recorded and analyzed.Results Except for two transperitoneal laparoscopic conversions and one hand-assisted laparoscopic conversion,the other procedures were completed successfully without conversion to open surgery.The mean operative time was 224.5 （155-297） minutes,estimated blood loss was 270.9 （50-900） ml,and hospital stay was 10.4 （5-15） days.The mean visual analog pain scale （VAPS） on the first postoperative day was 4.0/10.Final pathological analysis revealed renal cell carcinoma in all cases with a stage distribution of three T1a,five T1b,and three T2a tumors.With the mean followup period of 21.4 （12-28） months,all patients were alive without evidence of tumor recurrence or metastasis,and were satisfied with the appearance of the scars.Conclusion Transperitoneal LESS-RN using a home-made single-port device is technically feasible and safe in a selected group of patients （low body mass index and stage tumor） and has excellent cosmetic results.Although preliminary oncologic outcome is not compromised,the long-term evaluation of these patients is awaited.

经脐单孔腹腔镜肾上腺切除术初步经验总结

目的:探讨经脐单孔腹腔镜手术(LESS)行肾上腺切除术的疗效和安全性.方法:2010年4月～2011年2月期间,行LESS肾上腺肿瘤切除术5例.采用紧邻脐孔边缘弧形皮肤切口,穿刺针穿入腹腔建立气腹,于弧形切口穿入TriPort;正中的操作孔进入5 mm腹腔镜,余2个操作孔进入手术器械.评估手术时间、术中出血量、手术并发症、术后镇痛时间、术后住院日等相关指标.结果:5例患者LESS均获成功,其中1例右肾上腺切除术,因暴露困难,于腋前线右肋缘下增加一5 mm Trocar帮助暴露.术中、术后未发生严重并发症.结论:LESS可安全用于肾上腺切除术,而与传统腹腔镜相比,疗效相当且具有更好的美容效果.

自制单口装置在泌尿外科单孔后腹腔镜手术中的应用(附114例报告)

目的:探讨自制单口装置行单孔后腹腔镜手术治疗各种泌尿系统疾病的安全性和可行性.方法:使用自制单口装置对114例患者行单孔后腹腔镜泌尿外科手术,包括2个控制环和1个8号无粉外科手套组成一个单孔多通道操作器械,使用常规腹腔镜器械进行后腹腔镜手术.其中60例行根治性肾切除术,15例行根治性肾输尿管全长切除术,19例行肾部分切除术(包括1例同时行对侧肾上腺腺瘤切除术),11例行亲属活体供肾切取术,6例行肾上腺肿瘤切除术(包括1例同时行同侧肾囊肿去顶术),2例行肾囊肿去顶术,1例行输尿管切开取石术.结果:114例患者均经单孔后腹腔镜手术成功,无改行常规腹腔镜手术或开放手术.手术时间40～340 min,平均137.14 min；术中出血5～600ml,平均63.82 ml；住院时间6～36 d,平均12.71 d.无任何重大手术并发症,所有患者均表示满意.结论:应用自制单口装置行泌尿外科单孔后腹腔镜腔镜手术是安全可行的,费用低,可进一步减轻患者创伤,是一种有广阔应用前景的手术治疗方案.

经腹单孔多通道腹腔镜与标准腹腔镜肾上腺切除术对比研究

目的:探讨经腹单孔腹腔镜肾上腺切除术的可行性,安全性和有效性,并与标准经腹腹腔镜肾上腺切除术对照分析,评价其临床优势。方法:对经腹单孔腹腔镜肾上腺切除术13例和标准经腹腹腔镜肾上腺切除术26例患者的临床资料和随访资料进行统计学分析。结果:两组患者在基线水平,术中出血,术后住院时间方面差异无统计学意义。单孔腹腔镜手术组手术时间较标准腹腔镜手术组长(148.5:112.9 min,P=0.032),但在术后疼痛评分(2.3:3.7,P=0.001)、术后需阿片类镇痛药人数比例(30.8%:73.1%,P=0.011)、术后进食时间(21.6:26.0 h,P=0.002)、皮肤切口长度(2.3:5.9 cm,P<0.001)及满意度方面(9.5:9.1,P=0.042),单孔腹腔镜手术组患者均优于标准腹腔镜手术组患者。术后第1年随访结束时,两组患者均无肿瘤复发,且无药物无法控制的症状。结论:经腹单孔腹腔镜肾上腺切除术安全、可行、有效、且与标准腹腔镜肾上腺切除术相比,尽管手术时间略长,但具有患者术后疼痛轻,镇痛药物需要量少,肠道通气快,皮肤切口小及满意度高的优点。

单孔腹腔镜手术治疗泌尿系统肿瘤

目的:探讨应用单孔腹腔镜手术(LESS)治疗泌尿系肿瘤的临床安全性及可行性.方法:2009年10月～2012年8月,应用单孔4通道技术治疗7例前列腺癌,4例肾肿瘤,1例肾盂癌,1例输尿管癌,12例肾上腺肿瘤和囊肿.根治性前列腺切除术采用经脐切口腹膜外途径或经腹腔途径,肾切除术和肾输尿管切除术采用经脐腹腔途径,肾上腺切除术采用经后腹膜腔途径.记录手术时间、估计术中出血量、术中并发症、留置引流管时间、术后疼痛情况(VAPS)和术后住院时间,并对结果进行分析.结果:25例手术均由LESS完成,未加辅助通道,无转标准腹腔镜或开放手术.根治性前列腺切除术、肾切除术和肾输尿管切除术、肾上腺切除术平均手术操作时间分别为259.3(190～305)min、203.3(120～255)min、91.7(35～185)min.术后第1天平均VAPS为1.2(0～3)分、1.3(0～2)分、1.8(1～3)分.本组手术无术中严重并发症,无术后继发性出血和切口感染病例.本组恶性肿瘤标本外科切缘均阴性.结论:LESS治疗泌尿系肿瘤是安全和可行的手术选择.

Single-incision laparoscopic surgery for biliary tract disease

Single-incision laparoscopic surgery(SILS), or laparoendoscopic single-site surgery, has been employed in various fields to minimize traumatic effects over the last two decades. Single-incision laparoscopic cholecystectomy(SILC) has been the most frequently studied SILS to date. Hundreds of studies on SILC have failed to present conclusive results. Most randomized controlled trials(RCTs) have been small in scale and have been conducted under ideal operative conditions. The role of SILC in complicated scenarios remains uncertain. As common bile duct exploration(CBDE) methods have been used for more than one hundred years, laparoscopic CBDE(LCBDE) has emerged as an effective, demanding, and infrequent technique employed during the laparoscopic era. Likewise, laparoscopic biliary-enteric anastomosis is difficult to carry out, with only a few studies have been published on the approach. The application of SILS to CBDE and biliary-enteric anastomosis is extremely rare, and such innovative procedures are only carried out by a number of specialized groups across the globe. Herein we present a thorough and detailed analysis of SILC in terms of operative techniques, training and learning curves, safety and efficacy levels, recovery trends, and costs by reviewing RCTs conducted over the past three years and two recently updated meta-analyses. All existing literature on single-incision LCBDE and singleincision laparoscopic hepaticojejunostomy has been reviewed to describe these two demanding techniques.

Single-port transperitoneal robotic-assisted laparoscopic radical prostatectomy (spRALP): Initial experience

Objective:To assess the feasibility of single-port transperitoneal robotic-assisted laparoscopic radical prostatectomy(spRALP)and discuss its surgical technique.Methods:A 60-year-old male was admitted with an elevated prostate-specific antigen(PSA)level of 13.89 ng/mL and confirmed with prostate cancer on biopsy showing three of 22 positive cores with a Gleason score of 3þ4=7.Multiparametric magnetic resonance(MR)and bone scintigraphy showed organ-confined disease.spRALP was performed using da Vinci Si HD surgical system,with access of a quadri-channel laparoscopic port placed supraumbilically.Two drainage tubes were placed before wound closure.The surgical procedure was largely in consistence with a conventional robotic-assisted laparoscopic radical prostatectomy.Results:The surgery was successfully carried out with a duration of 152 min and an estimated blood loss of 100 mL.The patient was discharged on postoperative Day 4 after removal of both pelvic drainage tubes.Foley catheter was removed on postoperative Day 14.No major complications were encountered.Postoperative pathology showed a Gleason score of 3þ4=7 with no extraprostatic extension and negative surgical margins.Conclusion:Single-port robotic prostatectomy is feasible using the currently available robotic instruments in most Chinese robotic urological centers.Meticulous preoperative planning and careful patient selection are mandatory.Further studies concerning perioperative complications and pentafecta outcome compared with the conventional multi-port robotic prostatectomy is required.

Single-incision laparoscopic surgery to treat hepatopancreatobiliary cancer:A technical review

Single-incision laparoscopic surgery(SILS),or laparoendoscopic single-site surgery,was launched to minimize incisional traumatic effects in the 1990s.Minor SILS,such as cholecystectomies,have been gaining in popularity over the past few decades.Its application in complicated hepatopancreatobiliary(HPB)surgeries,however,has made slow progress due to instrumental and technical limitations,costs,and safety concerns.While minimally invasive abdominal surgery is pushing the boundaries,advanced laparoscopic HPB surgeries have been shown to be comparable to open operations in terms of patient and oncologic safety,including hepatectomies,distal pancreatectomies(DP),and pancreaticoduodenectomies(PD).In contrast,advanced SILS for HPB malignancy has only been reported in a few small case series.Most of the procedures involved minor liver resections and DP;major hepatectomies were rarely described.Singleincision laparoscopic PD has not yet been reported.We herein review the published SILS for HPB cancer in the literature and our three-year experience focusing on the technical aspects.

单一术者经脐单孔腹腔镜肾上腺切除术学习曲线分析

目的评估单一术者在不同阶段操作的经脐单孔腹腔镜肾上腺切除术(LESS-A)之手术效果,探讨该术式的学习曲线。方法回顾性分析南京中医药大学附属医院由同一术者在2015年3月至2019年12月连续完成的87例经脐单孔腹腔镜肾上腺切除术的临床资料。按时间顺序将患者分为4组(第一阶段组第1~21例,第二阶段组第22~42例,第三阶段组第43~63例,第四阶段组第64~87例),比较4组的手术时间、术中出血、引流管留置时间、术后住院天数等方面的差异。结果随术者经验例数的累积,手术时间、术中出血、引流管留置时间、术后住院天数均呈下降趋势。第一阶段组与第二阶段组间在除术中出血外的围术期资料差异均有统计学意义(P<0.05),第二阶段组与第三阶段组仅术中出血量的差异存在统计学意义(P<0.05)。第三阶段组与第四阶段组研究的各项围术期资料差异均无统计学意义(P均>0.05)。结论经脐单孔腹腔镜肾上腺切除术(LESS-A)学习曲线相对陡峭。单一术者达到40~45例手术的经验积累后可基本掌握,完成50例手术后熟练和稳定程度明显提高。

Laparoscopic single site surgery: Experience in pediatric urology

Laparoendoscopic single-site surgery(LESS) has been developed to benefit patients by enabling surgeons to perform scarless surgery. In this review we aimed to summarize and critically analyze the available evidence on the current status and future prospects for LESS in pediatric urology, with special emphasis on our experience with LESS in children. The clinical data available clearly demonstrate that LESS can safely and effectively be performed in a variety of pediatric urology settings. As clinical experience increases, expanding indications are expected to be documented and the efficacy of the procedure to improve. So far, the quality of evidence of all available studies remains low; mostly being small case series or case-control studies from selected centers. Thus, the only objective benefit of LESS remains improved cosmetic outcome. Prospective randomized studies are awaited to determine which LESS procedures will be established and which are unlikely to stand the test of time. Technological advances hold promise to minimize the challenging technical nature of scarless surgery. In this respect, robotics may be a driving force in the development of LESS.

经后腹膜腔单孔腹腔镜下肾上腺切除术的可行性和安全性研究

目的探讨应用经后腹膜腔单孔腹腔镜下肾上腺切除术的可行性和安全性。方法2009年10月至2012年1月应用单孔4通道技术，经后腹膜腔途径进行肾上腺切除术7例。患者年龄39～55岁，平均46岁。肿瘤最大径1．8～3．6cm，平均2．3cm。术中应用标准腹腔镜器械和5mm头端可弯腹腔镜。记录患者手术时间、术中出血量、术中并发症、留置引流管时间、术后视觉模拟疼痛量表（visual analog pains cale，VAPS）评分、术后住院时间、术后病理等临床资料，并对结果进行分析。结果7例手术均顺利，无中转标准腹腔镜或开放手术者，无另加腹腔镜手术操作通道者。手术时间70～180min，平均106min；术中出血量5～200ml，平均59ml。术后第一天VAPS评分1～3分，平均2分；引流管留置时间2～3d，平均2d；术后住院时间3～6d，平均5d。无围手术期并发症。术后病理：肾上腺皮质腺瘤5例，肾上腺嗜铬细胞瘤1例，肾上腺囊肿1例。结论经后腹膜腔单孔腹腔镜下肾上腺切除术具有良好的临床可行性和安全性。