OBJECTIVE: To describe our initial clinical experience of robotic single‐port (RSP) surgery. PATIENTS AND METHODS: The da Vinci® S robot (Intuitive, Sunnyvale, CA, USA) was used to perform radical prostatectomy (RP), dismembered pyeloplasty, and radical nephrectomy. A robot 12‐mm scope and 5‐mm robotic grasper were introduced through a multichannel single port (R‐port, Advanced Surgical Concepts, Dublin, Ireland). An additional 5‐mm or 8‐mm robotic port was introduced through the same umbilical incision (2 cm) alongside the multichannel port and used to introduce robotic instruments. Vesico‐urethral anastomosis and pelvi‐ureteric anastomosis were successfully performed robotically using running intracorporeal suturing. RESULTS: All three RSP surgeries were performed through the single incision without adding extra umbilical ports or 2‐mm instruments. For RP, the operative duration was 5 h and the estimated blood loss was 250 mL. The hospital stay was 36 h and the margins of resection were negative. For pyeloplasty, the operative duration was 4.5 h, and the hospital stay was 50 h. Right radical nephrectomy for a 5.5‐cm renal cell carcinoma was performed in 2.5 h and the hospital stay was 48 h. The specimen was extracted intact within an entrapment bag through the umbilical incision. There were no intraoperative or postoperative complications. At 1 week after surgery, all patients had minimal pain with a visual analogue score of 0/10. CONCLUSIONS: Technical challenges of single‐port surgery that may limit its widespread acceptance can be addressed by using robotic technology. Articulation of robotic instruments may render obsolete the long‐held laparoscopic principles of triangulation especially for intracorporeal suturing. We report the initial series of robotic surgery through a single transumbilical incision.

We report on a prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy for renal tumor. Between June 1999 and June 2001, 102 consecutive eligible patients with a computerized tomography identified renal tumor were prospectively randomized to undergo either a transperitoneal (group 1, 50 patients) or retroperitoneal (group 2, 52 patients) laparoscopic radical nephrectomy with intact specimen extraction. Exclusion criteria for the study included body mass index greater than 35 or a history of prior major abdominal surgery in the quadrant of interest. Both groups were matched regarding age (63 versus 65 years, p = 0.69), BMI (29 versus 28, p = 0.89), American Society of Anesthesiologists class (2.7 versus 2.8, p = 0.37), laterality (right side 46% versus 48%, p = 0.85) and mean tumor size (5.3 versus 5.0 cm, p = 0.73). All 102 procedures were technically successful without the need for open conversion. Compared to the transperitoneal approach, the retroperitoneal approach was associated with a shorter time to renal artery control (91 versus 34 minutes, p <0.0001), shorter time to renal vein control (98 versus 45 minutes, p <0.0001) and shorter total operative time (207 versus 150 minutes, p = 0.001). However, the transperitoneal and retroperitoneal approaches were similar in terms of estimated blood loss (180 versus 242 cc, p = 0.13), hospital stay (43 versus 45 hours, p = 0.55), intraoperative complications (10% versus 7.7%, p = 0.30), postoperative complications (20% versus 13.5%, p = 0.14) and postoperative analgesia requirements (27 versus 26 mg MSO4 equivalent p = 0.13). Pathology revealed renal cell carcinoma in 84% and 75% of cases, respectively, with no positive surgical margin in any case. Laparoscopic radical nephrectomy can be performed efficiently and effectively with the transperitoneal or the retroperitoneal approach. While renal hilar control and total operative time may be quicker with retroperitoneoscopy, the approaches are similar in terms of other patient outcomes evaluated.

Objective: To compare the perioperative outcomes of robotic partial nephrectomy ( RPN ) with laparoscopic PN ( LPN ) performed for small renal masses ( SRM s), in a large multi‐institutional series and to define a new composite outcome measure, termed ‘optimal outcome’ for the RPN group. Patients and Methods: Retrospective review of 2392 consecutive cases of RPN and LPN performed in five high‐volume centres from 2004 to mid‐2013. We limited our study to SRMs and cases performed by surgeons with significant expertise with the technique. The Trifecta was defined as negative surgical margin, zero perioperative complications and a warm ischaemia time of ≤25 min. The ‘optimal outcome’ was defined as achievement of Trifecta with addition of 90% estimated glomerular filtration rate preservation and no chronic kidney disease stage upgrading. Univariable and multivariable analysis were used to identify factors predicting Trifecta and ‘optimal outcome’ achievement. Results: In all, 1185 RPN and 646 LPN met our inclusion criteria. Patients in the RPN group were older and had a higher median Charlson comorbidity index and higher R.E.N.A.L . nephrometry score. The RPN group had lower warm ischaemia time (18 vs 26 min), overall complication rate (16.2% vs 25.9%), and positive surgical margin rate (3.2% vs. 9.7%). There was a significantly higher Trifecta rate for RPN (70% vs 33%) and the rate of achievement of ‘optimal outcome’ for the RPN group was 38.5%. Conclusions: In this large multi‐institutional series RPN was superior to LPN for perioperative surgical outcomes measured by Trifecta. Patients in the RPN group had better outcomes for all three components of Trifecta compared with their LPN counterparts. Our more strict definition for ‘optimal outcome’ might be a better tool for assessing perioperative and functional outcomes after minimally invasive PN . This tool needs to be externally validated.

OBJECTIVE: To present our initial experience in children undergoing single‐port laparoscopic varicocelectomy (SPLV) using a new approach in which the entire procedure is performed through a multichannel single laparoscopic port inserted in the umbilicus rather than the traditional LV performed through three abdominal ports. PATIENTS AND METHODS: We reviewed our experience with all paediatric patients who had undergone transumbilical SPLV [Uni‐X ^TM Single Port Access Laparoscopic System, Pnavel Systems, NJ, USA]. This novel 20‐mm laparoscopic port has three working channels and gas insufflation access. The system also includes a variety of curved laparoscopic instruments that can be introduced through the SP. A Hassan technique through an incision within the inferior aspect of the umbilicus is used to obtain laparoscopic port access to the abdominal cavity. The SP is then fixed into position with pre‐placed rectus facial sutures. Using a curved laparoscopic grasper and scissors, an incision is made within the posterior peritoneum on the medial and lateral aspects of the left testicular artery and veins, proximal to the vas deferens. The vessels, both artery and veins, are transected leaving clips both proximally and distally. RESULTS: Transumbilical SPLV was completed in three consecutive adolescents (aged 13, 15 and 16 years) without placing any additional ports or conversion to open surgery. All procedures were performed for left‐sided grade III varicoceles. The operative duration was <1 h for each procedure. All patients were discharged on the same day as their surgery and none required re‐hospitalization. At a mean (range) follow‐up of 8.7 (6–10) weeks there was a good cosmetic result, with no varicocele recurrence, or intraoperative or postoperative complications including wound infection, hydrocele, or incision site herniation. CONCLUSION: We report the first use of a multicannula single laparoscopic port in children and for SPLV. This new laparoscopic approach, similar to any new technique, requires further experience to fully evaluate its benefits and limitations.