[in Japanese]

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  Da Vinci S Surgical System was introduced to Kobe University Hospital in August 2010. First case of robot-assisted laparoscopic prostatectomy was performed in October 2010. It has 3 features（high definition 3D vision, 7 degree freedom instruments, and reduction of surgeon hand tremors）. Good performance of nerve sparing is expected using this system. We perform nerve sparing prostatectomy using both antegrade and retrograde methods with da Vinci.

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[in Japanese]

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  A total of 140 patients were treated with robot-assisted laparoscopic prostatectomy（RARP）since August 2009 at our institute. RARP was completed in all cases without conversion to open surgery or allogenic blood transfusion during operation. Our procedure consisted of preservation of endopelvic fascia, lateral approach to bladder neck transection and total pelvic reconstruction of urinary tract. The key is in delicate handling of tissues, reducing trauma, preserving supportive structures, and restoring postoperative anatomy as close as possible to preoperative anatomy.
  Pelvic lymph node dissection（PLND）at the time of prostatectomy is an important part of the surgical intervention for prostate cancer and is currently under-reported during robotic procedures. Important questions remain regarding patient selection, potential benefit, anatomic extent of the dissection, nodal yield, and complication rates. Certain literatures have clearly shown that the lymphatic drainage of the prostate is not limited to the obturator and external iliac lymph nodes, and thus a PLND limited to these regions does not address all the potential landing sites. An extended PLND（ePLND）, especially when including the internal and common iliac lymph nodes, more accurately reflects the true lymphatic drainage of the prostate, increases nodal yields and the ability to detect LNI. According to several guidelines, patients with intermediate to high risk prostate cancer should routinely have ePLND performed at the time of radical prostatectomy. Also, it seems safe to exclude PLND in patients undergoing any radical prostatectomy for low-risk prostate cancer.
  Robotic PLND for prostate cancer up to the common iliac bifurcation is feasible and increases nodal yield and positive nodal rate. Although extended PLND is recommended to the cases with intermediate to high-risk at RARP, complications associated with PLND should not be neglected.

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[in Japanese]

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[in Japanese]

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[in Japanese]

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[in Japanese]

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[in Japanese]

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[in Japanese]

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  To review the recent knowledge about complications of laparoscopic radical cystectomy（LRC）and robotic assisted radical cystectomy（RARC）. As with open surgery, major vessel injury and nerve injury are distress complications during radical cystectomy with extended pelvic lymph node dissection. Although there is no conclusive evidence, it is suggested that the rate of postoperative major complication in LRC/RARC is almost equivalent to that in open radical cystectomy. On the other hand, minor complications such as paralytic ileus may be less in LRC/RARC. In order to evaluate the complication of LRC/RARC, using standard criteria such as Clavien-Dindo classification must be taken into account.

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[in Japanese]

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  Purpose：To evaluated the efficacy and safety of laparoscopic partial nephrectomy（LPN）, we compared the results of ischemic LPN with hilar occlusion （ischemia group）and non-ischemic LPN using microwave tissue coagulator（non-ischemia group）.
  Methods：Between April 1994 and April 2010, 54 patients underwent pure LPN. We retrospectively made a comparative review of perioperative complication and postoperative renal function between two procedures. Results：The patients with complication who received non-ischemic LPN developed prolonged urine leakage and finally, he required nephrectomy due to uncontrollable infection.
  Postoperative estimated GFR in non-ischemia group was significantly worth than that in ischemia group at 3 months after operation.
  Conclusion：The thermal damage by Microwave tissue coagulator may unexpectedly broad and deep. Although non-ischemic LPN using microwave tissue coagulator is technically easy, it should be restricted to use for the small superficial renal tumors.

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  Purpose：We evaluated the surgical and post-operative results of laparoscopic partial nephrectomy.
  Methods：Between January 2007 and October 2011, 67 laparoscopics for suspected malignancy were completed in Yokohama City University Hospital. We retrospectively evaluated two sequential groups of patients：group with a retroperitoneal approach consisting of 43 patients, and group with a transperitoneal approach consisting of 24 patients
  Results：The mean surgical time, mean ischemic time, and mean blood loss were 171.1 minutes, 25.6 minutes, and 78.3 ml with the retroperitoneal approach and 182.3 minutes, 26.3 minutes, and 102.9 ml with the transperitoneal approach, respectively. Intra- and postoperative complications were seen in 3 cases. At present, no patient has developed local recurrence.
  Conclusion：The initial outcome of laparoscopic partial nephrectomy in our hospital was satisfactory in terms of both cancer control and ischemic time.

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  Influential factors of postoperative renal function were examined during the first year of 118 cases of laparoscopic partial nephrectomy. The average of age（years old）and renal ischemic time（min）of all cases were 59.5±12.3 and 44.4±15.9, respectively. The preoperative eGFR（estimated glomerular filtration rate）was 81.55±22.57，eGFR immediate after operation was 51.63±14.46，eGFR one month after operation was 68.99±17.35，and eGFR 12 months after operation was 67.87±16.43. The ΔeGFR（（preoperative eGFR－postoperative eGFR）/preoperative eGFR×100%）immediate after operation was －35.81±11.72，ΔeGFR one month after operation was －14.13±14.67，and ΔeGFR 12 months after operation was －11.10±13.53. It was concluded that the significant influential factors of postoperative renal function over a month were age, renal ischemic time（IT）, tumor size, and manitol injection. And those over 12 months were age and renal ischemic time.

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  Objective：We evaluated the effect of mannitol during laparoscopic partial nephrectomy（LPN）by comparing the postoperative renal function of the patients who received it and those who did not.
  Methods：We retrospectively reviewed the records of 43 patients who underwent LPN from June 2006 to August 2011 with normal contralateral renal function and who had been followed-up postoperatively for at least three months. Of these 43 patients, nine received mannitol and 34 did not. We compared the postoperative estimated glomerular filtration rate（eGFR）between the two groups.
  Results：There were no significant differences in perioperative patient characteristics between the two groups. Mannitol made no significant difference in the postoperative eGFR between the two groups at any point in the postoperative period within a year.
  Conclusion：There is no advantage to be gained by administering Mannitol during laparoscopic partial nephrectomy to patients with normal contralateral renal function.

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  The challenge of laparoscopic partial nephrectomy（LPN）is to resect a tumor within a limited warm ischemia time（WIT）, followed by hemostatic renorrhaphy under restricted movement of laparoscopic forceps. DaVinci device improved the movability of instruments and provided three-dimensional visualization.
  Since July 2010, we carried out seven cases of RALPN. Tumor size and WIT ranged from 15 to 62 mm, and from 13 to 37 minutes, respectively. RALPN was completed without open conversion or reoperation postoperatively. Urine leakage from the resected surface was noted in one case, which was successfully managed by urinary tract drainage.
  Introduction of daVinci device to LPN made this procedure, RALPN, a secured and promising one, leading to shorten the WIT and to achieve comfortable renorrhaphy. Even for the complex and technically challenging renal tumors, robotic assistance is expected to provide patients the benefit of minimally invasive surgery with maintenance of kidney function.

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  We herein report the initial experiences of robot-assisted radical cystectomy（RALC）using da Vinci^TM surgical system. We have performed RALC for 4 patients with muscle-invasive bladder cancer since October 2011. Robot-assisted procedures were completed in all cases without conversion to open surgery. Median console time was 238 minutes, and median blood loss was 580ml. No severe complication was observed.
  RALC may become one of the most favorable procedures for treatment of muscle-invasive bladder cancer nearly in the future although much more experiences and longer follow-up are required to confirm its effectiveness and safety.

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  A 59-year-old female patient visited the Department of Orthopedic Surgery for numbness of the extremities and difficulty in walking. Computed tomography evaluation revealed elevated blood glucose and hypokalemia, and a left adrenal tumor. Accumulation of the radionuclide in the tumor was seen in 123-MIBG scintigraphy, and T1- and T2-weighted magnetic resonance imaging（MRI）showed high intensity. Lacking abnormal findings in brain MRI, we finally diagnosed her condition as ACTH-producing pheochromocytoma and treated her with laparoscopic left adrenalectomy. Steroid replacement therapy was performed. Pulmonary edema and cytomegalovirus pneumonia occurred postoperatively. The pneumonia was treated with ganciclovir. Two months after the operation the patient recovered and 10 months later steroid replacement therapy was terminated. ACTH-producing pheochromocytoma presents various symptoms due to a high cortisol level and the condition of the patient is usually unstable preoperatively. Despite this, it is reasonable and safe to perform adrenalectomy with laparoscopic surgery.

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  Laparoscopic nephroureterectomy（LNU）has been used to treat upper urinary tract urothelial cell carcinomas, We performed a retrospective review of the parasurgical parameters, and used the E-PASS scoring system to predict surgical stress in patients undergoing 70 LNU and 25 open nephroureterectomie（ONUs） from May 2000 to November 2010. The median age was 71 years for LNU, and 66 for ONU（p=0.0355）. LNU had less blood loss（median：147.5 vs. 240ml, p=0.0125）, comparable operation times（351 vs. 280 min）, lower CRP levels（5.5 vs. 8.5μg/dl, p=0.0002）, an earlier postsurgical oral intake（1 vs. 2 days, p=0.0253）and a significantly lower E-PASS score. The 5 - year survival was 69.6% for all patients, 76.3% for LNU and 50.9% for ONU （p=0.0118）. After excluding the pT4 stage patients, the survival rates became comparable between the two groups. LNU was less invasive, had a faster recovery time and the prognosis was comparable.

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  Purpose：Ten years have passed since we started laparoscopic living donor nephrectomy（LLDN） in 2001. We investigated clinical outcomes of LLDN in our hospital.
  Study Design：We retrospectively reviewed the data of 143 cases of LLDN performed between September 2001 and December 2011 in Osaka University Hospital. We analyzed the intraoperative data and surgical complications.
  Results：The mean operative time was 240.1±61.9 minutes, with an average blood loss of 147.2±172.9 ml. The average warm ischemic time was 204.1±82.4 seconds. Five cases of laparoscopic procedures required conversion to open procedures due to a case of duodenum and diaphragm injury and 3 cases of peritoneum injury.
  Conclusions：We have performed LLDN without major complications for these ten years.

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  Between June 2006 and May 2011, we performed holmium laser enucleation of the prostate （HoLEP）on 90 patients；of these, 60 underwent enucleation with retrograde dissection HoLEP（group A）, and 30 underwent enucleation with anteroposterior dissection HoLEP（group B）. We evaluated and compared the surgical index, functional outcome, and postoperative complications between the 2 groups. Total operation time was significantly shorter for group B than for group A. The post-operative functional outcome was significantly improved in both groups. The 3-month post-operative incidence rate of transient stress urinary incontinence was significantly higher in group A than in group B. Therefore, anteroposterior dissection HoLEP may be an effective and normalized procedure to reduce the postoperative incidence rate of transient stress urinary incontinence.

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  Upper urinary tract cancer requires radical nephro-ureterectomy as standard surgical therapy. Endoscopic surgery is recommended for only low-stage and low-grade cancer, as recommendation grade B. We herein report 3 cases of noninvasive, low-grade ureteral cancer treated by intravesical perfusion of pirarubicin with ureteral stent placement post trans-urethral resection of a ureteral tumor（TURUT）. Six-eight weekly perfusions of pirarubicin at 40 mg were performed as possible. The 3 cases included 1 elective case and 2 imperative cases. Pathological findings in TURUT specimens revealed noninvasive papillary urothelial carcinoma, low-grade pTa-1 in all cases. One patient, case 3, had bladder recurrence 23 months after TURUT, but all patients, cases 1, 2, 3, have remained alive and experienced no recurrence in the cancer-side ureter for 43, 32, and 28 months, respectively. Pirarubicin perfusion post TUR for upper urinary tract noninvasive, low-grade urothelial tumors is tolerable and may prevent cancer recurrence, and also may prevent imperative cases with renal failure from requiring dialysis.

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  We analyzed the factors which influence laparoscopic suturing skill in beginners. A total of 124 medical students in our institution were instructed in laparoscopic suturing and ligation techniques with the use of dry-box by an expert in laparoscopic surgery. After one week of self-training, the total Suture to Ligation Time （SLT）, composed of suturing, twice ligation, cutting, and needle retrieving, was measured. We asked the students several questions：“Did you know laparoscopic surgery was conducted by a urologist?”, “Do you regularly play video games?”, “Are you interested in laparoscopic surgery?”, “Do you wish to be a surgeon in the future?” The SLT of students interested in laparoscopic surgery was significantly shorter than that of non- interested students（p=0.002）. The difference in the SLT between students who do and do not regularly was marginally significant（p=0.051）.

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