[in Japanese]

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[in Japanese]

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[in Japanese]

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  Our aim was to describe our early experience with laparoendoscopic single-site surgery (LESS) via the retroperitoneal approach for upper urinary tract tumors. Since April 2010, 21 patients with upper urinary tract cell carcinoma were treated by our team : 12 patients have undergone LESS nephroureterectomy and 9 have undergone standard retroperitoneal laparoscopic surgery. Nephrectomy was performed using procedures similar to those of conventional laparoscopic nephrectomy. The distal ureter and bladder cuff were excised by using the open method. All operations using retroperitoneal LESS nephroureterectomy were completed without conversion to standard laparoscopy or open surgery. No intraoperative or acute postoperative complications occurred. We found that the retroperitoneal LESS nephroureterectomy had significantly less estimated blood loss (p = 0.034). No significant difference was noted with respect to operation time, time to oral intake, length of hospitalization, and the visual analog pain scale score at discharge (p > 0.05). The initial reports of retroperitoneal LESS nephroureterectomy demonstrate that the technique is a safe and feasible procedure for upper urinary tract urothelial carcinoma.

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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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[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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[in Japanese]

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[in Japanese]

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  Partial nephrectomy is an effective surgical treatment for small renal mass. Laparoscopic partial nephrectomy (LPN) has technical challenges because it requires nephron-sparing and suturing skills to be used during shortened warm ischemia times. Robotic-assisted partial nephrectomy (RAPN) might allow complex procedures to be performed while minimizing the technical challenges of the LPN. In this study we evaluated the outcomes of the initial 28 patients who underwent an RAPN between August 2011 and March 2014 at our institution. We used a segmental clamping technique with a three-dimensional (3D) reconstructed from computed tomography using open source processing software, which were directly visualized on the screen of a da Vinci Si surgeon’s console with TilePro multi-input display functions. The mean operative time was 281.2 min, the mean warm ischemia time was 21.4 min, and the mean estimated blood loss was 50 mL. Only nine of the 16 patients for whom the 3D navigation system were used. We performed a univariate analysis to compare the tumor size, RENAL nephrometry score, operative time, console time, renal renorrhaphy time, warm ischemia time, pre-operative eGFR and pro-operative eGFR obtained with the total clamp versus the selective clamp. Significant associations with tumor size (p=0.039), operative time (p=0.021), and console time (p=0.015) were revealed. Only one patient developed a complication, which was Clavien grade III (a pseudoaneurysm).
  Finally, longer follow up and more experience are needed to extend the more difficult case of renal cell carcinoma and compare the total clamp and super selective clamp.

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  Introduction and Objectives : We evaluated the correlation between RENAL nephrometry score (RNS) and perioperative outcomes for patients undergoing laparoscopic partial nephrectomy (LPN) in our institutions.
  Methods : RNS was evaluated in 52 consecutive patients who underwent LPN using preoperative computed tomography. Of the 5 components, 4 (Radius, Exophytic/endophytic properties, Nearness of the tumor to the collecting system or sinus, Location relative to polar lines) were scored on a 1, 2, or 3-point scale. Renal tumors were categorized by RNS complexity as low (RNS sum, 4-6), intermediate (sum, 7-9), and high (sum, 10-12).
  Results : Significant differences were seen between low and moderate groups in overall operative time (222 min vs. 263 min ; p=0.03) and estimated blood loss (25 ml vs. 105 ml ; p=0.04). No difference was found between groups in warm ischemia time (p=0.74) or complication rate (p=0.81) ; however, a significant difference was observed in RNS (5.6 vs. 6.9 ; p<0.01) and warm ischemia time (38 min vs. 24 min ; p<0.01) between patients undergoing LPN in the first (n=26) and second halves (n=26). RNS shows a situation in which LPN was selected for technically difficult tumors in the second half as the laparoscopic technique was stabilized.
  Conclusions : RNS may stratify tumors based on the technical difficulty of LPN.

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  Objective : We developed an estimating formula to minimize the length of single incision in LESS donor nephrectomy (LESSDN).
  Materials and Methods : The estimating formula was calculated as x = (π√prs )/2q (x = minimal wound length, π = Pi, p = skin extension coefficient, q = kidney reduction coefficient, r and s = longer and shorter diameter of the kidney on CT, respectively). The estimating formula was applied for 28 donors who underwent LESSDN using GelPOINT^® involving pararectal single incision, and they were compared with 26 previous donors for whom the formula was not applied.
  Results : p and q were calculated as 1.45 and 0.80, respectively. The mean length of incision and warm ischemia time in the donors for whom the formula was applied were significantly shorter than those in donors without its application (5.62 vs. 5.32cm, p = 0.019 and 281 vs. 221 s, p = 0.019, respectively).
  Conclusion : The formula was effective to minimize the length of incision according to the size of the kidney and shorten the warm ischemia time in LESSDN.

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  Objective : To compare outcome and urinary function among radical prostatectomy procedures.
  Materials and Methods : From 2006 to 2012, 59 radical retropubic prostatectomies (RRP), 53 laparoscopic radical prostatectomies (LRP) and 60 robot-assisted laparoscopic prostatectomies (RALP) were enrolled. Expanded Prostate Cancer Index Composite (EPIC) questionnaire were collected before and 3, 6 and 12 months after the surgery. Logistic regression analysis was performed to find the parameters to predict post-surgical urinary incontinence.
  Results : Operative time was longer in LRP and blood loss was lower in RALP. Positive surgical margin rate was higher in LRP, however PSA recurrence was not significantly different. Urinary function score was lower in LRP at 3 and 12 months. Surgical procedure (LRP) is the only significant predictor for post-surgical urinary incontinence.
  Conclusions : PSA recurrence was not significantly different among the radical prostatectomy procedures. Post-surgical urinary incontinence was more common in LRP.

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  Several studies have shown that preservation of the functional urethral length (FUL), stability of the urethra and periurethral structures, and characteristics of patients are associated with early continence recovery after radical prostatectomy (RP). We investigated the influence of preserving FUL by comparing various factors associated with postoperative urinary continence. A total of 68 men who underwent laparoscopic RP (LRP) between January 2011 and April 2013 by a single surgeon, and whose continence data could be recorded at 1, 3 and 6 months after LRP were enrolled in this study. We evaluated FUL by measuring the distance between the superior margin of the femur head and external sphincter using pre and postoperative images. Urinary continence was defined as using no pad or one pad for security per day. Preservation of FUL significantly improved early continence recovery within 6 months after LRP (p = 0.001).

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  Purpose : We evaluated the efficacy and clinical outcome of transurethral lithotripsy (TUL) for upper urinary tract stones.
  Materials and Methods : Between 2007 and 2012, we performed 386 TULs in 299s patients (175 males and 124 females). The stone locations were the renal pelvis and calix (R2), ureteropelvic junction (R3), proximal ureter (U1), middle ureter (U2), distal ureter (U3), and multiple locations in 45, 18, 91, 29, 88, and 29 patients, respectively. Lithotripsy was performed with rigid and flexible ureteroscopes and the holmium-YAG laser.
  Results : The median operation time was 77 minutes. We performed a single TUL in 243 patients and multiple TULs in 56. The overall effective rate was followed : 80% for stones in R2, 94% for those in R3, 90% for those in U1, 97% for those in U2, and 98% for those in U3.
  Conclusion : TUL is an effective and safe method for managing upper urinary tract stones.

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  The aim of this study is to evaluate the clinical benefit of fluorescence assisted-transurethral resection of bladder tumor (FL-TURBT) using 5-aminolevulinic acid (5-ALA) by a comparison with conventional white-light TURBT (WL-TURBT). Nighty-six patients with bladder tumor were treated intravesically or orally with 5-ALA 2 hours prior to TURBT. Intravesical lesions were investigated by fluorescent detection mode and white-light detection mode. The association assessment of endoscopic findings and pathological examination revealed that fluorescent detection mode improved the sensitivity by 13% (from 71.6% to 84.5%), while the specificity decreased by 8% (from 84.6% to 76.3%). There were no significant differences in recurrence-free survival rates after initial TURBT between FL-TURBT and WL-TURBT as a historical control. No severe adverse event was caused by the administration of 5-ALA. FL-TURBT would be a safe and beneficial treatment modality to detect intravesical tumors, but a large-scale prospective comparative study is warranted to assess the oncological outcomes in Japan.

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  Purpose : To determine the optimal frequency of shock wave lithotripsy, in terms of efficacy and duration, by comparing rate of 90/min and 60/min.
  Patients and Method : Using the Siemens Lithostar Multiline, we treated 381 patients at 90/min, between September 2008 and April 2011, and 236 patients at 60/min, between May 2011 and August 2013.
  Results : The stone free rates of single and multiple session at 1 months after treatment of 90/min group and 60/min group were 64% and 69% (P=0.185), respectively. Multiple logistic regression analysis revealed that age (younger), stone location and size (small) was independent (better) prognostic factors determining stone clearance after ESWL of upper urinary tract stones. According to this analysis, however, the pulse rate (90/min vs 60/min) revealed to deny the prognostic factor. The mean total treatment durations were 86 and 100 minutes (P<0.001), respectively. Complication rates were low and same among the both groups.
  Conclusion : No significant difference in the stone-free and complication rates were observed by reducing the pulse rate from 90/min to 60/min. The results of our study have shown that optimal frequncy during shock wave lithotripsy is 90/min in terms of efficacy, duration and adverse effect.

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  A 44-year-old man presented to the emergency department with acute left flank pain. Abdominal computed tomography (CT) revealed a retroperitoneal hematoma originating from an adrenal myelolipoma, and the patient was eventually referred to our department. Because no active bleeding from the tumor was observed and the patient's symptoms and vital signs were stable, he was admitted to our department and observed carefully. A CT revealed a reduction in size of the hematoma and adrenal gland (3.5 cm), we performed laparoscopic left adrenalectomy, three month after initial presentation. There wasn't almost any adhesion around the tumor, and we were able to excite it without any complications. The postoperative course was uneventful, and the patient was discharged 9 days after the surgery. if the symptoms and vital signs are stable and there is no active bleeding, we recommend waiting for absorption of the hematoma prior to undertaking a low-invasive operation.

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  A 35-year-old-woman receiving an abdominal CT scan was incidentally discovered to have a left adrenal tumor, measuring 9 cm in diameter. Findings on endocrinological examination were within normal ranges. The patient was diagnosed with a non-functional left adrenal tumor, and laparoscopic left adrenalectomy was performed. During laparoscopic exploration, the tumor was relative to celiac ganglions and composed of several feeding vessels. The pathological diagnosis was ganglioneuroma originating from the retroperitoneal space.

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  A 74-year-old man was referred to our hospital because of a right kidney tumor and multiple lung nodules incidentally detected on chest X-ray and abdominal CT. CT and MRI revealed that his organs showed a complete mirror image. Furthermore, they revealed a heterogeneous kidney tumor of 8 cm in the right upper pole and multiple lung metastases. So, we diagnosed the patient with a right kidney cancer with multiple lung metastases secondary to complete situs inversus. We performed transperitoneal laparoscopic right nephrectomy using three ports placed in the right subcostal area. We did not encounter any procedural difficulties during the surgery. The operative duration was four hours and 30 minutes and the hemorrhagic volume was 100 mL. With a sufficient understanding of the anatomical mirror image, laparoscopic nephrectomy for cancer of the kidney in the presence of complete situs inversus could be performed safely and with minimal invasiveness, without any problems.

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  A 57-year-old woman had undergone retroperitoneal non-ischemic open partial nephrectomy for renal cell carcinoma at the upper pole of the left kidney 12 years previously. Ultrasonography detected another renal tumor in the left kidney. Enhanced CT demonstrated a renal tumor with strong enhancement at the hilar portion of the left kidney, suggesting local recurrence of renal cell carcinoma. Retroperitoneoscopic non-ischemic left partial nephrectomy using a microwave tissue coagulator (MTC) was performed without any complications. Retroperitoneal laparoscopic non-ischemic partial nephrectomy with MTC could be safely and effectively performed in the present case with local recurrence after ipsilateral retroperitoneal non-ischemic open partial nephrectomy. Since partial nephrectomy using MTC can keep the renal hilum intact, the surgical risk due to tissue adhesion around the renal hilum can be reduced on repeated renal surgery.

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  Patient 1 was a 64-year-old man with a chief complaint of gross hematuria. Cystoscopy showed bloody urine efflux from the left ureteral orifice, and left ureteral urine cytology was class V ; therefore, ureteroscopy was performed, which revealed a papillary tumor in the left upper renal calyx. On biopsy, the tumor was found to be UC, G2, high-grade, pTa, and was diagnosed as a left renal pelvic carcinoma. These findings led to a diagnosis of left renal pelvic carcinoma associated with horseshoe kidney, for which laparoscopic left total nephroureterectomy and isthmectomy were performed. Patient 2 was a 51-year-old woman who was found to have a horseshoe kidney with a right renal tumor on screening CT, and was referred to our department. She underwent laparoscopic right heminephrectomy and isthmectomy. We were able to perform the isthmectomy almost bloodlessly using LigaSure, stump suture, and soft coagulation. When performing laparoscopic heminephrectomy for malignant tumors in horseshoe kidneys, care should be taken because the arrangement of organs and course of blood vessels are often significantly different from those in normal subjects, but it can be performed relatively safely.

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  We present our experience of transperitoneal laparoscopic lithotomy for a ureteral stone in a pediatric patient. A 2-year-old boy with a 16-mm ureteral stone underwent laparoscopic calculus removal. Four trocars were placed and the ureter was dissected and incised longitudinally. The calculus showed moderate adhesion to the ureteral wall. After removing and retrieving the stone, the ureterostomy was repaired by suturing. The two braided tapes around the ureter were particularly useful in this procedure because they facilitated gentle retraction and surgical access. The operative time was 165 minutes, and there were no perioperative complications.
  This case indicates that the laparoscopic management of urolithiasis in pediatric patients, especially for a large and/or adhesive stone, is as effective and safe as it is in adults.

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  We evaluated the clinical efficacy of laparoscopic retroperitoneal renal biopsy. Between July 2007 and March 2013, laparoscopic retroperitoneal renal biopsy was performed in 19 patients who were considered inappropriate for standard percutaneous biopsy. Reasons for contraindication of percutaneous biopsy were solitary kidney (n=8), bilateral renal cysts (n=6), functional solitary kidney (n=3), horseshoe kidney and bleeding tendency (n=1). With the patient under general anesthesia and in the lateral position, operation was performed with 3 ports. Specimen was taken at the lower pole of kidney by 18 gauge biopsy needle. The mean operation time was 124.8 minutes, bleeding volume was little in all cases. An average of 3 tissue cores per patient was obtained, which was adequate for historogical diagnosis. No patient suffered from severe complications. Our study indicates laparoscopic retroperitoneal renal biopsy is safe and minimally invasive technique in patients at risk for percutaneous biopsy.

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