Endo-urology

Robotic Laparoendoscopic Single-Site Surgery Using GelPort as the

Access Platform

Robert J. Stein, Wesley M. White, Raj K. Goel, Brian H. Irwin, George Pascal Haber,Jihad H. Kaouk *

Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA

E U R O P E A N U R O L O G Y 5 7 ( 2 0 1 0 ) 1 3 2 – 1 3 7

avai lable at www.sciencedirect .com

journal homepage: www.europeanurology.com

Article info

Article history:

Accepted March 23, 2009Published online ahead ofprint on March 31, 2009

Keywords:

Da Vinci

Laparoscopic

Laparoscopy

LESS

Nephrectomy

NOTES

Partial nephrectomy

Pyeloplasty

Reconstructive

Robot

Robotic

Single access

Single port

Abstract

Background: Laparoendoscopic single-site surgery (LESS) allows for the perfor-

mance of major urologic procedures with a single small incision and minimal

scarring. The da Vinci Surgical System provides advantages of easy articulation and

improved ergonomics; however, an ideal platform for these procedures has not

been identified.

Objective: To evaluate the GelPort laparoscopic system as an access platform for

robotic LESS (R-LESS) procedures.

Design, setting, and participants: Since April 2008, 11 R-LESS procedures have

been completed successfully in a single institutional referral center. For the last

four consecutive cases, the GelPort has been used as an access platform through a

2.5–5-cm umbilical incision.

Intervention: R-LESS cases performed with the GelPort included pyeloplasty

(n = 2), radical nephrectomy (n = 1), and partial nephrectomy (n = 1).

Measurements: Perioperative data were obtained for all patients including demo-

graphic data, operative indications, operative records, length of stay, complica-

tions, and pathologic analysis.

Results and limitations: Forbothpyeloplastycases,averageoperativetime(OR time)

was 235 min and estimated blood loss (EBL) was 38 cm3. For the patient undergoing

radical nephrectomy for a 5.1-cm renal tumor, OR time was 200 min and EBL was

250 cm3. The final patient underwent partial nephrectomy without renal hilar

clamping for an 11-cm angiomyolipoma with OR time of 180 min and EBL of

600 cm3. All R-LESS procedures attempted with the GelPort were completed success-

fullyandwithoutcomplication.Averagelengthofhospitalstaywas1.75d(range:1–2).

The partial nephrectomy patient required transfusion of 1 U of packed red blood cells.

Conclusions: Use of the GelPort as an access platform for R-LESS procedures

provides adequate spacing and flexibility of port placement and acceptable access

to the surgical field for the assistant, especially during procedures that require a

specimen extraction incision. Additional platform and instrumentation develop-

ment will likely simplify R-LESS procedures further as experience grows.

# 2009 Published by Elsevier B.V. on behalf of European Association of Urology.

* Corresponding author. Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 EuclidAvenue/Q-10, Cleveland, Ohio 44195, United States. Tel: +1 216 444 2976; Fax: +1 216 445 7031.

E-mail address: kaoukj@ccf.org (J.H. Kaouk).

0302-2838/$ – see back matter # 2009 Published by Elsevier B.V. on behalf of European Association of Urology. doi:10.1016/j.eururo.2009.03.054

1. Introduction

Laparoendoscopic single-site surgery (LESS) provides the

ability to perform major surgery with minimal incisions and

nearly scar-free results. Use of a single incision within the

umbilicus conceals much, if not all, of the wound while

allowing access to the abdomen during transabdominal

procedures.

Several difficulties are immediately apparent with this

approach. The two greatest challenges include clashing of

the laparoscope with instruments and the loss of triangula-

tion with limitation of instrument maneuverability. To

overcome these obstacles, articulating instruments for

greater spacing have been developed. Nevertheless, current

articulating, laparoscopic equipment can be bulky and

difficult to master, thus reducing ergonomics and efficiency

for the surgeon.

The primary advantage of the da Vinci Surgical System

(Intuitive Surgical, Sunnyvale, CA, USA) for LESS includes

easier articulation using EndoWrist instruments. Other

Fig. 1 – Port placement prior to attaching the GelSeal cap to the woundprotector.

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Fig. 2 – Intraoperative image of the da Vinci S Surgical System docked intothe GelPort platform.

benefits include three-dimensional visualization, motion

scaling, and tremor filtration. We reported our initial

experience with robotic LESS (R-LESS) using a multichannel

single port (Triport, Advanced Surgical Concepts, Dublin,

Ireland), next to which one additional robotic port was

placed through the same umbilical incision [1]. This

platform arrangement is usable, but limitations include

less flexibility for customized placement of ports and

interference with placement of ports in tandem through the

single incision, as the multichannel port has a rigid outer

ring. The GelPort system (Applied Medical, Rancho Santa

Margarita, CA, USA) provides a larger working platform that

can be useful in all cases but especially for patients

requiring a 3–5-cm specimen extraction incision.

To this point, our experience includes 11 R-LESS

procedures: radical prostatectomy (n = 1), partial nephrec-

tomy (n = 2), ureteroneocystostomy (n = 1), radical

nephrectomy (n = 2), and dismembered pyeloplasty

(n = 5). We report our robotic single-site technique using

the GelPort as a surgical platform.

2. Materials and methods

Since April 2008, we have performed 11 R-LESS cases for patients

otherwise considered to be candidates for LESS surgery. Exclusion criteria

included body mass index >35 kg/m2, significant prior abdominal

operations, and evidence of systemic malignancy. For the four most

recent R-LESS procedures, the GelPort was used as the surgical platform

due to the subjective ease of use noted during the first such procedure.

2.1. Access

Access for renal procedures involves placement of the patient in modified

flank position. A 2–5-cm transumbilical incision (depending on the size of

the specimen for extraction) is created either directly through the middle

of the umbilicus or using a semicircle incision concealed within the

umbilicus. Access to the peritoneum is then obtained, and the wound

retractor is introduced and positioned. At this point, the GelSeal cap is

marked with a pen for ideal trocar positioning. For upper tract procedures,

a 12-mm trocar for the camera is placed in the most medial position. Eight

millimeter robotic trocars are then placed more laterally and near the

edges of the cap (Fig. 1). An assistant 5- or 12-mm port is positioned

between the camera and robotic ports, as needed. The GelSeal cap is then

latched to the wound retractor, and the robot is docked (Figs. 2 and 3). For

upper-tract procedures, a 308 robotic scope is positioned viewing

downward. Great care is used to visualize the initial positioning of robotic

instruments. A helpful maneuver to place the robotic instruments is to

introduce an atraumatic grasper through the robotic port to align the port

under vision, followed by positioning of the robotic instrument.

For all cases, standard 8-mm robotic instruments were used. A

standard three-arm robotic system or a da Vinci S system was used,

depending on availability for the procedure. The da Vinci S is preferred

due to the improved range of motion provided by the newer system.

2.2. Surgical procedure

Standard techniques for renal and ureteral dissection were used,

depending on the specifics of the surgery being performed. Table 1

provides data for each case. Partial nephrectomy was carried out for an

11-cm right renal angiomyolipoma not amenable to angioembolization.

Fig. 3 – Intraoperative image of the da Vinci standard system docked intothe GelPort platform.

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The renal mass was exposed, and the tumor was excised robotically with

a harmonic scalpel (Ethicon, Cincinnati, OH, USA) and Hem-o-lok clips

(Weck, Research Triangle Park, NC, USA), without hilar clamping.

Surgical assistance was possible through a port placed through the

GelPort. Hemostasis was achieved using the argon-beam coagulator and

Floseal (Baxter, Deerfield, IL, USA). The specimen was placed in a large

specimen bag for removal through the 5-cm umbilical skin incision.

Radical nephrectomy was performed for a 5-cm left lower pole renal

mass not amenable to nephron-sparing techniques. After R-LESS

dissection of the lower pole and renal hilum, the renal artery and vein

were controlled and transected separately with an endoscopic stapler.

Monopolar cautery with a robotic hook was used for upper-pole and

lateral dissection, and the kidney was placed in a large specimen bag for

removal through the 4-cm single incision.

Dismembered pyeloplasty was performed for ureteropelvic junction

(UPJ) obstruction in two patients. Neither patient had a lower-pole

crossing vessel. Ureteral spatulation and the running UPJ anastomoses

using 4-O Vicryl sutures were aided by robotic articulation.

3. Results

All data were retrospectively collected and entered into our

institutional review board–approved database. All four

R-LESS procedures attempted with the GelPort were

completed successfully without need for placement of

additional ports. Median operative time was 200 min, and

Table 1 – Perioperative data following robotic single-site surgery thro

Patient No. Age, yr Gender BMI (kg/m2) Procedure Side

1 55 M 31 Pyeloplastya Left

2 88 F 35 Partial nephrectomyb Righ

3 42 M 25 Radical nephrectomyc Left

4 24 F 25 Pyeloplastyd Righ

BMI = body mass index; F = female; M = male; NA = not available; OR = operativea Postoperative symptomatic and radiographic improvement.b Final pathology: angiomyolipoma.c Final pathology: Fuhrman grade III clear cell renal cell carcinoma, margin negad Awaiting follow-up imaging.

hospital stay was 1–2 days in all cases. The patient

undergoing partial nephrectomy had 600 cm3 of estimated

blood loss, as the lesion was excised using a harmonic

scalpel without hilar clamping, and was transfused 1 U of

packed red blood cells. Pathology revealed angiomyolipoma

with negative margins. Differential right renal function as

determined by radionuclide renal scanning remained stable

at 41% postoperatively compared with 41.2% preoperatively

Pathology after radical nephrectomy revealed a 4.9-cm

Fuhrman grade III clear cell renal cell cancer with negative

margins. The initial patient who underwent pyeloplasty had

resolution of flank pain postoperatively. Differential renal

function was maintained at 33%, and drainage as deter-

mined by diuretic radionuclide scanning was improved. The

final patient who also underwent pyeloplasty has not had

postoperative imaging, given the brevity of follow-up from

surgery. There were no operative or wound complications in

any case.

4. Discussion

The evolution of urologic surgery involves an increasingly

brisk progression toward scar-less technique. Natural

orifice translumenal endoscopic surgery (NOTES), in its

purest form, involves only visceral incisions to perform

surgical procedures. Severe challenges for NOTES currently

include deficient instrumentation and platforms, issues of

securely closing hollow viscera, and societal taboos

regarding access points. To date, largely hybrid techniques

involving visceral as well as transcutaneous access have

been used, especially for major procedures [2].

With the ability to perform laparoscopic surgery through

single-incision access, along with the ability to conceal such

an incision within the umbilicus, LESS has garnered

increasing interest in multiple specialties [3–5]. In urology,

LESS has been used to carry out several procedures that can

be performed laparoscopically, including nephrectomy,

partial nephrectomy, donor nephrectomy, adrenalectomy,

renal cryoablation, pyeloplasty, ileal interposition, ureter-

oneocystostomy, varicocelectomy, radical prostatectomy,

simple prostatectomy, and radical cystoprostatectomy [4–

13]. Early data from our donor nephrectomy and pyelo-

plasty experience suggest a modest advantage for LESS

when compared with standard laparoscopy in terms of

convalescence and postoperative pain (unpublished data).

ugh a GelPort

Tumor size, cm OR time, min EBL, cm3 LOS, d Transfusion, RBC

NA 270 50 2 0

t 11 180 600 2 1 U

5.1 200 250 2 0

t NA 200 25 1 0

; EBL = estimated blood loss; LOS = length of stay; RBC = red blood cells.

tive.

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The major challenges of LESS, including clashing of

instruments and lack of triangulation, can be addressed in

part by the use of articulating instruments. Nevertheless, at

present, laparoscopic articulating instruments can be

difficult to use, bulky, and generally nonergonomic. A

logical consideration is the use of the da Vinci Surgical

System to provide intuitive articulation with EndoWrist

technology and greater surgeon comfort. The authors’ initial

report using this approach used the R-port with one robotic

port in tandem through the single incision. R-LESS was

possible using this approach but was challenging at times,

with careful port placement being of the utmost impor-

tance. It must be mentioned that, thus far, the nomenclature

for these procedures has not been standardized; we have

used the term R-LESS as a close modification of the now

accepted term of LESS for single-incision surgeries.

For radical nephrectomy, we previously used several

robotic ports through a single incision without a specific

platform but found that assistant access is severely limited.

Ponsky and colleagues have described using the GelPort as a

platform for LESS radical nephrectomy [14]. Benefits of the

GelPort include a larger extracorporeal profile for greater

spacing of ports, flexibility of port placement anywhere on

the GelCap, easy replacement of ports if another config-

uration is desired, durability of the gel platform, and easy

specimen extraction without the need for removal of the

entire port. Disadvantages include the need to create a

slightly larger incision for positioning of the inner ring (at

least 2–2.5 cm) and bulging of the GelCap with insufflation.

Furthermore, a built-in central defect in the gel of the

GelCap should be sutured closed at the beginning of the

procedure, as this can lead to loss of pneumoperitoneum

during the surgery.

It is noted that the larger incision required to place the

GelPort can be efficiently used to extract specimens for

extirpative procedures; however, for purely reconstructive

procedures, the extended incision may provide the benefit

of improved range of motion for instruments for suturing

and tissue handling. Moreover, the extended incision can be

partially concealed within the umbilicus. The smaller

external profile of the da Vinci S system is preferred, as it

provides the greatest range of movement through the

smallest incision. Additionally, the da Vinci S system allows

the surgeon to use digital zoom and to maintain distance

from the operative area. Operative times in the present

series are longer than those usually required for corre-

sponding cases using conventional laparoscopic technique.

This is probably due to a requisite learning curve for

understanding robot and port positioning, which is likely to

improve with experience.

A comparison of R-LESS techniques to LESS and

conventional laparoscopic procedures is needed. As yet,

experience is still limited for R-LESS and consists of several

different procedures. With more experience, a comparison

of several of these minimally invasive techniques will be

more meaningful [15,16]. It is our purpose in this report to

convey a modification in technique that may facilitate the

early experience with R-LESS for other surgeons.

One patient in our series did require a transfusion of 1 U

of packed red blood cells. The patient was elderly and

underwent unclamped resection of a large angiomyoli-

poma. Use of an R-LESS technique for such a procedure

should be considered carefully and probably should be

performed by only a very experienced laparoscopic/robotic

surgeon.

Thus far, the GelPort has facilitated our R-LESS

procedures, largely due to greater spacing and flexibility

of port placement and easier access to the surgical field for

the assistant. Since using the GelPort for all R-LESS

procedures, we have not had to convert to a standard

robotic or laparoscopic approach or place any additional

ports. Use of the robot for LESS procedures has dramatically

improved surgeon ergonomics and made delicate recon-

structive suturing possible without additional port place-

ment.

Nevertheless, R-LESS still can be challenging, and the

surgeon must become accustomed to a variable amount of

restricted movement as well as clashing of robotic

instruments and the scope. In the future, robotic technology

with even less extracorporeal profile and greater flexibility

may simplify the R-LESS approach and make it a more

universal option for urologic procedures.

5. Conclusions

Use of the GelPort as a platform for single-site access has

provided advantages for performing R-LESS urologic

surgery, largely by allowing greater spacing of robotic

ports and easier assistant access. The GelPort requires a

slightly larger skin incision compared with available

multichannel single ports and may be especially attractive

for surgeries that involve eventual specimen extraction.

Currently, the existing robotic system and available ports

are not specifically designed for R-LESS procedures. Further

developments in robotic and access platform designs are

needed.

Author contributions: Jihad H. Kaouk had full access to all the data in the

study and takes responsibility for the integrity of the data and the accuracy

of the data analysis.

Study concept and design: Stein, Kaouk.

Acquisition of data: White, Goel, Irwin, Haber.

Analysis and interpretation of data: Stein, White, Kaouk.

Drafting of the manuscript: Stein, Kaouk.

Critical revision of the manuscript for important intellectual content: Kaouk,

Stein, Goel.

Statistical analysis: White.

Obtaining funding: None.

Administrative, technical, or material support: Kaouk, Haber, White.

Supervision: Kaouk.

Other (specify): None.

Financial disclosures: I certify that all conflicts of interest, including specific

financial interests and relationships and affiliations relevant to the subject

matter or materials discussed in the manuscript (eg, employment/affilia-

tion, grants or funding, consultancies, honoraria, stock ownership or

E U R O P E A N U R O L O G Y 5 7 ( 2 0 1 0 ) 1 3 2 – 1 3 7136

options, expert testimony, royalties, or patents filed, received, or pending),

are the following: Jihad Kaouk is affiliated with Intuitive Surgical.

Funding/Support and role of the sponsor: None.

References

[1] Kaouk JH, Goel RK, Haber GP, Crouzet S, Stein RJ. Robotic single-port

transumbilical surgery in humans: initial report. BJU Int

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[2] Branco AW, Branco Filho AJ, Kondo W, et al. Hybrid transvaginal

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[4] Raman JD, Bensalah K, Bagrodia A, Stern JM, Cadeddu JA. Laboratory

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[5] Kaouk JH, Haber GP, Goel RK, et al. Single-port laparoscopic surgery

in urology: initial experience. Urology 2008;71:3–6.

[6] Desai MM, Rao PP, Aron M, et al. Scarless single port transumbilical

nephrectomy and pyeloplasty: first clinical report. BJU Int

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Editorial Comment on: Robotic Laparoendoscopic

Single-Site Surgery Using GelPort as the Access Platform

Alexander Bachmann, Stephen Wyler

Department of Urology, University Hospital Basel,

Spitalstr. 21, 4031 Basel, Switzerland

bachmanna@uhbs.ch

More than 15 yr ago, duplicating standard open surgical

procedures with minimally invasive laparoscopic techni-

ques was considered to be very sophisticated, technically

demanding, or even sensational [1]. Over time, many

experienced centers have successfully established laparo-

scopy in their standard repertoires [2].

Focusing on radical prostatectomy, numerous papers

are being published in 2009 that deal with the comparison

of standard open retropubic radical prostatectomy

(RRP), conventional laparoscopic radical prostatectomy

(LRP), extraperitoneal endoscopic radical prostatectomy

(EERP), and robotic-assisted laparoscopic radical prosta-

tectomy (RALP) [3,4]. LRP has never shown an overall

advantage over RRP, except for less blood loss and

sometimes lower overall complication rates. Although

the surgical steps are comparable with LRP, RALP surges

ahead as the standard prostatectomy procedure in the

United States and in Europe. As medical equipment is

constantly being improved, the standard of care in

robotics in 2009 seems to be a four-arm HDTV system,

and older systems are replaced or are not recommended

any more.

The question arises of whether we can generally expect

better results with newer techniques. It seems that not

only clinical results can influence trends in minimally

[8] Goel RK, Kaouk JH. Single port access renal cryoablation (SPARC):

a new approach. Eur Urol 2008;53:1204–9.

[9] Rane A, Rao P, Rao P. Single-port-access nephrectomy and other

laparoscopic urologic procedures using a novel laparoscopic port

(R-port). Urology 2008;72:260–3, discussion 263–4.

[10] Gill IS, Canes D, Aron M, et al. Single port transumbilical (E-NOTES)

donor nephrectomy. J Urol 2008;180:637–41, discussion 641.

[11] Castellucci SA, Curcillo PG, Ginsberg PC, Saba SC, Jaffe JS,

Harmon JD. Single port access adrenalectomy. J Endourol 2008;

22:1573–6.

[12] Raman JD, Bagrodia A, Cadeddu JA. Single-incision, umbilical

laparoscopic versus conventional laparoscopic nephrectomy: a

comparison of perioperative outcomes and short-term measures

of convalescence. Eur Urol 2009;55:1198–206.

[13] Aron M, Canes D, Desai MM, Haber GP, Kaouk JH, Gill IS. Trans-

umbilical single-port laparoscopic partial nephrectomy. BJU Int

2009;103:516–21.

[14] Ponsky LE, Cherullo EE, Sawyer M, Hartke D. Single access site

laparoscopic radical nephrectomy: initial clinical experience.

J Endourol 2008;22:663–6.

[15] Rassweiler J. Editorial comment on: transumbilical single-port

surgery: evolution and current status. Eur Urol 2008;54:1030.

[16] Zigeuner R. Editorial comment on: transumbilical single-port sur-

gery: evolution and current status. Eur Urol 2008;54:1029.

invasive surgery: The financial interests of the industry

supporting novel techniques must be considered.

The paper published by Stein et al [5] demonstrates

that radical prostatectomy can be performed through one

single access. But the most important question is whether

patients are concerned about scars when having an

oncologic procedure performed. This advantage could

not be demonstrated for LRP in comparison with RRP

during the last 10 yr.

For cT1 renal tumors, the laparoscopic approach is

increasingly considered to be the standard technique [6].

The clinical rationale for laparoscopic renal surgery is the

smaller scar, minimally invasive access, less pain during

early and longer follow-up, and comparable oncologic

results to the open procedure. Therefore, further devel-

opments of minimal access techniques are obvious. The

manuscript of Stein et al [5] has to be seen in this context.

The next era of minimally invasive and virtually

invisible surgical procedures has already started with

natural orifice transluminal endoscopic surgery (NOTES)

and laparoendoscopic single-site surgery (LESS). Stein et al

[5] demonstrate the feasibility of robotic-assisted LESS

(R-LESS) procedures only, but the final importance and

benefit for the patient of LESS procedures has to be

clarified with consecutive comparative studies.

The undisputable advantage of LESS and NOTES is

surely the smaller or invisible scar and possibly less pain

compared with standard laparoscopy. As shown by

Stein et al [5], it will take many years to demonstrate

an advantage to performing radical prostatectomy, donor

nephrectomy, or tumor nephrectomy in large renal tumors

using LESS or NOTES. LESS, however, could become a

Editorial Comment on: Robotic Laparoendoscopic

Single-Site Surgery Using GelPort as the Access Platform

Andrea Cestari, Giorgio Guazzoni

Department of Urology, Vita-Salute University,

San Raffaele Turro Hospital, Milan, Italy

a_cestari@yahoo.it

Single-port surgery is still in its infancy, although

interest in this evolution of minimally invasive surgery is

progressively growing in the urological community.

Embryonic natural orifice transluminal endoscopic sur-

gery (E-NOTES) and single-port access could represent the

evolution of laparoscopy toward a new form of minimally

invasive surgery if proper indications were defined.

We are feeling the same enthusiasm that we experi-

enced in the early 1990s after the pioneering experiences

in laparoscopic nephrectomy [1], when laparoscopy

seemed likely to replace conventional open surgery.

Laparoscopy evolved over the years, thanks to the

experience of the leading groups and the technological

innovations that offered high-definition vision and opti-

mal instrumentation and tools for hemostatic control.

Similarly, a wide range of surgical procedures have used

single-port surgery, including complex and challenging

procedures such as radical nephrectomy, pyeloplasty, and

even living donor nephrectomy [2].

Nevertheless, actual instrumentation for single-port

surgery, although directly derived from laparoscopic

instrumentation, is still not adequate to allow proper

diffusion of this technique. The major problems concern-

ing the closeness of the optics and the working instru-

ments must be solved. Industry is directly involved in the

evolution and diffusion of this technique, with the creation

of a proper optical system, possibly with a steerable tip,

and instruments with moveable tips and moldable shafts

inside the body. Finally, even being able to slightly modify

the trocars could have pivotal importance. The authors

should be congratulated for the idea of using a GelPort for

the site of entry for the optical and surgical instruments in

single-port surgery [3]. GelPort is a valid device for the

entry site in the abdomen and offers the possibility of

modifying the relationship between the ports during the

procedure as well as a nice degree of angulation between

the instruments compared with the commercially avail-

able device.

References

[1] Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopic nephrec-

tomy: initial case report. J Urol 1991;146:278–82.

[2] Canes D, Desai MM, Aron M, et al. Transumbilical single-port

surgery: evolution and current status. Eur Urol 2008;54:1020–30.

[3] Stein RJ, White WM, Goel RK, Irwin BH, Haber PG, Kaouk JH.

Robotic laparoendoscopic single-site surgery using GelPort as the

access platform. Eur Urol 2010;57:132–7.

DOI: 10.1016/j.eururo.2009.03.056

DOI of original article: 10.1016/j.eururo.2009.03.054

standard procedure in reconstructive urologic surgery

(eg, pyeloplasty, ureterocystoneostomy) within the next

few years.

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[3] Berryhill Jr R, Jhaveri J, Yadav R, et al. Robotic prostatectomy:

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[4] Ficarra V, Novara G, Artibani W, et al. Retropubic, laparoscopic, and

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[5] Stein RJ, White WM, Goel RK, Irwin BH, Haber GP, Kaouk JH.

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access platform. Eur Urol 2010;57:132–7.

[6] Ljungberg B, Hanbury DC, Kuczyk MA, et al. Renal cell carcinoma

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