Update on Minimally Invasive Urologic Surgery: What’s New

Jeffrey A. Cadeddu, M.D.Professor of Urology and RadiologyUT Southwestern Medical Center

Surgical Revolution

• Across all specialties – a minimally invasive revolution

• Laparosopy = significant patient benefits:

Pain

Hospitalization

Recovery

Complications

Scars

COST

Robotic-assisted Laparoscopy

• Robotic technology/techniques

• LESS

• NOTES

Can We Get Even Less Invasive?

courtesy of A. Rane

Surgery without Scars?Yes!

Laparoendoscopic Single Site (LESS) Surgery

Principles:

• Limit trocars to single incision – usually umbilical

• Periumbilical specimen extraction• Improved cosmesis• Less transmural trocars = Less

pain• Faster recovery

Historical Perspective

LESS IS NOT A NOVEL CONCEPT !

The idea of a single access site surgical procedure has been utilized since the early 1970s.

LESS

• Unique requirements

– Access – how to get instruments into “1” hole?

– Instrumentation • loss of

triangulation?• collision

courtesy of J. Kaouk, D. Scott, and A. Rane

Access

• Several custom access ports– Most are “3 trocars in

one” with single 2-3 cm incision

Courtesy of P. Curcillo, MD

Camera Solutions

courtesy of D. Scott

Articulating Instrumentation

• Degrees of motion comparable to robotic system

• Allows for real time adjustments

• Principle of dissection– Instruments cross at

fulcrum to avoid collision

courtesy of D. Scott

LESS in General Surgery

• Cholecystectomy

• Adrenalectomy

• Appendectomy

LESS in Urology:Laparoscopic Nephrectomy

• 3-4 trocars• Kidney extracted

through small incision

August 2007: First report of single incision laparoscopic nephrectomy

Urology 70:1039, 2007

Urology 70:1039, 2007 Urology 70:1039, 2007

LESS Nephrectomy at UTSW(Urology, 2010)

• Clinical experience– 30 cases 8/2007 – 12/2009

• 47% of all lap neph• Indication: 50% benign

dz

LESS Pyeloplasty

• Since 10/07:– 50 LESS Pyeloplasties for

primary UPJOs • 20 robotic LESS

Robotic LESS

• DaVinci Si system adapted to LESS

Principles

• Trocars positioned at umbilical incision crossing similar to conventional LESS

• Multiport access technique limited by gas leak and crowding/collision of trocars/arms– Use commercial port to minimize

Trocars/Instruments

• 8 or 12 mm camera port

• 5 or 8 mm robotic port

• 5 mm robotic port

• 5 mm assistant port

Robotic Solution

• Instruments cross at midline

• Align trocar lines at level of skin to minimize incisional bruising

Instrumentation

• 30 degree UP scope

– Nonconventional image

– Creates space at GelPoint for assistant!

• 8 mm scissor + 5 mm graspers

• 5/8 mm graspers + 5 mm hook cautery

• 5 and/or 8 mm needle drivers

Pearls

• Instruments and camera moved in tandem short distances

• Cross instruments at incision above camera (30 deg up) and reassign instruments to right and left hands.

• At crossing point, top instrument can retract tissue upwards. To retract downwards need to re-cross so that grasper is below scissors/cautery.

R-LESS Pyeloplasty

Experience

• UTSW– 5 R-LESS nephrectomies

• Difficulty with dividing hilum. Assistant challenged to introduce stapler if ~ 3-4 cm incision. Must use clips.

• 1 converted to Lap nephrectomy

– 20 R-LESS pyeloplasties• Ease of anastomosis, no need for additional 3 mm

assistant ports.• Pre-place stent/ureteral access.

Published Literature

2011: Purpose-built Robotic Platform

Courtesy of David Canes

Is LESS Surgery Ready for Prime Time?

• Does single incision laparoscopy decrease convalescence in comparison to traditional laparoscopy while maintaining surgical outcomes?

Case-control comparison of early outcomes in SILS vs. Conventional Lap Nephretomy

(Eur Urol, 2009)

• IRB-approved, retrospective case-match series

– 11 SILN performed from August 2007 to March 2008 (cases)• Extra 3 mm sub-xyphoid trocar for liver

retraction

– 22 CLN performed from September 2004 to February 2007 (controls)

Results: Peri-operative parameters

All patients Laparoscopic approach

SILS Conventional P valueOR time (min) Mean (SD) Median (range)

143 (42)125 (90-240)

138 (35)122 (90-210)

145 (45)125 (90-240)

0.78 †

EBL (mL) Mean (SD) Median (range)

125 (143)100 (10-600)

80 (175)20 (10-600)

147 (123)100 (20-520)

0.001 †

Morphine equivalents (mg) Mean (SD) Median (range)

15 (13)13 (0-54)

15 (16)8 (1-54)

15 (12)15 (0-49)

0.69 †

Change in Hgb (%) Mean (SD) Median (range)

15.3 (6.0)15.5 (0-24)

14.1 (5.8)15.4 (5-23)

15.8 (6.2)16.0 (0-24)

0.52 †

Length of stay (hrs) Mean (SD) Median (range)

51 (18)52 (29-106

46 (14)49 (30-74)

53 (19)53 (29-106)

0.44 †

* Chi-square test† Kruskal-Wallis test

Case-matched LESS Pyeloplasty vs. Lap Pyeloplasty

Urology 2009

• Maybe extraction incision or morcellation for nephrectomy creates additional pain?

• Reconstructive procedures may have more benefit?

 Conventional Lap

(Range) LESS (Range) p-value

Mean LOS (hrs) 74 (36-215) 77 (50-149) 0.69*

Mean Operative time (min) 257 (210-360) 202 (178-240) < 0.001*

Mean EBL (mL) 85 (25-200) 35 (25-50) 0.002*

Mean MSO4 Eq  38 (0-119)  34 (0-117)  0.93*

Grade I/II complications (%) 4 (14.3%) 2 (14.3%) 1**

Grade IIIa/IIIb complications (%) 2 (10%) 3 (21.4%) 0.31**

LESS vs Standard Lap Donor Nephrectomy: Case-Match

Canes, Desai, Gill et al.Eur Urol 57:95, 2010

• No differences in LOS, OR time, EBL, analgesia equivalents or visual analog pain scores, but…

• Too good to be true? Confirmation Bias?

 Conventional Lap

(N = 17)LESS

(N = 18) p-valueMean Days on Oral Pain Meds 20 6 0.01

Mean Days Off Work 46 18 <0.01

Days to 100% recovery 83 29 0.03

LESS vs. Standard Lap Donor Neph: Randomized Prospective Trial

• Mahesh Desai et al.– Nadiad, India– AAGUS 2010

– 25 left DN in each group

Group A (Standard)

Group B (LESS) p Value

Operating time (minutes)

175.83±47.57 172.20±38.33 0.38

Conversion to Open surgery

0 0

Conversion to multiple ports LDN (%)

- 2 (8%)

Estimated blood loss (milliliters)

92.40±28.33 84.00±29.15 0.16

Graft artery length (millimeters)

24.36±2.43 25.25±6.23 0.26

Graft vein length (millimeters)

28.68±3.42 28.80±7.15 0.47

Graft ureter length (millimeters)

113.96±24.79 123.00±18.44 0.08

Length of incised wounds

(millimeters)133.60±16.99 51.47±14.37 <0.0001

Blood transfusion 0 0Hemoglobin drop

(gm/dL)0.87±0.77 0.68±0.87 0.21

Intra-operative complications (%)

2 (8%) 4 (16%) 0.20

LESS vs. Standard Lap Donor Neph: Randomized Prospective Trial

courtesy M. Desai

• 27 pts randomized

• Case matched• 2:1 Lap to LESS

– 38 and 19 pts

Importance of Cosmesis(BJUI 2011)

• UTSW Survey – all kidney and prostate patients (80 Lap, 17 LESS, 15 Open)

– PRE-OP: Ranked importance of various surgical outcomes

• Most important factor: Surgeon reputation

• Least important factor: Scar size & #

– Unless: Age < 50 or Benign Indication

• Bucher et al. Surg Endosc 2010; Jul 3.

– 75% would choose LESS over Lap if complication rate similar

Importance of Cosmesis(Eur Urol 2011)

• UTSW Survey – kidney surgery only– LESS vs. Lap vs Open

• Overall scar satisfaction by surgery type: – 67% - 43% - 40%

• Entire cohort cosmetic appeal of photographs of scars:– 69% very pleased with LESS vs. 46% and 23%

• Satisfaction with their scar after viewing other scars:– 80% vs. 57% vs. 50%

Observations

• Feasible surgical technique – the next revolution in MIS• Triangulation made possible by articulating

instrumentation or robotics• Learning curve due to close proximity of instruments

• Limitations:1. Instrument collision due to umbilical crowding2. Triangulation still a problem…working envelope

restrictions3. Limited to 3 working trocars – 4 possible if bigger

incision?

Natural Orifice Translumenal Endoscopic

Surgery (NOTES)

• “Incisionless Surgery”

– Transgastric (mouth)

– Transcolonic (anus)

– Transvaginal

– Transvesical (urethra)

– Advantages?: less pain, less scarring, faster recovery

• Proof of concept

– UTSW: Gettman, Cadeddu et al.: U.S., 2001, Porcine Model

– Reddy & Rao: India, 2004, Human Appendectomy

NOTES: Transgastric Appendectomy

Reddy & Rao: India, 2004

NOTES Human Cases

USA

• Bessler/Fowler, Columbia – 8 TV Chole

• Horgan/Talamini, UCSD – > 45 TV Chole (+ TG chole, TG Appy, TV

Appy)

• Swanstrom/Soper/Hungness, Legacy (Portland) + Northwestern – > 8

TG Chole

Abroad

• Brazil, > 200 cases, mostly TV

• France, ~ 20 cases, mostly TV

• Germany, > 200 cases, TV, rigid scope

• Italy, ~ 20 cases, TV

Urology NOTES

• NOTES nephrectomy

– 2002 Gettman et al.

– 2008 Clayman et al.

– 2009 human case reports

Equipment Limitations

• Lack of stability and torque

• Lack of maneuverability and

reach

• Inability to triangulate

• Lack of “surgical” instruments

• Inability to use multiple

instruments simultaneously

• Visual disorientation

Laparoscopy Endoscopy

LESS vs. NOTES

Both LESS and NOTES are contemporary minimally invasive techniques with obvious cosmetic and morbidity benefits.

LESS is here and now.

NOTES is still largely preclinical or investigational.