single port radical prostatectomy: current...
TRANSCRIPT
REVIEW ARTICLE
Single port radical prostatectomy: current status
Oscar Darıo Martın1,4 • Raed A. Azhar2,3 • Rafael Clavijo1 • Camilo Gidelman1 •
Luis Medina4 • Nelson Ramirez Troche4 • Leonardo Brunacci4 • Rene Sotelo3,4
Received: 3 September 2015 / Accepted: 28 March 2016
� Springer-Verlag London 2016
Abstract The aim of this study is to analyze the current
literature on single port radical prostatectomy (LESS-RP).
Single port radical prostatectomy laparoendoscopic (LESS-
RP) has established itself as a challenge for urological
community, starting with the proposal of different
approaches: extraperitoneal, transperitoneal and transvesi-
cal, initially described for laparoscopy and then laparo-
scopy robot-assisted. In order to improve the LESS-RP,
new instruments, optical devices, trocars and retraction
mechanisms have been developed. Advantages and disad-
vantages of LESS-RP are controversial, while some claim
that it is a non-trustable approach, regarding the low cases
number and technical difficulties, others acclaim that
despite this facts some advantages have been shown and
that previous described difficulties are being overcome,
proving this is novel proposal of robotics platform, the Da
Vinci SP, integrating the system into ‘‘Y’’. The LESS-RP
approach gives us a new horizon and opens the door for
rapid standardization of this technique. The few studies and
short series available can be result of a low interest in the
application of LESS-RP in prostate, probably because of
the technical complexity that it requires. The new robotic
platform, the da Vinci SP, shows that it is clear that the
long awaited evolution of robotic technologies for laparo-
scopy has begun, and we must not lose this momentum.
Keywords Single port radical prostatectomy � Single-sitesurgery � Robotic prostatectomy � Laparoscopicprostatectomy
Introduction
Radical prostatectomy (RP) is the most important standard
for the treatment of organ-confined disease in patients with
prostate cancer and it has useful life of 10 years more than
higher. This therapy has changed exponentially with
opening of minimally invasive techniques, is a milestone in
the surgical treatment of prostate disease [1].
Techniques minimally invasive have experienced pro-
gress constant in time, beginning with standard, evolution
mini-laparoscopic trocars and later development of la-
paroendoscopic single—site surgery (less). The aim was
not only to improve the aesthetic result, but also to
decrease the morbidity of the procedures, reducing the
number and size of trocars [2].
Here, we present a comprehensive overview about
development from this technique, which has been facing
major challenges not only in the removal of the prostate
gland but also in the reconstruction of the posterior urinary
tract. A specific emphasis is urethrovesical anastomosis,
that is one of the most difficult challenges to overcome due
to the proximity of the laparoscopic instruments, which
eliminates the principle of triangulation, increasing internal
and external collision of instruments, restriction of move-
ment (especially in intracorporeal suture) and hindering
access to the structures, so it requires more surgical skills.
& Oscar Darıo Martın
1 Fundacion de Ciencias de la Salud Hospital de San Jose,
Bogota, Colombia
2 Urology Department, King Abdulaziz University, Jeddah,
Saudi Arabia
3 Keck School of Medicine, Center for Advanced Robotic
Surgery, USC Institute of Urology, University of Southern
California, Los Angeles, CA, USA
4 Instituto Medico La Floresta, Centro de Cirugıa Robotica y
de Invasion Mınima-CIMI, Caracas, Venezuela
123
J Robotic Surg
DOI 10.1007/s11701-016-0589-5
In addition, this report describes the current state of
LESS-RP around the world, including existing techniques,
constraints and proposals to overcome these limitations. We
report the evolution of standard platforms through the arrival
of new proposals for the robotic single-port procedures. Also
we discuss the results in the literature, with a comparison of
conventional and LESS-RP surgery techniques.
Techniques, access, instruments and visualization
Working time through a single port, the reduction of the
workspace is immediately evident, as well the collision of
instruments, limited freedom of movement and display of
difficulties that inevitably lead to highly complex proce-
dures and requirements higher surgical skills. Bearing these
limitations in mind, the evolution of the strategy of a sin-
gle-port should be considered in terms of four main
aspects: trocars, instruments, mechanisms of contraction
and display as strategies to overcome technical problems
and improve the performance of the technique of.
The first single-port used in radical prostatectomy was
created with a rustic trocar, a single incision is made in the
skin and fascia, which is defined as a ‘site’ surgery (inci-
sion in the skin only with a multi-port) [3].
Other devices of a single-port access developed several
working channels (skin and fascia single-incision using a
multiple port channels). The most commonly used are the
TriPort/four ports (advanced surgical concepts, Bray, Ire-
land) and SILS TM (Covidien, Mansfield, MA, USA). Other
devices offer the option of a single channel in which
multiple trocars can be placed as shown in the GelPOINT
(medical application, Rancho Santa Margarita, CA, USA).
Recently, the Duo Rotate (or Keyport) system was devel-
oped (Richard Wolf GmbH, Knittlingen, Germany), which
offers advantages such as better fixation to the fascia and
the possibility of reusing and Rotary instruments without
the removal of the port. This concept allows optimization
of the tissue of traction, which brings greater accuracy and
freedom of movement, as well as fewer collisions and a
minimum loss of pneumoperitoneum [4]. The major limi-
tations of these devices are cost and availability. There are
devices of art with the previously described features which
allow the adaptation and use of items in the operating
room. The most widely used has been surgical glove, with
adaptation of trocars in each finger [5].
Another important advance in the development of
LESS-RP was the appearance of modified curved instru-
ments, articulated and flexible, allowing the proper trian-
gulation e intracorporeal mobility despite its insertion
through a single port device.
Published studies evaluating the utility of instruments
previously bent have shown a reduction in unnecessary
during the execution of certain tasks movements [6].
However, flexible instruments have not shown the same
advantage [7].
Traditional optics has been modified less surgery
because it occupies its own port and usually clogs and
collides with the other instruments. The field of view in
LESS surgery may be obstructed due to the linear position
of the port of the camera; to resolve this problem, initially
the size of optics was reduced.
Subsequently, optical flexible tip was developed, and
was finally introduced the curved handle of optical, all with
the intention of allowing a wider view of the surgical field
[8]. With the robotic platforms coming on 2012, optics s
was an important improvement the first platform Robotics
site with Scooter, that was designed to improve the inter-
face between the surgeon and the patient and to avoid
difficulty caused by movements of the reverse mirror on
the computer. However, these instruments lacked move-
ments articulated, hindering the complex movements such
as suturing. In addition, external arm collisions were found.
Passes the first third conventional model dimension end
offer a 3-D HD view in ‘‘da Vinci if’’, the second robotic
platform site, was based on a totally different concept
called single port ‘‘And’’ [9], which offers flexible tools
with intracorporeal triangulation, which prevents collisions
between instruments. The design is characterized by a
straight shaft, two side flexible instruments and a laparo-
scope 3D with a relatively small diameter. Optics of the
three instruments are introduced through a sheath provided
straight by the solid base for instruments.
The need for a retraction mechanism that does not
require an additional port led to the development of a
concept known as the maneuver of ¨puppet or internal
retraction. This technique involves the use of percutaneous
suture for selective contraction of the tissue to improve the
exposure of the surgical field [10].
Single-port laparoscopic radical prostatectomy(less-prl)
Four LESS-RP approaches have been described to date:
transumbilical, extraperitoneal, intraperitoneal and
transvesical. Whereas some groups use a single incision
device, others have required the additional use of one or
two 2 or 5 mm accessory ports.
Transumbilical approach (Fig. 1)
Kaouk et al. reported the first RP-LESS in 2008 [3] in a
series of 4 low-risk prostate cancer cases. Used a transab-
dominal approach using the Uni-X (Pnavel systems,
J Robotic Surg
123
Morganville, NJ, USA), that is a single port with three
channels from 5 mm each and one additional channel of
blow. In addition, used new tools such as a 5�, 0� flexible-tip mm endoscope (Olympus surgical, Orangeburg, NY,
USA) and a variety of flexible instruments, curves and
articulated (CambridgeEndo, Framingham, MA, USA;
Pnavel; Surgical systems of Novare, Cupertino, CA, USA).
The most difficult step in his description was anasto-
mosis ureterovesical, which could only be performed with
extracorporeal interrupted suture knots. Only three inter-
rupted suture knots were completed in the first patient,
considering that six knots at the patient end completed,
demonstrating the improvement through the perform. In
one of the four patients, was carried out excision of pelvic
lymph nodes, although he emphasized the extreme tech-
nical difficulty. In any case, the use of an additional port
was necessary. As a unique complication, this series
includes a patient who presented with a fistula urethrorectal
(grade Clavien IIIb) [11], which was resolved by surgical
treatment.
From the point of view of cancer, half of the patients had
positive surgical margins with supervision limited of pros-
tate-specific antigen (PSA) in the postoperative period. In
this series, following the procedure of erectile function was
not reported [3]. In subsequent series, such as Caceres, 2012
(31 cases), preservation of the nerve was reported in 32.3 %
of patients; as a result, 33 % of patients had an erectile
function correct during the postoperative period [Sexual
Health inventory for men (SHIM) score[21 points with or
without medication]. It is noteworthy that an additional
3.5 mm port was used in this series, and preservation of the
nerve was attempted only in patients with tumors of low risk
(T1c–T2a) and shoes preoperative[21.
Most urologists who perform LESS-RP practice a
transabdominal approach. However, Rabenalt et al. [12],
who used extraperitoneal access using the TriPort device
(Advanced Surgical Concepts, Bray, Ireland) and pre-
curved instruments, reported achieving an anterograde
dissection and six separate knots in the anastomosis in each
case. In 2011, Gao Xin describes an extraperitoneal
approach through two systems: the four-port multichannel
(Olympus, Japan) and a device made with a surgical glove
artisan multichannel. He also uses a flexible laparoscope
with pre-curved and flexible instruments [13]. The most
recent series was reported by 2013; Chun Jiang employed
an extraperitoneal approach in 20 patients with a device
made with a surgical glove art multi-channel using
instruments straight and the curved (see Table 1).
Fig. 1 a Lateral view,
b umbilical Quadport,
c prostatic-bladder junction
disection and cut. d Urethal-
bladder anatomosis, reported
with separate and continuos
stitches
J Robotic Surg
123
Transvesical approach (Fig. 2)
Transvesical method has been widely known since 2009,
when it was described by Desai and Sotelo for prostate
adenomectomy [14]. This novel concept led to transvesical
radical prostatectomy, reported in 2013 by Gao Xin. Xin
completed the longest series of patients subjected to this
technique: 20 patients at low risk confined prostate cancer
(PSA = 10 ng/ml, Gleason \7 and clinical stage T1c or
T2a). It was a dissection combined with initial retrograde
dissection into the bladder neck followed by dissection
anterograde of seminal vesicles and prostate. Finally, a
urethrovesical anastomosis was created by inserting a graft
of the foreskin with separate knots. No additional ports
were used, and the neurovascular bundle was preserved in
all patients. Reported results of the erectile function of 21
points or more in the IIEF-5 scale in 60 % of patients;
100 % was continent; and 0 % had positive surgical mar-
gins. The author reported 16 cases in which the anasto-
mosis was launched using an innovative method in addition
to previously described techniques. In this series, the
author made three incisions near the bladder neck, and
suture continuous anastomosis with sutures barbed was
performed on each side [15] (see Table 1).
Robotic-assisted laparoscopic single-port radicalprostatectomy
The wide range of movements that the surgical system da
Vinci � offers (surgical intuitive, Sunnydale, CA, USA) is
widely known as one of its advantages, which in theory
reduces internal and external instruments collision. How-
ever, this reputation is not entirely justified; the surgical
system da Vinci � is characterized by considerable size and
volume, and initial platforms were not clearly developed for
fewer procedures. Despite these factors, urologists have
performed LESS-RP with the da Vinci� System and have
demonstrated in the medical literature that it is feasible and
safe despite the absence of standardization of the technique.
Transumbilical technique (Fig. 3)
The first two cases of LESS-RP were recorded by the
Group of Montsouris in 2009. After performing the LESS-
RP without robotic assistance in a cadaveric model, this
group carries out robotic MOP-less in two patients and
reported their findings in two separate publications [16,
17].
Single-port devices were not used in each study. A
single umbilical incision was made with the subsequent
independent trocar insertion. There was a 12 mm port to
the camera and two robotic ports of 8 mm for instruments
of work, with a separation of approximately 3.5 cm port. In
the first case, an additional 5 mm trocar was placed in the
right quadrant lower to allow suction and retraction in the
header [16].
In the second case, the ports had a configuration of
diamond that allows the auxiliary port to be placed behind
the camera port, avoiding an additional incision [17].
Surgical time was 150 min, the dorsal venous complex was
linked with a knot, and settled with six separate knots
urethrovesical anastomosis. The main difficulty, according
to surgeons was external collision of robotic arms, that
subsequently limited movement and to interfere with the
proper progression of the procedure of the robotic arms.
This French technique and rhomboid configuration of the
port have been replicated by other groups, who have
demonstrated that it is feasible and successful.
To date, the largest series of LESS-RP using the tran-
sumbilical technique was reported by White et al. [18], that
describes the results of 20 patients who underwent LESS-
RP between 2008 and 2010.
Their approach used two robotic 8-mm ports, one placed
caudal and the other cephalad to a 2-cm umbilical incision.
Puerto SILS � was placed in the center of the incision
between the two ports of 8 mm thickness. The robotic
laparoscope was settled through a 12 mm working channel.
The surgical technique included an anterograde approach and
had followed the conventional robot-assisted radical prosta-
tectomy technique. The maneuver¨puppet was used to open
the field of work and pull the neck of the bladder or urethral
catheter forward during dissection of the neck of the bladder.
With continuous sutures urethrovesical anastomosis was
performed, and conventionally pelvic lymphadenectomy.
The authors reported satisfactory results: average oper-
ating time was less than 200 min. Only 4 of the 20 patients
experienced complications, including urosepsis with a
fatality. Intraoperative complications were not disclosed.
Oncological results revealed positive surgical margins in
24 % of evaluable patients (4/17). Dissection nodal in
60 % of patients, but with a low average of four nodes was
carried out per box. All patients had undetectable PSA
levels after surgery; However, there has been follow-up
reports.
Recently, results by 11 patients it shows that included
the use of a new port robotic platform, da Vinci SP, which
introduces the camera and instruments through a single
port (Fig. 5). In general, patients were young and not
obese, with medium sized prostates and low risk of prostate
cancer. The authors reported a conversion rate of 0 % and
complications that were mostly minor. The average surgi-
cal time was 239 min; 18.2 % of patients had positive
margins; and continence rates and the recovery of erectile
function at 30 days were 55 and 63.3 %, respectively [9].
J Robotic Surg
123
Transvesical technique (Fig. 4)
The first robotic LESS-RP was developed in 2008 by Desai
and Sotelo, using two cadaveric models [19]. In the first
model, the approach was developed through a horizontal
suprapubic incision (mini-Pfannestiel) and meant the
inclusion of multiple trocars in the fascia through the
bladder. For the second corpse, four ports � system was
used, which had an advantage over conventional trocars
due to the use of a single incision when four-port system
was later used in humans, surgeons reported great difficulty
to perform by Pneumovesicum urethrovesical anastomosis,
Table 1 Radical prostatectomy single-site surgery procedures: clinical series
N8 patients/approach
Additional
ports
Type port Conversion
1 (%)
Function
erectilbContinencea Positivity
Margin
Complicationsc
(%)
Kaouk et al. [3] n = 4
Laparoscopic
Transumbilical
No Uni-X� 0 N/R 100 % 50 % 25
Bachiller et al.
[22]
n = 4
Laparoscopic
Transumbilical
Yes
2 9 5 mm
SILS� 25 N/R N/R N/R 25
Ferrara et al. [23] n = 10
Laparoscopic
Transumbilical
Yes
1 9 5 mm
Tridport� 0 N/R N/R 20 % 0
White [18] n = 20
Robotic
Transumbilical
Yes
1 9 8 mm
SILS�
daVinci S da
Vinci Si
5 100 % 25 % 20 % 20
Wen et al. [13] n = 6
Laparoscopic
Transumbilical
No Quadport�
Homemade
0 50 % 100 % 0 % 0
Gaboardi et al.
[24]
n = 5
Laparoscopic
Transumbilical
No Tridport� 0 20 % 60 % 0 % 0
Gao et al. [25] n = 8
Laparoscopic
Transumbilical
Yes
1 9 5 mm
Normal
trocars
(single site)
0 N/R 75 % 12.5 % 0
Caceres et al. [4] n = 31
Laparoscopic
Transumbilical
Yes
1 9 3.5 mm
KeyPort� 0 33,3 % 33.3 %
(20 months)
16.1 % 19.4
Zhu et al. [26] n = 6
Laparoscopic
Transumbilical
No Quadport� 0 N/R 100 %
(12 months)
0 % 33.3
Gao et al. [15] n = 16
Laparoscopic
Transvesical
No Quadport� 0 75 % 100 % (3 months) 0 % 31.2
Jiang et al. [5] n = 6
Laparoscopic
Transumbilical
Yes (1 pt)
1 9 5 mm
Homemade 0 60 % 100 % (3 years) 5 % 20
Kaouk et al. [9] n = 11
Robotic
Transumbilical
Yes
1 9 5 mm
daVinci SP 0 0 % 100 % (3 years) 18.2 % 45.5
N/R not realizeda Use 0–1 security PADS ? conversion open or more 2 portsb SHIM[ 21c Intra and extra operative
J Robotic Surg
123
Fig. 2 a Lateral view, b umbilical Quadport, c mucosa-muscle incisions between 2 and 4 o0clock, 5 and 7 o0clock, and 8 and 10 o0clock, marked
as ‘‘X’’, ease uretro-bladder anastomosis (U-B), d continuos closure U-B anastomosis and enlargement of the mucosa-muscle incisions
Fig. 3 a Lateral view,
b DaVinci SP docking,
c systems elements entry,
d system components
deployment, ‘‘Y’’ principle is
observed
J Robotic Surg
123
Fig. 4 a Lateral view,
b DaVinci-Si docking,
c intravesical disection of de
prostate and seminal vesicles,
d urethral-bladder anastomosis
with anterior plication
Fig. 5 2009 First radical
prostatectomy—LESS,
romboidal configuration, 2012
first platform LESS-VesPa (not
used for prostate), 2014 second
platform LESS, DaVinci SP
uses ‘‘Y’’ principle
J Robotic Surg
123
which pulled the bladder cephalad and limited his approach
to the urethra.
Future directions
The challenges of the LESS platform in the surgical
management of urological diseases are clear. It is also very
important to provide minimally invasive surgery that
achieves the best aesthetic results without compromising
security or the expectations of the patient. Therefore, the
development of tools and techniques is necessary to
achieve these objectives.
Based on this ‘‘Y’’ platform concept of the second
robotic single-site platform, a new robotic single-port
prototype called a ‘‘plate spring mechanism’’ has been
developed. This system consists of a plate spring unit that
allows power transmission and improves workspace vol-
ume (Fig. 5).
A very interesting option developed for a minimally
invasive approach is the use of natural orifice transluminal
endoscopic surgery (NOTES). This surgical approach uses
an existing natural orifice (typically transoral or
transvaginal). This technique does not require the use of
ports through the skin and subcutaneous tissues to enter a
body cavity and approach the organ of interest.
In 2012, Nagele reported the first case of NOTES in a
77-year-old man; a 26 Fr resectoscope (Karl Storz GmbH,
Tuttlingen, Germany) and a 550-m WBER laser fiber with
a thulium: YAG laser fiber (RevolixTM 120 W laser sur-
gical, LISA laser products, Katlenburg, Germany) were
used to perform a complete intrafascial prostate dissec-
tion. The urethrovesical anastomosis was performed with
urethrovesical probe approximation, and organ extraction
was performed through a pfannenstiel incision [20].
An innovative for radical prostatectomy approach is to
be newly developed robotic approach to perenial with a
single site system GelPort demonstrates the feasibility and
possibility of other insurance and cash less focus to radical
prostatectomy [21].
These events clearly demonstrate the speed in which
surgical approaches are evolving in increasingly less forms
invasive, with the aim of achieving optimal results.
Conclusions
The surgery LESS-RP is a technique that it allows access
by decreasing the number of trocars. This technique has
given rise to a new concept of minimally invasive surgical
approach and the concomitant expansion of new instru-
mentation, technology, ports, optics and mechanisms of
contraction. To date, the RP less benefits have not been
endorsed definitively; only small series have been reported,
and the results have not been fully evaluated.
On the other hand, this technique has not become pop-
ular, we have explored different surgical approaches:
transperitoneal, retroperitoneal, transvesical, laparoscopic
and robotic even with changes to the platform. The current
environment may not be unbeatable for the widespread
acceptance of this technique; however, its popularity could
increase when one achieves the full development of a
robotic platform.
This overview demonstrates the great progress in the
clinical application of prostate surgery less. Continuous
development is expected to lead to wide acceptance of this
technique by the urology’s community next years. It is
clear that the expected evolution of robotic technologies for
laparoscopy has started, and we must not lose this con-
juncture time.
Acknowledgments Nelly Romero and Reinaldo Pacheco
Compliance with ethical standards
Conflict of interest The authors Oscar Darıo Martın, Raed A.
Azhar, Rafael Clavijo, Camilo Gidelman, Luis Medina, Nelson
Ramirez Troche, Leonardo Brunacci, Rene Sotelo declare that they
have no conflict of interest.
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