update on minimally invasive urologic surgery: what’s new jeffrey a. cadeddu, m.d. professor of...
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Update on Minimally Invasive Urologic Surgery: What’s New
Jeffrey A. Cadeddu, M.D.Professor of Urology and RadiologyUT Southwestern Medical Center
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Surgical Revolution
• Across all specialties – a minimally invasive revolution
• Laparosopy = significant patient benefits:
Pain
Hospitalization
Recovery
Complications
Scars
COST
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Robotic-assisted Laparoscopy
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• Robotic technology/techniques
• LESS
• NOTES
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Can We Get Even Less Invasive?
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courtesy of A. Rane
Surgery without Scars?Yes!
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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
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Historical Perspective
LESS IS NOT A NOVEL CONCEPT !
The idea of a single access site surgical procedure has been utilized since the early 1970s.
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LESS
• Unique requirements
– Access – how to get instruments into “1” hole?
– Instrumentation • loss of
triangulation?• collision
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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
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Courtesy of P. Curcillo, MD
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Camera Solutions
courtesy of D. Scott
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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
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LESS in General Surgery
• Cholecystectomy
• Adrenalectomy
• Appendectomy
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LESS in Urology:Laparoscopic Nephrectomy
• 3-4 trocars• Kidney extracted
through small incision
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August 2007: First report of single incision laparoscopic nephrectomy
Urology 70:1039, 2007
Urology 70:1039, 2007 Urology 70:1039, 2007
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LESS Nephrectomy at UTSW(Urology, 2010)
• Clinical experience– 30 cases 8/2007 – 12/2009
• 47% of all lap neph• Indication: 50% benign
dz
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LESS Pyeloplasty
• Since 10/07:– 50 LESS Pyeloplasties for
primary UPJOs • 20 robotic LESS
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Robotic LESS
• DaVinci Si system adapted to LESS
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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
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Trocars/Instruments
• 8 or 12 mm camera port
• 5 or 8 mm robotic port
• 5 mm robotic port
• 5 mm assistant port
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Robotic Solution
• Instruments cross at midline
• Align trocar lines at level of skin to minimize incisional bruising
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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
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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.
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R-LESS Pyeloplasty
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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.
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Published Literature
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2011: Purpose-built Robotic Platform
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Courtesy of David Canes
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Is LESS Surgery Ready for Prime Time?
• Does single incision laparoscopy decrease convalescence in comparison to traditional laparoscopy while maintaining surgical outcomes?
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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)
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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
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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**
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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
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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
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LESS vs. Standard Lap Donor Neph: Randomized Prospective Trial
courtesy M. Desai
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• 27 pts randomized
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• Case matched• 2:1 Lap to LESS
– 38 and 19 pts
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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
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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%
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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?
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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
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NOTES: Transgastric Appendectomy
Reddy & Rao: India, 2004
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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
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Urology NOTES
• NOTES nephrectomy
– 2002 Gettman et al.
– 2008 Clayman et al.
– 2009 human case reports
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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
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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.