Laparoscopy and Robotics Laparoendoscopic Single-site Surgery Simple Prostatectomy: Initial Report Rene J. Sotelo, Juan C. Astigueta, Mihir M. Desai, David Canes, Oswaldo Carmona, Robert J. De Andrade, Otto Moreira, Roy Lopez, Alejandro Velásquez, and Inderbir S. Gill OBJECTIVES METHODS
To report the first case and detailed technique of laparoendoscopic single-site (LESS) surgery simple prostatectomy for benign hypertrophy. A 67-year-old man presented with acute urinary retention requiring catheterization. Serum prostate-specific antigen level was 5 ng/mL, and a biopsy revealed benign hypertrophy with a transrectal ultrasound volume estimation of 110 mL. LESS simple prostatectomy was performed using a single multilumen port inserted through a solitary 2.5-cm intraumbilical incision. Standard laparoscopic ultrasonic shears and needle drivers, articulating scissors, and specifically designed bent grasping instruments facilitated dissection and suturing. An R-port was placed intraperitoneally through a 2.5-cm intraumbilical incision. No extraumbilical skin incisions were made. Total operative time was 120 minutes and estimated blood loss was 200 mL. A closed suction drain was externalized through the umbilical incision. No intraoperative or postoperative complications occurred. Hospital stay was 2 days, the retropubic drain was removed at 3 days, and the catheter removed at 1 week. Specimen weight was 95 g and final pathology revealed benign prostatic hyperplasia. At 3 months follow-up, the patient was completely continent and voiding spontaneously with a Qmax. of 85 mL/s. We demonstrate technical feasibility and describe the detailed surgical technique of LESS simple prostatectomy. Our initial experience suggests that this technique may be an alternative for large-volume benign prostatic hyperplasia in lieu of open surgery. Comparative studies with other surgical techniques will determine its place in the surgical armamentarium of benign prostatic hyperplasia. UROLOGY 74: 626 – 630, 2009. © 2009 Elsevier Inc.
aparoscopic surgery substantially reduces access trauma compared with open surgery. For many indications, this translates into less postoperative pain, faster convalescence, fewer wound complications, and improved cosmesis. The conventional laparoscopic approach to simple prostatectomy for benign prostate pathology requires 5 abdominal wall incisions.1 The umbilicus constitutes an opportunity for virtually scar-free surgery, whereby the scar is hidden within the umbilicus. Laparoendoscopic single-site surgery (LESS) is a variant of the laparoscopic surgery that uses a single small umbilical incision through which a single multi-channel access port is placed without any extraumbilical incisions.2 A novel single-port device (R-Port, Advanced Surgical Concepts, Wicklow, Ireland) was developed, which allows the introduction of 3 laparoscopic instruments From the Centro de Cirugía Robótica y de Invasión Mínima, Unidad de Urología, Instituto Médico La Floresta, Caracas, Venezuela; Instituto Regional de Enfermedades Neoplásicas, Trujillo, Peru; and Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio Reprint requests: Rene Sotelo Noguera, M.D., Centro de Cirugía Robótica y de Invasión Mínima, Instituto Médico La Floresta, Av. Principal Urb. La Floresta, PB 707, Caracas, Venezuela. E-mail: firstname.lastname@example.org Submitted: May 18, 2008, accepted (with revisions): March 25, 2009
© 2009 Elsevier Inc. All Rights Reserved
(two 5-mm and one 12-mm channel).3,4 We report the initial case using this single-port device inserted transumbilically for laparoscopic simple prostatectomy.
MATERIAL AND METHODS A 67-year-old man presented with an acute urinary retention requiring bladder catheterization. The serum prostate-specific antigen level was 5 ng/mL (25% free); biopsy demonstrated benign prostatic hyperplasia, with ultrasound volume estimated at 110 mL. The patient consented to laparoscopic simple prostatectomy. The body mass index was 21.4 and ASA (American Society of Anesthesiologists) class was II. The R-port allows simultaneous passage of several laparoscopic instruments through a single incision. The device consists of a retractor and a valve (Fig. 1). The retractor consists of 1 internal ring deployed inside the peritoneum and 1 external ring at the skin. The valve component incorporates 3 inlets for introducing laparoscopic instruments and a separate port for insufflation. Each inlet contains a thermoplastic elastomer that allows smooth introduction of instruments, including needles, with negligible air leak. The valve can be easily attached or removed from the retraction ring during the specimen extraction. The three-inlet valve (TriPort) has 1 inlet for a 12-mm instrument and 2 inlets for 5-mm instruments. To deploy the R-port, the inner ring is preloaded onto an unbladed introducer. 0090-4295/09/$34.00 doi:10.1016/j.urology.2009.03.039
Figure 1. Diagrammatic illustration (up) and deploying of the R-port (down). The R-port consists of a retractor part that contains the rings (r) and pulley sleeve (s), and a valve part that provides 3 or 4 inlets (i) for introducing instruments and the port for insufflation (p).
The introducer with the loaded inner ring is passed through an open (Hasson-type entry) incision into the abdominal cavity. An adequate fascial incision of about 2.5 cm is made before introducing the port. The size of the fascial incision determines the number and size of instruments that the port can accommodate and will vary depending on the specific operative indication. The inner ring is ejected from the introducer by pressing a button and the introducer is carefully removed, thus deploying the inner ring in the abdominal cavity. The plastic sleeve is then pulled outward to remove all slack and the external rings are cinched toward the abdominal wall. This incremental retraction of the sleeve and cinching down of the external rings draws the inner and outer rings together on either side of the abdominal wall, thereby creating tension in the sleeve between the rings that retracts the edges of the fasciotomy apart. The securely approximated rings via the plastic sleeve also create an effective seal, preventing gas leakage.
Surgical Technique The patient is administered general anesthesia and positioned in a modified Trendelenburg position with arms adducted. A UROLOGY 74 (3), 2009
2.5-cm semicircular incision was made at the inner edge of the umbilicus. A transverse incision was made in the anterior rectus sheath, and rectus muscles were mobilized laterally. The posterior rectus sheath was opened to expose preperitoneal fat. To facilitate subsequent dissection of the bladder from the anterior abdominal wall, digital dissection into the preperitoneal space was performed. The peritoneum was then opened, and the R-port was introduced and secured into position. A 10-mm rigid 30째? video-laparoscope (EndoEYE, Olympus Medical, Tokyo, Japan) was inserted through one of the access port inlets. The other 2 inlets in the R-port were used to insert working instruments for dissection (Table 1). No extraumbilical skin incisions were used. A transverse cystotomy was made proximal to the junction of the bladder and prostate using an ultrasonic scalpel (SonoSurg, Olympus, Center Valley, PA). In this manner, the anterior bladder neck is incised and entry is gained into the bladder lumen. The bulging prostate with median lobe is then visualized and retracted with a 2-0 Prolene suture that is introduced through the skin and is bent to pass the adenoma. The sling suture is then externalized with a Carter-Thomason wound closure device. A transverse (horizontal) incision is 627
Table 1. Instrumentation Instrument Size R-Port Flexible grasper/scissors SonoSurg Grasper, monopolar hook Hem-O-Lok clips Optic Suction Carter Thomason wound closure
n/a 5 5 5 5 10 5 n/a
Advanced Surgical Concepts, Wicklow, Ireland Cambridge Endo, Framingham, MA Olympus Olympus, altered manually to bent configuration Teleflex Medical Olympus EndoEYE Altered manually to bent configuration
Figure 2. Schematic diagram and pictures of LESS simple prostatectomy and postoperative appearance. The instruments dissect the adenoma through a cystotomy at the bladder neck (left). Photograph shows the R-port in place at the umbilicus (up). Completely, intraumbilical incision, urethral Foley catheter, and externalized closed suction drain. Inset shows the extracted adenoma (down). Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2009. All Rights Reserved.
made posteriorly on the vesical mucosa overlying the prostate lobes in the vicinity of the bladder neck. This semicircular mucosal incision, beginning from the “8” through the 6 up to the 4 o’clock positions, is deepened until the prostate adenoma is identified. Careful blunt and electrocautery dissection is performed to reach the proper subcapsular plane outside the prostate adenoma. Semicircular movements using J hook electrocautery, ultrasonic scalpel, scissors, and a bent suction irrigation cannula are made progressively to free the adenoma from the inside of the prostate capsule. The initial mucosal incision is then completed circumferentially. If a median lobe is present, it is completely mobilized and transected at its junction to the lateral lobes. The left lateral lobe is dissected first with dissection proceeding distal in a largely vascular plane. Any perforating tethering blood vessels were controlled with electrocautery or ultrasonic scalpel as they are encountered. Hemostasis was confirmed, and a Foley catheter was inserted. The horizontal cystotomy incision was closed in 1 layer with a running suture and completed with a Hem-o-Lok clip to limit cumbersome intracorporeal suturing. The valve of the R-port was disconnected, and the prostate adenoma was extracted through the ring. A drain was exteriorized through the umbilical incision, and the laparoscopic exit was completed (Fig. 2). 628
RESULTS The procedure was technically more difficult than the standard laparoscopic approach. Total operating time was 120 minutes, estimated blood loss was 200 mL, and hospital stay was 2 days. There were no intraoperative or postoperative complications. The skin incision was 2.8 cm. For analgesia, the patient received intravenous nonsteroidal anti-inflammatory drugs during the first 36 hours. The retropubic drain was removed at 3 days, and the catheter at 1 week. Specimen weight was 95 g. At 3 months follow-up, AUA (American Urological Association) symptom score was 3/35. On uroflowmetry, the patient voided 250 mL in 13 seconds, with the maximum and average flow of 85 and 19 mL/s, respectively (Table 2).
COMMENT The benefits of laparoscopic surgery in urology, including lower morbidity, decreased blood loss, decreased pain, shorter hospital stay, and earlier return to normal activities, have been widely accepted across multiple proceUROLOGY 74 (3), 2009
Table 2. Demographics and perioperative data Variable Age Body mass index (BMI) Indication Prior open surgery Incision site Incision size Method of access Operative time Estimated blood loss Hospital Stay Closed suction drainage Foley catheter removal
Result 67 y 21.4 kg/m2 Benign prostatic hyperplasia None Umbilicus 2.8 cm Open Hasson 120 min 200 mL 2d 3d 7d
dures. In a standard laparoscopic surgery, 3-5 laparoscopic ports are needed.1 Although only skin incisions are made and ports are introduced bluntly, patients have temporary incision pain and muscle spasms. The potential for epigastric vessel injury further complicates port placement. With increasing levels of comfort in the laparoscopic environment, there have been continuous attempts to further decrease access-related morbidity. As part of the continual evolution of minimally invasive therapies, NOTES (Natural Orifice Translumenal Endoscopic Surgery) was recently developed with the aim of performing surgical procedures without trauma to the abdominal wall through natural orifices.5,6 However, because of technical difficulties it did not achieve adequate diffusion and the approach for performing this surgical technique has changed with the emergence of intermediate or hybrid alternatives in which a single incision is made in the umbilicus through which several trocars or a trocar with multiple channels are placed.7-10 This new modality received different names such as E-NOTES (Embryonic Natural Orifice Transumbilical Endoscopic Surgery),11,12 Notus (Natural Orifice Transumbilical Surgery)13 and SPA (single port access),14,15 among others.16 Finally, in the recent meeting of the Single Port Consensus, the agreement was reached to use the term LESS to name all laparoscopic or endoscopic procedures performed through a single abdominal incision.2 Although the benefits of consolidating access at the umbilicus are theoretical, if each trocar adds some morbidity, a decrease might be achieved in overall morbidity with a solitary access point. In addition to the superior cosmetic result, the potential other advantages of minimizing skin incisions may also apply.11-16 There are multiple reports of procedures by a single umbilicus puncture, including hysterectomy, salpingectomy, appendectomy, cholecystectomy, the recently developed nephrectomy, and pyeloplasty.17-21 This report constitutes the first report of single-port simple prostatectomy, in which the scar is concealed within the umbilicus. The procedure was technically successful, albeit taking longer than expected for their conventional laparoscopic counterparts. We experienced UROLOGY 74 (3), 2009
significant instrument crowding extracorporeally, which after some time can be overcome. Compared with conventional laparoscopic surgery, the new technique has limitations, including a steep learning curve. Previous substantial laparoscopic expertise is imperative. Clearly, before LESS gains widespread acceptance, the technology should become simpler and more reproducible. Limitations in current instrumentation should be overcome. Several points are worth highlighting. First, the optics must be 5 mm “chip on a stick” with a 30° angle or a flexible tip. With the light source and camera consolidated, significant extracorporeal bulk is minimized, which limits crowding. Second, the assistant should have laparoscopic expertise to achieve multiple and sometimes counterintuitive or suboptimal viewing angles such that the surgeon has room to operate. Third, we believe that the ideal situation is to use a flexible or bent instrument alongside a rigid straight instrument. This achieves some degree of triangulation while maintaining stability at the instrument tip for robust dissection. Ultimately, the development of novel robotic instruments through multichannel introducers will facilitate the diffusion of LESS. Quality of life and pain score comparisons to matched cohorts undergoing the standard laparoscopic technique are ongoing. References 1. Sotelo R, Spalviero M, Garcia A, et al. “Laparoscopic retropubic simple prostatectomy. Novel technique.” J Urol. 2005;173:757-760. 2. Box G, Averch T, Badlani G, et al. Nomenclature of natural orifice translumenal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) in procedures in urology. J Endourol. 2008;22:2575-2581. 3. Rane A, Rao P, Rao P. Clinical evaluation of a novel laparoscopic port (R-PortTM) in urology and evolution of the single laparoscopic port procedures (SLIPP) and one port umbilical surgery (OPUS). Eur Urol Suppl. 2008;7(3):193. 4. Rane A, Rao P, Rao P. Single port access nephrectomy and other laparoscopic urologic procedures using a novel laparoscopic port (R-Port). Urology. 2008;72:260-263. 5. Rattner D, Hawes R. NOTES. Gathering momentum. Gastrointest Endosc. 2006;63:838-839. 6. Rattner D, Kalloo A. ASGE/SAGES working group on natural orifice translumenal endoscopic surgery. Surg Endosc. 2006;20:329333. 7. Pelosi MA, Pelosi Ma 3rd. Laparoscopic hysterectomy with bilateral salpingo-oophorectomy using a single umbilical puncture. N J Med. 1991;88:721-726. 8. Pelosi MA, Pelosi Ma 3rd. Laparoscopic appendectomy using a single umbilical puncture (minilaparoscopy). J Reprod Med. 1992; 37:588-594. 9. Piskun G, Rajpal S. Transumbilical laparoscopic cholecystectomy utilizes no incisions outside the umbilicus. J Laparoendosc Adv Surg Tech A. 1999;9:361-364. 10. Raman JD, Bensalah K, Bagrodia A, et al. Laboratory and clinical development of single keyhole umbilical nephrectomy. Urology. 2007;70:1039-1042. 11. Gill IS, Canes D, Aron M, et al. Single port transumbilical (ENOTES) donor nephrectomy. J Urol. 2008;180:637-641. 12. Desai M, Aron M, Stein R, et al. Embryonic natural orifices transumbilical endoscopic Surgery (E-NOTES) for advanced reconstruction: initial experience. Urology. 2009;73:182-187.
13. Isariyawongse JP, McGee MF, Rosen MJ, et al. Pure natural orifice transluminal endoscopic surgery (NOTES) nephrectomy using instruments in the porcine model. J Endourol. 2008;22: 1087-1091. 14. Castellucci SA, Curcillo PG, Ginsberg PC, et al. Single port access (SPA) adrenalectomy. J Endourol. 2008;22:1573-1576. 15. Bucher P, Pugin F, Morel P. Single port access laparoscopic right hemicolectomy. Int J Colorectal Dis. 2008;23:1013-1016. 16. Ates O, Hakguder G, Olguner M, et al. Single port laparoscopic appendectomy conducted intracorporeally with the aid of a transabdominal sling suture. J Pediatr Surg. 2007;42:10711074.
17. Kaouk JH, Palmer JS. Single-port laparoscopic surgery: initial experience in children for varicocelectomy. BJU Int. 2008;102: 97-99. 18. Desai M, Rao P, Aron M, et al. Scarless single port transumbilical nephrectomy and pyeloplasty: first clinical report. BJU Int. 2008; 101:83-88. 19. Kaouk JH, Haber GP, Goel RK, et al. Single-port laparoscopic surgery in urology: initial experience. Urology. 2008;71:3-6. 20. Remzi FH, Kirat HT, Kaouk JH, et al. Single port laparoscopy in colorectal surgery. Colorectal Dis. 2008;10:823-826. 21. Canes D, Desai MM, Aron M, et al. Transumbilical single-port Surgery: evolution and current status. Eur Urol. 2008;54:1020-1030.
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