Table 1. Instrumentation Instrument Size R-Port Flexible grasper/scissors SonoSurg Grasper, monopolar hook Hem-O-Lok clips Optic Suction Carter Thomason wound closure
Millimeter
Manufacturer
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