3.10.2
LESS Adenomectomy
RenĂŠ Sotelo, Camilo Giedelman, Mihir Desai
Introduction
Surgical treatment of symptomatic benign prostatic hyperplasia (BPH) depends on the gland volume and includes open surgical enucleation, transurethral resection, and energy-based ablation. In general, enucleation techniques (i.e. open, laparoscopic or transurethral holmium:yttrium-aluminumgarnet enucleation) are preferred for moderate- to large-volume adenomas. These techniques provide removal of large-volume adenomas and durable long-term outcomes in comparison to transurethral ablative and resection procedures. Encouraging results of laparoscopic and robotic simple prostatectomies have been reported, and these techniques have become alternatives to open simple prostatectomy in select patients with lower urinary tract symptoms due to large-volume prostatic adenomas. More recently, the introduction of novel single-port devices has enabled the performance of many laparoscopic ablative and reconstructive procedures in a virtually scarless fashion through a solitary umbilical incision [1–3]. Laparoendoscopic single-site (LESS) adenomectomy can be performed by placing a single port device by transperitoneal approach in the umbilicus. The transperitoneal approach is more challenging since the bladder must be pushed dorsally and the enucleation cannot be facilitated using the finger. Moreover, the cystotomy incision has to be closed laparoscopically in a watertight manner at the end of the procedure. With the new prebent instruments, the transperitoneal approach is simplified but remains difficult to carry out. Nevertheless, the procedure can also be performed by placing the device under pneumovesicum in a suprapubic incision and inserting it directly into the bladder. Standard or articulating laparoscopic instrumentation can be used [4, 5]. In this section, we focus on the transvesical approach.
Indications
"
Preoperative evaluation includes a thorough medical history and physical examinations. Also, digital rectal examination and routine laboratory tests are necessary and include prostate-specific antigen, International Prostate Symptom Score (IPSS) and quality of life (QOL) questionnaires, uroflowmetry and transrectal ultrasound (TRUS) evaluation with prostate volume measurement. !" Selection criteria are a symptomatic BPH and a gland weight of 60 g or more, as estimated by TRUS
Contraindications " "
!" Prostate cancer !" Morbid obesity !" Anticoagulation, antiplatelet therapy !" Anaesthetic contraindications
Preoperative Preparation
!" The patient should pause antiplatelet or any anticoagulant therapy at least 8 days before surgery
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Step 1: Operative setup and instrumentation
b
a
All procedures are performed under general anaesthesia with the patient in a modified low-lithotomy position (Step 1a). LESS adenomectomy can be performed by placing a single multilumen port via the transperitoneal approach in the umbilicus. Multilumen ports allow the insertion of several instruments simultaneously through the same incision. Specialised prebent instruments have been introduced to facilitate the performance of com-
c
plex procedures through these ports. The combination of the above instruments and conventional laparoscopic instruments is also possible and frequently advisable. Endoscopic cameras of small diameter and special design should also be used. Step 1b and Step 1c show an ideal configuration for LESS surgery using prebent instruments and a camera with a bent shaft.
Step 2: Multilumen port insertion (transvesical approach)
a
Initially, cystoscopy is performed for the evaluation of the prostate and the bladder is filled with normal saline. An approximately 2.5-cm-long skin incision is made down to the rectus fascia. The incision is located just above the pubis. The bladder wall is identified and cleared of any prevesical fat. Two 2/0 Vicryl stay sutures are placed. The bladder wall is entered sharply between
b
the stay sutures and the inner ring of the Triport is inserted by an introducer into the bladder (Step 2a). The inner and outer rings are approximated by removing the slack on the plastic sleeve, thus clinching the abdominal and bladder walls between the rings of the Triport in an airtight seal (Step 2b).
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Step 3: Multilumen port placement
3
a
The valve of the Triport is inserted and the bladder is insufflated with carbon dioxide to create the pneumovesicum. The insertion and deployment of the Triport is monitored cystoscopically (Step 3a). Absorbable sutures are passed through the entire thickness of the vesical wall and are placed opposite each other. The sutures provide traction, facilitate the introduction of the trocar
b
and are used for closure of the vesical defect at the end of the procedure. The incision of the fascia and the bladder should be less than 2.5 cm long since the inner ring of the Triport would be easily retracted outside the bladder. Step 3b shows the inner ring of the Triport to be outside of the bladder.
Step 4: Incision of bladder mucosa
a
A U-shaped incision is made on the bladder mucosa, immediately over the adenoma extending between the 3 o’clock and 9 o’clock position (Step 4a). A reddish zone of mucosa is present immediately lateral to the internal meatus and serves as a reliable guide for creating the mucosal incision. The horizontal limb of the U-incision is made by using a hook electrode and dissecting to reach
b
the whitish prostatic adenoma. The plane between the surgical capsule and the adenoma is created using the electrocautery hook and suction cannula. The circumferential mucosal incision follows. Separate excisions of each mobilised lobe of the adenoma provide superior visualisation of the adenoma (Step 4b).
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Step 5: Enucleation of the adenoma (Sotelo prostatotomy)
a
b
Several manoeuvres are used to facilitate the enucleation of the adenoma: the Sotelo prostatotome (Step 5a), a device similar to a curette or an osteotome, facilitates enucleation of the adenoma during laparoscopic simple prostatectomy. Its metallic, curvilinear tip, with a sharp
cold knife on the distal side of the forceps, is used to dissect the margin between the adenoma and its capsule during the circumferential dissection of the adenoma (Step 5b). The instrument provides efficient and precise dissection of the adenoma.
Step 6: Finger enucleation of the adenoma and transurethral apical incision
a
Another method for adenoma enucleation is the insertion of the right index finger through the port after the Triport valve is removed. The latter manoeuvre expedites the distal part of the enucleation. The left index finger is placed in the rectum to elevate the prostate. Once the finger dissection has been completed, the Triport valve is reattached. The pneumovesicum is re-established for
b
the dissection of the urethra at the prostatic apex and the termination of the procedure. The latter method can be facilitated by the incision of the urethra with a bipolar resectoscope, immediately after the placement of the port (Step 6a) and before any dissection from cephalad direction (Step 6b).
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Step 7: Haemostasis
3
a
After removing the adenoma (Step 7a), haemostatic figure-eight sutures are made using an extracorporal knot pusher (Step 7b). The sutures are placed at the 4 and 8 o’clock positions of the prostatic capsule in order to control the main prostatic vessels. The lateral pros-
b
tatic pedicles should be thoroughly checked and the pneumopressure should be reduced to ensure that there is no active bleeding. Any minor bleeding can be controlled with a monopolar or bipolar cautery. If there is still doubt, absorbable sutures could be placed.
Step 8: Trigonisation and closure of the bladder
a
The prostatic adenoma is extracted through the Triport ring after dividing it into multiple pieces during extraction with Allis forceps. After adenoma removal, trigonisation of the prostatic fossa can be performed by suturing the posterior segment of the bladder neck stump
b
(Step 8a) distally towards the apex of the prostatic fossa (Step 8b). The extracorporal knot pusher is useful for this task. The bladder neck opening is sutured using 3/0 Vicryl. The rectus fascia and skin are closed in a standard fashion.
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Step 9: Suprapubic and urethral catheter insertion
a
b
A suprapubic catheter can be inserted through the inner ring of the Triport depending on the amount of bleeding. The balloon is inflated and the Triport can be removed. Step 9a shows the suprapubic and the urethral catheter, which are left for the postoperative management of the patient. The diameter of the Triport ring is large enough
Postoperative Management
for insertion of the suprapubic catheter balloon (Step 9b). Thus, correct placement of the catheter inside the bladder can be ensured. The stay sutures on the bladder wall can be tied along with any additional sutures, providing a watertight closure of the bladder incision.
!" A suprapubic catheter remains in place for 2–3 days !" The Foley catheter is removed on the 6th postoperative day
References 1. Sotelo R, Spaliviero M, Garcia-Segui A, Novoa J, Desai MM, Kaouk JH, Gill IS (2005) Laparoscopic retropubic simple prostatectomy. J Urol 173:757–760 2. Sotelo R, Clavijo R, Carmona O et al (2008) Robotic simple prostatectomy. J Urol 179:513–515 3. Rane A, Rao P, Rao P (2008) Clinical evaluation of a novel laparoscopic port (R-Port) in urology and evolution of the single laparoscopic port procedures (SLIPP) and one port umbilical surgery (OPUS). Eur Urol Suppl 7:193 4. Sotelo R, Astigueta J, Desai M, Canes D et al (2009) Laparoendoscopic single-site surgery simple prostatectomy: initial report. Urology 74:626–630 5. Desai M, Aron M, Canes D, Fareed K, et al. (2008) Single-port transvesical simple prostatectomy: initial clinical report. Urology 72: 960–965