Original Paper
Urologia Internationalis
Received: February 15, 2013 Accepted after revision: July 26, 2013 Published online: May 20, 2014
Urol Int 2014;92:414–421 DOI: 10.1159/000354733
‘Scarless’ Laparoscopic Urologic Surgery by the Combination of Mini-Laparoscopic and Laparoendoscopic Single-Site Surgery Equipment Panagiotis Kallidonis a Ioannis Georgiopoulos a Iason Kyriazis a Abdulrahman Al-Aown a Stavros Kontogiannis a Jens-Uwe Stolzenburg b Evangelos N. Liatsikos a a
Department of Urology, University of Patras, Patras, Greece; b Department of Urology, University of Leipzig, Leipzig, Germany
Key Words Laparoendoscopic single-site surgery · Needlescopic · Pyeloplasty · Radical prostatectomy · Partial nephrectomy · Scarless surgery
Abstract Objective: We evaluated reconstructive and oncological laparoendoscopic single-site surgery (LESS) combined with mini-laparoscopic instruments as standard equipment. Patients and Methods: 30 patients underwent reconstructive and oncological LESS: mini-laparoscopic-assisted LESS pyeloplasty (LESS-P, n = 18), mini-laparoscopic-assisted LESS partial nephrectomy (LESS-PN, n = 7) or mini-laparoscopicassisted LESS radical prostatectomy (LESS-RP, n = 5). Perioperative data were prospectively collected. Results: The 18 LESS-P cases had operative times ranging between 120 and 180 min (average 147.9 min). Estimated blood loss ranged between 100 and 300 ml (average 202.1 ml). Two patients required additional management for failed reconstruction. LESS-PN was performed in 7 patients with tumor size ranging between 2.5 and 3.8 cm (average 2.7 cm). Average operative time and blood loss were 155 (140–180) min and 321.4 (250–550) ml, respectively. Renal artery clamping took
© 2014 S. Karger AG, Basel 0042–1138/14/0924–0414$39.50/0 E-Mail [email protected] www.karger.com/uin
place in 1 case. LESS-RP was performed in 5 patients; average operative time was 156 (140–180) min and average blood loss 196 (100–400) ml. Functional and oncological outcome was directly comparable to laparoscopic radical prostatectomy. Conclusion: The combination of LESS and mini-laparoscopic instrumentation as routine equipment of reconstructive LESS reveals a different perspective for ‘scarless’ urologic surgery. © 2014 S. Karger AG, Basel
Introduction
Laparoendoscopic single-site surgery (LESS) has significantly evolved within the last 5 years despite the ergonomic difficulties of the technique [1]. These difficulties are overcome to some extent by the use of instruments specifically designed for LESS [1, 2]. Single-site ablative procedures such as simple and radical nephrectomy have been developed as feasible and safe alternatives to conventional laparoscopy. Nevertheless, procedures such as pyeloplasty, prostatectomy, partial nephrectomy or cystectomy, which require suturing and sometimes timesensitive reconstruction, have been reported in a low number of studies with small patient populations [1]. AdEvangelos N. Liatsikos, MD, PhD Department of Urology University of Patras Medical School GR–26504 Rion, Patras (Greece) E-Mail liatsikos @ yahoo.com
Color version available online
ditional conventional laparoscopic or 3 mm mini-laparoscopic instruments have been used for the successful accomplishment of the above LESS procedures [3, 4]. The use of 3 mm instruments should be considered as the most favorable option since these instruments require a very small incision, which results in minimal postoperative scarring [3, 5]. Despite the fact that the use of minilaparoscopic instruments is currently considered as a means to overcome the ergonomic difficulties of LESS procedures, mini-laparoscopic instruments have never been considered as standard equipment for the safe and efficient accomplishment of LESS procedures. As a result, the lack of evidence regarding the successful performance of LESS surgery in combination with mini-laparoscopic instruments as standard equipment led us to investigate the results in three LESS procedures associated with complex reconstructive technique.
Fig. 1. The combination of needlescopic instrument and LESS in-
struments during needlescopic-assisted LESS-PN. Notice the use of a 3 mm needle holder which is inserted without the use of a trocar. A Gelpoint multi-port is used.
Patients and Methods A total of 30 patients underwent LESS reconstructive and oncological surgery in two institutions actively involved in LESS over a period of 24 months [3, 5, 6]. Mini-laparoscopic-assisted LESS pyeloplasty (LESS-P) was performed in 18 patients while 7 patients underwent mini-laparoscopic-assisted LESS partial nephrectomy (LESS-PN) and 5 mini-laparoscopic-assisted LESS radical prostatectomy (LESS-RP). The perioperative data for the above patients were prospectively collected, including complications classified according to the Clavien system [7]. Indications Patients with indication for pyeloplasty were candidates for LESS-P. The preoperative assessment included intravenous pyelography, computed tomography-urography or renal scintigraphy. LESS-PN took place for the management of renal tumors up to 4 cm in diameter. LESS-RP was done in accordance to the indications for radical prostatectomy at our institutions [8]. Surgical Technique: Instruments Specially designed instruments for LESS were used for the accomplishment of the above procedures. Several types of multi-lumen ports were used, such as Endocone (Karl Storz, Tuttlingen, Germany), QuadPort (Olympus, Hamburg, Germany) and Gelpoint (Applied Medical, Rancho Santa Margarita, Calif., USA). These ports allow the insertion of curved and conventional laparoscopic instruments. Mini-laparoscopic instruments (3 mm instruments, Karl Storz) with their respective trocars were used for tissue/organ retraction and significantly facilitated suturing tasks. All instruments with diameters larger than 3 mm were inserted through the multi-lumen port (fig. 1). Upper Urinary Tract The single port was usually inserted at the umbilicus through a small incision. Occasionally, in overweight and obese patients, a more lateral port placement was required (at the lateral margin of the rectus muscle). The first steps of the procedure were similar for
‘Scarless’ Laparoscopic Urologic Surgery
both LESS-P and LESS-PN. The colon was mobilized; Gerota’s fascia was identified and dissected. The ureter was identified and prepared up to the renal hilum. Mini-laparoscopic instruments were used efficiently for tissue dissection. In addition, a combination of 5 mm curved and straight instruments through the single port was also possible. LESS-P. The ureter was prepared up to the renal hilum and the lower pole was released from its attachments. The site of the stenosis was identified and resected. The ureter was spatulized and sutured to the pelvis after percutaneous insertion of a double-J stent. Vicryl 5-0 sutures with a 3 mm needle holder placed through the abdominal wall and a conventional instrument through the single port were used for suturing (fig. 2). The combined use of two 3 mm instruments through the abdominal wall could also be considered. LESS-PN. The renal vessels, lower and upper poles were carefully prepared. The kidney was mobilized from the liver or spleen depending on the side of the tumor. A 3 mm instrument was sufficient for liver retraction in right-sided cases. The renal vessels were not clamped and tumor excision was performed using ultrasonic scissors and bipolar coagulation. After excision of the tumor, the renal lesion was reconstructed through the combined use of sliding clip renorrhaphy and Surgicel bolsters (Ethicon Inc., Somerville, N.J., USA). Suturing was performed with the combination of mini-laparoscopic and conventional instruments as described above for LESS-P. In case of small exophytic tumors, excision of the tumor by ultrasonic scissors accompanied by bipolar coagulation and placement of TachoSil (Nycomed, Linz, Austria) on the lesion was usually adequate for hemostasis, and suturing was not necessary. LESS-RP. For the insertion of the single port, a paraumbilical incision was used and balloon dilation of Retzius’ space was performed, similarly to endoscopic extraperitoneal radical prostatectomy (EERPE) [8]. Three instruments were inserted through the port, the 5 mm endoscopic camera and two curved instruments or a combination of curved and conventional laparoscop-
Urol Int 2014;92:414–421 DOI: 10.1159/000354733
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Color version available online
Fig. 2. Suturing during needlescopic-as-
a
b
Color version available online
sisted LESS-P. Two needlescopic instruments are used; one is inserted through the multi-port. a Suturing is more difficult in comparison to conventional instruments, but remains efficient. b Intracorporeal knot tying requires accuracy. Small sutures such as 5-0 Vicryl can be used.
ic instruments. The use of a curved suction cannula by the assistant facilitated ergonomics outside the single port since the surgeon was able to insert conventional instruments for dissection such as the ultrasonic scissors. Additional 3 mm instruments were inserted on both sides on the line between the umbilicus and the iliac spine. As a result, the surgeon and assistant used one instrument through the single port and one 3 mm instrument outside the port (fig. 3). A third 3 mm instrument could be placed on the side of the surgeon to facilitate vesicourethral anastomosis. The steps of the procedure were identical to those described for EERPE [8]. Postoperative Management Postoperative pain as perceived by the patient was evaluated by visual analog score documentation with the pain scale ranging from 1 to 10. Minimal pain was described as score 1 and the worst possible pain as score 10. Evaluation of pain took place 3 times daily starting on the first postoperative day and continued for the next 2 days (until the second postoperative day). Administration of analgesic medication was recorded for the first 2 postoperative days. In LESS-P cases, the double-J stent was removed in the 4th postoperative week (after retrograde pyelography). The catheter was removed on the 5th postoperative day (cystography) after LESS-RP. Follow-up of the patients was extended over a period of 1 year. LESS-P patients were evaluated every 3 months with renal ultrasound and/or renal scintigraphy. Success was defined by resolution of symptoms and improvement in diuretic renogram (halftime 38 ° C) postoperatively resulting in extension of hospitalization. Another patient had anastomotic leakage requiring the placement of nephrostomy. One patient complained of symptom recurrence and another patient had no improvement in the diuretic renogram at 3 months. These patients were managed by percutaneous endopyelotomy. LESS-PN (table 2) was performed in 7 patients, including 5 overweight patients. Two of them were managed by trocar insertion on the lateral margin of the rectus muscle. Renal artery clamping was performed only in the largest tumor (3.8 cm in diameter). Although the preoperative plan regarding this tumor did not include renal artery clamping, intraoperative bleeding deemed it necessary.
Kallidonis et al.
Table 1. Perioperative and follow-up data of LESS-P
Table 3. Perioperative data of LESS-RP
Perioperative parameters Patients Male/female Mean age, years (range) Mean BMI, kg/m2 (range) Overweight Obese Flank pain/urinary tract infection Mean operative time, min (range) Blood loss, ml (range) Transfusion/conversion Mean hospitalization, days (range) Symptom recurrence/management
Perioperative parameters Patients Mean age, years (range) Mean BMI, kg/m2 (range) Overweight Mean PSA, ng/ml (range) Mean operative time, min (range) Mean blood loss, ml (range) Transfusions Conversion to conventional laparoscopy/ open surgery Nerve-sparing technique/side Pelvic lymph node dissection Mean prostate weight, g (range) Duration of catheterization Mean hospitalization, days (range)
Recurrence in renogram Complications Fever >38°C, 1 patient Anastomotic leakage, 1 patient
18 11/7 31.4 (19–49) 25.1 (20.2–31.6) 6 1 17/7 147.9 (120–180) 202.1 (100–300) 0/0 2.66 (2–4) 1 patient/cold knife antegrade endopyelotomy 1 patient/cold knife antegrade endopyelotomy Clavien grade II, managed with antibiotics Clavien grade III, managed with nephrostomy placement
Complications Fever >38°C, 1 patient
Histology evaluation Postoperative Gleason score
BMI = Body mass index.
TNM staging Table 2. Perioperative and follow-up data of LESS-PN
Perioperative parameters Patients Tumor side Left Right Mean age, years (range) Mean BMI, kg/m2 (range) Overweight Average tumor diameter, cm (range) Location Lower Upper Mean operative time, min (range) Mean estimated blood loss, ml (range) Clamp technique/warm ischemia time Conversion to conventional/ laparoscopy open surgery Conversion to open approach
5 66.6 (62–72) 25.6 (22.8–28.1) 3 7.6 (6.3–8.8) 156 (140–180) 196 (100–400) 0 0/0 2 patients/bilateral 0 59.4 (48–70) 5 days, all patients 3.66 (3–5) Clavien grade II, managed with antibiotics 3+3=6: 2 patients 3+4=7: 2 patients 4+3=7: 1 patient pT2a: 2 patients pT2b: 3 patients
BMI = Body mass index; PSA = prostate-specific antigen.
7 3 4 53 (45–62) 26 (24.8–28.4) 5 2.7 (2.0–3.8) 4 3 155 (140–180) 321.4 (250–550) 1/22 min 0/0 0
Complications Intraoperative bleeding, 1 patient
Clavien grade I, not managed
Oncological evaluation pT1a (≤4 cm) Positive surgical margins RCC histology Follow-up 6 months postoperatively Follow-up 12 months postoperatively
7 0 6 clear cell/1 papillary no recurrence no recurrence
BMI = Body mass index.
‘Scarless’ Laparoscopic Urologic Surgery
Warm ischemia time was 22 min and blood loss was 550 ml. Suturing of the pelvicalyceal system was also necessary in this case. The majority of the tumors were exophytic (n = 5), and excision with the combined use of coagulation, ultrasonic scissors and TachoSil was usually adequate for hemostasis. Selective suturing was performed in two cases while sliding clip renorrhaphy took place in two cases. No positive surgical margins were revealed and recurrences were not observed during the follow-up period of 12 months. The LESS-RP data are summarized in table 3. One intraoperative bleeding from the dorsal vein complex was managed by additional suturing. Nerve-sparing procedure was not considered in three patients due to preoperative erectile dysfunction, while bilateral nerve sparing was done in two patients. The urinary catheters of all five patients were removed on the 5th postoperative day. The functional and oncological outcome is presented in table 4. It should be noted that due to the high degree of correlation among the IIEF questionnaires and the SEP Urol Int 2014;92:414–421 DOI: 10.1159/000354733
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Table 4. Oncological and functional follow-up of LESS-RP
Follow-up Continence 0 pads/day 1 pad/day 2 pads/day ≥3 pads/day
Catheter removal, number of patients
3 months, number of patients
6 months, number of patients
12 months, number of patients
0 2 3 0
3 2 0 0
5 0 0 0
5 0 0 0
Potency With nerve-sparing technique, 2 patients Without nervesparing technique, 3 patients PSA recurrence PSA ≥ 0.2 ng/ml
–
2 patients: spontaneous 1 patient: erections sufficient for erections insufficient for intercourse with medical treatment 1 patient: spontaneous erections intercourse insufficient for intercourse 3 patients: no erections 3 patients: no erections
2 patients: erections sufficient for intercourse with medical treatment 1 patient: spontaneous erections insufficient for intercourse 2 patients: no erections
no recurrence
no recurrence
no recurrence
Table 5. Average values of postoperative pain perception and analgesia requirement
Needlescopic-assisted LESS Average value of the pain score (range) On the day of operation On the first postoperative day On the second postoperative day
Pyeloplasty 2.8 (2–6) 2.1 (1–4) 1.4 (1–3)
Average consumption of pethidine (mg) after the operation (range) On the day of operation 29.5 (0–80) On the first postoperative day 9.5 (0–80) On the second postoperative day 4.2 (0–30)
diaries, the outcome of potency is presented in the latter table based on the SEP diaries and the aforementioned definition of postoperative potency [11]. The visual analog scores and the use of analgesic medication of all procedures are presented in table 5.
Discussion
LESS has been an important step on the road towards ‘scarless’ laparoscopic surgery and has been the motive for the development of new techniques and improvement in laparoscopic instruments [4, 5, 12, 13]. LESS nephrectomy has been established as an alternative to laparosco418
Urol Int 2014;92:414–421 DOI: 10.1159/000354733
Partial nephrectomy
Radical prostatectomy
3.1 (2–5) 2.0 (1–4) 1.3 (1–2)
2.6 (2–4) 1.8 (1–3) 1.1 (1–2)
38.6 (0–80) 12.9 (0–40) 2.9 (0–20)
28.0 (10–60) 8.0 (0–20) 4.0 (0–20)
py [1, 13] while procedures requiring complex suturing and reconstructive tasks are still associated with limited experience and are feasible only in the hands of experienced laparoscopic surgeons [14, 15]. Additional 5 or 3 mm instruments have been used for tissue/organ retraction to facilitate the completion of LESS procedures [2, 15]. In reconstructive surgery, additional instruments played a more important role as the lack of triangulation rendered the procedure into a task suited only for highly skilled laparoscopic surgeons [16]. In addition, the insertion of a 5 mm instrument practically converted the procedure to conventional laparoscopy [17]. Our experience with the use of 3 mm instruments during LESS revealed that these instruments left Kallidonis et al.
scars that were almost invisible and did not seem to compromise the cosmetic outcome [3]. This concept led us to investigate the possibility of combined use of minilaparoscopic and LESS instruments during the performance of LESS techniques including complex suturing tasks. LESS-P has been reported in a limited number of studies [4, 16–22]. Tracy et al. [19] compared LESS-P (n = 14) to laparoscopic pyeloplasty (n = 28) and observed significantly lower mean operative time (207 vs. 237.5 min, p < 0.001) and mean blood loss (30 vs. 72.5 ml, p = 0.002) in the case of LESS-P. Nevertheless, the accumulated experience in laparoscopy may have influenced the results of laparoscopic pyeloplasty. An additional 5 mm instrument was inserted to facilitate suturing in all cases while an additional 3 mm instrument was placed below the xiphoid to provide tissue retraction in some cases. Stein et al. [20] also compared the above procedures but did not observe any significant advantage of LESS-P over laparoscopic pyeloplasty. In fact, laparoscopic pyeloplasty was performed for the management of patients with significantly higher body mass index with similar operative time. A 2 mm needle holder was used in all cases for suturing, while in some cases a 2 mm grasper facilitated tissue dissection. Similar results were reported by Ju et al. [22]. Other investigators showed that LESS-P has an acceptable rate of complications, which is not higher than in laparoscopic pyeloplasty. The use of additional instruments (2 or 5 mm in diameter) was controversial among some investigators [23, 24]. LESS-PN has been reported in larger series presenting the experience of specialized laparoscopy centers [4, 21]. Additional instruments such as a 3 mm grasper were used by some of the investigators [16]. The use of robotic assistance reduces the steep learning curve of LESS in both pyeloplasty and partial nephrectomy [25–27]. Small series (up to 5 cases) of LESS-RP have been reported by several investigators [15, 27]. The challenging nature of the procedure was underlined by the use of at least one additional instrument port, extracorporeal knot tying and high operative times [15, 28]. Our experience with LESS showed that the use of additional instruments is not imperative but significantly facilitates LESS. Mini-laparoscopic instruments do not leave any significant scar [5]. The combined use of mini-laparoscopic instruments and a multi-port provides a safe route for large bore instrument insertion and adequate triangulation capabilities for complex suturing tasks. Surgical specimens resulting from LESSRP or LESS-PN could be easily extracted through the
incision of the trocar. In fact, extension of the incision was never necessary in the current series. Mini-laparoscopic instruments are effective in all surgical tasks. Nevertheless, these instruments require more accurate manipulation than conventional laparoscopic instruments since any tremor in the hands of the surgeon is augmented. In the current series, LESS-P proved to be efficient and operative time was similar to the aforementioned LESS and laparoscopic pyeloplasty studies. The success of the procedure in the management of ureteropelvic junction obstruction and complication rate was 83.3% (15/18 patients) and 8.8% (16/18 patients), respectively. These figures are comparable to those in the literature [12, 14, 17–20]. All LESS-P procedures were performed by the use of a 3 mm instrument inserted through the abdominal wall and a 5 mm instrument inserted through the umbilical multi-lumen trocar. The advantage of this setting in comparison to previously reported mini-laparoscopic pyeloplasty techniques is the reduction of one 3 mm trocar inserted through the abdominal wall [29]. It should also be noted that the use of a 3 and a 5 mm (through the multi-port) instrument facilitates the performance of intraoperative tasks. The insertion of a second transabdominal 3 mm instrument is possible if deemed necessary. Nevertheless, the latter approach should probably be considered as a technique similar to the mini-laparoscopic pyeloplasty rather than LESS [29]. LESS-PN is more challenging since intraoperative bleeding and warm ischemia time are issues that should be addressed with efficiency and in a time-sensitive manner. Renal vessels were clamped in only one case and ultrasonic scissors with bipolar coagulation provided hemostasis. The use of ultrasonic scissors and LigaSure instruments was possible by inserting these instruments through the multi-lumen port. The mini-laparoscopic instruments were useful for tissue retraction during exposure of the tumor and for suturing. Operative time, blood loss and complication rate were comparable to laparoscopic partial nephrectomy [30]. LESS-RP remained a very challenging procedure despite the use of mini-laparoscopic instruments. In fact, operative time was clearly higher in comparison to our published experience with EERPE [8]. Mini-laparoscopic instruments were used for tissue dissection throughout the procedure and the size of the instruments provided efficient grasping, but required more accuracy and dexterity by the surgeon in comparison to conventional laparoscopic instruments. The functional and oncological outcome was not compro-
‘Scarless’ Laparoscopic Urologic Surgery
Urol Int 2014;92:414–421 DOI: 10.1159/000354733
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mised by the aforementioned combination of instruments. It should be noted that a limitation of the current study is that LESS-PN and LESS-RP cases were too low in number to obtain any solid conclusions. The current study shows that the combined use of mini-laparoscopic and LESS instruments provides an efficient method to perform the aforementioned procedures without compromising their outcome. In fact, operative time and procedure outcome are directly comparable to those in the literature. Nevertheless, an important limitation of the study is the lack of any validated questionnaire evaluating the cosmetic outcome. Our experience shows that the incisions of 3 mm instruments do not require any suturing and the scar left is practically not visible. The use of a questionnaire would have been more appropriate for comparison of the current population to patients that underwent LESS with the use of 5 mm instruments. An important point of criticism is probably the efficiency of robotic-assisted LESS in complex LESS procedures like those evaluated in the current study [31]. The robotic systems are the way of the future, but currently these systems are not available in a large number of insti-
tutions worldwide. Thus, the performance of ‘scarless’ surgery by the combined use of 3 mm and LESS instruments may represent an option for these institutions. Moreover, the use of recently introduced multi-use single ports such as the Endocone may result in reduction of the cost of LESS procedures and in conjunction to the accumulation of experience in the currently presented setting may be the way for wider acceptance of LESS in the above procedures.
Conclusion
Combination of mini-laparoscopic and LESS instruments improves the intraoperative ergonomics of procedures requiring complex suturing and reconstructive tasks. The cosmetic outcome seems not to be compromised by the practically imperceptible scar of the 3 mm instrument. The current promising results reveal a different perspective for ‘scarless’ urologic surgery based on the combined use of LESS and mini-laparoscopic instrumentation.
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Urologia Internationalis
Received: February 15, 2013 Accepted after revision: July 26, 2013 Published online: May 20, 2014
Urol Int 2014;92:414–421 DOI: 10.1159/000354733
‘Scarless’ Laparoscopic Urologic Surgery by the Combination of Mini-Laparoscopic and Laparoendoscopic Single-Site Surgery Equipment Panagiotis Kallidonis a Ioannis Georgiopoulos a Iason Kyriazis a Abdulrahman Al-Aown a Stavros Kontogiannis a Jens-Uwe Stolzenburg b Evangelos N. Liatsikos a a
Department of Urology, University of Patras, Patras, Greece; b Department of Urology, University of Leipzig, Leipzig, Germany
Key Words Laparoendoscopic single-site surgery · Needlescopic · Pyeloplasty · Radical prostatectomy · Partial nephrectomy · Scarless surgery
Abstract Objective: We evaluated reconstructive and oncological laparoendoscopic single-site surgery (LESS) combined with mini-laparoscopic instruments as standard equipment. Patients and Methods: 30 patients underwent reconstructive and oncological LESS: mini-laparoscopic-assisted LESS pyeloplasty (LESS-P, n = 18), mini-laparoscopic-assisted LESS partial nephrectomy (LESS-PN, n = 7) or mini-laparoscopicassisted LESS radical prostatectomy (LESS-RP, n = 5). Perioperative data were prospectively collected. Results: The 18 LESS-P cases had operative times ranging between 120 and 180 min (average 147.9 min). Estimated blood loss ranged between 100 and 300 ml (average 202.1 ml). Two patients required additional management for failed reconstruction. LESS-PN was performed in 7 patients with tumor size ranging between 2.5 and 3.8 cm (average 2.7 cm). Average operative time and blood loss were 155 (140–180) min and 321.4 (250–550) ml, respectively. Renal artery clamping took
© 2014 S. Karger AG, Basel 0042–1138/14/0924–0414$39.50/0 E-Mail [email protected] www.karger.com/uin
place in 1 case. LESS-RP was performed in 5 patients; average operative time was 156 (140–180) min and average blood loss 196 (100–400) ml. Functional and oncological outcome was directly comparable to laparoscopic radical prostatectomy. Conclusion: The combination of LESS and mini-laparoscopic instrumentation as routine equipment of reconstructive LESS reveals a different perspective for ‘scarless’ urologic surgery. © 2014 S. Karger AG, Basel
Introduction
Laparoendoscopic single-site surgery (LESS) has significantly evolved within the last 5 years despite the ergonomic difficulties of the technique [1]. These difficulties are overcome to some extent by the use of instruments specifically designed for LESS [1, 2]. Single-site ablative procedures such as simple and radical nephrectomy have been developed as feasible and safe alternatives to conventional laparoscopy. Nevertheless, procedures such as pyeloplasty, prostatectomy, partial nephrectomy or cystectomy, which require suturing and sometimes timesensitive reconstruction, have been reported in a low number of studies with small patient populations [1]. AdEvangelos N. Liatsikos, MD, PhD Department of Urology University of Patras Medical School GR–26504 Rion, Patras (Greece) E-Mail liatsikos @ yahoo.com
Color version available online
ditional conventional laparoscopic or 3 mm mini-laparoscopic instruments have been used for the successful accomplishment of the above LESS procedures [3, 4]. The use of 3 mm instruments should be considered as the most favorable option since these instruments require a very small incision, which results in minimal postoperative scarring [3, 5]. Despite the fact that the use of minilaparoscopic instruments is currently considered as a means to overcome the ergonomic difficulties of LESS procedures, mini-laparoscopic instruments have never been considered as standard equipment for the safe and efficient accomplishment of LESS procedures. As a result, the lack of evidence regarding the successful performance of LESS surgery in combination with mini-laparoscopic instruments as standard equipment led us to investigate the results in three LESS procedures associated with complex reconstructive technique.
Fig. 1. The combination of needlescopic instrument and LESS in-
struments during needlescopic-assisted LESS-PN. Notice the use of a 3 mm needle holder which is inserted without the use of a trocar. A Gelpoint multi-port is used.
Patients and Methods A total of 30 patients underwent LESS reconstructive and oncological surgery in two institutions actively involved in LESS over a period of 24 months [3, 5, 6]. Mini-laparoscopic-assisted LESS pyeloplasty (LESS-P) was performed in 18 patients while 7 patients underwent mini-laparoscopic-assisted LESS partial nephrectomy (LESS-PN) and 5 mini-laparoscopic-assisted LESS radical prostatectomy (LESS-RP). The perioperative data for the above patients were prospectively collected, including complications classified according to the Clavien system [7]. Indications Patients with indication for pyeloplasty were candidates for LESS-P. The preoperative assessment included intravenous pyelography, computed tomography-urography or renal scintigraphy. LESS-PN took place for the management of renal tumors up to 4 cm in diameter. LESS-RP was done in accordance to the indications for radical prostatectomy at our institutions [8]. Surgical Technique: Instruments Specially designed instruments for LESS were used for the accomplishment of the above procedures. Several types of multi-lumen ports were used, such as Endocone (Karl Storz, Tuttlingen, Germany), QuadPort (Olympus, Hamburg, Germany) and Gelpoint (Applied Medical, Rancho Santa Margarita, Calif., USA). These ports allow the insertion of curved and conventional laparoscopic instruments. Mini-laparoscopic instruments (3 mm instruments, Karl Storz) with their respective trocars were used for tissue/organ retraction and significantly facilitated suturing tasks. All instruments with diameters larger than 3 mm were inserted through the multi-lumen port (fig. 1). Upper Urinary Tract The single port was usually inserted at the umbilicus through a small incision. Occasionally, in overweight and obese patients, a more lateral port placement was required (at the lateral margin of the rectus muscle). The first steps of the procedure were similar for
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both LESS-P and LESS-PN. The colon was mobilized; Gerota’s fascia was identified and dissected. The ureter was identified and prepared up to the renal hilum. Mini-laparoscopic instruments were used efficiently for tissue dissection. In addition, a combination of 5 mm curved and straight instruments through the single port was also possible. LESS-P. The ureter was prepared up to the renal hilum and the lower pole was released from its attachments. The site of the stenosis was identified and resected. The ureter was spatulized and sutured to the pelvis after percutaneous insertion of a double-J stent. Vicryl 5-0 sutures with a 3 mm needle holder placed through the abdominal wall and a conventional instrument through the single port were used for suturing (fig. 2). The combined use of two 3 mm instruments through the abdominal wall could also be considered. LESS-PN. The renal vessels, lower and upper poles were carefully prepared. The kidney was mobilized from the liver or spleen depending on the side of the tumor. A 3 mm instrument was sufficient for liver retraction in right-sided cases. The renal vessels were not clamped and tumor excision was performed using ultrasonic scissors and bipolar coagulation. After excision of the tumor, the renal lesion was reconstructed through the combined use of sliding clip renorrhaphy and Surgicel bolsters (Ethicon Inc., Somerville, N.J., USA). Suturing was performed with the combination of mini-laparoscopic and conventional instruments as described above for LESS-P. In case of small exophytic tumors, excision of the tumor by ultrasonic scissors accompanied by bipolar coagulation and placement of TachoSil (Nycomed, Linz, Austria) on the lesion was usually adequate for hemostasis, and suturing was not necessary. LESS-RP. For the insertion of the single port, a paraumbilical incision was used and balloon dilation of Retzius’ space was performed, similarly to endoscopic extraperitoneal radical prostatectomy (EERPE) [8]. Three instruments were inserted through the port, the 5 mm endoscopic camera and two curved instruments or a combination of curved and conventional laparoscop-
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Color version available online
Fig. 2. Suturing during needlescopic-as-
a
b
Color version available online
sisted LESS-P. Two needlescopic instruments are used; one is inserted through the multi-port. a Suturing is more difficult in comparison to conventional instruments, but remains efficient. b Intracorporeal knot tying requires accuracy. Small sutures such as 5-0 Vicryl can be used.
ic instruments. The use of a curved suction cannula by the assistant facilitated ergonomics outside the single port since the surgeon was able to insert conventional instruments for dissection such as the ultrasonic scissors. Additional 3 mm instruments were inserted on both sides on the line between the umbilicus and the iliac spine. As a result, the surgeon and assistant used one instrument through the single port and one 3 mm instrument outside the port (fig. 3). A third 3 mm instrument could be placed on the side of the surgeon to facilitate vesicourethral anastomosis. The steps of the procedure were identical to those described for EERPE [8]. Postoperative Management Postoperative pain as perceived by the patient was evaluated by visual analog score documentation with the pain scale ranging from 1 to 10. Minimal pain was described as score 1 and the worst possible pain as score 10. Evaluation of pain took place 3 times daily starting on the first postoperative day and continued for the next 2 days (until the second postoperative day). Administration of analgesic medication was recorded for the first 2 postoperative days. In LESS-P cases, the double-J stent was removed in the 4th postoperative week (after retrograde pyelography). The catheter was removed on the 5th postoperative day (cystography) after LESS-RP. Follow-up of the patients was extended over a period of 1 year. LESS-P patients were evaluated every 3 months with renal ultrasound and/or renal scintigraphy. Success was defined by resolution of symptoms and improvement in diuretic renogram (halftime 38 ° C) postoperatively resulting in extension of hospitalization. Another patient had anastomotic leakage requiring the placement of nephrostomy. One patient complained of symptom recurrence and another patient had no improvement in the diuretic renogram at 3 months. These patients were managed by percutaneous endopyelotomy. LESS-PN (table 2) was performed in 7 patients, including 5 overweight patients. Two of them were managed by trocar insertion on the lateral margin of the rectus muscle. Renal artery clamping was performed only in the largest tumor (3.8 cm in diameter). Although the preoperative plan regarding this tumor did not include renal artery clamping, intraoperative bleeding deemed it necessary.
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Table 1. Perioperative and follow-up data of LESS-P
Table 3. Perioperative data of LESS-RP
Perioperative parameters Patients Male/female Mean age, years (range) Mean BMI, kg/m2 (range) Overweight Obese Flank pain/urinary tract infection Mean operative time, min (range) Blood loss, ml (range) Transfusion/conversion Mean hospitalization, days (range) Symptom recurrence/management
Perioperative parameters Patients Mean age, years (range) Mean BMI, kg/m2 (range) Overweight Mean PSA, ng/ml (range) Mean operative time, min (range) Mean blood loss, ml (range) Transfusions Conversion to conventional laparoscopy/ open surgery Nerve-sparing technique/side Pelvic lymph node dissection Mean prostate weight, g (range) Duration of catheterization Mean hospitalization, days (range)
Recurrence in renogram Complications Fever >38°C, 1 patient Anastomotic leakage, 1 patient
18 11/7 31.4 (19–49) 25.1 (20.2–31.6) 6 1 17/7 147.9 (120–180) 202.1 (100–300) 0/0 2.66 (2–4) 1 patient/cold knife antegrade endopyelotomy 1 patient/cold knife antegrade endopyelotomy Clavien grade II, managed with antibiotics Clavien grade III, managed with nephrostomy placement
Complications Fever >38°C, 1 patient
Histology evaluation Postoperative Gleason score
BMI = Body mass index.
TNM staging Table 2. Perioperative and follow-up data of LESS-PN
Perioperative parameters Patients Tumor side Left Right Mean age, years (range) Mean BMI, kg/m2 (range) Overweight Average tumor diameter, cm (range) Location Lower Upper Mean operative time, min (range) Mean estimated blood loss, ml (range) Clamp technique/warm ischemia time Conversion to conventional/ laparoscopy open surgery Conversion to open approach
5 66.6 (62–72) 25.6 (22.8–28.1) 3 7.6 (6.3–8.8) 156 (140–180) 196 (100–400) 0 0/0 2 patients/bilateral 0 59.4 (48–70) 5 days, all patients 3.66 (3–5) Clavien grade II, managed with antibiotics 3+3=6: 2 patients 3+4=7: 2 patients 4+3=7: 1 patient pT2a: 2 patients pT2b: 3 patients
BMI = Body mass index; PSA = prostate-specific antigen.
7 3 4 53 (45–62) 26 (24.8–28.4) 5 2.7 (2.0–3.8) 4 3 155 (140–180) 321.4 (250–550) 1/22 min 0/0 0
Complications Intraoperative bleeding, 1 patient
Clavien grade I, not managed
Oncological evaluation pT1a (≤4 cm) Positive surgical margins RCC histology Follow-up 6 months postoperatively Follow-up 12 months postoperatively
7 0 6 clear cell/1 papillary no recurrence no recurrence
BMI = Body mass index.
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Warm ischemia time was 22 min and blood loss was 550 ml. Suturing of the pelvicalyceal system was also necessary in this case. The majority of the tumors were exophytic (n = 5), and excision with the combined use of coagulation, ultrasonic scissors and TachoSil was usually adequate for hemostasis. Selective suturing was performed in two cases while sliding clip renorrhaphy took place in two cases. No positive surgical margins were revealed and recurrences were not observed during the follow-up period of 12 months. The LESS-RP data are summarized in table 3. One intraoperative bleeding from the dorsal vein complex was managed by additional suturing. Nerve-sparing procedure was not considered in three patients due to preoperative erectile dysfunction, while bilateral nerve sparing was done in two patients. The urinary catheters of all five patients were removed on the 5th postoperative day. The functional and oncological outcome is presented in table 4. It should be noted that due to the high degree of correlation among the IIEF questionnaires and the SEP Urol Int 2014;92:414–421 DOI: 10.1159/000354733
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Table 4. Oncological and functional follow-up of LESS-RP
Follow-up Continence 0 pads/day 1 pad/day 2 pads/day ≥3 pads/day
Catheter removal, number of patients
3 months, number of patients
6 months, number of patients
12 months, number of patients
0 2 3 0
3 2 0 0
5 0 0 0
5 0 0 0
Potency With nerve-sparing technique, 2 patients Without nervesparing technique, 3 patients PSA recurrence PSA ≥ 0.2 ng/ml
–
2 patients: spontaneous 1 patient: erections sufficient for erections insufficient for intercourse with medical treatment 1 patient: spontaneous erections intercourse insufficient for intercourse 3 patients: no erections 3 patients: no erections
2 patients: erections sufficient for intercourse with medical treatment 1 patient: spontaneous erections insufficient for intercourse 2 patients: no erections
no recurrence
no recurrence
no recurrence
Table 5. Average values of postoperative pain perception and analgesia requirement
Needlescopic-assisted LESS Average value of the pain score (range) On the day of operation On the first postoperative day On the second postoperative day
Pyeloplasty 2.8 (2–6) 2.1 (1–4) 1.4 (1–3)
Average consumption of pethidine (mg) after the operation (range) On the day of operation 29.5 (0–80) On the first postoperative day 9.5 (0–80) On the second postoperative day 4.2 (0–30)
diaries, the outcome of potency is presented in the latter table based on the SEP diaries and the aforementioned definition of postoperative potency [11]. The visual analog scores and the use of analgesic medication of all procedures are presented in table 5.
Discussion
LESS has been an important step on the road towards ‘scarless’ laparoscopic surgery and has been the motive for the development of new techniques and improvement in laparoscopic instruments [4, 5, 12, 13]. LESS nephrectomy has been established as an alternative to laparosco418
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Partial nephrectomy
Radical prostatectomy
3.1 (2–5) 2.0 (1–4) 1.3 (1–2)
2.6 (2–4) 1.8 (1–3) 1.1 (1–2)
38.6 (0–80) 12.9 (0–40) 2.9 (0–20)
28.0 (10–60) 8.0 (0–20) 4.0 (0–20)
py [1, 13] while procedures requiring complex suturing and reconstructive tasks are still associated with limited experience and are feasible only in the hands of experienced laparoscopic surgeons [14, 15]. Additional 5 or 3 mm instruments have been used for tissue/organ retraction to facilitate the completion of LESS procedures [2, 15]. In reconstructive surgery, additional instruments played a more important role as the lack of triangulation rendered the procedure into a task suited only for highly skilled laparoscopic surgeons [16]. In addition, the insertion of a 5 mm instrument practically converted the procedure to conventional laparoscopy [17]. Our experience with the use of 3 mm instruments during LESS revealed that these instruments left Kallidonis et al.
scars that were almost invisible and did not seem to compromise the cosmetic outcome [3]. This concept led us to investigate the possibility of combined use of minilaparoscopic and LESS instruments during the performance of LESS techniques including complex suturing tasks. LESS-P has been reported in a limited number of studies [4, 16–22]. Tracy et al. [19] compared LESS-P (n = 14) to laparoscopic pyeloplasty (n = 28) and observed significantly lower mean operative time (207 vs. 237.5 min, p < 0.001) and mean blood loss (30 vs. 72.5 ml, p = 0.002) in the case of LESS-P. Nevertheless, the accumulated experience in laparoscopy may have influenced the results of laparoscopic pyeloplasty. An additional 5 mm instrument was inserted to facilitate suturing in all cases while an additional 3 mm instrument was placed below the xiphoid to provide tissue retraction in some cases. Stein et al. [20] also compared the above procedures but did not observe any significant advantage of LESS-P over laparoscopic pyeloplasty. In fact, laparoscopic pyeloplasty was performed for the management of patients with significantly higher body mass index with similar operative time. A 2 mm needle holder was used in all cases for suturing, while in some cases a 2 mm grasper facilitated tissue dissection. Similar results were reported by Ju et al. [22]. Other investigators showed that LESS-P has an acceptable rate of complications, which is not higher than in laparoscopic pyeloplasty. The use of additional instruments (2 or 5 mm in diameter) was controversial among some investigators [23, 24]. LESS-PN has been reported in larger series presenting the experience of specialized laparoscopy centers [4, 21]. Additional instruments such as a 3 mm grasper were used by some of the investigators [16]. The use of robotic assistance reduces the steep learning curve of LESS in both pyeloplasty and partial nephrectomy [25–27]. Small series (up to 5 cases) of LESS-RP have been reported by several investigators [15, 27]. The challenging nature of the procedure was underlined by the use of at least one additional instrument port, extracorporeal knot tying and high operative times [15, 28]. Our experience with LESS showed that the use of additional instruments is not imperative but significantly facilitates LESS. Mini-laparoscopic instruments do not leave any significant scar [5]. The combined use of mini-laparoscopic instruments and a multi-port provides a safe route for large bore instrument insertion and adequate triangulation capabilities for complex suturing tasks. Surgical specimens resulting from LESSRP or LESS-PN could be easily extracted through the
incision of the trocar. In fact, extension of the incision was never necessary in the current series. Mini-laparoscopic instruments are effective in all surgical tasks. Nevertheless, these instruments require more accurate manipulation than conventional laparoscopic instruments since any tremor in the hands of the surgeon is augmented. In the current series, LESS-P proved to be efficient and operative time was similar to the aforementioned LESS and laparoscopic pyeloplasty studies. The success of the procedure in the management of ureteropelvic junction obstruction and complication rate was 83.3% (15/18 patients) and 8.8% (16/18 patients), respectively. These figures are comparable to those in the literature [12, 14, 17–20]. All LESS-P procedures were performed by the use of a 3 mm instrument inserted through the abdominal wall and a 5 mm instrument inserted through the umbilical multi-lumen trocar. The advantage of this setting in comparison to previously reported mini-laparoscopic pyeloplasty techniques is the reduction of one 3 mm trocar inserted through the abdominal wall [29]. It should also be noted that the use of a 3 and a 5 mm (through the multi-port) instrument facilitates the performance of intraoperative tasks. The insertion of a second transabdominal 3 mm instrument is possible if deemed necessary. Nevertheless, the latter approach should probably be considered as a technique similar to the mini-laparoscopic pyeloplasty rather than LESS [29]. LESS-PN is more challenging since intraoperative bleeding and warm ischemia time are issues that should be addressed with efficiency and in a time-sensitive manner. Renal vessels were clamped in only one case and ultrasonic scissors with bipolar coagulation provided hemostasis. The use of ultrasonic scissors and LigaSure instruments was possible by inserting these instruments through the multi-lumen port. The mini-laparoscopic instruments were useful for tissue retraction during exposure of the tumor and for suturing. Operative time, blood loss and complication rate were comparable to laparoscopic partial nephrectomy [30]. LESS-RP remained a very challenging procedure despite the use of mini-laparoscopic instruments. In fact, operative time was clearly higher in comparison to our published experience with EERPE [8]. Mini-laparoscopic instruments were used for tissue dissection throughout the procedure and the size of the instruments provided efficient grasping, but required more accuracy and dexterity by the surgeon in comparison to conventional laparoscopic instruments. The functional and oncological outcome was not compro-
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mised by the aforementioned combination of instruments. It should be noted that a limitation of the current study is that LESS-PN and LESS-RP cases were too low in number to obtain any solid conclusions. The current study shows that the combined use of mini-laparoscopic and LESS instruments provides an efficient method to perform the aforementioned procedures without compromising their outcome. In fact, operative time and procedure outcome are directly comparable to those in the literature. Nevertheless, an important limitation of the study is the lack of any validated questionnaire evaluating the cosmetic outcome. Our experience shows that the incisions of 3 mm instruments do not require any suturing and the scar left is practically not visible. The use of a questionnaire would have been more appropriate for comparison of the current population to patients that underwent LESS with the use of 5 mm instruments. An important point of criticism is probably the efficiency of robotic-assisted LESS in complex LESS procedures like those evaluated in the current study [31]. The robotic systems are the way of the future, but currently these systems are not available in a large number of insti-
tutions worldwide. Thus, the performance of ‘scarless’ surgery by the combined use of 3 mm and LESS instruments may represent an option for these institutions. Moreover, the use of recently introduced multi-use single ports such as the Endocone may result in reduction of the cost of LESS procedures and in conjunction to the accumulation of experience in the currently presented setting may be the way for wider acceptance of LESS in the above procedures.
Conclusion
Combination of mini-laparoscopic and LESS instruments improves the intraoperative ergonomics of procedures requiring complex suturing and reconstructive tasks. The cosmetic outcome seems not to be compromised by the practically imperceptible scar of the 3 mm instrument. The current promising results reveal a different perspective for ‘scarless’ urologic surgery based on the combined use of LESS and mini-laparoscopic instrumentation.
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