Brian H. Irwin

Laparoendoscopic Single-site Surgery: Initial Hundred Patients

OBJECTIVES To report our initial experience with laparoendoscopic single-site (LESS) surgery in 100 patients in urology. METHODS Between October 2007 and December 2008, we performed LESS urologic procedures in 100 patients for various indications. These included nephrectomy (N = 34; simple 14, radical 3, donor 17), nephroureterectomy (N = 2), partial nephrectomy (N = 6), pyeloplasty (N = 17), transvesical simple prostatectomy (N = 32), and others (N = 9). Data were prospectively collected in a database approved by the Institutional Review Board. All procedures were performed using a novel single-port device (r-Port) and a varying combination of standard and specialized bent/articulating laparoscopic instruments. Robotic assistance was used to perform LESS pyeloplasty (N = 2) and simple prostatectomy (N = 1). In addition to standard perioperative data, we obtained data on postdischarge analgesia requirements, time to complete convalescence, and time to return to work. RESULTS In the study period, LESS procedures accounted for 15% of all laparoscopic cases by the authors for similar indications. Conversion to standard multiport laparoscopy was necessary in 3 cases, addition of a single 5-mm port was necessary in 3 cases, and conversion to open surgery was necessary in 4 cases. On death occurred following simple prostatectomy in a Jehovahs Witness due to patient refusal to accept transfusion following hemorrhage. Intra- and postoperative complications occurred in 5 and 9 cases, respectively. Mean operative time was 145, 230, 236, and 113 minutes and hospital stay was 2, 2.9, 2, and 3 days for simple nephrectomy, donor nephrectomy, pyeloplasty, and simple prostatectomy, respectively. CONCLUSIONS The LESS surgery is technically feasible for a variety of ablative and reconstructive applications in urology. With proper patient selection, conversion and complications rates are low. Improvement in instrumentation and technology is likely to expand the role of LESS in minimally invasive urology.

Robotic Laparoendoscopic Single-Site Surgery Using GelPort as the Access Platform

BACKGROUND Laparoendoscopic single-site surgery (LESS) allows for the performance of major urologic procedures with a single small incision and minimal scarring. The da Vinci Surgical System provides advantages of easy articulation and improved ergonomics; however, an ideal platform for these procedures has not been identified. OBJECTIVE To evaluate the GelPort laparoscopic system as an access platform for robotic LESS (R-LESS) procedures. DESIGN, SETTING, AND PARTICIPANTS Since April 2008, 11 R-LESS procedures have been completed successfully in a single institutional referral center. For the last four consecutive cases, the GelPort has been used as an access platform through a 2.5-5-cm umbilical incision. INTERVENTION R-LESS cases performed with the GelPort included pyeloplasty (n=2), radical nephrectomy (n=1), and partial nephrectomy (n=1). MEASUREMENTS Perioperative data were obtained for all patients including demographic data, operative indications, operative records, length of stay, complications, and pathologic analysis. RESULTS AND LIMITATIONS For both pyeloplasty cases, average operative time (OR time) was 235 min and estimated blood loss (EBL) was 38 cm(3). For the patient undergoing radical nephrectomy for a 5.1-cm renal tumor, OR time was 200 min and EBL was 250 cm(3). The final patient underwent partial nephrectomy without renal hilar clamping for an 11-cm angiomyolipoma with OR time of 180 min and EBL of 600 cm(3). All R-LESS procedures attempted with the GelPort were completed successfully and without complication. Average length of hospital stay was 1.75 d (range: 1-2). The partial nephrectomy patient required transfusion of 1 U of packed red blood cells. CONCLUSIONS Use of the GelPort as an access platform for R-LESS procedures provides adequate spacing and flexibility of port placement and acceptable access to the surgical field for the assistant, especially during procedures that require a specimen extraction incision. Additional platform and instrumentation development will likely simplify R-LESS procedures further as experience grows.

Laparoendoscopic Single Site Surgery in Urology

Laparoendoscopic single site (LESS) surgery is a recently coined term that refers to a group of techniques that perform laparoscopic intervention through a single abdominal incision often hidden within the umbilicus. The relative ease and swiftness of early success of LESS surgery is in large part because of the familiarity of current practitioners with advanced laparoscopic techniques and the advent of several technologic advances in the areas of instrumentation, camera systems, and access devices. As ongoing advancements in instrumentation and future robotics platforms are incorporated, the scope and application of LESS surgery is likely to expand. Ultimately, prospective studies that compare the safety and effectiveness of this new approach with the standard conventional laparoscopic approach will determine the future role in surgical practice.

Where do we really stand with LESS and NOTES

Matthew T. Gettman *, Wesley M. White, Monish Aron, Riccardo Autorino, Tim Averch, Geoffrey Box, Jeffrey A. Cadeddu, David Canes, Edward Cherullo, Mihir M. Desai, Igor Frank, Indebir S. Gill, Mantu Gupta, Georges-Pascal Haber, Mitchell R. Humphreys, Brian H. Irwin, Jihad H. Kaouk, Louis R. Kavoussi, Jaime Landman, Evangelos N. Liatsikos, Estevao Lima, Lee E. Ponsky, Abhay Rane, Maria Ribal, Robert Rabenhalt, Pradeep Rao, Lee Richstone, Mark D. Sawyer, Rene Sotelo, Jens-Uwe Stolzenburg, Chad R. Tracy, Robert J. Stein; Endourological Society NOTES and LESS Working Group; European Society of Urotechnology NOTES and LESS Working Group E U RO P E AN URO LOGY 5 9 ( 2 0 1 1 ) 2 3 1 – 2 3 4

Single‐port transvesical enucleation of the prostate: a clinical report of 34 cases

Study Type – Therapy (case series)
Level of Evidence 4

Laparoendoscopic single‐site pyeloplasty: a comparison with the standard laparoscopic technique

Study Type – Therapy (case series)

Single-port Transvesical Excision of Foreign Body in the Bladder

OBJECTIVES To present a novel technique to remove intravesical polypropylene mesh through a single laparoscopic port placed directly into the bladder. METHODS A Triport single-site access system was placed transvesically and carbon dioxide was used for insufflation of the bladder. A combination of straight and articulating laparoscopic instruments was used to dissect the mesh away from the bladder mucosa and transect each end for complete removal of foreign bodies. Mucosal reapproximation was performed on the latter case. RESULTS Two patients were managed adequately in the outpatient setting. No suprapubic catheters were necessary, and patients were discharged within 23 hours. CONCLUSIONS Removal of foreign bodies of the bladder through a single transvesical laparoscopic port is technically feasible. This procedure offers excellent visualization of mesh material, especially near the bladder neck where these foreign bodies often reside. This approach offers patients a minimally invasive approach through a single small incision.

DIFFERENTIAL EXPRESSION OF BLADDER NEUROTROPHIC FACTOR mRNA IN MALE AND FEMALE RATS AFTER BLADDER OUTFLOW OBSTRUCTION

PURPOSE We validated a male rat model of bladder outflow obstruction and compared the expression of bladder neurotrophic factor mRNA in male and female rats 6 weeks after bladder outlet obstruction. MATERIALS AND METHODS We examined the proximal urethra in male Wistar rats. Urethral lumen reducing ligatures were placed in 15 females and 19 males, while 10 male and 10 female controls underwent sham surgery. Awake cystometry was performed 6 weeks after surgery. Ribonuclease protection assay was used to measure changes in bladder neurotrophic factor mRNA expression in the 2 sexes. RESULTS Average bladder capacity in rats with bladder outlet obstruction increased 3-fold in males and 4.4-fold in females compared with controls, while bladder weight increased 2.2 and 4.3-fold, respectively. Filling and threshold pressure increased significantly and nonvoiding bladder contractions were recorded in 100% of female and 80% of male rats with bladder outlet obstruction. An 8-fold increase in bladder brain derived neurotrophic factor mRNA was noted in each sex after obstruction. A 2-fold increase in bladder nerve growth factor mRNA after obstruction was only observed in females. CONCLUSIONS This male rat model of bladder outlet obstruction was created by placing lumen reducing ligatures at the urethrovesical junction. The dramatic increase in bladder brain derived neurotrophic factor mRNA expression and differential expression of nerve growth factor mRNA in male and female rats with bladder outlet obstruction suggest that additional neurotrophic factors may contribute to the lower urinary tract neuroplasticity associated with bladder outlet obstruction and this contribution may be gender dependent.

Complications and conversions of upper tract urological laparoendoscopic single-site surgery (LESS): multicentre experience: results from the NOTES Working Group

Study Type – Therapy (case series)
Level of Evidence 4

Laparoscopic Radical Cystectomy: Current Status, Outcomes, and Patient Selection

Opinion statementRadical cystectomy remains the gold standard for the treatment of muscle invasive and high-risk urothelial cancers of the bladder. In attempts to decrease the morbidity of the procedure, minimally invasive techniques have been employed for both the extirpative as well as the reconstructive portions of the procedure. Current laparoscopic and robotic-assisted techniques allow for the performance of these procedures in selected patients with improvements in estimated blood loss while adhering to the oncologic principles required for cancer control including obtaining negative margins and performing an adequate extended lymph node dissection. While completely intracorporeal approaches are technically feasible, they have been, thus far, associated with significant increases in operative times and perioperative complications. Open-assisted approaches in which the extirpative portions of the case (i.e. radical cystectomy, extended lymph node dissection) are completed laparoscopically and the urinary reconstruction is performed in a limited open fashion appear to provide the best outcomes with current techniques. Intermediate cancer outcomes are promising when compared to their open surgical counterparts. While this approach remains investigational, long-term outcomes are currently being accrued and may allow for the shift of the standard of care to minimally invasive approaches for select patients as has been the case in renal and prostatic cancers.