Geoffrey N. Box

Nomenclature of Natural Orifice Translumenal Endoscopic Surgery (NOTES™) and Laparoendoscopic Single-Site Surgery (LESS) Procedures in Urology

INTRODUCTION The twenty first century has witnessed some amazing advancements in surgery. In urology minimally invasive surgery has become the standard treatment for many disease processes and procedures. One of the newest innovations into this field has been the development of Natural Orifice Translumenal Endoscopic Surgery (NOTES) and Laparoendoscopic Single-site Surgery (LESS). While the practice and application of these new techniques are in their infancy, there has been a great deal of confusion regarding the nomenclature and terminology associated with these procedures. The aim of this publication is to attempt to define the many issues associated with the standardization of terminology for these procedures in order to promote effective scientific progress and communication. MATERIALS AND METHODS A literature search using Medline and pubmed focusing on all terminology to describe NOTES and LESS from 1990 to 2008 was done. In addition, various acronyms were searched using four separate online acronym databases. The information was recorded by number of citations and by the number of citations specific to the urologic literature. Based on common usage, definitions and criteria were developed to describe these procedures for current scientific publication. These terms were then collectively reviewed and agreed upon by the Urologic NOTES Working Group as a platform for consensus to begin the arduous process of standardization. RESULTS There is wide variation in the terminology and use of acronyms for natural orifice translumenal endoscopic surgery and laparo-endoscopic single-site surgery. The keyword literature search uncovered 8710 citations from MEDLINE and pubmed, with 363 citations specific to urology. There was significant overlap in the search of different terms. The search of established abbreviation and acronym databases revealed many citations, but relatively few specific to urology. CONCLUSION Standardization of the nomenclature applied to natural orifice transluminal endoscopic surgery (NOTES) and laparo-endoscopic single-site surgery (LESS) is essential as the body of literature continues to grow in order to allow clear and precise scientific communication. As the techniques continue to evolve, we propose that NOTES and LESS be designated as the common terms to define these new procedures in urology.

Robotic versus standard laparoscopic partial/wedge nephrectomy: a comparison of intraoperative and perioperative results from a single institution.

PURPOSE Laparoscopic partial/wedge nephrectomy, similar to laparoscopic radical prostatectomy, is a technically challenging procedure that is performed by a limited number of expert laparoscopic surgeons. The incorporation of a robotic surgical interface has dramatically increased the use of minimally invasive pelvic surgery such that robotic laparoscopic radical prostatectomy is commonly performed even by laparoscopically naïve surgeons. This analysis compares the outcomes of our initial experience with robot-assisted laparoscopic partial nephrectomy (RLPN) performed by an experienced open surgeon to that of standard laparoscopic partial nephrectomy (LPN) performed by two experienced laparoscopic surgeons. PATIENTS AND METHODS We reviewed the medical records of 11 consecutive patients who underwent 12 standard LPNs (EMM, RVC) (one patient had two unilateral tumors) and 10 consecutive patients (representing the first 11 of such robotic procedures performed at our institution) who underwent 11 RLPNs (one patient had bilateral tumors managed in an asynchronous manner) (DKO). RESULTS The mean tumor size was 2.3 cm (range 1.7-6.2 cm) for LPN and 3.1 cm (range 2.5-4 cm) for RLPN. The mean total procedure time was 289.5 minutes (range 145-369 min) for LPN and 228.7 minutes (range 98-375 min) for RLPN (P=0.102). The mean estimated blood loss was 198 mL (range 75-500 mL) for LPN v 115 mL (25-300 mL) for RLPN (P=0.169). The mean warm ischemia time was 35.3 minutes (range 15-49 min) in the LPN group and 32.1 minutes (range 30-45 minutes) in the RLPN group (P=0.501). CONCLUSIONS Introducing a robotic interface for laparoscopic partial/wedge resection allowed a fellowship-trained urologic oncologist with limited reconstructive laparoscopic experience to achieve results comparable to those for laparoscopic partial/wedge resection performed by experienced laparoscopic surgeons. In this regard, the learning curve appears truncated, similar to that with robot-assisted laparoscopic prostatectomy.

Consensus statement on natural orifice transluminal endoscopic surgery and single-incision laparoscopic surgery: heralding a new era in urology?

Matthew T. Gettman *, Geoffrey Box , Timothy Averch , Jeffrey A. Cadeddu , Edward Cherullo , Ralph V. Clayman , Mihr Desai , Igor Frank , Indebir Gill , Mantu Gupta , Georges-Pascal Haber , Mitchell Humphreys , Jihad Kaouk , Jaime Landman , Estevao Lima , Lee Ponsky e Mayo Clinic, Department of Urology, Rochester, MN, United States University of California Irvine, CA, United States University of Pittsburgh Medical Center, PA, United States University of Texas Southwestern Medical Center, Dallas, TX, United States Case Western Reserve University, Cleveland, OH, United States Cleveland Clinic, Cleveland, OH, United States Columbia University Medical Center, New York, NY, United States University of Minho, School of Health Science, Braga, Portugal

Percutaneous and Laparoscopic Cryoablation of Small Renal Masses

PURPOSE We reviewed our 4-year experience with percutaneous cryoablation and laparoscopy for treating small renal masses. MATERIALS AND METHODS After institutional review board approval we retrospectively analyzed renal cryoablation procedures performed between March 2003 and October 2007. An in-depth analysis was performed concerning demographics, hospital course and short-term outcome with respect to percutaneous vs laparoscopic cryoablation. RESULTS A total of 37 patients underwent treatment for 43 renal masses. Of the 37 patients 19 underwent laparoscopic cryoablation (24 tumors) and 18 underwent percutaneous cryoablation (19 tumors) using computerized tomography fluoroscopy. For percutaneous cryoablation a saline instillation was used in 58% of cases to move nonrenal vital structures away from the targeted renal mass. There were 5 cases of hemorrhage requiring transfusion, all of which were associated with the use of multiple cryoprobes. The transfusion rate in the percutaneous and laparoscopic cryoablation groups was 11.1% and 27.8%, respectively. Operative time was significantly longer in the laparoscopic cryoablation group compared to the percutaneous cryoablation group at 147 (range 89 to 209) vs 250.2 (range 151 to 360) minutes, respectively. The overall complication rate (including transfusion) was lower in the percutaneous cryoablation group compared to the laparoscopic cryoablation group (4 of 18 [22.2%] vs 8 of 20 [40%], respectively). Hospital stay was significantly shorter in the percutaneous vs laparoscopic cryoablation group at 1.3 vs 3.1 days, p <0.0001, respectively. Narcotic use in the percutaneous cryoablation group was more than half that used by the laparoscopic cryoablation group (5.1 vs 17.8 mg, p = 0.03, respectively). Among patients with biopsy proven renal cell carcinoma during a median followup of 11.4 and 13.4 months in the percutaneous and laparoscopic cryoablation groups, cancer specific survival was 100% and 100%, respectively, and the treatment failure rate was 5.3% and 4.2%, respectively. CONCLUSIONS Percutaneous cryoablation is an efficient, minimally morbid method for the treatment of small renal masses and it appears to be superior to the laparoscopic approach. Short-term followup has shown no difference in tumor recurrence or need for re-treatment. Of note, hemorrhage was solely associated with the use of multiple probes.

Rapid Communication: Robot-Assisted NOTES Nephrectomy: Initial Report

BACKGROUND AND PURPOSE Natural Orifice Transluminal Endoscopic Surgery (NOTES) using the daVinci robot (Intuitive Surgical, Sunnyvale, CA) has never been applied to urologic surgery. Here we present our initial experience with a combined transvaginal and transcolonic, single-port, robot-assisted NOTES nephrectomy. METHODS An acute experiment was performed in a female farm pig. A single 12-mm trocar was placed in the midline, and two 12-mm standard laparoscopic ports were placed into the abdomen via the vagina and the colon. The robotic ports were then telescoped into the 12-mm ports, and the daVinci S robot was docked. Dissection was performed using the Hot Shears and the ProGrasp instruments. The robotic camera was placed via the midline port and held by an assistant. Using the 12-mm transvaginal port, the renal artery and vein were divided separately with a vascular Endo GIA (US Surgical, Norwalk, CT) stapler. The kidney was placed into a 10-mm entrapment sack and removed intact via the vagina. RESULTS Total operative time was 150 minutes. Estimated blood loss was less than 50 mL. No intraoperative complications occurred. CONCLUSION A robot-assisted NOTES nephrectomy was accomplished in a porcine model using the daVinci S robot. Additional testing on survival animals is necessary to further explore this approach.

Bone marrow stem cells for urologic tissue engineering

ObjectivesExperiments in rats and dogs have demonstrated the potential of bone marrow-derived mesenchymal stem cells (MSCs) for urinary tract tissue engineering. However, the small graft size in rats and a failure to identify the MSCs in engineered tissues made it difficult to assess the true potential of these cells. Our goals were to characterize MSCs from pigs, determine their ability to differentiate into smooth muscle cells (SMCs) and use them in an autologous augmentation cystoplasty.MethodsMSCs were isolated from pigs and analyzed for common markers of MSCs by flow cytometry. SMC differentiation was determined by immunoblotting. MSCs were isolated, genetically labeled, expanded in vitro, seeded onto small intestinal submucosa (SIS) and used for autologous bladder augmentation.ResultsPorcine MSCs are morphologically and immunophenotypically similar to human MSCs. Culturing MSCs at low density enhances proliferation rates. MSCs consistently differentiate into mature SMCs in vitro when maintained at confluence. Labeled MSCs grew on SIS over one week in vitro and survived a 2-week implantation as an autologous bladder augment in vivo. Some label-positive cells with SMC morphology were detected, but most SMCs were negative. Notably, many cells with a urothelial morphology stained positively.ConclusionsPorcine MSCs have similar properties to MSCs from other species and consistently undergo differentiation into mature SMC in vitro under specific culture conditions. Labeled MSCs within SIS may assist tissue regeneration in augmentation cystoplasty but may not significantly incorporate into smooth muscle bundles.

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

Robotic radical prostatectomy: long-term outcomes.

Purpose of review In 2001, approximately 250 robotic-assisted laparoscopic prostatectomies were performed; in 2007, this number is expected to approach 50 000 surgeries. This surge has arguably been driven by the improved (real or perceived) clinical outcomes. In this review we assess ‘long-term’ experience based on reports recently published over the past 18 months. Recent findings The short-term clinical outcomes for robotic-assisted laparoscopic prostatectomies such as deaths, transfusions, postoperative complications and bladder neck contractures are excellent, and appear to be improved when compared to open radical retropubic prostatectomy. Recent findings regarding the early return of potency have emphasized the benefit of avoiding thermal energy when preserving the neurovascular bundle. In similar fashion, early continence rates appear to be improved by restoring posterior anatomic fascia. Local disease control as measured by surgical margin status appears to be at least equivalent to contemporary open series, but longer follow-up is needed. Summary Three-dimensional and 10 times magnified vision, precise instrument control, and improved exposure coupled with the tamponade effect associated with the pneumoperitoneum have translated into reproducible improvements in patient comfort, and decreased mortality, blood loss and complications, including bladder neck contracture and deep venous thrombosis. These technical improvements would lead one to believe that improved results with continence, potency and oncologic outcomes should logically follow. Ultimately, long-term outcomes and possibly financial impact will determine the role of robotic-assisted laparoscopic prostatectomy.

Comparative Analysis of Laparoscopic and Robot-Assisted Radical Cystectomy with Ileal Conduit Urinary Diversion

PURPOSE To compare our experience with laparoscopic radical cystectomy (LACIC) and robot-assisted laparoscopic radical cystectomy (RACIC) with ileal conduit urinary diversion. PATIENTS AND METHODS Prospective data were gathered on 20 consecutive patients undergoing LACIC performed between August 2002 and July 2005, and on 14 consecutive patients undergoing RACIC performed between March 2005 and December 2006. Radical cystectomy with pelvic lymphadenectomy was performed laparoscopically or robotically, and an ileal conduit urinary diversion was performed extracorporeally. RESULTS There was no significant difference in terms of preoperative factors or baseline tumor characteristics and no significant difference in mean operative time (410 min v 419 min) between groups. There was less blood loss (212 mL v 653 mL; P < 0.0001) and fewer transfusions (42.8% v 70%; P < 0.0011) in the RACIC group. There was one intraoperative complication (7%) and no conversions in the RACIC group. There were three (15%) intraoperative complications all leading to conversion in patients undergoing LACIC. Three (21%) patients in the RACIC group and 10 (50%) patients in the LACIC group had at least 1 post-operative complication. The mean number of days to oral intake was less in the RACIC group (2.3 v 6.1; P = 0.012). There was no significant difference in the number of lymph nodes excised (P = 0.09) between groups. Bilateral extended lymphadenectomy was performed in 10 (71%) RACIC patients with a mean of 22.3 lymph nodes harvested and in 16 (80%) LACIC patients with a mean of 16.5 lymph nodes harvested. There were no positive margins in patients in the LACIC group and one (7.1%) among patients in the RACIC group--a patient with pT4 disease. CONCLUSION Both laparoscopic and robot-assisted radical cystectomies can be performed safely without compromising oncologic standards for surgical margins and extent of lymphadenectomy. In this early experience, the robot-assisted approach appears to have a shorter learning curve, and it is associated with less blood loss, fewer postoperative complications, and earlier return of bowel function than LACIC.

Long-Term Impact of a Robot Assisted Laparoscopic Prostatectomy Mini Fellowship Training Program on Postgraduate Urological Practice Patterns

PURPOSE Robot assisted laparoscopic prostatectomy has stimulated a great deal of interest among urologists. We evaluated whether a mini fellowship for robot assisted laparoscopic prostatectomy would enable postgraduate urologists to incorporate this new procedure into clinical practice. MATERIALS AND METHODS From July 2003 to July 2006, 47 urologists participated in the robot assisted laparoscopic prostatectomy mini fellowship program. The 5-day course had a 1:2 faculty-to-attendee ratio. The curriculum included lectures, tutorials, surgical case observation, and inanimate, animate and cadaveric robotic skill training. Questionnaires assessing practice patterns 1, 2 and 3 years after the mini fellowship program were analyzed. RESULTS One, 2 and 3 years after the program the response rate to the questionnaires was 89% (42 of 47 participants), 91% (32 of 35) and 88% (21 of 24), respectively. The percent of participants performing robot assisted laparoscopic prostatectomy in years 1 to 3 after the mini fellowship was 78% (33 of 42), 78% (25 of 32) and 86% (18 of 21), respectively. Among the surgeons performing the procedure there was a progressive increase in the number of cases each year with increasing time since the mini fellowship training. In the 3 attendees not performing the procedure 3 years after the mini fellowship training the reasons were lack of a robot, other partners performing it and a feeling of insufficient training to incorporate the procedure into clinical practice in 1 each. One, 2 and 3 years following the mini fellowship training program 83%, 84% and 90% of partnered attendees were performing robot assisted laparoscopic prostatectomy, while only 67%, 56% and 78% of solo attendees, respectively, were performing it at the same followup years. CONCLUSIONS An intensive, dedicated 5-day educational course focused on learning robot assisted laparoscopic prostatectomy enabled most participants to successfully incorporate and maintain this procedure in clinical practice in the short term and long term.