Mitchell R. Humphreys

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.

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

Bilateral laparoscopic nephrectomy for significantly enlarged polycystic kidneys: a technique to optimize outcome in the largest of specimens

To present our experience with bilateral laparoscopic nephrectomy (BLN) for symptomatic autosomal‐dominant polycystic kidney disease (ADPKD), as surgical management of massively enlarged polycystic kidneys can be a daunting task.

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

Holmium Laser Enucleation of the Prostate—Outcomes Independent of Prostate Size?

PURPOSE Generally treatment decisions for benign prostatic hyperplasia are based on prostate size and surgeon experience. Prostates greater than 100 gm often require open surgery. However, less invasive options are available. Randomized, controlled trials have demonstrated that holmium laser enucleation of the prostate is a viable and effective treatment for benign prostatic hyperplasia. We examined the outcome of holmium laser enucleation of the prostate based on prostate size. MATERIALS AND METHODS We retrospectively reviewed the records of all patients in our institutional review board approved database who underwent holmium laser enucleation of the prostate from January 1999 to October 2006. Patients were divided into 3 cohorts based on preoperative transrectal ultrasound prostate measurements, including less than 75, 75 to 125 and more than 125 gm. Patients with prostate cancer were excluded from study. Demographic, laboratory, operative, preoperative and postoperative data were obtained. RESULTS As prostate size increased, so did prostate specific antigen, and the urinary retention and enucleation rates. Hospitalization, catheterization, preoperative and postoperative outcomes were similar among the groups. On linear regression the decrease in prostate specific antigen highly correlated with the amount of tissue removed (p <0.0001). The complication rate was similar among the treatment groups. All patients did equally well in terms of postoperative urinary function independent of prostate size. CONCLUSIONS Holmium laser enucleation of the prostate is a safe and effective minimally invasive treatment for benign prostatic hyperplasia. It improved patient prostate specific antigen, American Urological Association symptom score and maximum urinary flow rate independent of the amount of benign prostatic hyperplasia present. Our results demonstrate the advantage of holmium laser enucleation of the prostate to treat all prostates regardless of size with favorable and equivalent outcomes.

Natural Orifice Translumenal Endoscopic Surgical Radical Prostatectomy : Proof of Concept

BACKGROUND AND PURPOSE Innovations in minimally invasive surgery have led to the proposal of incision-free natural orifice translumenal endoscopic surgery (NOTES). The purpose of this manuscript is to describe the initial technique of natural orifice translumenal endoscopic surgical radical prostatectomy (NOTES-RP). MATERIALS AND METHODS NOTES-RP was performed on four male cadavers in a surgical simulation laboratory setting. The 100 W holmium:yttrium-aluminum-garnet laser, 550 microm end-firing laser fiber, 26F resectoscope, 7F laser stabilizing catheter, and continuous irrigation were used to radically resect and deliver the prostate of each cadaver into the bladder. The neurovascular bundles were preserved bilaterally, as well as the dorsal venous complex, bladder neck, and external sphincter. The entire resection was performed with the laser, while a rigid offset 27F nephroscope was used to perform the vesicourethral anastomosis using a laparoscopic suture device and knot pusher in an interrupted fashion. The prostate tissue was removed endoscopically with a tissue morcellator. After the initial NOTES-RP, a pelvic exploration with biopsy of neurovascular bundles, bladder, and urethral margins was performed. RESULTS NOTES-RP was successfully executed in the cadaveric model. Pathologic evaluation of tissue demonstrates complete removal of all prostate tissue with preservation of the neurovascular bundles bilaterally as well as the external urinary sphincter. CONCLUSION The present work demonstrates the feasibility of NOTES-RP in the cadaver model. While further testing and instrument modification are necessary before clinical application, this concept demonstrates the evolving nature of minimally invasive surgery and what could be possible for patients.

Holmium laser enucleation of the prostate: efficiency gained by experience and operative technique.

PURPOSE Holmium laser enucleation of the prostate is highly effective for symptomatic benign prostatic hyperplasia. Despite its steep learning curve the procedure is an efficient treatment, especially for large prostate glands. We determined the change in enucleation efficiency with time with increased operative experience and improved technique. MATERIALS AND METHODS We reviewed the records of all 949 consecutive men who underwent holmium laser enucleation of the prostate between 1999 and 2007. Patients were excluded from analysis when enucleated gm or time was not recorded and enucleated tissue was less than 5 gm. Efficiency was measured in gm enucleated prostate tissue per minute. Descriptive statistics on laser time, gland weight and efficiency were evaluated in an 8-year period. RESULTS A total of 91 patients met study exclusion criteria, leaving 858 available for evaluation. Mean enucleation time was 94 minutes (range 12 to 485). Mean prostate specimen weight was 77 gm (range 5 to 376). Mean efficiency or enucleation rate was 0.55 vs 1.32 gm per minute in the first 4 vs the last 5 years. Further efficiency improvements were noted in the last 5 years with a mean of 1.57 gm per minute enucleated in the last 2 years. CONCLUSIONS As experience with holmium laser enucleation of the prostate grows, advances in operative technique have been made. Prostatic enucleation efficiency continues to improve, further strengthening the role of holmium laser enucleation of the prostate for benign prostatic hyperplasia of small and large prostate glands.

Comparison of total, selective, and nonarterial clamping techniques during laparoscopic and robot-assisted partial nephrectomy

PURPOSE This study evaluates the feasibility, perioperative, and renal functional outcomes with total, selective, and nonarterial clamping techniques during minimally invasive partial nephrectomy. METHODS A retrospective review of laparoscopic and robot-assisted partial nephrectomies by a single surgeon from January 2007 to July 2010 was performed. Patients underwent total hilar clamping, selective (segmental) artery clamping, progressive clamping from segmental to main renal artery clamping, or resection without hilar clamping. Patient demographic, perioperative, and oncologic outcomes were analyzed. Change in renal function was assessed by glomerular filtration rate (GFR) calculation and differential function on pre- and postoperative renal scans. RESULTS A total of 68 patients underwent laparoscopic or robot-assisted partial nephrectomy. Those with a history of surgery for renal masses and elective conversion to radical nephrectomy were excluded. A total of 57 patients were analyzed (32 total hilar, 8 progressive arterial clamping, 13 selective arterial, and 4 without clamping). There were no significant differences in preoperative patient or disease characteristics between the groups. The progressive clamping technique was found to significantly decrease the total renal ischemia time compared with the total hilar clamp technique. There was no other significant difference in transfusion rate, complications, or other postoperative outcomes. There were no significant differences between the groups in intermediate-term (mean 411 days) renal function changes. CONCLUSIONS Minimally invasive partial nephrectomy without vascular occlusion and with selective arterial clamping is feasible and can be safely performed. With this intermediate-term follow-up there was no clinically significant benefit seen for selective regional or nonischemic techniques.

Multicenter Analysis of Postoperative CT Findings After Percutaneous Nephrolithotomy: Defining Complication Rates

OBJECTIVES To perform a multi-institutional study to characterize CT-detected complications after PNL. Computed tomography (CT) is commonly performed after percutaneous nephrolithotomy (PNL). One benefit of this imaging modality is the detection of procedure-related complications. Presently, the incidence of such complications is not well-defined. PATIENTS AND METHODS PNL procedures performed at 5 stone referral centers between July 2007 and June 2008 were reviewed. All patients undergoing CT within 24 hours after surgery were selected for further analysis. All CT studies were reviewed by a staff radiologist. RESULTS One-hundred ninety-seven patients satisfied the study inclusion criteria. A body mass index >30 was present in 27.5% of patients. Treated stone burden was staghorn in 70 (35.5%), >2 cm in 72 (36.5%), and <2 cm in 55 (28%). Six treated renal units (3%) were ectopic; 45.4% of calculi were predominantly lower pole. Thoracic complications encountered were atelectasis in 88 (44.7%), pleural effusion in 17 (8.6%), pneumothorax in 3 (1.5%), hemothorax in 2 (1%), and hydrothorax in 1 (0.5%). Renal complications were perinephric hematoma in 15 (7.6%), collecting system perforation in 4 (2%), subcapsular hematoma in 3 (1.5%), urinoma in 2 (1%), and pseudoaneurysm in 1 (0.5%). There was 1 trans-splenic nephrostomy without splenic hematoma. No injuries to hollow viscera were detected. Two patients (1%) were found to have ascites. CONCLUSIONS Major post-PNL complications detected by CT are uncommon, and when encountered, they are generally amenable to conservative management.

Incontinence after radical prostatectomy: A patient centered analysis and implications for preoperative counseling

PURPOSE Incontinence after radical prostatectomy is common yet poorly defined in the current literature. We aimed to accurately characterize incontinence after robot-assisted radical prostatectomy to achieve improved preoperative patient counseling. MATERIALS AND METHODS After receiving institutional review board approval we performed a cross-sectional survey of the first 600 patients with prostate cancer who underwent robot-assisted radical prostatectomy at our institution. The International Consultation on Incontinence Modular Questionnaire-Lower Urinary Tract Symptoms Quality of Life and Urinary Incontinence Short Form were used to evaluate incontinence and quality of life after robot-assisted radical prostatectomy. Surveys were mailed by a third party. Data were analyzed on the prevalence of incontinence after robot-assisted radical prostatectomy. More specifically we characterized in detail the nature of incontinence and its effect on quality of life. RESULTS The response rate was 68% (408 of 600 participants). Response time since surgery was 2.5 months to 4 years. Overall incontinence bother scores and ratings of life interference were quite low. Patients reported that most incontinence occurred during physical activity but 35% reported interference with sleep. Of the patients 31% experienced some anxiety due to urinary difficulties and 51% had to occasionally change clothes due to leakage. Patients did not report much interference with traveling, visiting friends or family and family life. The most bothersome aspects of incontinence were its effects on partner relationship, sexual life and energy levels. CONCLUSIONS Despite patient concerns of incontinence after prostatectomy they report little interference with quality of life.