Raj K. Goel

Transumbilical Single-Port Surgery: Evolution and Current Status

CONTEXT Single-port transumbilical laparoscopy, also known as embryonic natural orifice transumbilical endoscopic surgery (E-NOTES), has emerged as an attempt to further enhance cosmetic benefits and reduce morbidity of minimally invasive surgery. Within a short span, several clinical reports have emerged in the urologic literature. As this field is poised to move forward, a complete understanding of its evolution and current status is timely. OBJECTIVE To summarize and review the history of E-NOTES across surgical disciplines. This review emphasizes nomenclature, surgical technique, instrumentation, and perioperative outcomes. Specific urological and nonurological applications of single-port surgery to date are summarized. EVIDENCE ACQUISITION Using the National Library of Medicine database, the English-language literature was reviewed for the past 40 yr. Keyword searches included: scarless, scar free, single port/trocar/incision, intraumbilical, and transumbilical. Within the bibliography of selected references, additional sources were retrieved. EVIDENCE SYNTHESIS The gynecologic and general surgical literature includes approximately 19 papers fulfilling the search criteria, encompassing extirpative procedures only. The urologic literature contains eight published reports of single-trocar transumbilical procedures. These reports are summarized in a chronological manner and grouped by subject. No prospective studies comparing outcomes to standard laparoscopy have been reported. Technical feasibility has been demonstrated for a broad range of extirpative and reconstructive procedures on the upper and lower urinary tracts, including simple and radical nephrectomy, donor nephrectomy, renal cryotherapy, pyeloplasty, ileal ureteral replacement, sacrocolpopexy, and varicocelectomy. CONCLUSIONS E-NOTES has made its initial forays into laparoscopic surgery. Ongoing refinement in technique and instrumentation is likely to expand its future role.

Single-Port Laparoscopic Surgery in Urology: Initial Experience

OBJECTIVES To present our initial experience with single-port laparoscopic urologic surgery using the Uni-X Single Port Access Laparoscopic System, a single port, multichannel cannula, with specially designed curved laparoscopic instrumentation. METHODS We performed single-port laparoscopic surgery in 10 patients, including renal cryotherapy in 4, wedge kidney biopsy in 1, radical nephrectomy in 1, and abdominal sacrocolpopexy in 4. For the transperitoneal approach, the multichannel port was inserted transumbilically, and for retroperitoneoscopy, the port was inserted at the tip of the 12th rib. Data were collected prospectively into our institutional review board-approved data registry. RESULTS Since September 25, 2007, a total of 10 patients have undergone single-port laparoscopic surgery for various upper abdominal and pelvic pathologic findings. All cases were completed successfully, without conversion to a standard laparoscopic approach. The total operative time for the various kidney procedures was 2.5 hours (range 2 to 3.2) and was 2.5 hours (range 2 to 3) for sacrocolpopexy. The mean blood loss was 100 mL for the renal procedures and 90 mL for sacrocolpopexy. The hospital stay was 2.8 days (range 1 to 8) for the kidney procedures and 2 days for sacrocolpopexy. One complication occurred in a patient with baseline congestive heart failure who underwent cryoablation and required oxygen mask ventilation postoperatively that delayed her hospital discharge for 1 week. The same patient, who was anemic preoperatively, was transfused with 3 U of packed red blood cells, although the postoperative computed tomography scan revealed a small perinephric hematoma. CONCLUSIONS Single-port laparoscopic renal cryotherapy, wedge kidney biopsy, radical nephrectomy, and abdominal sacrocolpopexy are safe and feasible. Additional experience and continued investigation are warranted.

Single-port Urological Surgery: Single-center Experience With the First 100 Cases

OBJECTIVES To present perioperative outcomes in an observational cohort of patients who underwent LaparoEndoscopic Single Site (LESS) surgery at a single academic center. METHODS A prospective study was performed to evaluate patient outcomes after LESS urologic surgery. Demographic data including age, body mass index, operative time, estimated blood loss, operative indications, complications, and postoperative Visual Analog Pain Scale scores were accrued. Patients were followed postoperatively for evidence of adverse events. RESULTS Between September 2007 and February 2009, 100 patients underwent LESS urologic surgery. Specifically, 74 patients underwent LESS renal surgery (cryoablation, 8; partial nephrectomy, 15; metastectomy, 1; renal biopsy, 1; simple nephrectomy, 7; radical nephrectomy, 6; cyst decortication, 2; nephroureterectomy, 7; donor nephrectomy, 19; and dismembered pyeloplasty, 8) and 26 patients underwent LESS pelvic surgery (varicocelectomy, 3; radical prostatectomy, 6; radical cystectomy, 3; sacral colpopexy, 13; and ureteral reimplant, 1). Mean patient age was 54 years. Mean body mass index was 26.2 kg/m(2). Mean operative time was 199 minutes. Mean estimated blood loss was 136 mL. No intraoperative complications occurred. Six patients required conversion to standard laparoscopy. Mean length of hospitalization was 3 days. Mean Visual Analog Pain Scale score at discharge was 1.5/10. At a mean follow-up of 11 months, 9 Clavien Grade II (transfusion, 7; urinary tract infection, 1; deep vein thrombosis, 1) and 2 Clavien Grade IIIb (recto-urethral fistula, 1; angioembolization, 1) surgical complications occurred. CONCLUSIONS In our experience, LESS urologic surgery is feasible, offers improved cosmesis, and may offer decreased pain. Complications are consistent with the published data. Whether LESS urologic surgery is superior in comparison with standard laparoscopy is currently speculative.

Robotic single‐port transumbilical surgery in humans: initial report

To describe our initial clinical experience of robotic single‐port (RSP) surgery.

Single-Port Laparoscopic Radical Prostatectomy

OBJECTIVES To present the initial experience in laparoscopic radical prostatectomy performed exclusively through an umbilical incision using a single three-channel port and specially designed flexible laparoscopic instrumentation. METHODS Since November 26, 2007, we have performed single-port laparoscopic radical prostatectomy in 4 patients diagnosed with prostate cancer. Patients with early-stage prostate cancer (T1c), no previous pelvic surgery, and a body mass index <or=35 kg/m(2) were selected for single-port laparoscopic radical prostatectomy. A multichannel port was inserted transperitoneally through a 1.8-cm umbilical incision. No additional extraumbilical instruments or ports were inserted. Urethrovesical anastomosis was performed using free-hand interrupted suturing and extracorporeal knot tying. Data were collected prospectively into our institutional review board-approved data registry. RESULTS All cases were completed successfully, without conversion to a standard laparoscopic approach. The total operative time was 285 +/- 30 minutes, with a mean operative time for prostate excision and urethrovesical anastomosis of 3.25 hours and 1.1 hours, respectively. The mean blood loss was 288 +/- 131 mL, and no patient required a blood transfusion. The hospital stay was 2.5 +/- 0.6 days. The Foley catheter was removed 2 weeks (range 1-3) after surgery. No intraoperative complications occurred; however, 1 patient developed a rectourethral fistula that was noted 2 months after surgery. At 18 weeks of follow-up, 3 patients used 1 or 0 pads for continence daily, 2 patients had positive margins noted at the site of extracapsular extension, and all patients had an undetectable prostate-specific antigen level. CONCLUSIONS Single-port laparoscopic radical prostatectomy is feasible. Additional investigation is needed to evaluate the safety and oncologic adequacy of this new approach.

Single-Port Laparoscopic and Robotic Partial Nephrectomy

BACKGROUND Partial nephrectomy (PN) for small renal masses provides effective oncologic outcomes. Single-port laparoscopic (SPL) and robotic surgeries are evolving approaches to advance minimally invasive surgery. OBJECTIVE To determine the feasibility of laparoscopic and robotic single-port PN. DESIGN, SETTING, AND PARTICIPANTS Since 2007, evaluation of patients undergoing SPL and single-port robotic (SPR) PN at a primary referral center was performed. Patients with small, solitary, exophytic-enhancing renal masses were selected. Patients with a solitary kidney, endophytic or hilar tumors, and previous abdominal and/or kidney surgery were excluded. Perioperative and pathologic data were entered prospectively into an institutional review board (IRB)-approved database. INTERVENTIONS Tumor location determined either an open Hasson transperitoneal or retroperitoneal approach. A single multichannel port or Triport provided intra-abdominal access. The Harmonic Scalpel was used for tumor excision under normal renal perfusion. The da Vinci surgical robot was used for SPR cases. MEASUREMENTS Patient demographics, perioperative, hematologic, and pathologic data as well as pain assessment using the Visual Analog Pain Scale (VAPS) were assessed. RESULTS AND LIMITATIONS A total of seven patients underwent single-port PN (SPL=5, SPR=2). One patient with a right anterior upper-pole mass required conversion from SPL to standard laparoscopy following tumor excision because of intraoperative bleeding. Pathology revealed six lesions compatible with renal cell carcinoma (RCC) and one benign cyst. One negative frozen section came back focally positive on final histopathology. All other surgical margins were negative. A mean difference of 3.0+/-2.0 g/dl in hemoglobin was noted in all patients. Minimal pain was noted at discharge following both laparoscopic and robotic single-port surgery (VAPS=1.7+/-1.2 vs 1+/-0.5/10). CONCLUSIONS SPL and SPR PN is feasible for select exophytic tumors. Robotics may improve surgical capabilities during single-port surgery.

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.

Robotic NOTES (Natural Orifice Translumenal Endoscopic Surgery) in Reconstructive Urology: Initial Laboratory Experience

OBJECTIVES To present an initial experience with robotic natural orifice translumenal surgery (R-NOTES) in reconstructive urology using the da Vinci surgical system. METHODS In 10 female farm pigs (mean weight, 34.5 kg), 10 pyeloplasties (right 5, left 5), 10 partial nephrectomies (right 5, left 5), and 10 radical nephrectomies (right 5, left 5) were performed. The robot telescope and the first robotic arm were placed through a single 2-cm umbilical incision, and the second robotic arm was placed through the vagina. RESULTS All 30 R-NOTES procedures were performed successfully without any addition of laparoscopic port or open conversion. Mean length of the umbilical incision was 2.6 cm. Mean operative time was 154 minutes, and mean estimated total blood loss was 72 mL. Mean warm ischemia time in the partial nephrectomy group was 25.4 minutes. There were no intraoperative complications. There were no robotic system failures during the entire experiment. We did not find any significant difference when comparing right-side and left-side procedures. When analyzing the learning curve, only robot preparation time reached a statistically significant inverse correlation with increasing number of cases (r = -0.72, P = .018). CONCLUSIONS Robotic NOTES pyeloplasty, partial nephrectomy, and radical nephrectomy are feasible and safe in the porcine model. This approach has the potential for a less morbid and scarless outcome. Intracorporeal suturing is significantly enhanced using the robot, especially through the challenging translumenal natural orifice approach. Further development of robots adaptive to NOTES would boost efforts toward clinical NOTES applications.

Single Port Access Renal Cryoablation (SPARC): A New Approach

BACKGROUND Cryoablation has been performed laparoscopically for small renal masses using 3-4 ports with promising oncologic results. OBJECTIVES To report the initial experience of Single Port Access Renal Cryoablation (SPARC). DESIGN, SETTING, AND PARTICIPANTS Beginning in September 2007, outcomes of patients undergoing SPARC have been recorded into an IRB approved database. Patients with localized small renal mass (<3 cm) ineligible for partial or radical nephrectomy were included. Patients with multiple abdominal surgeries or solitary kidneys were excluded. INTERVENTION The novel multichannel single port was positioned in the umbilicus during the transperitoneal approach and at the tip of the 12th rib during the retroperitoneal approach. Intraoperative ultrasound was used to localize and observe the renal mass during cryoablation. MEASUREMENT Operative time, blood loss, hospital stay, and complications were noted. Tumor characteristics and follow-up CT scans were evaluated. RESULTS AND LIMITATIONS All six cases, four retroperitoneal and two transperitoneal, underwent SPARC without conversion to laparoscopy or open surgery. Patient age and body mass index was 73+/-9 yr and 33+/-10 kg/m2, respectively. Mean tumor size was 2.6+/-0.4 cm. Total freeze time was 15+/-1.8 min. There were no intraoperative complications and mean hospital stay was 2.3 d. One patient had a prolonged hospital stay due to preexisting respiratory condition. CT with contrast was performed in three patients and documented no residual tumor enhancement. Although flexible laparoscopic instruments allow parallel insertion through a single port, surgical range of motion is limited and clashing of instruments is frequent. CONCLUSION Single Port Access Renal Cryoablation (SPARC) for small renal masses is feasible and safe. Transperitoneal approach provides a virtually scarless surgery since the surgical incision is hidden in the umbilicus. Further studies are needed to define the role of and evaluate the potential advantages of single port surgery.

Pure Natural Orifice Translumenal Endoscopic Surgery (NOTES) Transvaginal Nephrectomy

Natural orifice translumenal endoscopic surgery (NOTES) within urology has largely been limited to experimental animal studies and diagnostic procedures in humans. Attempts to complete a pure NOTES transvaginal nephrectomy have thus far been unsuccessful. We report the first clinical experience with pure NOTES transvaginal nephrectomy. A 58-year-old woman presented with recurrent urinary tract infections and an atrophic right kidney. Transvaginal access was obtained through a 3-cm posterior colpotomy. The right kidney was mobilized, the renal hilum was divided, and the specimen was removed through the vaginal incision. Operative time was 420 min. Estimated blood loss was 50 ml. There were no perioperative complications.