Rene Sotelo

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.

Consensus statement of the consortium for laparoendoscopic single-site surgery

Inderbir S. Gill • Arnold P. Advincula • Monish Aron • Jeffrey Caddedu • David Canes • Paul G. Curcillo II • Mihir M. Desai • John C. Evanko • Tomasso Falcone • Victor Fazio • Matthew Gettman • Andrew A. Gumbs • Georges-Pascal Haber • Jihad H. Kaouk • Fernando Kim • Stephanie A. King • Jeffrey Ponsky • Feza Remzi • Homero Rivas • Alexander Rosemurgy • Sharona Ross • Philip Schauer • Rene Sotelo • Jose Speranza • John Sweeney • Julio Teixeira

Laparoendoscopic Single-site Surgery in Urology: Worldwide Multi-institutional Analysis of 1076 Cases

BACKGROUND Laparoendoscopic single-site surgery (LESS) has gained popularity in urology over the last few years. OBJECTIVE To report a large multi-institutional worldwide series of LESS in urology. DESIGN, SETTING, AND PARTICIPANTS Consecutive cases of LESS done between August 2007 and November 2010 at 18 participating institutions were included in this retrospective analysis. INTERVENTION Each group performed a variety of LESS procedures according to its own protocols, entry criteria, and techniques. MEASUREMENTS Demographic data, main perioperative outcome parameters, and information related to the surgical technique were gathered and analyzed. Conversions to reduced-port laparoscopy, conventional laparoscopy, or open surgery were evaluated, as were intraoperative and postoperative complications. RESULTS AND LIMITATIONS Overall, 1076 patients were included in the analysis. The most common procedures were extirpative or ablative operations in the upper urinary tract. The da Vinci robot was used to operate on 143 patients (13%). A single-port technique was most commonly used and the umbilicus represented the most common access site. Overall, operative time was 160±93 min and estimated blood loss was 148±234 ml. Skin incision length at closure was 3.5±1.5 cm. Mean hospital stay was 3.6±2.7 d with a visual analog pain score at discharge of 1.5±1.4. An additional port was used in 23% of cases. The overall conversion rate was 20.8%; 15.8% of patients were converted to reduced-port laparoscopy, 4% to conventional laparoscopy/robotic surgery, and 1% to open surgery. The intraoperative complication rate was 3.3%. Postoperative complications, mostly low grade, were encountered in 9.5% of cases. CONCLUSIONS This study provides a global view of the evolution of LESS in the field of minimally invasive urologic surgery. A broad range of procedures have been effectively performed, primarily in the academic setting, within diverse health care systems around the world. Since LESS is performed by experienced laparoscopic surgeons, the risk of complications remains low when stringent patient-selection criteria are applied.

Single-port transvesical simple prostatectomy: initial clinical report.

INTRODUCTION To present the initial report of single-port transvesical enucleation of the prostate in 3 patients with large-volume benign prostatic hyperplasia. METHODS Single-port transvesical enucleation of the prostate was performed in 3 patients with large-volume (187, 93, and 92 g) benign prostatic hyperplasia. A novel single-port device (r-Port) was introduced percutaneously into the bladder through a 2.5-cm incision under cystoscopic guidance. After establishing pneumovesicum, the adenoma was enucleated in its entirety transvesically under laparoscopic visualization using standard and articulating laparoscopic instrumentation. The adenoma was extracted through the solitary skin and bladder incision after bivalving the prostate lobes within the bladder. RESULTS Single-port transvesical enucleation of the prostate was technically feasible in all 3 cases. The operative time was 6, 1.5, and 2.5 hours, and the blood loss was 900, 250, and 350 mL. In patient 1, who had previously undergone open suprapubic surgery, a bowel injury occurred during r-Port insertion; the injury was recognized and repaired intraoperatively without sequelae. The urethral Foley catheter was removed on day 4, and all patients were voiding spontaneously with a minimal postvoid residual volume and full continence. CONCLUSIONS Transvesical single-port laparoscopic simple prostatectomy is technically feasible. Additional experience at our and other institutions is necessary to determine its role in the surgical management of large-volume symptomatic benign prostatic hyperplasia.

Robotic Simple Prostatectomy

PURPOSE Minimally invasive approaches for large, symptomatic benign prostatic hyperplasia are replacing the gold standard open surgical approach, duplicating its results with lower morbidity. We describe our initial experience with robotic simple prostatectomy. MATERIALS AND METHODS Since January 2007, robotic simple prostatectomy was performed via a transperitoneal approach in 7 patients with symptomatic significant prostatomegaly on transrectal ultrasound (mean 77.66 gm). Demographic, perioperative and outcome data were recorded and all procedures were performed by the same surgeon. RESULTS Average patient age was 63.2 years (range 56 to 72) and estimated blood loss was 298 ml (range 60 to 800). Average operative time was 205 minutes (range 120 to 300). Average hospital stay was 1.4 days (range 1 to 2), average Foley catheter duration was 7 days (range 6 to 9) and drains were removed after an average of 3.75 days (range 3 to 4). Mean specimen weight on pathological examination was 50.48 gm (range 40 to 64.5). Transfusion was necessary in 1 patient. No complications were documented. Considerable improvement from baseline was noted in International Prostate Symptom Score (preoperative vs postoperative 22 vs 7.25) and maximum urine flow (preoperative vs postoperative 17.75 vs 55.5 ml per minute). Four patients were in acute urinary retention preoperatively. CONCLUSIONS Robotic simple prostatectomy is a feasible, reproducible procedure. Further publications are expected with larger series and larger prostatic adenomas.

Robotic Intracorporeal Orthotopic Ileal Neobladder: Replicating Open Surgical Principles

BACKGROUND Robotic radical cystectomy (RC) for cancer is beginning to gain wider acceptance. Yet, the concomitant urinary diversion is typically performed extracorporeally at most centers, primarily because intracorporeal diversion is perceived as technically complex and arduous. Previous reports on robotic, intracorporeal, orthotopic neobladder may not have fully replicated established open principles of reservoir configuration, leading to concerns about long-term functional outcomes. OBJECTIVE To illustrate step-by-step our technique for robotic, intracorporeal, orthotopic, ileal neobladder, urinary diversion with strict adherence to open surgical tenets. DESIGN, SETTING, AND PARTICIPANTS From July 2010 to May 2012, 24 patients underwent robotic intracorporeal neobladder at a single tertiary cancer center. This report presents data on patients with a minimum of 3-mo follow-up (n=8). SURGICAL PROCEDURE We performed robotic RC, extended lymphadenectomy to the inferior mesenteric artery, and complete intracorporeal diversion. Our surgical technique is demonstrated in the accompanying video. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Baseline demographics, pathology data, 90-d complications, and functional outcomes were assessed and compared with patients undergoing intracorporeal ileal conduit diversion (n=7). RESULTS AND LIMITATIONS Robotic intracorporeal urinary diversion was successfully performed in 15 patients (neobladder: 8 patients, ileal conduit: 7 patients) with a minimum 90-d follow-up. Median age and body mass index were 68 yr and 27 kg/m2, respectively. In the neobladder cohort, median estimated blood loss was 225 ml (range: 100-700 ml), median time to regular diet was 5 d (range: 4-10 d), median hospital stay was 8 d (range: 5-27 d), and 30- and 90-d complications were Clavien grade 1-2 (n=5 and 0), Clavien grade 3-5 (n=2 and 1), respectively. This study is limited by small sample size and short follow-up period. CONCLUSIONS An intracorporeal technique of robot-assisted orthotopic neobladder and ileal conduit is presented, wherein established open principles are diligently preserved. This step-wise approach is demonstrated to help shorten the learning curve of other surgeons contemplating robotic intracorporeal urinary diversion.

NOTES Hybrid Transvaginal Radical Nephrectomy for Tumor: Stepwise Progression Toward a First Successful Clinical Case

BACKGROUND Natural orifice translumenal endoscopic surgery (NOTES) has been used to perform nephrectomy in the laboratory; however, clinical reports to date have used multiple abdominal trocars to assist the transvaginal procedure. OBJECTIVE To present our stepwise technique development and the first successful clinical case of NOTES transvaginal radical nephrectomy for tumor with umbilical assistance without extraumbilical skin incisions. DESIGN, SETTING, AND PARTICIPANTS The four transvaginal NOTES procedures were performed at two institutions after obtaining institutional review board approval. Various operative steps were developed experimentally in three clinical cases, and on March 7, 2009, we performed the first successful case of NOTES hybrid transvaginal radical nephrectomy without any extraumbilical skin incisions. Using one multichannel access port in the vagina and one in the umbilicus, laparoscopic visualization, intraoperative tissue dissection, and hilar control were performed transvaginally and transumbilically. The intact specimen was extracted transvaginally. MEASUREMENTS All perioperative data were accrued prospectively. A stepwise progression to the successful completion of the fourth case is systematically presented. RESULTS AND LIMITATIONS Intraoperatively, at incrementally more advanced stages of the procedure, the first three NOTES clinical cases were electively converted to standard laparoscopy because of rectal injury during vaginal entry, of failure to progress, and of gradual bleeding during upper-pole dissection after transvaginal hilar control, respectively. The fourth case was successfully completed via transvaginal and umbilical access without conversion to standard laparoscopy. Operative time was 3.7 h, estimated blood loss was 150 cm(3), and hospital stay was 1 d. Final pathology confirmed a 220-g, pT1b, 7-cm, grade 2, clear-cell renal cell carcinoma with negative margins. The patient was readmitted for an intraabdominal collection that responded to drainage and antibiotics. CONCLUSIONS We report our stepwise progression and the initial successful clinical case of NOTES hybrid transvaginal radical nephrectomy for tumor, assisted with only one umbilical trocar. Although transvaginal nephrectomy is feasible in the highly selected patient with favorable intraoperative circumstances, considerable refinements in technique and technology are necessary if this approach is to advance beyond mere anecdote.

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

Transvesical robotic radical prostatectomy.

To report the technical feasibility of performing transvesical robotic radical prostatectomy (TRRP) in a cadaver.

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

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