Update on Minimally Invasive Urologic Surgery: What’s New Jeffrey A. Cadeddu, M.D. Professor of Urology and Radiology UT Southwestern Medical Center

Surgical Revolution Across all specialties – a minimally invasive revolution Laparosopy = significant patient benefits: Pain Hospitalization Recovery Complications Scars COST

Robotic-assisted Laparoscopy

Robotic technology/techniques LESS NOTES

Can We Get Even Less Invasive?

Surgery without Scars? Yes! courtesy of A. Rane

Laparoendoscopic Single Site (LESS) Surgery Principles: Limit trocars to single incision – usually umbilical Periumbilical specimen extraction Improved cosmesis Less transmural trocars = Less pain Faster recovery

The Rationale Decrease number or eliminating ports to minimize morbidity while simultaneously improving cosmesis

Historical Perspective LESS IS NOT A NOVEL CONCEPT ! The idea of a single access site surgical procedure has been utilized since the early 1970s.

LESS Unique requirements Access – how to get instruments into “1” hole? Instrumentation loss of triangulation? collision

courtesy of J. Kaouk, D. Scott, and A. Rane Access Several custom access ports Most are “3 trocars in one” with single 2-3 cm incision courtesy of J. Kaouk, D. Scott, and A. Rane

Courtesy of P. Curcillo, MD

Camera Solutions courtesy of D. Scott

Articulating Instrumentation Degrees of motion comparable to robotic system Allows for real time adjustments Principle of dissection Instruments cross at fulcrum to avoid collision courtesy of D. Scott

LESS in General Surgery Cholecystectomy Adrenalectomy Appendectomy

LESS in Urology: Laparoscopic Nephrectomy 3-4 trocars Kidney extracted through small incision

August 2007: First report of single incision laparoscopic nephrectomy Urology 70:1039, 2007 Urology 70:1039, 2007 August 2007: First report of single incision laparoscopic nephrectomy Urology 70:1039, 2007 22

LESS Nephrectomy at UTSW (Urology, 2010) Clinical experience 30 cases 8/2007 – 12/2009 47% of all lap neph Indication: 50% benign dz

LESS Pyeloplasty Since 10/07: 50 LESS Pyeloplasties for primary UPJOs 20 robotic LESS

Robotic LESS DaVinci Si system adapted to LESS

Principles Trocars positioned at umbilical incision crossing similar to conventional LESS Multiport access technique limited by gas leak and crowding/collision of trocars/arms Use commercial port to minimize

Trocars/Instruments 8 or 12 mm camera port 5 or 8 mm robotic port 5 mm assistant port

Robotic Solution Instruments cross at midline Align trocar lines at level of skin to minimize incisional bruising

Instrumentation 30 degree UP scope Nonconventional image Creates space at GelPoint for assistant! 8 mm scissor + 5 mm graspers 5/8 mm graspers + 5 mm hook cautery 5 and/or 8 mm needle drivers

Pearls Instruments and camera moved in tandem short distances Cross instruments at incision above camera (30 deg up) and reassign instruments to right and left hands. At crossing point, top instrument can retract tissue upwards. To retract downwards need to re-cross so that grasper is below scissors/cautery.

R-LESS Pyeloplasty

Experience UTSW 5 R-LESS nephrectomies Difficulty with dividing hilum. Assistant challenged to introduce stapler if ~ 3-4 cm incision. Must use clips. 1 converted to Lap nephrectomy 20 R-LESS pyeloplasties Ease of anastomosis, no need for additional 3 mm assistant ports. Pre-place stent/ureteral access.

Published Literature

2011: Purpose-built Robotic Platform

Courtesy of David Canes

Is LESS Surgery Ready for Prime Time? Does single incision laparoscopy decrease convalescence in comparison to traditional laparoscopy while maintaining surgical outcomes?

Case-control comparison of early outcomes in SILS vs Case-control comparison of early outcomes in SILS vs. Conventional Lap Nephretomy (Eur Urol, 2009) IRB-approved, retrospective case-match series 11 SILN performed from August 2007 to March 2008 (cases) Extra 3 mm sub-xyphoid trocar for liver retraction 22 CLN performed from September 2004 to February 2007 (controls) 39

Results: Peri-operative parameters All patients Laparoscopic approach SILS Conventional P value OR time (min) Mean (SD) Median (range) 143 (42) 125 (90-240) 138 (35) 122 (90-210) 145 (45) 0.78 † EBL (mL) 125 (143) 100 (10-600) 80 (175) 20 (10-600) 147 (123) 100 (20-520) 0.001 † Morphine equivalents (mg) 15 (13) 13 (0-54) 15 (16) 8 (1-54) 15 (12) 15 (0-49) 0.69 † Change in Hgb (%) 15.3 (6.0) 15.5 (0-24) 14.1 (5.8) 15.4 (5-23) 15.8 (6.2) 16.0 (0-24) 0.52 † Length of stay (hrs) 51 (18) 52 (29-106 46 (14) 49 (30-74) 53 (19) 53 (29-106) 0.44 † * Chi-square test † Kruskal-Wallis test 40

Case-matched LESS Pyeloplasty vs. Lap Pyeloplasty Urology 2009   Conventional Lap (Range) LESS (Range) p-value Mean LOS (hrs) 74 (36-215) 77 (50-149) 0.69* Mean Operative time (min) 257 (210-360) 202 (178-240) < 0.001* Mean EBL (mL) 85 (25-200) 35 (25-50) 0.002* Mean MSO4 Eq  38 (0-119)  34 (0-117)  0.93* Grade I/II complications (%) 4 (14.3%) 2 (14.3%) 1** Grade IIIa/IIIb complications (%) 2 (10%) 3 (21.4%) 0.31** Maybe extraction incision or morcellation for nephrectomy creates additional pain? Reconstructive procedures may have more benefit?

LESS vs Standard Lap Donor Nephrectomy: Case-Match Canes, Desai, Gill et al. Eur Urol 57:95, 2010   Conventional Lap (N = 17) LESS (N = 18) p-value Mean Days on Oral Pain Meds 20 6 0.01 Mean Days Off Work 46 18 <0.01 Days to 100% recovery 83 29 0.03 No differences in LOS, OR time, EBL, analgesia equivalents or visual analog pain scores, but… Too good to be true? Confirmation Bias?

LESS vs. Standard Lap Donor Neph: Randomized Prospective Trial Group A (Standard) Group B (LESS) p Value Operating time (minutes) 175.83±47.57 172.20±38.33 0.38 Conversion to Open surgery Conversion to multiple ports LDN (%) - 2 (8%) Estimated blood loss (milliliters) 92.40±28.33 84.00±29.15 0.16 Graft artery length (millimeters) 24.36±2.43 25.25±6.23 0.26 Graft vein length (millimeters) 28.68±3.42 28.80±7.15 0.47 Graft ureter length (millimeters) 113.96±24.79 123.00±18.44 0.08 Length of incised wounds (millimeters) 133.60±16.99 51.47±14.37 <0.0001 Blood transfusion Hemoglobin drop (gm/dL) 0.87±0.77 0.68±0.87 0.21 Intra-operative complications (%) 4 (16%) 0.20 Mahesh Desai et al. Nadiad, India AAGUS 2010 25 left DN in each group

LESS vs. Standard Lap Donor Neph: Randomized Prospective Trial courtesy M. Desai

27 pts randomized

Case matched 2:1 Lap to LESS 38 and 19 pts

Importance of Cosmesis (BJUI 2011) UTSW Survey – all kidney and prostate patients (80 Lap, 17 LESS, 15 Open) PRE-OP: Ranked importance of various surgical outcomes Most important factor: Surgeon reputation Least important factor: Scar size & # Unless: Age < 50 or Benign Indication Bucher et al. Surg Endosc 2010; Jul 3. 75% would choose LESS over Lap if complication rate similar

Importance of Cosmesis (Eur Urol 2011) UTSW Survey – kidney surgery only LESS vs. Lap vs Open Overall scar satisfaction by surgery type: 67% - 43% - 40% Entire cohort cosmetic appeal of photographs of scars: 69% very pleased with LESS vs. 46% and 23% Satisfaction with their scar after viewing other scars: 80% vs. 57% vs. 50%

Observations Feasible surgical technique – the next revolution in MIS Triangulation made possible by articulating instrumentation or robotics Learning curve due to close proximity of instruments Limitations: Instrument collision due to umbilical crowding Triangulation still a problem…working envelope restrictions Limited to 3 working trocars – 4 possible if bigger incision?

Natural Orifice Translumenal Endoscopic Surgery (NOTES) “Incisionless Surgery” Transgastric (mouth) Transcolonic (anus) Transvaginal Transvesical (urethra) Advantages?: less pain, less scarring, faster recovery Proof of concept UTSW: Gettman, Cadeddu et al.: U.S., 2001, Porcine Model Reddy & Rao: India, 2004, Human Appendectomy

NOTES: Transgastric Appendectomy Reddy & Rao: India, 2004

NOTES Human Cases USA Bessler/Fowler, Columbia – 8 TV Chole Horgan/Talamini, UCSD – > 45 TV Chole (+ TG chole, TG Appy, TV Appy) Swanstrom/Soper/Hungness, Legacy (Portland) + Northwestern – > 8 TG Chole Abroad Brazil, > 200 cases, mostly TV France, ~ 20 cases, mostly TV Germany, > 200 cases, TV, rigid scope Italy, ~ 20 cases, TV

Urology NOTES NOTES nephrectomy 2002 Gettman et al. 2008 Clayman et al. 2009 human case reports

Equipment Limitations Laparoscopy Endoscopy Lack of stability and torque Lack of maneuverability and reach Inability to triangulate Lack of “surgical” instruments Inability to use multiple instruments simultaneously Visual disorientation

LESS vs. NOTES Both LESS and NOTES are contemporary minimally invasive techniques with obvious cosmetic and morbidity benefits. LESS is here and now. NOTES is still largely preclinical or investigational.