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

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

3. Robotic-assisted Laparoscopy

4. Robotic technology/techniques
LESS
NOTES

5. Can We Get Even Less Invasive?

6. Surgery without Scars? Yes!
courtesy of A. Rane

7. 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

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

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

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

14. 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

15. Courtesy of P. Curcillo, MD

17. Camera Solutions
courtesy of D. Scott

18. 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

20. LESS in General Surgery
Cholecystectomy
Adrenalectomy
Appendectomy

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

22. 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

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

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

25. Robotic LESS
DaVinci Si system adapted to LESS

26. 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

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

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

30. 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

31. 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.

32. R-LESS Pyeloplasty

33. 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.

34. Published Literature

35. 2011: Purpose-built Robotic Platform

37. Courtesy of David Canes

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

39. 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

40. 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

41. 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 ( )
202 ( )
< 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?

42. 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?

43. 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

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

45. 27 pts randomized

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

47. 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

48. 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%

49. 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?

50. 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

51. NOTES: Transgastric Appendectomy
Reddy & Rao: India, 2004

52. 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

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

54. 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

55. 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.