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258
S.L. Best and J.A. Cadeddu
younger patients who are more likely to have had few prior abdominal surgeries and
to be thinner, conditions that tend to be favorable for a successful LESS operation.
Last, younger patients may also be more interested in “scarless” surgery.
Despite its desirability, LESS pyeloplasty has several challenges associated with
it, namely related to the complex task of suturing the anastomosis. The loss of trian-
gulation that affects all LESS procedures particularly encumbers sewing. Strategies
for dealing with these challenges will be discussed.
Preoperative Planning and Evaluation
As is the case for the surgical management of UPJ obstructions regardless of
approach, imaging studies such as diuretic renography, computerized tomographic
(CT) angiography, intravenous urogram, and/or retrograde pyelography may be use-
ful in determining the site or source of obstruction as well as the renal function.
Additionally, CT can demonstrate the amount of perinephric fat tissue, a large amount
of which can amplify the challenges of LESS, especially early in one’s experience.
Factors that may affect the decision to proceed with a LESS rather than traditional
laparoscopic pyeloplasty are patient characteristics such as body habitus and prior
abdominal surgical history. Substantial abdominal girth increases the distance between
the operative site and the umbilicus, which can make the procedure more dif fi cult.
Additionally, the clustering of instruments and the resultant loss of triangulation can
make adhesions from prior abdominal surgeries dif fi cult to manage. Thus, thinner
patients with few or no prior abdominal operations may be prime candidates for LESS,
though certainly these challenges can be overcome with patience and experience.
A limited bowel preparation with a bottle of magnesium citrate is advisable
as it may improve the ease of visualization. Con fi rmation of a sterile urine cul-
ture is also prudent.
Finally, consideration should be given to retrograde (cystoscopic) stent place-
ment immediately prior to pyeloplasty on the day of surgery. While many sur-
geons place the ureteral stent in an antegrade fashion after transection of the
UPJ during traditional laparoscopic pyeloplasty, the limited working angles cre-
ated by LESS can make this dif fi cult.
Patient Positioning
The positioning for LESS pyeloplasty essentially mirrors that of traditional laparo-
scopic pyeloplasty. The patient can be placed in full or modi fi ed fl ank position,
depending on the surgeon’s preference. A Foley catheter draining to gravity should
be placed. Careful attention to padding is also important. Mild fl exion of the table
may be helpful in some cases though is not always necessary.
259
20 LESS: Pyeloplasty
Access to the Abdominal Cavity
The incision location for LESS pyeloplasty is typically at the umbilicus, which
provides a “straight-on” view of the UPJ as well as an opportunity to conceal the
scar. A 2–3-cm incision is typically suf fi cient and can be made in a semilunar fash-
ion, following the circle of the umbilicus itself. A variety of purpose-built LESS
ports have been developed, and the surgeon should feel free to use whichever port
he or she is most comfortable using. The insertion of these ports is typically per-
formed in a Hasson fashion, under direct vision.
As an alternative to using a custom LESS port, three standard 5-mm trocars can
be used instead. These can be inserted through a semilunar umbilical incision, simi-
lar to a custom LESS port, or they can each be inserted through separate skin inci-
sions, clustered at the umbilicus (Fig. 20.1 ).
In right-sided procedures, the insertion of a 2- or 3-mm grasper in the subxy-
phoid region can provide helpful liver retraction. In order to diminish the cosmetic
impact, this instrument can often be passed across the abdominal wall through a tiny
skin incision without the actual port.
Procedure
The goal of LESS pyeloplasty is to reproduce the operation as it is performed during
traditional laparoscopy. Therefore, the steps of the operation remain unchanged,
though the loss of triangulation and potential clashing of instruments may require
some special maneuvers. These dif fi culties can often be overcome using the standard
principles of LESS, such as crossing the instruments just inside the fascial incision,
Fig. 20.1 Use of three
separate 5-mm ports,
clustered at umbilicus, for
LESS pyeloplasty
260
S.L. Best and J.A. Cadeddu
using a fl exible endoscope, and using bent or articulating instruments. While the
merits of each of the modi fi cations are discussed elsewhere, it is important to point
out that there is no “right way” to deal with these challenges and surgeons should use
whichever combination of tools they are most comfortable using.
After port placement (and cystoscopic retrograde stent placement), the colon
is fi rst re fl ected medially. The proximal ureter is identi fi ed and mobilized, along
with the renal pelvis. A careful effort is made to identify and preserve any cross-
ing vessels. After mobilization, if a dismembered pyeloplasty is planned, the
ureter is transected at the level of the UPJ, using caution not to cut the stent if it
has already been placed. The proximal curl of the stent is dislodged from its
position inside the renal pelvis so that the transected ureter is more mobile. In
order to spatulate the ureter, due to the loss of triangulation, we fi nd it helpful
to draw the ureter toward the port, such that the cut end of the ureter is perpen-
dicular to the scissors tips (Fig. 20.2 ). The spatulated ureter and renal pelvis are
then brought anterior to any crossing vessels prior to anastomosis. The hiatus in
the renal pelvis can also be widened and any redundant tissue excised at this
time as well.
While some authors have reported accomplishing the LESS pyeloplasty anasto-
mosis without assistant trocars [ 1 ] , most report using a 3-mm instrument placed
laterally to facilitate the complex task of sewing. It has been our practice to place a
3-mm port in the mid-axillary line, through which the surgical drain can also be
drawn at the end of the procedure. Through this port, a 3-mm grasper can be placed
and used along with a standard 5-mm laparoscopic needle driver, placed through the
LESS port, to sew the anastomosis in a fashion that replicates standard laparoscopic
pyeloplasty. We typically use 3-0 polyglactin running sutures, sewing the posterior
wall fi rst, then the anterior portion.
It is advisable to leave an intraabdominal closed bulb suction drain near the site
of the anastomosis. We place a 10 Fr Jackson–Pratt drain through the site of our
mid-axillary line trocar. If a lateral assistant trocar is not used, the drain can alterna-
tively be brought out through the umbilical incision (Fig. 20.3 ).
Fig. 20.2 The angle for the
scissors to spatulate the ureter
can be improved by drawing
the transected ureter toward
the port
261
20 LESS: Pyeloplasty
Upon completion of the procedure, the port(s) are removed. The fascia does not
need to be closed if it was only traversed with separate 5-mm ports. If a purpose-
built LESS port was used, the fascial incision can be closed under direct vision with
an absorbable suture, making sure not to catch the drain with the needle if it is exit-
ing through the incision. The skin itself can then be closed in whichever cosmeti-
cally pleasing way the surgeon prefers.
Postoperative Management
The care of a patient undergoing LESS pyeloplasty is essentially the same as that of
traditional laparoscopy. Admission is typically about 48 h long so that postoperative
drain output can be monitored. A Foley catheter is left place in order to maximally
drain the urinary system, and this is usually removed after 24 h. Once this is removed,
the drain output is carefully monitored for 8–12 h to make sure there is no urine
leakage. The stent is left in place for 4–6 weeks. A diuretic renogram is typically
obtained 6 weeks after the stent removal to make sure that the kidney drains well.
Robotic LESS Pyeloplasty
The triangulation challenges of LESS have led surgeons to explore a variety of pos-
sible tools to make LESS easier. The da Vinci
®
Surgical System (Intuitive Surgical,
Sunnyvale, CA), with its articulating, wristed instruments, has been adapted for
Fig. 20.3 Immediate
post-operative image of the
LESS umbilical incision,
with the surgical drain exiting
262
S.L. Best and J.A. Cadeddu
LESS by some authors. Just as in multiport surgery, robotics may be particularly
helpful for reconstructive operations, such as pyeloplasty, where sewing is
required.
A few cases of robotic LESS pyeloplasty have already been reported in the
literature, and more are anticipated [ 2– 4 ] . Our experience with robotic LESS
pyeloplasty (unpublished data) suggests there are several modi fi cations that can
make this procedure easier to perform. We make a 2.5–3-cm curved umbilical
incision and insert a GelPOINT
®
device (Applied Medical, Rancho Santa
Margarita, CA) using the Hasson technique. Two pediatric 5-mm robotic ports,
a 12-mm camera port, and a 10-mm assistant trocar are then preplaced through
the gel in a diamond con fi guration (Fig. 20.4 ), with the camera port at the top
and the assistant’s trocar at the bottom. Pediatric instrumentation, as opposed to
the standard 8-mm robotic instruments, occupies less of the limited incision
space, reducing instrument con fl ict. The robot is then docked. We use an 8-mm
robotic camera lens oriented in the 30° up con fi guration. This modi fi cation,
a
b
Fig. 20.4 Port placement for
a robotic LESS pyeloplasty,
( a ) before and ( b ) after
docking of the robot. In this
case, two 5-mm robotic
cannulas were used, along
with two 12-mm laparoscopic
ports. The robot’s camera arm
is docked to the top port and
the lens is inserted in a “30°
up” con fi guration. The
bottom 12-mm trocar is used
by the bedside assistant
263
20 LESS: Pyeloplasty
while different from what is typically used for robotic renal surgery, diminishes
clashing between the camera and the robotic instruments as well as helps keep
the assistant trocar from being blocked externally. A 5-mm hook cautery device
and graspers are then inserted into the robotic cannula, whose “black lines,” the
remote centers, are set at the level of the fascial incision. We have found it very
useful to insert the robotic instruments such that they cross each other just inside
the fascial incision (Fig. 20.5 ). This crossing technique, also used by some sur-
geons in standard nonrobotic LESS, results in greater separation of the instru-
ments, both in and outside the body, reducing clashing. In standard LESS, this
technique can be challenging, since the instrument that comes in from the left
side of the screen on the monitor is actually controlled by the surgeon’s right
hand, and vice versa. An advantage of the robotic platform is that the master
controllers (right and left “hands”) on the console can be swapped, avoiding this
problem.
Once inserted and crossed, the tips of the instruments can be brought back toward
each other using the wristed segment. One other difference we have noted, com-
pared to traditional robotic renal surgery, is that all three of the robotic components
(camera and two instruments) must be moved in unison in order to avoid clashing.
In other words, if the surgeon wishes to move to a different part of the surgical fi eld,
he or she must alternately move the camera and working instruments together small
distances in the same direction; otherwise, the camera would bump into them and be
unable to move. In our experience, these modi fi cations on traditional robotic sur-
gery have a fairly short learning curve.
Once the robot is docked and the instruments positioned in this way, the rest of
the steps of the procedure are unchanged. Due to the ease of sewing with robotic
instrumentation, the use of the robotic platform negates the need for an additional
instrument outside the LESS incision, used by many LESS surgeons to facilitate
sewing the anastomosis.
Fig. 20.5 The remote centers
of the robotic ports ( “black
lines” ) are set at the level of
the fascial incision and then
the ports are arranged to
“cross” each other. This
increases the separation of
the instrument tips, which
decreases clashing and
restores a degree of
triangulation
264
S.L. Best and J.A. Cadeddu
Outcomes
Due to the relatively recent adoption of the LESS technique, the literature outlining
outcomes of LESS pyeloplasty, particularly in the long term, is limited. Since the
fi rst LESS pyeloplasty was reported by Desai and colleagues in 2008 [
5 ] , a number
of other series have been described using various port types as well as varying com-
binations of straight and articulating instruments [ 1, 2, 6– 10 ] . Several authors have
reported utilizing an additional small-caliber grasper, inserted through the lateral
abdominal wall (outside the LESS port) to facilitate sewing.
There is a learning curve associated with any new technique, and LESS is no
exception, particularly for a complex reconstructive operation such as pyeloplasty.
This learning curve may result in an increased rate of complications early in one’s
experience. Indeed, an investigation into the complications associated with this
learning curve by Best and colleagues found that 71 % of complications occurred in
the fi rst 10 cases of their 28 case series, with an overall complication rate of 25 %
during their preliminary experience [ 11 ] . While most of the individual case series
reported in the literature reported a low complication rate, a multiinstitutional study
focusing on complication rates for a variety of LESS procedures found the inci-
dence of complications to be 25.7 %, though most of these were minor and self-
limited [ 7 ] . Importantly, the authors found a signi fi cant difference in complication
rates between reconstructive and extirpative LESS procedures (27.1 vs. 7.8 %).
While no prospective, randomized comparisons have been conducted to date, two
institutions have performed matched comparisons between patients undergoing
LESS or standard laparoscopic pyeloplasty. Stein et al. (16 LESS patients) [ 8 ] and
Tracy et al. (14 LESS patients) [ 9 ] both found an equivalent length of stay, postop-
erative pain measures, and complication rates. They also found similar early success
rates between conventional laparoscopic and LESS pyeloplasty. A longer follow-up
will help determine if long-term success rates are indeed equivalent.
References
1. Rais-Bahrami S, Montag S, Atalla MA, et al. Laparoendoscopic single-site surgery of the
kidney with no accessory trocars: an initial experience. J Endourol. 2009;23(8):1319–24.
2. Desai MM, Berger AK, Brandina R, et al. Laparoendoscopic single-site surgery: initial hundred
patients. Urology. 2009;74(4):805–12.
3. Kaouk JH, Goel RK, Haber GP, et al. Robotic single-port transumbilical surgery in humans:
initial report. BJU Int. 2009;103(3):366–9.
4. Stein RJ, White WM, Goel RK, et al. Robotic laparoendoscopic single-site surgery using
GelPort as the access platform. Eur Urol. 2010;57(1):132–6.
5. Desai MM, Rao PP, Aron M, et al. Scarless single port transumbilical nephrectomy and
pyeloplasty: fi rst clinical report. BJU Int. 2008;101(1):83–8.
6. Desai MM, Stein R, Rao P, et al. Embryonic natural ori fi ce transumbilical endoscopic sur-
gery (E-NOTES) for advanced reconstruction: initial experience. Urology. 2009;73(1):
182–7.
265
20 LESS: Pyeloplasty
7. Irwin BH, Cadeddu JA, Tracy CR, et al. Complications and conversions of upper tract
urological laparoendoscopic single-site surgery (less): multicentre experience: results from
the NOTES Working Group. BJU Int. 2011;107(8):1284–9.
8. Stein RJ, Berger AK, Brandina R, et al. Laparoendoscopic single-site pyeloplasty: a compari-
son with the standard laparoscopic technique. BJU Int. 2011;107(5):811–5.
9. Tracy CR, Raman JD, Bagrodia A, et al. Perioperative outcomes in patients undergoing con-
ventional laparoscopic versus laparoendoscopic single-site pyeloplasty. Urology. 2009;74(5):
1029–34.
10. White WM, Haber GP, Goel RK, et al. Single-port urological surgery: single-center experience
with the fi rst 100 cases. Urology. 2009;74(4):801–4.
11. Best SL, Donnally C, Mir SA, et al. Complications during the initial experience with laparo-
endoscopic single site (LESS) pyeloplasty. BJU Int. 2011;108(8):1326–9.
267
A. Rane et al. (eds.), Scar-Less Surgery,
DOI 10.1007/978-1-84800-360-6_21, © Springer-Verlag London 2013
Keywords LESS • Nephrectomy • Robotic • Donor nephrectomy • Partial
nephrectomy • Nephroureterectomy
Introduction
Since the fi rst laparoscopic nephrectomy by Clayman et al. in 1991 [ 1 ] , there has
been a progressive development of minimally invasive urologic procedures. Upper
and lower urinary tract procedures can be performed laparoscopically through the
use of three to fi ve laparoscopic ports. However, there are well-recognized compli-
cations related to port placement. These include risk of bleeding, infection, organ
damage, and scar formation.
Ongoing re fi nement in surgical technique to reduce surgical morbidity and
improve cosmesis has led to the development of laparoscopic surgery through a
single incision site. Multiple monikers have been used to describe this approach,
such as “single-port laparoscopic surgery” (SILS), “scarless surgery,” and “one-port
umbilical surgery” [ 2 ] . In 2010, the term “laparoendoscopic single-site surgery”
and the LESS acronym were coined by consensus [ 3 ] .
The initial reports of LESS nephrectomy were described by Rane and Raman
[ 4, 5 ] . The usage of fewer port sites is believed to be associated with reduced mor-
bidity, a lower incidence of port-site hernia, and improved cosmesis [ 6 ] . In addition,
LESS has the potential to decrease postoperative pain, length of hospital stay (LOS),
duration of recovery, and time to return to work in comparison with traditional
laparoscopic surgery [
7 ] .
D. J. Lee , M.D. (*) • M. M. Desai , M.D.
Department of Urology , University of Southern California Institute of Urology ,
1441 Eastlake Avenue, Suite 7416 , Los Angeles , CA 90089 USA
e-mail: dennisjl@use.edu; adityadesai2003@gmail.com
Chapter 21
LESS: Extirpative Renal Surgery Including
Donor
Dennis J. Lee and Mihir M. Desai
268
D.J. Lee and M.M. Desai
The evolution of the LESS technique required the concomitant development of
new laparoscopic access devices, instrumentation, and optics in order to accommo-
date the unique requirements of LESS.
Access during LESS can be obtained through multiple small-diameter trocars or
through the use of multichannel ports [
8 ] . Multichannel ports allow for the insertion
of instruments and a camera through a single fascial incision. There are multiple
ports made for LESS, such as TriPort
®
, previously known as R-Port (Olympus,
Tokyo, Japan), and GelPOINT
®
(Applied Medical, Rancho Santa Margarita, CA).
Due to the limited commercial availability of multichannel ports in some regions
and the higher associated costs of multichannel ports, handmade ports have also
been described in the literature. These handmade ports are made by placing an
Alexis
®
wound retractor (Applied Medical, Rancho Santa Margarita, CA) into the
incision and then placing trocars into the cut ends of a surgical glove. The trocars
are then fi xed into place using a silk tie or a rubber band [ 9 ] .
Instrumentation also creates a distinct challenge in LESS. Conventional laparo-
scopic instruments can be used for LESS, but often result in suboptimal ergonomics
for the surgeon. The parallel insertion of the instruments results in internal and
external clashing and decreased maneuverability. These challenges have resulted in
the development of articulating and prebent instruments. The modi fi ed instruments
provide working space for the surgeon’s hands, while keeping the instrument tips
triangulated in the operative fi eld. These changes result in better ergonomics and
force application. In addition, needlescopic instruments have increased in popular-
ity as an adjunct to LESS, as they can be introduced through a small puncture with-
out a formal closure [ 8, 10 ] .
Optics have also been optimized to accommodate the needs of LESS.
Conventional laparoscopes result in external clashing because of their large camera
head and light cable exiting at 90°. Newer scopes combine light and camera sys-
tems to keep the camera head and light cord out of the operative fi eld. In addition,
extra-long scopes allow the camera operator to work outside the operative space,
providing the surgeon with more room to operate [ 8 ] .
Robotic LESS urologic surgery has also been described in the literature using
the da Vinci
®
Surgical System (Intuitive Surgical, Sunnyvale, CA). The robotic
console provides a more ergonomic work setting for the surgeon and the
EndoWrist
®
(Intuitive Surgical, Sunnyvale, CA) allows for more facile suturing.
Access can be obtained via a GelPort. However, robotic LESS surgery still
encounters problems inherent to the LESS approach: namely, limited range of
motion, extracorporeal instrument clashing, and inability to use the fourth arm for
tissue retraction [
11 ] . Modi fi cations to the existing platform have been tested in
the experimental setting to overcome the parallel arrangement of instruments. The
technique of “chopstick” surgery arranges ports so that instruments cross at the
abdominal wall, thus separating the robotic arms. The left- and right-hand assign-
ments are subsequently reassigned in the console to correct for the change in
handedness [ 12 ] . New robotic equipment is also currently being developed for the
application of LESS surgery. One such prototype is the VeSPA
®
surgical instru-
ment (Intuitive Surgical, Sunnyvale, CA) designed for use with the da Vinci Si
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