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289
22 LESS: Adrenal Surgery
Conclusions
LESS adrenalectomy has been reported as a safe and feasible extension of conventional
laparoscopy to minimize incisions as well as decrease postoperative pain and convales-
cence time without signi fi cantly compromising other operative parameters. This tech-
nique has been used in a variety of centers for extirpative surgery for a wide range of
adrenal pathologies. In the future, LESS adrenal surgery will likely be provided as a
viable surgical option by more urologists, providing a more minimally invasive approach
than the current gold standard laparoscopic adrenalectomy for most adrenal masses.
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22 LESS: Adrenal Surgery
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293
A. Rane et al. (eds.), Scar-Less Surgery,
DOI 10.1007/978-1-84800-360-6_23, © Springer-Verlag London 2013
Keywords LESS • Laparoendoscopic single-site surgery • Reconstructive surgery
Pelvic urological surgery • Reconstructive urological surgery • Single port • LESS
urology • Pelvic reconstructive urological surgery
Abbreviations
EBL Estimated blood loss
LOS Length of stay
OR Operating room
VAPS Visual analog pain scale
LESS Laparoendoscopic single-site surgery
BMI Body mass index
Introduction
Over the last two decades, laparoscopic urologic surgery has become an established
approach for the treatment of various urological diseases [ 1, 2 ] . Since the very
beginning, pioneers in laparoscopic urology were at a disadvantage not just from the
viewpoint of de fi ning and learning a new procedure, but also from the lack of appro-
priate instruments [ 3 ] . In the early days, laparoscopic urological procedures were
primarily extirpative. With increasing experience and the development of new tools,
laparoscopic surgery became more widespread. Nowadays, even complex
A. L. de Castro Abreu , M.D. (*) • M. Aron , M.D., MCh, FRCS
Department of USC Institute of Urology, Center for Advanced Robotic and Laparoscopy
Surgery, USC Institute of Urology, Keck Medical Center of USC, University of Southern
California , 1411 East Lake Avenue, Suite 7416 , Los Angeles , CA 90089-2211 , USA
e-mail: andreluisabreu@gmail.com ; monisharon@hotmail.com
Chapter 23
LESS: Pelvic Reconstructive Urological Surgery
André Luis de Castro Abreu and Monish Aron
294
A.L. de Castro Abreu and M. Aron
reconstructive urological procedures can be performed laparoscopically that com-
pare favorably to conventional open surgery [ 4 ] .
The fundamental rationale behind the success of laparoscopy is the reduced
trauma of access while reproducing the excellent outcomes of open surgery with
the bene fi ts of a quicker recovery, decreased blood loss, decreased postoperative
pain, and superior cosmesis, among others. Conventional laparoscopic proce-
dures are performed using multiple ports placed in different parts of the abdomen,
which allows triangulated access to the organ of interest. The triangulation
between the ports allows excellent visualization of the operative fi eld and facili-
tates the optimal angles to retract structures and perform a variety of surgical
maneuvers.
Most recently, laparoendoscopic single-site surgery (LESS) emerged as an evo-
lution of conventional laparoscopy to further improve cosmesis and provide a poten-
tially “scarless” surgery [
5, 6 ] .
LESS most commonly uses a multichannel device through a single skin incision
to perform laparoscopic interventions [ 7 ] . Despite the “loss” of traditional triangu-
lation between ports, a wide variety of extirpative and reconstructive urinary tract
surgeries have been performed using the LESS platform [ 8 ] .
In this chapter, we present a review of the literature pertaining to the use of LESS
in reconstructive pelvic urologic surgery.
Materials and Methods
A comprehensive electronic literature review was performed using PubMed as the
source, for papers published in the English language between and including January
2001 and June 2011. The keywords used for the search were “LESS,” “single port,”
“laparoendoscopic single-site surgery,” “reconstructive urologic surgery,” and “pel-
vic reconstructive urologic surgery” [ 9 ] .
Results
A total of eight original articles met the criteria of LESS for pelvic reconstructive
urological surgery although there was some overlap of cases among the case series
reported [ 10– 17 ] .
The results are summarized in Tables 23.1 , 23.2 , and 23.3 . Overall, reconstruc-
tive pelvic urological surgeries were performed in 27 patients, encompassing six
different types of procedures. The most common procedure ( n = 14, 52 %) was
abdominal sacrocolpopexy. In three cases (11.1 %), the da Vinci
®
(Intuitive Surgical,
Sunnyvale, CA) robot assisted LESS sacrocolpopexy. The mean age of the patients
ranged from 20 to 77 years, and the mean BMI ranged from 26 to 31.5 kg/m
2
. In
92 % ( n = 24) of the cases, the approach was transperitoneal with the single port
295
23 LESS: Pelvic Reconstructive Urological Surgery
Table 23.1 Demographics of LESS reconstructive urological pelvic surgery series
Author Procedure n Indication Technique Age (year)
a
BMI (kg/m
2
)
a
Previous surgery
White
b
[ 10, 11 ] ASC
c
10 POP I (1), POP II
(9)
Retroperitoneal
mesh
59.5 25.8 Pelvic surgery for
prolapse in fi ve
patients
White
b
[ 11 ] Ureteral reimplant 1 NA Psoas hitch NA NA NA
Tome [
12 ] ASC 1 POP 4 Retroperitoneal
mesh
52 NA Vaginal hysterec-
tomy, TOT,
perineoplasty
Ingber [
13 ] Excision of foreign
body in the
bladder
2 Sling mash inside
bladder
Sling mesh
excision
77 31.5 Midurethral sling
Stolzenburg [
14 ] Bladder
diverticulec-
tomy
4 8.5 (4–9) cm
bladder
diverticulum
Bladder
diverticulec-
tomy
51 26 NA
Desai
d
[ 15, 16 ] Ureteral reimplant 2 Ureteral stricture Psoas hitch
d
42, 22 25, 20 Vaginal
hysterectomy
Desai
d
[ 15, 16 ] Ileal ureter 3 Ureteral stricture Ileal ureter
replacement
49 (25) 26 (2) Ureteral instrumen-
tation for
recurrent stone
disease
Nogueira [
17 ] Augmentation
enterocysto-
plasty
1 Neurogenic bladder Subtotal
cystectomy +
enterocysto-
plasty
20 NA NA
ASC abdominal sacral colpopexy, n number of patients, POP pelvic organ prolapse, BMI body mass index, TOT transobturatory sling, NA not available
a
Results in mean (standard deviation)
b
The same group published 13 ASC in the same year, including two robotic LESS cases. We assume that it was the same cohort of patients with the addition
of three new cases
c
Concomitant procedures were performed: tension-free vaginal tape (1), trans-obturator tape (5), and vaginal cystocele repair (1) were performed
d
The same author published in the same year a ureteral reimplant using a Psoas hitch ( n = 1) technique; in the other case the technique was not mentioned
296
A.L. de Castro Abreu and M. Aron
placed at the umbilicus, and the mean skin incision length ranged from 1.5 to 5 cm
(Table 23.1 ). In 25 (96 %) procedures, commercial ports available in the market
were used with or without articulating or prebent instruments and fl exible-tip cam-
eras speci fi cally designed for LESS (Table 23.2 ).
The mean operative time ranged from 113 to 300 min, and the mean estimated
blood loss ranged from 47.5 to 250 ml. Blood transfusion was not required in any
case. Except for one series of abdominal sacrocolpopexy, all other series employed
additional maneuvers such as percutaneous placed sutures, additional transperito-
neal needlescopic grasper, transurethral grasper, extracorporeal knots, or exterioriza-
tion of the bowel, to expose the operative fi eld or to facilitate retraction or suturing.
There were no conversions to standard laparoscopic, robotic, or open surgery.
There were no intraoperative complications. Only one (3.7 %) postoperative com-
plication occurred. It was anastomotic urine leak requiring nephrostomy tube in one
patient that underwent ileal ureter replacement. No patient died. In three series, the
visual analog pain scale (VAPS, minimum 1 and maximum 10) scores were evalu-
ated; the mean VAPS ranged from 0.7 to 3. The mean hospital stay ranged from
19.25 h to 6 days. Cosmesis was not evaluated by any validated questionnaires in
any series. There was no recurrence or treatment failure during the short follow-up
(Table 23.3 ).
Discussion
With the evolution of laparoscopy in the last two decades and with increasing expe-
rience, even advanced reconstructive surgeries can be performed laparoscopically
[ 4 ] . Although feasible, complex reconstructive urological procedures requiring
Table 23.2 Instruments used for LESS reconstructive urological pelvic surgery
Procedure Port type Instrument type Camera type
ASC [
10, 11 ] Uni-X Standard and
articulating
5-mm fl exible; 0°
Ureteral reimplant [
11 ] NA da Vinci platform da Vinci platform
ASC [
12 ] Alexis + hand-
made
Conventional
laparoscopic
10-mm rigid; 0°
Excision of foreign body in
the bladder [
13 ]
TriPort Standard and
articulating
NA
Bladder diverticulectomy
[
14 ]
TriPort Straight and prebent 5-mm HD 30°
Ureteral reimplant [
15, 16 ] R-Port Straight and prebent 5-mm 30° rigid or
0° fl exible-tip
Ileal ureter [
15, 16 ] R-Port Straight and prebent 5-mm 30° rigid or
0° fl exible-tip
Augmentation enterocysto-
plasty [
17 ]
QuadPort Standard and
articulating
5-mm fl exible; 0°
ASC abdominal sacral colpopexy, NA not available
297
23 LESS: Pelvic Reconstructive Urological Surgery
Table 23.3 Intraoperative and follow-up of LESS reconstructive urological pelvic surgery
Procedure Access
Incision
(cm)
a
Additional port
or maneuver VAPS
a
OR time
(min)
a
EBL
(ml)
a
LOS
(days)
a
Conversion/
complication Follow-up
ASC [ 10, 11 ] Umbilicus;
transperitoneal
1.8 None 0.7/10 162 (25) 47.5 1.5 No/no 6 months; one vaginal
cystocele repair
and two TVT
Ureteral reimplant [
11 ] NA NA NA 3/10 180 100 3 No/no MAG3 normal
ASC [ 12 ] Umbilicus;
transperitoneal
3.5 None
b
(external
sutures, knotless)
NA 150 100 <1 No/no 3 months, apical
anatomic success
Excision of foreign
body in the bladder
[ 13 ]
Transvesical 1.5 None
c
(transurethral
grasper)
3/10 113 100 <1 No/no 7 months; no mesh
erosion recurrence
Bladder diverticulec-
tomy [ 14 ]
Umbilicus;
transperitoneal
NA None
d
(external
sutures)
1.25 130
(median)
<150 NA No/no 1, 3, and 6 months; not
detailed
Ureteral reimplant
[ 15, 16 ]
Umbilicus;
transperitoneal
2 2-mm grasper NA 210, 140 100, 250 2 No/no Unobstructed drainage
Ileal ureter [ 15, 16 ] Umbilicus;
transperitoneal
3 2-mm grasper
e
(exteriorized
bowel)
NA 330 (42) 170 (113) 4 No/1
f
Unobstructed drainage
Augmentation
enterocystoplasty
[ 17 ]
Umbilicus;
transperitoneal
5 None
g
(exteriorized
bowel)
NA 300 <100 6 No/no 1-month improvement
in bladder capacity
ASC abdominal sacral colpopexy, NA not available, TVT tension-free vaginal tape, VAPS visual analog pain scale, OR operating room, EBL estimated blood loss, LOS
hospital stay
a
Results in mean (standard deviation)
b
Two external (percutaneous) sutures were used to retract the sigmoid colon (laterally) and the vagina (anteriorly) and weck clips were applied at the end of the stitch to
avoid intracorporeal knots
c
In one patient a transurethral Maryland grasper was used to aid suturing and hemostasis
d
External (percutaneous) suture was used to retract the diverticulum
e
Bowel was exteriorized to prepare the ileal graft and to reconstruct the bowel
f
Anastomotic urine leak requiring nephrostomy drainage in one patient
g
Bowel was exteriorized to prepare the graft and to reanastomose the bowel. A combination of intracorporeal and extracorporeal knot tying was used to facilitate the
anastomosis
298
A.L. de Castro Abreu and M. Aron
extensive intracorporeal suturing remain challenging. With an aim to further improve
cosmesis and decrease surgical morbidity, LESS emerged as an evolution of the
conventional laparoscopic procedure.
In this chapter we reviewed the LESS literature pertaining to pelvic reconstruc-
tive urological surgery. LESS is still in its infancy; many surgeons are still on the
learning curve, and the development of specialized instruments is still lagging
behind surgical needs. Pelvic reconstructive urological LESS poses multiple chal-
lenges, and this is one of the reasons behind the paucity of publications in this area.
In fact, a recent multiinstitutional analysis showed that 86 % of LESS urological
procedures were performed in the upper urinary tract and 84 % were extirpative or
ablative [
18 ] . To our knowledge, there are no urinary diversions performed by LESS
yet, but complex procedures like bladder augmentation and ileal ureteral replace-
ment have been safely performed through single-port techniques [ 15, 16 ] . Kaouk
et al. [ 19 ] performed LESS radical cystectomy in three patients, but the urinary
diversions were performed extracorporeally.
Certainly, the most challenging issues with LESS come from its use of a single
incision to perform major laparoscopic procedures. As such, the instruments and
camera are in close proximity to each other. This makes the operative fi eld crowded,
externally and internally, and hence instrument clashing is common both externally
and internally. Another major technical challenge of LESS is the lack of triangula-
tion between the instruments. Therefore, retraction and countertraction as well as
achieving optimum angles for intracorporeal suturing are dif fi cult. In the series
reviewed in this chapter, additional 2-mm needlescopic instruments, percutaneous
sutures, or exteriorizing the bowel were some of the maneuvers employed to improve
visualization, optimize retraction and countertraction, as well as facilitate suturing
and knotting.
Indeed, Desai et al. [ 15, 16 ] and Noguera et al. [ 17 ] exteriorized the bowel during
LESS ileal ureter and bladder augmentation, respectively. This was reported to
facilitate either ileal graft preparation as well as bowel reconstruction, thereby
decreasing the operative time. The use of ancillary needlescopic instruments during
LESS does not invalidate the surgery as a LESS procedure [ 7 ] . Desai et al. [ 15, 16 ]
have reported the use of needlescopic instruments to perform ureteral reimplanta-
tion and ileal ureter replacement directly through a skin puncture without using an
additional port.
The surgical device industry is actively developing new instruments, cameras,
and robotic systems to assist LESS. In fact, the majority of the series in this review
used articulating instruments and fl exible-tip cameras as well as prebent instruments
to improve the feasibility of LESS, especially for reconstructive procedures. White
et al. [ 10, 11 ] successfully used robotic technology to assist LESS in three cases.
Indeed, the use of robots can be the link to facilitate LESS, improve ergonomics and
visualization, and increase degrees of freedom of the surgical instruments, thereby
facilitating dissection and suturing [ 20, 21 ] .
There is a lack of randomized studies comparing different approaches such as
LESS, conventional laparoscopy, robotics, or open surgery for pelvic reconstructive
urological surgeries. White et al. [ 10 ] compared 30 patients who underwent abdom-
299
23 LESS: Pelvic Reconstructive Urological Surgery
inal sacrocolpopexy according to the approach: 10 laparoscopic, 10 robotic, and 10
LESS. They reported no signi fi cant difference in terms of OR time, EBL, VAPS, or
LOS among the groups. Performing LESS ureteral reimplant in two cases, Desai
et al. [
15 ] reported an OR time of 240 and 140 min, EBL of 100 and 250 cc, and
LOS of 2 days. These results are comparable to those reported by Seideman et al.
[ 22 ] performing conventional laparoscopic reimplantation, although this group per-
formed Boari fl ap in 21 patients (47 %). For ileal ureter replacement, again, OR
time (470 vs. 330 min), EBL (375 vs. 170 cc), and LOS (5 vs. 4 days) are compa-
rable when performed by conventional laparoscopy or LESS, respectively [ 15, 23 ] .
Noguera et al. [ 17 ] performing LESS enterocystoplasty reported similar results as
Gill et al. [ 24 ] , who reported the initial cases of conventional laparoscopic entero-
cystoplasty. Both exteriorized the bowel to prepare the ileal graft as well as com-
plete the bowel anastomosis. The OR time, EBL, and LOS were 5 versus 5.3 h,
<100 versus 50 cc, 6 versus 7 days, respectively, for LESS versus standard laparo-
scopic bladder augmentation.
There was only one complication reported in the series reviewed in this paper.
It was an anastomotic urine leak requiring drainage. Also, there were no conver-
sions to standard laparoscopy, or to open surgery. In the largest series reported
with LESS so far, the overall intraoperative and postoperative complications
were 3.3 % and 9.5 %, respectively, and the rate of conversion was 20.8 % [ 18 ] .
The very low complication rate noted in this review of LESS pelvic reconstruc-
tion could be attributed to the small number of patients, careful case selection,
and surgeon/team experience with standard laparoscopic as well as LESS proce-
dures [ 7 ] .
Conclusions
LESS pelvic reconstruction is still in its infancy, although complex reconstructive
procedures have been reported with gratifying results. Additional studies with larger
numbers of patients as well as prospective randomized studies are still needed to eval-
uate the real bene fi ts of LESS over conventional laparoscopy or robotic surgery. The
use of appropriate tools speci fi cally designed for LESS seems to facilitate these com-
plex procedures, although they are not essential. The use of robotic platforms to assists
LESS appears to be the future.
References
1 . http://www.auanet.org/content/media/renalmass09.pdf .
2 .
http://www.uroweb.org/fileadmin/guidelines/2012_Guidelines_large_text_print_total_file.pdf .
3. Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopic nephrectomy. N Engl J Med.
1991;324(19):1370–1.
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