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A.L. de Castro Abreu and M. Aron
4. Rassweiler J, Pini G, Gözen AS, et al. Role of laparoscopy in reconstructive surgery. Curr Opin
Urol. 2010;20(6):471–82.
5. Rane A, Kommu S, Eddy B, et al. Clinical evaluation of a novel laparoscopic port (R-port) and
evolution of the single laparoscopic port procedure (SliPP). J Endourol. 2007;21 Suppl 1:
A22–3.
6. Raman JD, Bensalah K, Bagrodia A, et al. Laboratory and clinical development of single key-
hole umbilical nephrectomy. Urology. 2007;70:1039–42.
7. Gill IS, Advincula AP, Aron M, et al. Consensus statement of the consortium for laparoendo-
scopic single-site surgery. Surg Endosc. 2010;24(4):762–8.
8. Desai MM, Rao PP, Aron M, et al. Scarless single port transumbilical nephrectomy and pyelo-
plasty: fi rst clinical report. BJU Int. 2008;101(1):83–8.
9 .
http://www.ncbi.nlm.nih.gov/pubmed/ .
10. White WM, Goel RK, Swartz MA, et al. Single-port laparoscopic abdominal sacral colpopexy:
initial experience and comparative outcomes. Urology. 2009;74(5):1008–12.
11. 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.
12. Tome AL, Tobias-Machado M, Correa WF. Laparoendoscopic single-site (LESS) sacrocol-
popexy: feasibility and ef fi cacy of knotless procedure performed with conventional instru-
ments. Int Urogynecol J Pelvic Floor Dysfunct. 2011;22(7):885–7.
13. Ingber MS, Stein RJ, Rackley RR, et al. Single-port transvesical excision of foreign body in
the bladder. Urology. 2009;74(6):1347–50.
14. Stolzenburg JU, Do M, Kallidonis P, et al. Laparoendoscopic single-site bladder diverticulec-
tomy: technique and initial experience. J Endourol. 2011;25(1):85–90.
15. Desai MM, Berger AK, Brandina R, et al. Laparoendoscopic single-site surgery: initial hun-
dred patients. Urology. 2009;74(4):805–12.
16. Desai MM, Stein R, Rao P, et al. Embryonic natural ori fi ce transumbilical endoscopic surgery
(E-NOTES) for advanced reconstruction: initial experience. Urology. 2009;73(1):182–7.
17. Noguera RJ, Astigueta JC, Carmona O, et al. Laparoscopic augmentation enterocystoplasty
through a single trocar. Urology. 2009;73(6):1371–4.
18. Kaouk JH, Autorino R, Kim FJ, et al. Laparoendoscopic single-site surgery in urology: world-
wide multi-institutional analysis of 1076 cases. Eur Urol. 2011;60(5):998–1005.
19. Kaouk JH, Goel RK, White MA, et al. Laparoendoscopic single-site radical cystectomy and
pelvic lymph node dissection: initial experience and 2-year follow-up. Urology. 2010;76(4):
857–61.
20. Rane A, Autorino R. Robotic natural ori fi ce translumenal endoscopic surgery and laparoendo-
scopic single-site surgery: current status. Curr Opin Urol. 2011;21(1):71–7.
21. Rane A, Tan GY, Tewari AK. Laparo-endoscopic single-site surgery in urology: is robotics the
missing link? BJU Int. 2009;104(8):1041–3.
22. Seideman CA, Huckabay C, Smith KD, et al. Laparoscopic ureteral reimplantation: technique
and outcomes. J Urol. 2009;181(4):1742–6.
23. Stein RJ, Turna B, Patel NS, et al. Laparoscopic assisted ileal ureter: technique, outcomes and
comparison to the open procedure. J Urol. 2009;182(3):1032–9.
24. Gill IS, Rackley RR, Meraney AM, et al. Laparoscopic enterocystoplasty. Urology. 2000;55(2):
178–81.
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A. Rane et al. (eds.), Scar-Less Surgery,
DOI 10.1007/978-1-84800-360-6_24, © Springer-Verlag London 2013
Keywords Prostatic neoplasms • Prostate cancer • Prostatectomy • Radical pros-
tatectomy • LESS • Single port • R-LESS • Robotics • NOTES
Introduction
Prostate cancer is the most commonly diagnosed nonskin cancer and the second
leading cause of cancer-related death in men in the United States [ 1 ] . The anatomi-
cal approach to radical retropubic prostatectomy was developed by Walsh et al. in
the early 1980s [ 2 ] . It rapidly became the standard surgical procedure for radical
prostatectomy. In 1997, Schuessler et al. performed the fi rst laparoscopic radical
prostatectomy [ 3 ] . After Guillonneau et al. reported their technique in 1998, the
laparoscopic approach started to receive more acceptance for the treatment of pros-
tate cancer [ 4 ] .
Two decades ago, the desire to offer patients a reduced morbidity and
improved cosmesis was the driving force for the development of laparoscopy
and is once again what motivates surgeons to perform laparoscopic surgery
through a small single incision [ 5 ] . The use of laparoendoscopic single-site
H. K. Laydner , M.D.
Laparoscopic and Robotic Surgery , Glickman Urological and Kidney Institute,
Cleveland Clinic , 9500 Euclid Avenue, Glickman Urological and Kidney Institute,
Q9/100A , Cleveland , OH 44195 , USA
e-mail: laydneh@ccf.org , dr.1berto@terra.com.br
J. H. Kaouk , M.D. (
*)
Director, Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute ,
Cleveland Clinic , 9500 Euclid Avenue, Glickman Urological and Kidney Institute, Q10-1 ,
Cleveland , OH 44195 , USA
e-mail: kaoukj@ccf.org
Chapter 24
LESS: Radical Prostatectomy
Humberto Kern Laydner and Jihad H. Kaouk
302
H.K. Laydner and J.H. Kaouk
surgery (LESS) has increased rapidly, and nearly the entire spectrum of urologic
laparoscopic surgery has been demonstrated to be feasible with this approach
[ 6– 8 ] . We started the application of this technique for the treatment of
adenocarcinoma of the prostate in 2007, when it was still named “single-port
laparoscopic radical prostatectomy” [
9 ] . In 2008, the terminology LESS was
consensually adopted, replacing the term “single-port laparoscopy,” among
others [
10 ] .
Our group introduced the da Vinci Surgical System to several LESS procedures,
including radical prostatectomy, and named it robotic LESS (R-LESS) [ 11 ] .
R-LESS Radical Prostatectomy
In the past 10 years, robotic surgery has revolutionized the way laparoscopic sur-
gery is performed in the United States. Radical prostatectomy is probably the best
example of this shift. Currently, the majority of radical prostatectomies in the United
States are performed using the robot [ 12 ] . Much of the acceptance of this trend
among surgeons can be credited to the dramatic improvements enabled by the
robotic system to ergonomics and shortening of the learning curve. Present in LESS
and NOTES, the idea of surgery with an invisible scar and minimal morbidity is
fascinating for both patients and surgeons. However, it was made possible only at
the expense of the surgeon’s physical comfort, with a learning curve even steeper
than standard laparoscopy.
Both robotic surgery and the pursuit of scarless surgery seem to be a no-way-back
tendency. We have been trying to combine the best of both worlds in the clinical set-
ting since May 2008. The robot notably improves the ergonomics of LESS, reduces
instrument crossing, and adds instrument tip articulation, which facilitates suturing.
Patient Selection
Ideal candidates for LESS or R-LESS radical prostatectomy are patients with a life
expectancy of 10 years or more, early-stage prostate cancer (T1c), no previous his-
tory of surgery or radiation to the lower abdomen or pelvic region, a medium-sized
prostate (>20 and <60 g), few or no comorbidities, and a body mass index £ 35 kg/
m
2
. The appropriate patient selection is essential to warrant the safety of LESS radi-
cal prostatectomy; this is especially true during the initial learning curve. As the
surgeon gains experience and con fi dence with the technique, these limits can be
cautiously expanded.
The contraindications are the same as for standard laparoscopy, including uncor-
rected coagulopathy, signi fi cant conditions affecting cardiac output or pulmonary
gas exchange, intestinal obstruction, abdominal wall infection, and peritoneal
in fl ammatory process.
303
24 LESS: Radical Prostatectomy
Surgical Technique
In this section, we’ll describe the technique of R-LESS, which became our preferred
approach when a patient is considered suitable for radical prostatectomy through a
single skin incision.
Positioning
Under general anesthesia and endotracheal intubation, the patient is placed in the
low lithotomy position with his legs on spreader bars, and the abdomen and genital
area are prepped. Pneumatic compression is used to prevent deep vein thrombosis.
The patient is secured to the table, with arms alongside the body. Strapping must be
tight enough to avoid patient dislodgement during surgery, but breathing should not
be limited. Abundant foam is used in pressure points. The robot is introduced into
the fi eld between the legs of the patient.
Access
An umbilical 2–5-cm skin incision is made. The size of the fascial incision varies
according to the selected access device. When the SILS
®
port (Covidien, Norwalk,
CT) is used, a fi nger is placed to guide the introduction of two robotic trocars adja-
cent to the fascial incision through two separate fascial stab incisions (Fig. 24.1 ). If
using a GelPort
®
(Applied Medical, Rancho Santa Margarita, CA), the access device
is placed through the fascial incision and the robot is docked in a three-arm approach.
Alternatively, four trocars can be placed through separate fascial incisions in a
diamond-shaped con fi guration.
Fig. 24.1 Separate
placement of SILS port and
robotic trocars through the
same skin incision
304
H.K. Laydner and J.H. Kaouk
Bladder Mobilization
Using the 8-mm EndoWrist® (Intuitive Surgical, Sunnyvale, CA) monopolar shears
in the right arm, a 5-mm EndoWrist Schertel Grasper in the left, and a 30° lens look-
ing upward, the parietal peritoneum is widely incised high on the anterior abdomi-
nal wall, and the bladder is dissected.
Incision of the Endopelvic Fascia
The endopelvic fascia is exposed and sharply incised, using the 8-mm EndoWrist
monopolar shears in the right hand and a 5-mm EndoWrist Schertel Grasper or
8-mm EndoWrist ProGrasp forceps in the left. The prostate is mobilized off the
levator muscle fi bers.
Ligation of the Dorsal Venous Complex
The penile dorsal venous complex is ligated with a 2.0 polyglactin suture (Vicryl),
using an 8- and 5-mm EndoWrist robotic needle driver. The dorsal vein stitch is
secured to the pubic symphysis in an attempt to improve the early continence recov-
ery rate [ 13 ] . Cranially, a back-bleeding stitch is placed across the anterior surface
of the prostate.
Bladder Neck Dissection
A marionette suture is passed through the distal bladder neck or prostatic base to
serve as a retractor. The anterior bladder neck is transected. The urethral catheter is
suspended from the abdominal wall with a 2-0 suture and the posterior bladder neck
is dissected away from the prostate (Fig. 24.2 ).
Seminal Vesicle Dissection
After incision of the anterior layer of the Denonvillier’s fascia, the vas deferens and
seminal vesicles are mobilized athermally with Hem-o-lok
®
clips (Tele fl ex Medical,
Research Triangle Park, NC) in a nerve-sparing approach and with the 5-mm har-
monic scalpel in a nonnerve-sparing approach.
305
24 LESS: Radical Prostatectomy
Prostatic Dissection
The use of the 8-mm robotic clip applier enables us to replicate the nerve-sparing
technique used in RALP. With a combination of robotically applied Hem-o-lok clips
and sharp dissection, an interfascial nerve-sparing approach is accomplished. Assistant
retraction with the suction device and/or marionette sutures allows for placement of
Hem-o-lok clips. A 5-mm harmonic scalpel can be used in the right arm, in a non-
nerve-sparing surgery, to cauterize the lateral pedicles bilaterally. However, it can be
dif fi cult sometimes, as this instrument does not de fl ect or articulate.
Urethral Dissection and Division
The ligated dorsal vein complex is incised with the 8-mm monopolar shears. The
underlying urethra is exposed and transected sharply, without electrocautery. The
prostate apex is dissected in a retrograde fashion; the specimen is released and
placed in a 10-mm laparoscopic bag.
Specimen Extraction
Some LESS procedures often require an extended skin incision to allow the retrieval
of a large specimen inside the laparoscopic bag. Usually, this is not required in
R-LESS radical prostatectomy (Fig. 24.3 ).
Fig. 24.2 Urethral catheter
suspended with marionette
suture
306
H.K. Laydner and J.H. Kaouk
Pelvic Lymph Node Dissection
The lymph node dissection is performed in the same manner as in our RALP tech-
nique. External iliac and obturator fossa nodal tissues are removed with a laparo-
scopic spoon.
Urethrovesical Anastomosis
The urethrovesical anastomosis is performed with robotic needle drivers in both
arms. Two sutures of 2-0 poliglecaprone 25 (Monocryl) on an RB-1 needle are
placed in a semicircular “running” fashion starting from the 6 o’clock position
toward the 12 o’clock position and then tied together. Before completion of the
anastomosis, a 20 Fr Foley catheter is inserted into the bladder. The anastomosis is
tested by instilling 100 ml of saline into the bladder to ensure water tightness. A
Jackson–Pratt drain is placed in the pelvis and exited through a separate fascial stab
but via the same skin incision.
Outcomes
At Cleveland Clinic, we initially performed four LESS radical prostatectomies
without intraoperative complications [ 9 ] . One patient developed a rectourethral
fi stula, treated with a mucosal advancement fl ap. The mean operative time was
4.75 h. The mean hospital stay was 2–3 days. A Foley catheter and Jackson–Pratt
Fig. 24.3 Late postoperative
aspect of the incision
307
24 LESS: Radical Prostatectomy
drain were removed 2 weeks after surgery. Three patients used one or no pads daily
for continence at 18 weeks of follow-up. Although the initial clinical disease stage
for all patients was T1c, it was upstaged on fi nal pathologic examination, with
Gleason score 3 + 4 = 7 and extracapsular extension (T3a). Two patients had positive
margins located at the site of the extracapsular penetration. One of these patients has
an undetectable prostate-speci fi c antigen (PSA) level (<0.03 ng/dl) at 33 months of
follow-up. After PSA recurrence (3.55 ng/dl), the other patient with a surgical posi-
tive margin had benign prostatic and seminal vesicle tissue demonstrated at biopsy
of a prostate fossa nodule, with no evidence of carcinoma. PSA immunostains were
used to evaluate the case and a senior pathologist was consulted. The remaining
patients persist with undetectable levels of PSA.
Rabenalt et al. reported one case of a 74-year-old man, with a clinically localized
prostate cancer Gleason score 3 + 3 = 6, who underwent extraperitoneal LESS radi-
cal prostatectomy. The operative time was 290 min. The estimated blood loss was
100 ml. There were no intra- or postoperative complications, and no additional ports
were used. Histopathology showed bilateral adenocarcinoma without extracapsular
extension, Gleason 3 + 4 = 7, with negative margins. Two weeks after surgery, the
patient reported only mild urinary incontinence [
14 ] .
Since May 2008, we have abandoned standard LESS radical prostatectomy and
switched our approach to R-LESS. Recently, we reported our initial experience of
20 R-LESS radical prostatectomies [ 15 ] . The mean operative time was 187.6 min,
and the mean estimated blood loss was 128.8 ml. The visual analog pain score at
discharge was 1.6 of 10. The mean hospital stay was 2.5 days. There was one con-
version to standard RALP due to a large median lobe, which required better retrac-
tion. Conversion to hybrid R-LESS was necessary in two cases due to clashing and
CO
2
leakage from the port, with the addition of an 8-mm robotic port placed. We
had four complications, including an ileus in one patient, managed conservatively
(Clavien grade 1), a transfusion in a patient on postoperative day 1 due to blood loss
anemia (Clavien grade 2), a pulmonary embolus manifested 2 weeks after surgery
and managed with 6 months of oral anticoagulation (Clavien grade 2), and one case
of urosepsis that occurred 45 days after surgery, which required intensive care sup-
port and resolved with intravenous antibiotics (Clavien grade 4).
Pathology revealed four focal positive margins (three in T2 and one in T3a dis-
ease), with two occurring during the fi rst three cases. Three of the four margins
occurred at the apex; one occurred laterally. All of the positive margins were in
nonnerve-sparing cases. The Gleason score was of 3 + 3 = 6 in 3 patients, 3 + 4 = 7 in
11 patients, 4 + 3 = 7 in 4 patients, and 4 + 4 = 8 in 2 patients. Lymph nodes were
negative in all cases [ 15 ] . Currently, the PSA levels of all patients are undetectable,
with a mean follow-up of 16 months.
A trend toward improved urinary continence was observed over the follow-up
period. Three patients underwent an athermal nerve-sparing technique, and at 3
months postoperatively, one had an SHIM ³ 21. Seventy-one percent of patients had
their Foley catheters removed 1 week after surgery. Five patients who were found to
have an anastomotic leak on cystogram required an additional week before removal
of the catheter.
308
H.K. Laydner and J.H. Kaouk
Barret et al. reported their experimental and clinical experience with hybrid
R-LESS radical prostatectomy [ 16 ] . A 5-mm port was added at the right lower
abdomen for suction and drain placement. There were no intraoperative complica-
tions, and margins were negative. Later, the same authors reported a complete
R-LESS radical prostatectomy, with an operative time of 210 min and an estimated
blood loss of 300 ml. There were no complications and prostatic margins were neg-
ative [
17 ] .
In 2010, Leewansangtong et al. from Thailand reported the fi rst R-LESS radical
prostatectomy in Asia [ 18 ] . A 71-year-old man with a clinical T3 adenocarcinoma
of the prostate, Gleason score 4 + 4 = 8 on biopsy, received androgen deprivation for
3 months followed by R-LESS radical prostatectomy. The operative time was
335 min, the estimated blood loss was 250 ml, and no blood transfusion was
required. There were no postoperative complications. The hospital stay was 4 days.
Pathology exam showed T3c adenocarcinoma Gleason 9 with tumor regression
after hormonal therapy, which was continued.
Fortunately, initial series were successful; however, we still advocate that LESS
or R-LESS radical prostatectomy should be reserved only for highly selected cases,
especially during the initial learning curve.
Limitations
Although the enthusiasm among surgeons and patients caused by promising early
results, LESS still has several technical constraints that limit its applicability to a
very selected number of patients and surgical centers. The restricted space available
causes signi fi cant instrument clashing, which impairs adequate tissue retraction.
The limited triangulation can be partially restored with prebent or articulating
instruments. However, they often cause force dissipation and have counterintuitive
maneuverability due to crossing.
Even though the robotic system added important bene fi ts to LESS, R-LESS is
not free of limitations. When a reduction in the range of motion of the robotic
instruments is experienced, it is useful to switch the 8-mm robotic instruments to
the 5-mm pediatric set. The 5-mm instruments de fl ect instead of articulate. Because
the da Vinci
®
robot (Intuitive Surgical, Sunnyvale, CA) is bulky, an important adjust-
ment is to set the system to fi ne-tuning, slowing the movement of the robotic arms
and reducing external collisions [ 19 ] . Another helpful strategy is to identify in the
surgical fi eld the points where clashing starts to occur and attempt to stay inside
these boundaries, keeping movements within a mentally delineated “clashing-free”
area. If the surgeon needs to work in another area, he or she does it, moving all the
instruments en bloc.
The possibility to obtain mid- and long-term oncological results equivalent to
open surgery with standard laparoscopy has been well demonstrated for several dif-
ferent urological malignancies [ 20 ] . As the nature of standard laparoscopy and
LESS is essentially the same, at least in theory, oncological outcomes should not be
309
24 LESS: Radical Prostatectomy
different between the two approaches. For LESS and R-LESS radical prostatec-
tomy, the initial step of feasibility has already been demonstrated, yet the oncologi-
cal ef fi cacy has not been directly addressed. Certainly, longer-term results would be
ideal in order to bolster the proof of oncologic equivalence, yet thus far only short-
to mid-term follow-up is available due to the novelty of these techniques.
Future Directions
The application of robotic technology to the LESS approach solved some of the
limitations inherent to this technique. However, the currently available robotic plat-
form and its instruments were not designed speci fi cally for LESS. Novel robotic
instruments (Single-Site
TM
; Intuitive Surgical, Sunnyvale, CA) were evaluated in a
porcine model (Fig. 24.4 ) [ 21 ] . Recently, we evaluated in the cadaver model the
second generation of this new robotic system speci fi cally designed for R-LESS,
which is now available for clinical use [ 22 ] . The con fi guration of the da Vinci Si
®
Surgical System (Intuitive Surgical) was specially adapted to perform R-LESS sur-
gery. Only the robotic arms 1 and 2 and the camera arm are used, while the console
and the slave remain the same. Two crossing curved cannulae for the robotic instru-
ments, an 8.5-mm scope, and a 12-mm cannula are inserted through a multichannel
port (Intuitive Surgical), which can be deployed through a single skin and fascial
incision. The biggest limitation is the lack of articulation at the tip, which makes
suturing more dif fi cult than with the use of EndoWrist instruments. Some potential
advantages of this system in comparison to standard LESS are improved range of
motion, dexterity, instrument and scope stability, ergonomics, and decreased instru-
ment collisions.
The convergence between robotic and LESS techniques is already bringing
bene fi ts. With further technological development, a better integration of robotic
Fig. 24.4 Robotic Single-
Site
TM
platform and
instruments
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