Trans-umbilical laparo-endoscopic single-site donor nephrectomy without the use of a single-port access device

Page 1

Review Articleiju_2963 416..428

Transumbilical laparoendoscopic single-site surgeryin urologyJohn E Humphrey and David CanesDepartment of Urology, Tufts University School of Medicine, Lahey Clinic Institute of Urology, Burlington, Massachusetts, USA

Abbreviations & AcronymsCL = conventionallaparoscopyDVT/PE = deep venousthrombosis/pulmonaryembolusEBL = estimated blood lossE-NOTES = embryonicnatural orificetransumbilical endoscopicsurgeryLap = laparoscopicLESS = laparoendoscopicsingle-site surgeryLOS = length of hospitalstayMAG3 = technetium-99mmercaptoacetyltriglycineMOT = mean operativetimeOPUS = one port umbilicalsurgerySIL = single incisionlaparoscopySILS = single portlaparoscopySPA = single port accessSPL = single portlaparoscopy

Correspondence: David CanesM.D., Department of Urology,Tufts University School ofMedicine, Lahey Clinic Instituteof Urology, 41 Mall Road ,Burlington, MA 01805, USA.Email: [email protected]

Received 18 October 2011;accepted 4 January 2012.Online publication 15 February2012

Abstract: Laparoendoscopic single-site surgery has seen a dramatic rise in the uro-logical community. With the advent of new techniques and instrumentation, laparoen-doscopic single-site surgery has become more accessible for a wide variety ofapplications. The majority have been carried out through a transumbilical incision inorder to effectively hide the scar within the umbilicus. Here, we review the history andclinical applications for transumbilical laparoendoscopic single-site surgery withinurology. The current scope is broad, and great strides have been made, but the overallbenefit appears to be predominantly cosmetic. Diffusion of laparoendoscopic single-sitesurgery techniques from tertiary referral centers to the community urologist remainsunknown. This review demonstrates the feasibility of transumbilical laparoendoscopicsingle-site surgery as shown in the urological literature.

Key words: laparoendoscopic single-site surgery, minimally invasive, review,transumbilical.

Introduction

Rise of minimally invasive surgery

Single-port surgery, like many advances in medicine, is the result of constant fine-tuning ofprior techniques, and questioning how they can be improved on. The initial impetus drivingtowards minimally invasive surgery was the morbidity from an open laparotomy incision.The pain, recovery time and inherent wound complications, such as infection and incisionalhernias, as well as the cosmetic nature of open surgery drove us to push the field towardslaparoscopic surgery, and subsequently its robotic counterpart. The subsequent evolution oftechnique, ability and technology has led to the development of transumbilical single-portsurgery. This is thought to be the next natural step in accomplishing safe, effective proce-dures while limiting the morbidity and cosmetic consequences of large and/or severalincisions.

Assumptions that surgical morbidity is simply linearly related to the sum-total of incisionlength(s), however, have not held under scrutiny in the past. The present review is focusedon the urological experience with single-port surgery specifically using a transumbilicalapproach. The umbilicus provides a location in which the resultant scar can be at leastpartially hidden from view, enhancing the benefit of improved cosmesis with single-portsurgery. The application of transumbilical single-port surgery in urology is ever growing,and herein we describe the worldwide use of this technique to date.

The term now used to describe single-port surgery in the urological literature is LESS.This was developed to incorporate and standardize the various previous terms used todescribe one overall concept of minimally invasive operations performed through a singleincision using conventional laparoscopic or newer instrumentation such as fixed pre-bent ordeflectable flexible instruments.1 Previous terms included E-NOTES, SILS, OPUS, SPA,SPL and SIL, among others. The first transumbilical urological LESS procedure describedwas by Raman et al. where three nephrectomies were carried out, each using a singleincision with multiple trocars.2 Since that time, the clinical experience has increased

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International Journal of Urology (2012) 19, 416–428 doi: 10.1111/j.1442-2042.2012.02963.x

416 © 2012 The Japanese Urological Association

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dramatically and LESS has cemented itself as an excellenttechnique for a broad range of urological procedures.

Early history

The first description of a true LESS procedure, evident nowonly in retrospect, was in the field of gynecology for tuballigation in 1972.3 A 1-cm infraumbilical incision was made,through which a laparoscope was inserted to visualize andthen cauterize each fallopian tube. The fallopian tubes wereexposed using an external tenaculum placed on the uterusfrom the vagina. The cosmetic benefit of the technique wasimmediately evident, and eventually led gynecologists toexplore similar techniques for larger procedures, includingtotal abdominal hysterectomy and bilateral salpingo-oophorectomy by 1991.4

General surgeons also began to explore the use oftransumbilical LESS surgery for appendectomy andcholecystectomy.5–7 During this process, a new techniquewas developed in 1999 for use in cholecystectomy, by whicha single skin incision is made, but two fascial incisions areused to accommodate 5-mm trocars within this commonskin incision.8 This allows more ports for instrumentswithout compromising the cosmetic benefit.

Initial urological applications

Although LESS procedures were being developed in theseother arenas, the evolution from open to laparoscopic andfinally robotic surgery was taking place in urology. Thebenefits realized during this transition included less bleed-ing, fewer complications and shorter hospital stays leadingto faster convalescence.9 It was thus inevitable that urolo-gists would also begin exploring the single-port system.

Although we focus here on transumbilical LESS, in2007, the first case in urology used a flank incision forplacement of an R-port (Advanced Surgical Concepts,Wicklow, Ireland) to complete a nephrectomy on a small,non-functioning kidney.10 This technique has also beenused for radical nephrectomy with a 7-cm paramedian inci-sion just lateral to the rectus muscle for placement of aGelPort (Applied Medical, Rancho Santa Margarita, CA,USA).11 Another case report described a 4-cm flank inci-sion with a GelPort to carry out retroperitoneal radicalnephrectomy for renal cell carcinoma in a dialysis patient.12

The pfannenstiel incision has also been explored as a focalpoint for LESS. In one report, a 7.5-cm pfannenstiel inci-sion was used to carry out both nephrectomy and neph-roureterectomy, using a GelPort as an access device.13

These approaches proved to be feasible options utilizingnon-umbilical incisions. However, the majority of urologi-cal single-site experience, as described here, has been withtransumbilical access.

Benefits of LESS

The transition from CL to LESS creates inherent technicalchallenges. In order for the urological community at large toembrace LESS, clear benefits of LESS over CL must beshown rigorously and scientifically. This has been difficult,as the salient advantage is improved cosmesis, a variable forwhich there is a paucity of objective measures. An earlycomparison between LESS and CL among patients under-going nephrectomy showed a subjective cosmetic advan-tage, while also showing comparable outcomes for operativetime, analgesic use, hospital stay and complication rate.14

Similar subjective outcomes have been reproduced withvarious procedures,15–18 but a recent study by Park et al. usedan objective measure to quantify the cosmetic advantage.19

This group used a body image questionnaire to comparepatient satisfaction after kidney surgery. Although the scalewas non-validated, it does represent the first objectivemeasure of improved cosmesis with LESS. As rigorous datacontinues to accumulate, by preliminary observation itseems clear that at least from the surgeon’s perspective,cosmesis is excellent after umbilical LESS surgery. Figure 1shows the immediate intraoperative cosmetic result of apatient in our own group undergoing a LESS left renal cystdecortication. For this procedure, a 4-cm vertical intraum-bilical incision was made, with the result as shown at6 weeks postoperatively in Figure 2.

Other theoretical benefits of LESS include decreasedpostoperative pain and fewer postoperative wound compli-cations (infection, hernia). Jeong et al. presented dataamong patients undergoing adrenalectomy (9 LESS, 17 CL)showing significantly lower postoperative pain in the LESScohort.17 However, most comparison series have not hadlong enough follow up or were powered with sample sizesnecessary to show a meaningful difference in woundcomplications.

Fig. 1 LESS renal cyst decortication immediate cosmeticresult.

Transumbilical LESS in urology

© 2012 The Japanese Urological Association 417

Page 3

Technique and instruments

As with any new surgical platform, LESS has been associ-ated with unique ergonomic challenges to overcome andinherent difficulties, which continue to be present. Multiportlaparoscopic surgery with strategically placed trocarsachieves triangulation for improved tissue retraction andonly rare instrument clashing. Triangulation and instrumentcrowding becomes even more difficult during LESS,whereby bulky instrument handles clash in preciouslylimited external “real estate”. These difficulties have put theonus not only on the surgeon to creatively overcome theselimitations given current instruments, but also on industry todesign purpose-built access devices and instrumentation.The technical and equipment challenges with LESS havepreviously been described by Sawyer and Ponsky.20 Theynote the rapid innovation seen with LESS and highlight theobstacles that are inherent to single-port surgery. Twoapproaches are described: (i) a coaxial approach in whichinstruments are used in parallel; or (ii) a novel platform. Thecoaxial approach leads to limited visual perspective, asinstruments are in line with the operator’s vision. The tran-sition to novel platforms to overcome this challenge isdescribed below.

Before the current devices were created, surgeons firstexperimented by using existing laparoscopic instrumentsthrough a single skin incision and multiple fascial incisions.This “keyhole” technique (as described above as the firsturological transumbilical LESS procedure) was used tocomplete three nephrectomies (two for chronic infection,one for a 4.5-cm enhancing renal mass) with three adjacenttrocars in an umbilical incision.2 Articulating graspers, stan-dard endoshears and a 45° 5-mm rigid laparoscope or 5-mmdeflectable tip laparoscope were used. The authors citedinternal and external instrument collision as a constant chal-lenge, as well as a difficult learning curve. Similarly, adrena-

lectomy has been carried out using a 2-cm incision withadjacent trocars through multiple fascial punctures.21 Thefascial incisions were connected in these cases for specimenextraction. The three challenges noted were limited maneu-verability with tearing of port site fascia, difficult visualiza-tion and potential difficulty with vascular control. In order tomeet these challenges, new access platforms were createdthat depended on only one fascial incision with the potentialto accommodate up to three or four instruments at a time(such as with Triport and QuadPort; Advanced SurgicalConcepts). The main concept behind new platforms is toprovide access for multiple instruments through one incisionwhile limiting device profile. One solution is provided by theGelPOINT Advanced Access Platform (Applied Medical),which allows the surgeon to place multiple trocars throughany location in the device. Table 1 shows current accessdevices and instrumentation for LESS procedures. Figure 3shows an intraoperative view of the GelPOINT AdvancedAccess Platform being used for the aforementioned LESSleft renal cyst decortication.

One notable addition is that of mini-laparoscopic orneedlescopic instruments, which have been and continue tobe used as adjuncts during LESS procedures. For certainprocedures, in addition to the transumbilical single-port, asmall 2- or 3-mm port has been used for a retracting device,requiring no skin suturing and virtually no scar. This adjunctwas embraced as a way to bridge the gap between standardlaparoscopy and LESS in the consensus statement on LESSin 2010.22

Applications

As described earlier, nephrectomy was the initial procedurereported for transumbilical LESS in 2007. Since that timein only 4 years, an impressive array of procedures havebeen successfully completed using a transumbilical LESSapproach, spanning almost the full urological surgical arma-mentarium for intra-abdominal procedures. We summarizethe literature here, including only those procedures com-

Fig. 2 Cosmetic result 6 weeks after LESS renal cystdecortication.

Fig. 3 GelPOINT Advanced Access Platform intraoperatively.

JE HUMPHREY AND D CANES

418 © 2012 The Japanese Urological Association

Page 4

pleted through the umbilicus. We have extracted such datafrom series in which multiple techniques and access siteswere included. As the literature is ever growing, this is notintended to be a comprehensive summary. We hope to givethe reader the current scope of the clinical applicationsutilizing transumbilical LESS. Currently-reported transum-bilical LESS applications by organ systems are detailedbelow.

Kidney

Raman first described nephrectomy using three trocarsthrough a single umbilical incision.2 Kidney surgery com-prises the majority of transumbilical LESS surgery to date.It is therefore instructive to subdivide kidney proceduresinto the following categories: oncology, reconstructive,donor nephrectomy and other. Oncological procedures with

a LESS approach must be able to be completed withoutcompromising cancer outcomes. This began by demonstra-tion of renal mass cryoablation using a 3.8-mm cryoprobe(Endocare, Irvine, CA, USA) through a Uni-X accessdevice.23 The authors described this method with both tran-sumbilical and retroperitoneal approaches. The utility of thismethod was confirmed later in a review of a single-center’stransumbilical LESS experience.24

Extirpative oncological surgery has also been shown to befeasible. Aron et al. reported five partial nephrectomies in200825 using the R-Port access device. An extra 2-mm portwas used for a grasper, and one patient needed an additional5-mm port for liver retraction. The R-Port was again usedwhen carried out on six patients in an overall review ofseveral LESS procedures by Desai.26 Other devices havebeen used for partial nephrectomy including the Uni-X27 andGelPort,28 as well as standard trocars through a single inci-

Table 1 Current devices and instrumentation for LESS (alphabetical order)

Company Design Currentlyavailable

Access devicesAirseal Surgiquest, Orange, CT, USA Maximize movement with small incision

by using oval cannulaYes

GelPOINT AdvancedAccess Platform

Applied Medical, Rancho SantaMargarita, CA, USA

1.5–7-cm incisions with self-retainingports for 5–10-mm diameterinstruments

Yes

Quadport Advanced Surgical Concepts, Wicklow,Ireland

Accommodates up to 4 instruments(1 ¥ 5 mm, 2 ¥ 10 mm, 1 ¥ 15 mm indiameter)

Yes

SILS Port Covidien, Dublin, Ireland Accommodates up to 3ports/instruments of variable sizes

Yes

Triport Advanced Surgical Concepts, Wicklow,Ireland

Accommodates up to 3 instruments(12 mm and two 5 mm in diameter)

Yes

Uni-X Pnavel Systems, Brooklyn, NY, USA Three 5-mm diameter ports/instruments NoX-cone Storz, Tuttlingen, Germany Reusable, accommodates 3 working

channels (5 or 12.5 mm in diameter)Yes

Camera systemsEndocameleon Storz, Tuttlingen, Germany 10-mm diameter with adjustable angle

0° to 120°Yes

Endoeye LTF Olympus, Center Valley, PA, USA Deflectable tip 5–10-mm diameter scope YesExtra long Storz, Tuttlingen, Germany 5-mm diameter with 30° lens YesEyemax Richard Wolf Medical Instruments

Corporation, Vernon Hills, IL, USA5–10-mm diameter with 0–30° digital

lensYes

Ideal Eyes HD Stryker, Kalamazoo, MI, USA 5-mm diameter articulating scope YesInstruments

Roticulator Covidien, Dublin, Ireland 5-mm diameter instruments YesPrebent Various companies Basic curved instruments YesReal Hand Novare, Cupertino, CA, USA 5-mm instruments NoAutonomy laparo-angle Cambridge Endo, Framingham, MA, USA 5-mm articulating instruments Yes

Devices are presented in alphabetical order.

Transumbilical LESS in urology

© 2012 The Japanese Urological Association 419

Page 5

sion29 and homemade access devices.30 Radical nephrec-tomy has also seen broad use in several series.14,24,26,28–31 Acommon practice for right-sided nephrectomy has been theaddition of a small 2–3-mm port to aid with liver retraction.This gives the surgeon a technical advantage while not sac-rificing the cosmetic benefit of LESS. A more recent serieshas shown that non-ischemic partial nephrectomy is safe andfeasible with LESS.32 Table 2 details LESS kidney surgeryfor malignancy.

The full cosmetic benefit of transumbilical LESS can berealized with reconstructive renal procedures. Unlike withmany oncological indications, these do not require extensionof the original incision for specimen extraction. Desai et al.reported the first pyeloplasty using the R-Port with an addi-tional 2-mm port for a grasper and to aid with intracorporealsuturing.33 A similar technique was described for simplenephrectomy in a patient with a poorly functioning leftkidney. The same group later published results with single-session bilateral pyeloplasty in two patients, as well as anileal ureter and a ureteroneocystostomy with a psoas hitch.34

This shows the evolution of transumbilical LESS techniquesto more complex procedures. When compared with conven-tional laparoscopic pyeloplasty, transumbilical LESS pyelo-plasty has been found to have similar immediate outcomes,including length of hospital stay, morphine equivalents, andminor and major complications.15 Surprisingly, they alsofound that median operative times and median estimatedblood loss were lower in patients undergoing LESS. Thismight represent increased attending involvement with LESSinherent at teaching institutions with new techniques.

The transplantation arena has been fertile ground forLESS application and investigation. Transumbilical LESSdonor nephrectomy provides the patient cosmetic benefitand potentially faster recovery time with decreased periop-erative pain compared with conventional laparoscopic andopen donor nephrectomy. The first experience with LESSdonor nephrectomy used the R-Port, as well as a 2-mm portwithout an incision to aid in retraction.35 A comparison withconventional laparoscopy has shown that there is an associ-ated quicker convalescence with LESS patients, includingdays on oral pain medication, days off work and days to100% recovery.36

Other miscellaneous renal procedures have been com-pleted successfully with transumbilical LESS. These includesimple nephrectomy for benign indications and cyst decor-tication. See Table 3 for experience with these procedures,as well as the reconstructive and donor nephrectomyexperience.

Adrenal

A rare application of transumbilical LESS has been foradrenalectomy, perhaps because retraction is so crucial toexpose the gland. Several series have been published to

date,26,30 including the largest that includes a matched case–control study comparing conventional laparoscopic withtransumbilical LESS adrenalectomy.17 Nine LESS proce-dures were compared with 17 conventional laparoscopicadrenalectomies matched to age, sex, surgical indicationsand tumor size. The indications for the LESS procedureswere benign adenoma (n = 3), Cushing’s Syndrome (n = 1)and pheochromocytoma (n = 5). Tumor size differed signifi-cantly between groups, with an average size of 2.8 cm(1–5.4 cm) in the LESS cohort compared with 4.3 cm (2.5–6.0 cm) in the CL group. However, the techniques weresimilar in terms of conversion rate, operative time, estimatedblood loss, complications and hospital stay. The LESS groupdid have a shorter duration of patient controlled anesthesia(0.9 days vs 1.9 days). Table 4 summarizes the current lit-erature in regard to transumbilical LESS adrenalectomy.

Ureter

One of the theoretical advantages of the umbilicus as aportal-of-entry is the ability to operate in all quadrants. Asthe ureter encompasses such a long path, ureteral pathologypresents a potential opportunity to capitalize on the versa-tility of umbilical LESS. The variety of ureteral proceduresspans oncology, reconstructive and stone diseases. Table 5describes current literature for LESS ureteral surgeriesacross this spectrum.

The series of ureterolithotomy described by Lee et al. is thelargest report.42 Here, 30 transumbilical LESS ureterolitho-tomies were carried out successfully with no conversions toconventional laparoscopy. A homemade device was used foraccess using a 2–3-cm umbilical incision. Patient satisfactionwas analyzed and the authors found that 28 out of 30 patients(93.3%) were satisfied with their postoperative outcomes.

Bladder

Current LESS experience with bladder procedures includesthose listed in Table 6. Procedures accomplished to datethrough a LESS approach include radical and partial cystec-tomy, augmentation enterocystoplasty, sacral colpopexy andvesicovaginal fistula repair. Of note, a comparative studycarried out by White et al. looking at sacral colpopexy foundsimilar efficacy and improved cosmesis for transumbilicalLESS versus laparoscopic and robotic techniques.18 Therewere no conversions and no immediate complications. Thepatients showed prolapse reduction at 6 months follow up,and were overall satisfied with the outcomes. The authorsstate that they are exploring this technique robotically toovercome the learning curve associated with the procedure.

Prostate

With tremendous experience in minimally invasive (laparo-scopic and robotic) prostatectomy, it is not surprising that

JE HUMPHREY AND D CANES

420 © 2012 The Japanese Urological Association

Page 6

Tab

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Cur

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exp

erie

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with

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calr

enal

pro

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ures

usin

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Aut

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year

Pro

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(n)

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m)

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stru

men

tsus

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dd

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T(m

in)

EBL

(mL)

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(day

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(n)

Con

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l,20

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bla

tion

(2)

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exib

le,

5m

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°Fl

exib

legr

asp

er,

10m

mfle

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ound

pro

be,

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165

(150

–180

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ted

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are

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rved

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artic

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ing

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mp

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)

270

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420

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with

pro

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le,

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m,0

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37)

-125

(50–

200)

-3(2

–4)

Del

ayed

hem

orrh

age

req

uiri

ngan

gio-

emb

oliz

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n

0A

lso

per

form

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phr

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mie

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roug

hp

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enst

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inci

sion

Part

ialn

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my

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(120

–184

)-1

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0–20

0)-2

Stol

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2009

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adic

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my

(10)

Trip

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m,

30°

Stra

ight

and

flexi

ble

Yes

(3-m

mgr

asp

er)

146.

4(1

20–1

80)

202

(50–

900)

Not

rep

orte

dIn

trao

per

ativ

eb

leed

req

uiri

ngb

lood

tran

sfus

ion

0Su

gges

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ntin

stru

men

tsw

ould

aid

tech

niq

ue

Ram

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2009

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adic

alne

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my

(6)

Sing

lein

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raig

htan

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ticul

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sub

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hoid

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122

(90–

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20(1

0–60

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3.08

)N

one

0C

omp

ared

to22

conv

entio

nal

lap

aros

cop

icca

ses,

LESS

had

low

erm

ean

EBL

(20

vs10

0)

Stei

n,20

1028

All

rob

otic

:pye

lop

last

y(2

),ra

dic

alne

phr

ecto

my

(1),

par

tialn

ephr

ecto

my

(1)

Gel

Port

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mm

rob

otic

scop

e,30

°an

d0°

Stan

dar

dro

bot

icin

stru

men

tsN

oV

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sw

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dur

eV

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sw

ithp

roce

dur

e1–

2B

lood

tran

sfus

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(1)

0La

rger

inci

sion

for

Gel

Port

used

for

extr

actio

nof

spec

imen

s

Jeon

,20

1030

LESS

:rad

ical

nep

hrec

tom

y(8

),ne

phr

oure

tere

ctom

y(3

),p

artia

lnep

hrec

tom

y(2

),ro

bot

ic-L

ESS:

par

tial

nep

hrec

tom

y(1

1),

nep

hrou

rete

rect

omy

(3),

rad

ical

nep

hrec

tom

y(1

)

Hom

e-m

ade

dev

ice

Var

iab

lew

ithp

roce

dur

eR

igid

,5–

10m

m,

30°;

12m

mro

bot

icsc

ope

Stra

ight

,art

icul

atin

g,an

dfle

xib

leN

oV

arie

sw

ithp

roce

dur

eV

arie

sw

ithp

roce

dur

eV

arie

sw

ithp

roce

dur

eB

owel

inju

ry(2

),d

iap

hrag

min

jury

(1),

tran

sfus

ion

(1)

1(r

obot

icp

artia

lne

phr

ecto

my

due

tob

leed

ing)

Dem

onst

rate

sve

rsat

ility

ofho

me-

mad

ed

evic

efo

rva

riou

sur

olog

ical

pro

ced

ures

Baz

zi,

2011

32N

onis

chem

icp

artia

lne

phr

ecto

my

(14)

Sing

lein

cisi

onw

ith3

adja

cent

troc

ars

3–4

Rig

id,5

mm

,0°

and

rigi

d,

5m

m,4

5°

Stra

ight

conv

entio

nal

inst

rum

ents

No

177.

414

8.1

2.57

Uri

nele

ak(1

)1

(con

vert

edto

open

due

toad

hesi

ons)

Dem

onst

rate

abili

tyto

per

form

non-

clam

pin

gp

artia

lne

phr

ecto

my

with

LESS

Transumbilical LESS in urology

© 2012 The Japanese Urological Association 421

Page 7

Tab

le3

Non

-onc

olog

ical

rena

ltra

nsum

bili

calL

ESS

exp

erie

nce

Aut

hor,

year

Pro

ced

ure

(n)

Acc

ess

dev

ice

Post

oper

ativ

ein

cisi

on(c

m)

Scop

eIn

stru

men

tsus

edA

dd

ition

alp

orts

MO

T(m

in)

EBL

(mL)

LOS

(day

s)C

omp

licat

ions

(n)

Con

vers

ion

toop

en/la

pC

omm

ents

Rec

onst

ruct

ive

Des

ai,

2008

33Si

mp

lene

phr

ecto

my

(1)

R-P

ort

1–2

Rig

id,5

mm

,30°

Stra

ight

and

ben

tYe

s(2

-mm

por

t)-2

20-1

00-1

Non

e0

2m

mp

ort

aid

sw

ithin

trac

orp

orea

lsut

urin

gP

yelo

pla

sty

(1)

-160

-50

-2

Des

ai,

2009

34B

ilate

ral

pyel

opla

sty

(2),

ileal

uret

er(1

),ur

eter

o-ne

ocys

tost

omy

with

pso

ashi

tch

(1)

R-P

ort

1.5–

3N

otre

por

ted

Stra

ight

and

ben

tYe

s(2

-mm

por

t)27

7(1

80–3

60)

68.7

5(5

0–10

0)2

(1–3

)N

one

0P

lace

dJa

ckso

n-P

ratt

dra

ins

via

umb

ilica

lin

cisi

on

Trac

y,20

0915

Pye

lop

last

y(1

4)Si

ngle

inci

sion

with

3ad

jace

nttr

ocar

s

2.5

Rig

id,5

mm

,45°

Stra

ight

and

artic

ulat

ing

Yes

(3-m

man

d5-

mm

por

t)20

2(1

78–2

40)

35(2

5–50

)77

(50–

149)

Hem

atur

ia(2

),ur

ine

leak

(2),

acut

ecl

otob

stru

ctio

n(1

)

0A

llou

tcom

em

easu

res

wer

esi

mila

rto

28co

nven

tiona

lla

par

osco

pic

pyel

opla

stie

s

Rai

s-B

ahra

mi,

2009

29P

yelo

pla

sty

(2)

Stag

gere

dp

orts

inum

bili

cal

inci

sion

Not

rep

orte

dFl

exib

le,5

mm

,0°

Stra

ight

and

flexi

ble

No

-203

(199

–207

)-1

00-2

Non

e0

Als

op

erfo

rmed

4LE

SSd

onor

nep

hrec

tom

ies

via

pfa

nnen

stie

lin

cisi

on

Des

ai,

2009

26P

yelo

pla

sty

(17)

R-P

ort

Not

rep

orte

dR

igid

,5m

m,3

0°or

Flex

ible

,5

mm

,0°

Stra

ight

,ben

t,an

dar

ticul

atin

gYe

s(5

-mm

por

tre

qui

red

in2

case

s)

236

(12–

360)

79(1

0–15

0)2

(2–3

)N

one

1 conv

entio

nal

lap

All

pat

ient

ssy

mp

tom

free

Whi

te,

2009

24P

yelo

pla

sty

(8)

Var

iab

le,n

otre

por

ted

dir

ectly

Not

rep

orte

dN

otre

por

ted

Stra

ight

and

artic

ulat

ing

No

Var

ies

with

pro

ced

ure

Var

ies

with

pro

ced

ure

Var

ies

with

pro

ced

ure

Her

nia

(1)

Non

ePa

rtof

larg

erse

ries

exam

inin

gfir

st10

0ca

ses

atsi

ngle

cent

er

Stei

n,20

1028

All

rob

otic

:py

elop

last

y(2

)G

elPo

rt2.

5–5

12m

mro

bot

icsc

ope,

30°

and

0°

Stan

dar

dro

bot

icin

stru

men

tsN

oV

arie

sw

ithp

roce

dur

eV

arie

sw

ithp

roce

dur

e1–

2N

one

0R

obot

ic-a

ssis

ted

LESS

with

Gel

Port

affo

rds

grea

ter

spac

ing

ofp

orts

Don

orne

phr

ecto

my

Gill

,20

0835

Don

orne

phr

ecto

my

(4)

R-P

ort

4–5

Rig

id,5

mm

,30°

Stra

ight

,plu

scu

rved

and

artic

ulat

ing

sele

ctiv

ely

Yes

(2-m

mp

ort)

198

(180

–300

)50

(50–

200)

3N

one

0U

seof

2m

mp

ort

help

sim

pro

vetr

iang

ulat

ion

with

out

actu

alin

cisi

on

Can

es,

2010

36Le

ftd

onor

nep

hrec

tom

y(1

7)

R-P

ort

2–2.

5ex

tend

edto

4.1

cm(m

edia

n)

Rig

id,5

mm

,30°

Stra

ight

,cur

ved

,an

dar

ticul

atin

gYe

s(2

-mm

need

lesc

opic

gras

per

)

269

(180

–495

)10

8(5

0–20

0)3

(1–6

)A

llogr

aft

thro

mb

osis

in1

pat

ient

1to

conv

entio

nal

lap

aros

copy

Pro

long

edw

arm

isch

emia

time

whe

nco

mp

ared

with

conv

entio

nal

lap

aros

copy

Gan

pul

e,20

0937

Don

orne

phr

ecto

my

(13)

Trip

ort/

Qua

dp

ort

5.23

(4–7

)N

otre

por

ted

Stra

ight

and

ben

tYe

s(3

-or

5-m

min

11ca

ses

for

retr

actio

n)

176.

9(9

0–24

0)15

8.18

(50–

300)

3(2

–5)

Non

e0

Com

men

tth

atxi

pho

id-t

o-um

bili

cus

leng

th>1

6cm

incr

ease

sd

ifficu

lty

Des

ai,

2009

26D

onor

nep

hrec

tom

y(1

7)

R-P

ort

Not

rep

orte

dR

igid

,5m

m,3

0°or

Flex

ible

,5

mm

,0°

Stra

ight

,ben

t,an

dar

ticul

atin

gN

o23

0(1

80–3

20)

104

(50–

200)

2.9

(1–6

)C

orne

alab

rasi

on(1

),d

yski

nesi

afr

oman

tiem

etic

s(1

),gr

aft

loss

due

toin

trav

ascu

lar

clot

ting

(1)

Non

eM

edia

nw

arm

isch

emia

5.8

min

JE HUMPHREY AND D CANES

422 © 2012 The Japanese Urological Association

Page 8

Whi

te,

2009

24D

onor

nep

hrec

tom

y(1

9)

Var

iab

le,n

otre

por

ted

dir

ectly

Not

rep

orte

dN

otre

por

ted

Stra

ight

and

artic

ulat

ing

No

218

116

3.4

Non

e2

toco

nven

tiona

lla

pM

ean

war

mis

chem

ia5.

29m

in

Dub

ey,

2011

38D

onor

nep

hrec

tom

y(5

)Si

ngle

inci

sion

with

3ad

jace

nttr

ocar

s

4.5

Rig

id,1

0m

m,

45°

Stra

ight

conv

entio

nal

inst

rum

ents

Yes

(1.5

-mm

por

t)15

7.2

(134

–184

)15

0(1

35–1

80)

3N

one

0N

ote

that

sing

le-u

seac

cess

dev

ices

are

exp

ensi

vean

dm

aylim

itm

aneu

vera

bili

ty

Oth

erre

nalp

roce

dur

esR

ane,

2009

39Si

mp

lene

phr

ecto

my

(3)

Trip

ort

Not

rep

orte

dR

igid

,5m

m,3

0°St

raig

htan

dar

ticul

atin

gN

o95

(45–

150)

66.6

(50–

100)

2.33

(2–3

)Po

rt-s

iteb

ruis

ing,

tran

sien

tp

osto

per

ativ

epy

rexi

a

0A

lso

per

form

ed2

case

sw

ithp

ort

inm

id-c

lavi

cula

rlin

e

Des

ai,

2009

26Si

mp

lene

phr

ecto

my

(14)

R-P

ort

Not

rep

orte

dR

igid

,5m

m,3

0°or

Flex

ible

,5

mm

,0°

Stra

ight

,ben

t,an

dar

ticul

atin

gYe

s(2

-mm

por

tre

qui

red

in5

case

s)

-145

(70–

300)

-109

(20–

300)

Var

ies

with

pro

ced

ure

Non

e0

All

sim

ple

nep

hrec

tom

ies

mor

cella

ted

and

extr

acte

d;c

yst

with

unob

stru

cted

dra

inag

e-K

idne

ycy

stex

cisi

on(1

)-6

0-<

50

Whi

te,

2009

24-S

imp

lene

phr

ecto

my

(7)

Var

iab

le,n

otre

por

ted

dir

ectly

Not

rep

orte

dN

otre

por

ted

Stra

ight

and

artic

ulat

ing

No

-156

-121

2.3

Non

e0

Part

ofla

rger

seri

esex

amin

ing

first

100

case

sat

sing

lece

nter

-Cys

td

ecor

ticat

ion

(2)

Ram

an,

2009

14Si

mp

lene

phr

ecto

my

(5)

Sing

lein

cisi

onw

ith3

adja

cent

troc

ars

2.5

Rig

id,5

mm

,45°

Stra

ight

and

artic

ulat

ing

Yes

(3-m

msu

bxy

pho

idtr

ocar

for

righ

tne

phr

ecto

my)

122

(90–

210)

20(1

0–60

0)2.

04(1

.25–

3.08

)N

one

0C

omp

ared

to22

conv

entio

nal

lap

aros

cop

icca

ses,

LESS

had

low

erm

ean

EBL

(20

vs10

0)

Ray

bou

rn,

2010

16Si

mp

lene

phr

ecto

my

(11)

R-P

ort

2Fl

exib

le,5

mm

,0°

Stra

ight

,flex

ible

,an

db

ent

Yes

(2-m

mgr

asp

erin

one

case

,3-m

min

cisi

onfo

r5

mm

gras

per

inon

eca

se)

151

(45–

290)

51(2

0–10

0)2.

36(1

–4)

Port

-site

bru

isin

g,tr

ansi

ent

pos

top

erat

ive

pyre

xia

0C

omp

ared

totr

aditi

onal

lap

aros

copy

,co

smet

icad

vant

age,

but

noot

her

sign

ifica

ntd

iffer

ence

s

Han

,20

1040

Sim

ple

nep

hrec

tom

y(1

4)

Hom

e-m

ade

dev

ice

2–3

Flex

ible

,5m

m,

0°or

rigi

d,

10m

m,0

°

Stra

ight

and

flexi

ble

No

151

(85–

230)

108

(0–5

00)

3.1

(2–6

)M

ildfe

ver

(1),

mild

ileus

(2)

0D

emon

stra

tes

abili

tyto

use

hom

e-m

ade

dev

ice

for

acce

ss

Jeon

,20

1030

LESS

:sim

ple

nep

hrec

tom

y(8

),cy

std

ecor

ticat

ion

(8)

Hom

e-m

ade

dev

ice

Var

iab

lew

ithp

roce

dur

eR

igid

,5–1

0m

m,

30°;

12m

mro

bot

icsc

ope

Stra

ight

,ar

ticul

atin

g,an

dfle

xib

le;s

tand

ard

rob

otic

inst

rum

ents

No

Var

ies

with

pro

ced

ure

Var

ies

with

pro

ced

ure

Var

ies

with

pro

ced

ure

Bow

elin

jury

(1)

dur

ing

rob

otic

LESS

sim

ple

nep

hrec

tom

y

0D

emon

stra

tes

vers

atili

tyof

hom

e-m

ade

dev

ice

for

vari

ous

urol

ogic

alp

roce

dur

esR

obot

ic-L

ESS:

sim

ple

nep

hrec

tom

y(1

)

Zhan

g,20

1141

Ren

alp

edic

lely

mp

hatic

dis

conn

ectio

nfo

rre

frac

tory

chyl

uria

Hom

e-m

ade

dev

ice

2–3

Rig

id,1

0m

m,

30°

and

flexi

ble

,5

mm

,0°

Stra

ight

and

flexi

ble

Yes

(3-m

mp

ort

for

liver

retr

actio

nin

1p

atie

nt)

125

(96–

165)

112

(50–

250)

3.5

(2–7

)Ly

mp

hatic

leak

age

(1)

0N

ore

curr

ence

ofch

ylur

iaw

ithav

erag

eof

8.3

mon

ths

follo

wup

Transumbilical LESS in urology

© 2012 The Japanese Urological Association 423

Page 9

Tab

le4

Ad

rena

lpro

ced

ures

usin

gtr

ansu

mb

ilica

lLES

S

Aut

hor,

year

Pro

ced

ure

(n)

Acc

ess

dev

ice

Post

oper

ativ

ein

cisi

on(c

m)

Scop

eIn

stru

men

tsus

edA

dd

ition

alp

orts

MO

T(m

in)

EBL

(mL)

LOS

(day

s)C

omp

licat

ions

(n)

Con

vers

ion

toop

en/la

pC

omm

ents

Jeon

g,20

0917

Ad

rena

lect

omy

(9)

Hom

e-m

ade

dev

ice

2Fl

exib

le,5

mm

,0°

Stra

ight

and

artic

ulat

ing

No

169.

2(8

9–28

9)17

7.8

(50–

400)

3.2

(2–4

)Se

rosa

ltea

r(1

)0

Mat

ched

toco

nven

tiona

lla

par

osco

pyw

ithco

mp

arab

lere

sults

Des

ai,2

00926

Ad

rena

lect

omy

(1)

R-P

ort

Not

rep

orte

dR

igid

,5m

m,3

0°or

Flex

ible

,5

mm

,0°

Stra

ight

,ben

t,an

dar

ticul

atin

gYe

s(2

-mm

por

t)15

035

03

Ble

edin

gw

ithri

ght

rena

lvei

nin

jury

,su

bse

que

ntre

nal

vein

thro

mb

us(1

)

1to

conv

entio

nal

lap

aros

copy

Onl

yca

sew

asco

nver

ted

due

tori

ght

rena

lvei

nin

jury

Jeon

,201

030A

dre

nale

ctom

y(2

)H

ome-

mad

ed

evic

eN

otre

por

ted

Rig

id,5

–10

mm

,30

°;12

mm

rob

otic

scop

e

Stra

ight

,ar

ticul

atin

g,an

dfle

xib

le

N0

260

125

3N

one

0D

emon

stra

tes

vers

atili

tyof

hom

e-m

ade

dev

ice

for

vari

ous

urol

ogic

alp

roce

dur

es

Tab

le5

Ure

tera

lpro

ced

ures

usin

gtr

ansu

mb

ilica

lLES

S(e

xclu

din

gne

phr

oure

tere

ctom

y)

Aut

hor,

Year

Pro

ced

ure

(n)

Acc

ess

dev

ice

Post

oper

ativ

ein

cisi

on(c

m)

Scop

eIn

stru

men

tsus

edA

dd

ition

alp

orts

MO

T(m

in)

EBL

(mL)

LOS

(day

s)C

omp

licat

ions

(n)

Con

vers

ion

toop

en/la

pC

omm

ents

Des

ai,2

00933

Ileal

uret

er(1

),ur

eter

o-ne

ocys

tost

omy

with

pso

ashi

tch

(1)

R-P

ort

1.5–

3N

otre

por

ted

Stra

ight

and

ben

tYe

s(2

-mm

por

tfo

rgr

asp

er,n

otr

uein

cisi

on)

277

(180

–360

)68

.75

(50–

100)

2(1

–3)

Non

e0

Pla

ced

Jack

son-

Pra

ttd

rain

svi

aum

bili

cali

ncis

ion

Des

ai,2

00926

-Ure

tera

lre

imp

lant

(2)

R-P

ort

Not

rep

orte

dR

igid

,5m

m,3

0°or

Flex

ible

,5

mm

,0°

Stra

ight

,ben

t,an

dar

ticul

atin

gYe

s(2

-mm

por

t)-1

75(1

40–2

10)

-175

(100

–250

)-4

Ana

stom

otic

leak

(1)

0Pa

rtof

larg

erse

ries

exam

inin

gfir

st10

0ca

ses

atsi

ngle

cent

er-Il

ealu

rete

r(3

)-3

30(3

00–3

60)

-170

(90–

250)

-2

Whi

te,2

00924

Ure

tera

lre

imp

lant

(1)

Not

rep

orte

dN

otre

por

ted

Not

rep

orte

dSt

raig

htan

dar

ticul

atin

gN

o18

010

03

Non

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MA

G3

norm

al

Jeon

,201

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rect

omy

(1)

Hom

e-m

ade

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ice

Not

rep

orte

dR

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m,

30°;

12m

mro

bot

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ope

Stra

ight

,ar

ticul

atin

g,an

dfle

xib

le

No

-80

-150

-3N

one

0U

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rect

omy

for

dup

licat

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ecto

pic

uret

er-U

rete

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my

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-2-3

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2011

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Rig

id,1

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m,0

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Yes

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atie

nt,s

ize

not

rep

orte

d)

110.

4361

.17

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ildile

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elit

hotr

ipsy

not

avai

lab

le

JE HUMPHREY AND D CANES

424 © 2012 The Japanese Urological Association

Page 10

Tab

le6

Bla

dd

erP

roce

dur

esus

ing

tran

sum

bili

calL

ESS

Aut

hor,

year

Pro

ced

ure

(n)

Acc

ess

dev

ice

Post

oper

ativ

ein

cisi

on(c

m)

Scop

eIn

stru

men

tsus

edA

dd

ition

alp

orts

MO

T(m

in)

EBL

(mL)

LOS

(day

s)C

omp

licat

ions

(n)

Con

vers

ion

toop

en/la

pC

omm

ents

Nog

uera

,200

943A

ugm

enta

tion

ente

rocy

stop

last

y(1

)

Qua

dp

ort

5Fl

exib

le,5

mm

,0°

Stra

ight

and

flexi

ble

No

300

<100

6N

one

0B

owel

rese

ctio

nan

dan

asto

mos

isp

erfo

rmed

extr

acor

por

eally

Whi

te,2

00918

Sacr

alco

lpop

exy

(10)

Uni

-X1.

8Fl

exib

le,5

mm

,0°

Stra

ight

and

artic

ulat

ing

No

162

47.5

1.5

Cys

toce

le(1

),st

ress

inco

ntin

ence

(2)

0Si

ngle

-por

tco

mp

arab

lein

seri

esto

mat

ched

lap

aros

cop

ican

dro

bot

icca

ses

Whi

te,2

00924

Rad

ical

cyst

ecto

my

(3)

Var

iab

le,n

otre

por

ted

dir

ectly

Not

rep

orte

dN

otre

por

ted

Stra

ight

and

artic

ulat

ing

No

-315

-216

-6.6

Non

e0

Cys

tect

omy

lym

ph

nod

eyi

eld

=16

Sacr

alco

lpop

exy

(13)

-182

-46.

9-1

.6

Kaou

k,20

1044

Rad

ical

cyst

ecto

my

(3)

Uni

-X4.

5–5

(1.8

cmb

efor

eex

trac

tion)

Flex

ible

,5m

m,

0°St

raig

htan

dfle

xib

leN

o31

5(2

85–3

60)

217

(200

–250

)6

(5–7

)N

one

0O

per

ativ

etim

ed

ecre

ased

from

first

toth

ird

pat

ient

Jeon

,201

030Pa

rtia

lcy

stec

tom

y(1

)H

ome-

mad

ed

evic

eV

aria

ble

with

pro

ced

ure

Rig

id,5

–10

mm

,30

°;12

mm

rob

otic

scop

e

Stra

ight

,ar

ticul

atin

g,an

dfle

xib

le

No

175

504

Non

e0

Dem

onst

rate

sve

rsat

ility

ofho

me-

mad

ed

evic

efo

rva

riou

sur

olog

ical

pro

ced

ures

Ab

del

-Kar

im,

2011

45V

esic

ovag

inal

fistu

lare

pai

r(5

)Tr

ipor

t2

Flex

ible

,5m

m,

0°B

ent

Yes

(inal

lcas

es,

5-m

mp

ort

add

edfo

rsu

turi

ngan

dtr

iang

ulat

ion)

198

(170

–240

)90

(70–

120)

2N

one

0Le

ssp

ain

and

shor

ter

hosp

ital

stay

than

sam

egr

oup

’sco

nven

tiona

lla

par

osco

pic

case

s

Transumbilical LESS in urology

© 2012 The Japanese Urological Association 425

Page 11

LESS prostatectomy would ultimately be cautiouslyexplored. This has been described both laparoscopically andwith robotic LESS. Robotic instruments with articulatingtips provide the surgeon with better dexterity when operat-ing through the LESS avenue. The largest series described20 patients undergoing robotic LESS prostatectomy withreasonable mean operative time (187.6 min), estimatedblood loss (128.8 mL) and average length of stay(2.5 days).46 They concluded that robotic assistance“reduces or eliminates instrument crossing, has superiorergonomics, and instrument tip articulation significantlyfacilitates suturing.” Their series is compared with otherLESS prostate series in Table 7.

Robotic LESS

Use of robotics for assistance with LESS procedures wasintended to bring increased dexterity to offset some of thefrustrations with standard laparoscopic LESS surgery. Theda Vinci robotic system (Intuitive Surgical, Sunnyvale, CA,USA) has been used successfully through a single transum-bilical port in a variety of procedures. In 2009, Rane et al.discussed the use of robotics with LESS and its implicationsfor future directions.49 They described how robotics can aidLESS with superior visualization of the operative field,enhanced surgical dexterity and excellent ergonomics.

However, the original da Vinci robotic system was notdesigned specifically for single-site surgery, and thereforehas its own limitations. First, the external size and straightshape of the robotic arms lead to external clashing over asingle port. Second, the original robotic instrument shaftsthemselves do not articulate, and therefore intracorporealclashing can occur as well.

To this end, the newer da Vinci Si surgical system hasbeen modified to be more amenable to single-site surgery.There has been development of VeSPA surgical instruments(Intuitive Surgical) to overcome the aforementioned limita-tions. These instruments are inserted through curved cannu-lae and allow multiple ports through one incision while stillallowing intra-abdominal triangulation. The feasibility ofthis technique was shown in a porcine model in 2010, inwhich the authors completed various kidney procedures(pyeloplasty, partial nephrectomy, nephrectomy) showingimproved ergonomics and minimal instrument clashing.50

Disadvantages

Transumbilical LESS does have difficulties associated withit that the surgeon must weigh with the cosmetic benefit. Asaforementioned, in general utilizing a LESS technique willlead to either no true triangulation or a reliance on curved orbent instruments in order to create triangulation. Thus, thereis a learning curve to LESS that might dissuade communityurologists from accepting LESS into their practice. Another Ta

ble

7P

rost

ate

pro

ced

ures

usin

gtr

ansu

mb

ilica

lLES

S

Aut

hor,

year

Pro

ced

ure

(n)

Acc

ess

dev

ice

Post

oper

ativ

ein

cisi

on(c

m)

Scop

eIn

stru

men

tsus

edA

dd

ition

alp

orts

MO

T(m

in)

EBL

(mL)

LOS

(day

s)C

omp

licat

ions

(n)

Con

vers

ion

toop

en/la

pC

omm

ents

Kaou

k,20

0847

Rad

ical

pro

stat

ecto

my

(4)

Uni

-X2–

3Fl

exib

le,5

mm

,0°

Flex

ible

shea

rs,

curv

edan

dar

ticul

atin

g

No

285

(240

–300

)28

7(1

50–4

00)

2.5

(2–3

)R

ecto

uret

hral

fistu

la0

Flex

ible

-tip

scop

ehe

lps

limit

inst

rum

ent

clas

hing

Whi

te,2

00924

Rad

ical

pro

stat

ecto

my

(6)

Var

iab

le,n

otre

por

ted

dir

ectly

Not

rep

orte

dN

otre

por

ted

Stra

ight

and

artic

ulat

ing

No

270

250

2.3

Fist

ula

(1)

03

foca

llyp

ositi

vem

argi

ns

Bar

ret,

2009

48R

obot

ic-a

ssis

ted

rad

ical

pro

stat

ecto

my

(1)

Sing

lein

cisi

ons

with

3ad

jace

nttr

ocar

s

412

mm

rob

otic

scop

eSt

and

ard

rob

otic

inst

rum

ents

Yes

(5-m

mri

ght

low

erab

dom

inal

por

tfo

rsu

ctio

nan

dco

unte

rtr

actio

n)

150

500

Not

Rep

orte

dN

one

0U

sed

5m

mad

diti

onal

por

tfo

rhe

lpin

tran

sitio

nto

sing

le-p

ort

surg

ery

Whi

te,2

01046

Rob

otic

-ass

iste

dra

dic

alp

rost

atec

tom

y(2

0)

SILS

3–4.

512

mm

rob

otic

scop

eSt

and

ard

rob

otic

inst

rum

ents

Yes

(tw

oca

ses

with

8-m

mro

bot

icp

ort

due

toex

cess

ive

exte

rnal

clas

hing

)

187.

6(1

20–3

00)

128.

8(5

0–35

0)2.

5(1

–6)

Ileus

(1),

blo

odtr

ansf

usio

n(1

),p

ulm

onar

yem

bol

us(1

),ur

osep

sis

(1)

1(t

ost

and

ard

rob

otic

-ass

iste

dla

par

osco

pic

pro

stat

ecto

my)

Rob

otic

sre

duc

esin

stru

men

tcr

ossi

ng,

imp

rove

ssu

turi

ngab

ility

JE HUMPHREY AND D CANES

426 © 2012 The Japanese Urological Association

Page 12

important aspect of incorporating transumbilical LESS isthe potential cost of newer instruments and access devices. Itmight not be worth both the training and cost associatedwith LESS for the urologist who only has a limited use forLESS. However, there has been no dedicated analysis of costassociated with LESS to this date.

Conclusion

The progression of minimally invasive surgery has ledurologists to explore LESS. Born out of a desire forimproved cosmesis, and the potential for reduced operativetrauma, decreased postoperative pain and complications,transumbilical LESS has successfully been implementedinto the urologist’s armamentarium. However, the futurerole of LESS is still uncertain. Although large specialtycenters have described LESS for virtually all urologicallaparoscopic procedures, it is unclear whether LESS willdiffuse beyond select centers. The majority of data availableare based on non-randomized series, whereby selection biasmight play a significant role. However, a randomized pro-spective trial would be very difficult to complete comparingLESS to conventional laparoscopy. It does seem evident thatthe cosmetic benefit from LESS is real and reproducible, butany incremental benefit apart from cosmesis seems unlikelyto match the leap previously witnessed from open surgery tolaparoscopy.

Surgical device companies have responded by developingaccess devices, scopes and instruments more specificallyaimed towards LESS. As technology improves, this will nodoubt continue to make the transition to LESS easier for moresurgeons. Currently-available LESS training courses shouldbe considered for surgeons interested in LESS techniques tobenefit from the collective experience of early adopters.

The urological transumbilical LESS experience is rapidlygrowing, but many questions remain. Whether the benefits ofLESS truly outweigh its technical challenges is currently un-known. We also cannot predict whether LESS in some formwill become a permanent fixture in our arsenal, or a historicalfootnote. For now, LESS surgery remains the subject ofintense scrutiny, and is a laudable example of surgical cre-ativity aimed at minimizing surgical trauma for our patients.

Conflict of interest

None declared.

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JE HUMPHREY AND D CANES

428 © 2012 The Japanese Urological Association