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

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

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

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

3 Robotic-assisted Laparoscopy

4 Robotic technology/techniques LESS NOTES

5 Can We Get Even Less Invasive?

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

7 Laparoendoscopic Single Site (LESS) Surgery Principles: Limit trocars to single incision – usually umbilical Periumbilical specimen extraction Improved cosmesis Less transmural trocars = Less pain Faster recovery

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

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

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

14 courtesy of J. Kaouk, D. Scott, and A. Rane Access Several custom access ports –Most are “3 trocars in one” with single 2-3 cm incision

15 Courtesy of P. Curcillo, MD

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17 Camera Solutions courtesy of D. Scott

18 Articulating Instrumentation Degrees of motion comparable to robotic system Allows for real time adjustments Principle of dissection –Instruments cross at fulcrum to avoid collision courtesy of D. Scott

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20 LESS in General Surgery Cholecystectomy Adrenalectomy Appendectomy

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

22 August 2007: First report of single incision laparoscopic nephrectomy Urology 70:1039, 2007

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

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

25 Robotic LESS DaVinci Si system adapted to LESS

26 Principles Trocars positioned at umbilical incision crossing similar to conventional LESS Multiport access technique limited by gas leak and crowding/collision of trocars/arms –Use commercial port to minimize

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

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

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30 Instrumentation 30 degree UP scope –Nonconventional image –Creates space at GelPoint for assistant! 8 mm scissor + 5 mm graspers 5/8 mm graspers + 5 mm hook cautery 5 and/or 8 mm needle drivers

31 Pearls Instruments and camera moved in tandem short distances Cross instruments at incision above camera (30 deg up) and reassign instruments to right and left hands. At crossing point, top instrument can retract tissue upwards. To retract downwards need to re-cross so that grasper is below scissors/cautery.

32 R-LESS Pyeloplasty

33 Experience UTSW –5 R-LESS nephrectomies Difficulty with dividing hilum. Assistant challenged to introduce stapler if ~ 3-4 cm incision. Must use clips. 1 converted to Lap nephrectomy –20 R-LESS pyeloplasties Ease of anastomosis, no need for additional 3 mm assistant ports. Pre-place stent/ureteral access.

34 Published Literature

35 2011: Purpose-built Robotic Platform

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37 Courtesy of David Canes

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

39 Case-control comparison of early outcomes in SILS vs. Conventional Lap Nephretomy (Eur Urol, 2009) IRB-approved, retrospective case-match series –11 SILN performed from August 2007 to March 2008 (cases) Extra 3 mm sub-xyphoid trocar for liver retraction –22 CLN performed from September 2004 to February 2007 (controls)

40 Results: Peri-operative parameters All patientsLaparoscopic approach SILSConventionalP value OR time (min) Mean (SD) Median (range) 143 (42) 125 (90-240) 138 (35) 122 (90-210) 145 (45) 125 (90-240) 0.78 † EBL (mL) Mean (SD) Median (range) 125 (143) 100 (10-600) 80 (175) 20 (10-600) 147 (123) 100 (20-520) † Morphine equivalents (mg) Mean (SD) Median (range) 15 (13) 13 (0-54) 15 (16) 8 (1-54) 15 (12) 15 (0-49) 0.69 † Change in Hgb (%) Mean (SD) Median (range) 15.3 (6.0) 15.5 (0-24) 14.1 (5.8) 15.4 (5-23) 15.8 (6.2) 16.0 (0-24) 0.52 † Length of stay (hrs) Mean (SD) Median (range) 51 (18) 52 ( (14) 49 (30-74) 53 (19) 53 (29-106) 0.44 † * Chi-square test † Kruskal-Wallis test

41 Case-matched LESS Pyeloplasty vs. Lap Pyeloplasty Urology 2009 Maybe extraction incision or morcellation for nephrectomy creates additional pain? Reconstructive procedures may have more benefit? Conventional Lap (Range)LESS (Range)p-value Mean LOS (hrs)74 (36-215)77 (50-149)0.69* Mean Operative time (min)257 ( )202 ( )< 0.001* Mean EBL (mL)85 (25-200)35 (25-50)0.002* Mean MSO4 Eq 38 (0-119) 34 (0-117) 0.93* Grade I/II complications (%)4 (14.3%)2 (14.3%)1** Grade IIIa/IIIb complications (%)2 (10%)3 (21.4%)0.31**

42 LESS vs Standard Lap Donor Nephrectomy: Case-Match Canes, Desai, Gill et al. Eur Urol 57:95, 2010 No differences in LOS, OR time, EBL, analgesia equivalents or visual analog pain scores, but… Too good to be true? Confirmation Bias? Conventional Lap (N = 17) LESS (N = 18)p-value Mean Days on Oral Pain Meds Mean Days Off Work4618<0.01 Days to 100% recovery

43 LESS vs. Standard Lap Donor Neph: Randomized Prospective Trial Mahesh Desai et al. –Nadiad, India –AAGUS 2010 –25 left DN in each group Group A (Standard)Group B (LESS) p Value Operating time (minutes) ± ± Conversion to Open surgery 00 Conversion to multiple ports LDN (%) -2 (8%) Estimated blood loss (milliliters) 92.40± ± Graft artery length (millimeters) 24.36± ± Graft vein length (millimeters) 28.68± ± Graft ureter length (millimeters) ± ± Length of incised wounds (millimeters) ± ±14.37 < Blood transfusion00 Hemoglobin drop (gm/dL) 0.87± ± Intra-operative complications (%) 2 (8%)4 (16%)0.20

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

45 27 pts randomized

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

47 Importance of Cosmesis (BJUI 2011) UTSW Survey – all kidney and prostate patients (80 Lap, 17 LESS, 15 Open) –PRE-OP: Ranked importance of various surgical outcomes Most important factor: Surgeon reputation Least important factor: Scar size & # –Unless: Age < 50 or Benign Indication Bucher et al. Surg Endosc 2010; Jul 3. –75% would choose LESS over Lap if complication rate similar

48 Importance of Cosmesis (Eur Urol 2011) UTSW Survey – kidney surgery only –LESS vs. Lap vs Open Overall scar satisfaction by surgery type: –67% - 43% - 40% Entire cohort cosmetic appeal of photographs of scars: –69% very pleased with LESS vs. 46% and 23% Satisfaction with their scar after viewing other scars: –80% vs. 57% vs. 50%

49 Observations Feasible surgical technique – the next revolution in MIS Triangulation made possible by articulating instrumentation or robotics Learning curve due to close proximity of instruments Limitations: 1.Instrument collision due to umbilical crowding 2.Triangulation still a problem…working envelope restrictions 3.Limited to 3 working trocars – 4 possible if bigger incision?

50 Natural Orifice Translumenal Endoscopic Surgery (NOTES) “Incisionless Surgery” –Transgastric (mouth) –Transcolonic (anus) –Transvaginal –Transvesical (urethra) –Advantages?: less pain, less scarring, faster recovery Proof of concept –UTSW: Gettman, Cadeddu et al.: U.S., 2001, Porcine Model –Reddy & Rao: India, 2004, Human Appendectomy

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

52 NOTES Human Cases USA Bessler/Fowler, Columbia – 8 TV Chole Horgan/Talamini, UCSD – > 45 TV Chole (+ TG chole, TG Appy, TV Appy) Swanstrom/Soper/Hungness, Legacy (Portland) + Northwestern – > 8 TG Chole Abroad Brazil, > 200 cases, mostly TV France, ~ 20 cases, mostly TV Germany, > 200 cases, TV, rigid scope Italy, ~ 20 cases, TV

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

54 Equipment Limitations Lack of stability and torque Lack of maneuverability and reach Inability to triangulate Lack of “surgical” instruments Inability to use multiple instruments simultaneously Visual disorientation LaparoscopyEndoscopy

55 LESS vs. NOTES  Both LESS and NOTES are contemporary minimally invasive techniques with obvious cosmetic and morbidity benefits.  LESS is here and now.  NOTES is still largely preclinical or investigational.


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