Laparoendoscopic Single-site Radical Prostatectomy – Is LESS Really More?

Jonathan L Silberstein, Nicholas E Power, Karim A Touijer
European Urological Review, 2011;6(2):128-131
pdf icon download pdf ejournal view ejournal

Abstract

Laparoendoscopic single-site radical prostatectomy (LESS-RP) is a modification of traditional laparoscopy in which all ports are consolidated at a single incision site that is also used for specimen extraction. Theoretically, by limiting the total amount of skin incised and trauma to subcutaneous soft tissues, LESS may potentially result in decreased pain and shorter convalescence while improving cosmesis and patient satisfaction. However, LESS-RP is technically challenging. Combining all working ports at a single site eliminates triangulation and results in increased instrument clashing, decreased visualisation and poor ergonomics. In order to overcome these limitations, surgeons and industry innovators have developed a variety of methods to make these procedures feasible. In this review, we will discuss the impediments to LESS-RP and the methods to overcome these obstacles. We will also describe new technologies on the horizon and, finally, review the existing data comparing LESS-RP with conventional laparoscopy.

Acknowledgements: The publication of this article was supported by The Sidney Kimmel Center for Prostate and Urologic Cancers and by funds provided by David H Koch through the Prostate Cancer Foundation and by Award Number U54CA137788/U54CA132378 from the National Cancer Institute. The authors would like to thank Michael McGregor for the editorial assistance provided in preparing this manuscript.
Keywords
Radical prostatectomy, laparoendoscopic single-site surgery, single incision laparoscopic surgery, robotic, laparoscopic
Disclosure The authors have no conflicts of interest to declare.
Received: August 03, 2011 Accepted September 20, 2011
Correspondence: Karim A Touijer, Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, US. E: touijera@mskcc.org

The technique of radical prostatectomy (RP) has undergone a number of refinements throughout its evolution as a treatment for prostate cancer. Initially, investigators defined a more comprehensive anatomical understanding of the pelvis, resulting in surgical modifications that have reduced functional morbidity while maintaining sound oncological principles.1 The next major series of advances were the development of minimally invasive techniques, either with or without robotic assistance, which have been reliably demonstrated to result in less blood loss than open procedures and may result in shorter convalescence as well.2 More recently, there have been a variety of investigators exploring the possibility of reducing incisional morbidity and increasing patients’ cosmetic satisfaction by decreasing the number of incisions for port access in laparoscopic prostatectomies and consolidating them at the prostate extraction site. This has been termed laparoendoscopic single-site radical prostatectomy (LESS–RP).

While the concept of LESS-RP is exciting, the primary limitation is that the combination of all of the laparoscopic instruments at a single site limits triangulation – a fundamental principle of laparoscopy. This profound constraint results in both intra- and extracorporeal instrument clashing and limits range or motion. As a consequence, LESS-RP, though first described in the clinical setting in 2008,3 is a technique that is still in its infancy. To date, the largest published series of LESS-RP is 20 patients4 and the primary goal of existing studies has been demonstrating the feasibility of LESS-RP rather than measuring oncological or functional outcomes.5 In this review, we will update the reader on the current state of LESS-RP, various techniques for performing the procedure, the obstacles that currently exist and the strategies employed to overcome them. Finally, we will review the existing data comparing LESS-RP with conventional laparoscopy in an attempt to better understand the outcomes of LESS-RP and its forward momentum.

Technical Considerations – Access, Instrumentation and Visualisation

Consolidating all incisions at a single site invariably results in instrument clashing, limited range of motion and difficulties with visualisation. To make these procedures feasible, urologists and surgical instrument engineers have used several strategies to begin to overcome these technical challenges – although many barriers and obstacles remain. We will briefly outline the current techniques to access the abdominal cavity, as well as review laparoscopic instruments and laparoscopes designed specifically for LESS surgery.

References:
  1. Walsh PC, Anatomic radical prostatectomy: evolution of the surgical technique, J Urol, 1998;160:2418–24.
  2. Parsons JK, Bennett JL, Outcomes of retropubic, laparoscopic, and robotic-assisted prostatectomy, Urology, 2008;72:412–6.
  3. Kaouk JH, Goel RK, Haber GP, et al., Single-port laparoscopic radical prostatectomy, Urology, 2008;72:1190–3.
  4. White MA, Haber GP, Autorino R, et al., Robotic laparoendoscopic single-site radical prostatectomy: technique and early outcomes, Eur Urol, 2010;58:544–50.
  5. Silberstein J, Power N, Touijer K, Laparoendoscopic single site (LESS) radical prostatectomy:a review of the initial experience, Minerva Urol Nefrol, 2011;63:123–9.
  6. Gill IS, Advincula AP, Aron M, et al., Consensus statement of the consortium for laparoendoscopic single-site surgery, Surg Endosc, 2010;24:762–8.
  7. Botden S, Strijkers R, Fransen S, et al., The use of curved vs. straight instruments in single port access surgery, on standardized box trainer tasks, Surg Endosc, 2011;25:2703–10.
  8. Stolzenburg JU, Kallidonis P, Oh MA, et al., Comparative assessment of laparoscopic single-site surgery instruments to conventional laparoscopic in laboratory setting, J Endourol, 2011;24:239–45.
  9. Derweesh IH, Silberstein JL, Bazzi W, et al., Laparo-endoscopic single-site surgery for radical and cytoreductive nephrectomy, renal vein thrombectomy, and partial nephrectomy: a prospective pilot evaluation, Diagn Ther Endosc, 2010:2010;1–8.
  10. Dindo D, Demartines N, Clavien PA, Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey, Ann Surg, 2004;240:205–13.
  11. Bachiller Burgos J, Alonso Flores J, Sanchez De La Vega J, et al., [Early experience in laparoscopic radical prostatectomy using the laparoscopic device for umbilical access SILS Port], Actas Urol Esp, 2010;34:495–9.
  12. Ferrara V, Giannubilo W, Azizi B, et al., SILS extraperitoneal radical prostatectomy, Minerva Urol Nefrol, 2010;62:363–9.
  13. Stein RJ, White WM, Goel RK, et al., Robotic laparoendoscopic single-site surgery using GelPort as the access platform, Eur Urol, 2010;57:132–6.
  14. Barret E, Sanchez-Salas R, Cathelineau X, et al., Re: Initial complete laparoendoscopic single-site surgery robotic assisted radical prostatectomy (LESS-RARP), Int Braz J Urol, 2009;35:92–3.
  15. Barret E, Sanchez-Salas R, Kasraeian A, et al., A transition to laparoendoscopic single-site surgery (LESS) radical prostatectomy: human cadaver experimental and initial clinical experience, J Endourol, 2009;23:135–40.
  16. Leewansangtong S, Vorrakitkatorn P, Amornvesukit T, et al., Laparo-endoscopic single site (LESS) robotic radical prostatectomy in an Asian man with prostate cancer: an initial case report, J Med Assoc Thai, 2010;93:383–7.
  17. White WM, Haber GP, Goel RK, et al., Single-port urological surgery: single-center experience with the first 100 cases, Urology, 2009;74:801–4.
  18. Leveillee RJ, Castle SM, Gorin MA, et al., Initial Experience with Laparoendoscopic Single-Site Simple Nephrectomy Using the TransEnterix SPIDER Surgical System: Assessing Feasibility and Safety, J Endourol, 2011;25:923–5.
  19. Haber GP, Autorino R, Laydner H, et al., SPIDER Surgical System for Urologic Procedures With Laparoendoscopic Single-Site Surgery: From Initial Laboratory Experience to First Clinical Application, Eur Urol, 2011; [Epub ahead of print].
  20. Gettman MT, Lotan Y, Napper CA, et al., Transvaginal laparoscopic nephrectomy: development and feasibility in the porcine model, Urology, 2002;59:446–50.
  21. Kaouk JH, Haber GP, Goel RK, et al., Pure natural orifice translumenal endoscopic surgery (NOTES) transvaginal nephrectomy, Eur Urol, 2010;57:723–6.
  22. Alcaraz A, Peri L, Molina A, et al., Feasibility of transvaginal NOTES-assisted laparoscopic nephrectomy, Eur Urol, 2010;57:233–7.
  23. Swain P, Nephrectomy and natural orifice translumenal endoscopy (NOTES): transvaginal, transgastric, transrectal, and transvesical approaches, J Endourol, 2008;22:811–8.
  24. Bazzi WM, Wagner O, Stroup SP, et al., Transrectal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy in a porcine model, Urology, 2011;77:518–23.
  25. Humphreys MR, Krambeck AE, Andrews PE, et al., Natural orifice translumenal endoscopic surgical radical prostatectomy: proof of concept, J Endourol, 2009;23:669–75.
  26. Park S, Bergs RA, Eberhart R, et al., Trocar-less instrumentation for laparoscopy: magnetic positioning of intra-abdominal camera and retractor, Ann Surg, 2007;245:37–84.
  27. Power N, Power A, Reducing port sites: evaluation and introduction of a novel fan retractor, Presented at: the American Urological Association Annual Meeting, San Antonio, Texas, 21–26 May, 2005.
  28. Cadeddu JA, Porcine nephrectomy using magnetically anchored laparoscopic instruments, Presented at: the American Urological Association Annual Meeting, San Antonio, Texas, 21–26 May, 2005.
  29. Zeltser IS, Cadeddu JA, A novel magnetic anchoring and guidance system to facilitate single trocar laparoscopic nephrectomy, Curr Urol Rep, 2008;9:62–4.
  30. Raman JD, Bergs RA, Fernandez R, et al., Complete transvaginal NOTES nephrectomy using magnetically anchored instrumentation, J Endourol, 2009;23:367–71.
  31. Cadeddu J, Fernandez R, Desai M, et al., Novel magnetically guided intra-abdominal camera to facilitate laparoendoscopic single-site surgery: initial human experience, Surg Endosc, 2009;23:1894–9.
  32. Tugcu V, Ilbey YO, Mutlu B, et al., Laparoendoscopic single-site surgery versus standard laparoscopic simple nephrectomy: a prospective randomized study, J Endourol, 2010;24:1315–20.
  33. Kurien A, Rajapurkar S, Sinha L, et al., First prize: standard laparoscopic donor nephrectomy versus laparoendoscopic single-site donor nephrectomy: a randomized comparative study, J Endourol, 2011;25:365–70.
  34. Schroeck FR, Krupski TL, Sun L, et al., Satisfaction and regret after open retropubic or robot-assisted laparoscopic radical prostatectomy, Eur Urol, 2008;54:785.
  35. Touijer K, Marketing versus science: a fight between necessary evil and stern good over the adoption of new technology in medicine, Eur Urol, 2010;58:522–4.
  36. Leff B, Finucane TE, Gizmo idolatry, JAMA, 2008;299:1830–2.
close

This content is copyright protected

However, if you would like to share the information on this webpage, you may use the headline and link below:

Laparoendoscopic Single-site Radical Prostatectomy – Is LESS Really More?

Read more: Laparoendoscopic Single-site Radical Prostatectomy – Is LESS Really More?