Urology & Kidney Disease News Fall 2009 - Cleveland Clinic

32 Urology & Kidney Disease News
Robotics and Laparoscopy
Laparoscopic Surgery Without Visible Scars:
Experience with the First 100 Cases
Jihad Kaouk, MD, Robert Stein, MD, Courtenay Moore, MD,
and Raymond Rackley, MD
In the past 2 years, the surgical community has witnessed
an exciting foray into the burgeoning field of single-port
laparoscopic or laparoendoscopic single site (LESS) surgery.
Developed as an extension of standard laparoscopy that
requires 3 to 6 small incisions, LESS seeks to minimize
patient discomfort, shorten convalescence, and improve
cosmesis by placing all instruments through a readily concealed
2cm incision mostly within the umbilicus. Initial
series have been published that extol the safety, aesthetics,
and superior pain profile of the single-port approach. However,
questions remain regarding the comparative benefit of
LESS, its applicability, its potentially lengthy learning curve,
and technical limitations of existing instrumentation.
We present our initial experience with 100 patients who underwent
LESS urologic surgery from September 2007 to February
2009. Specifically, 74 patients underwent LESS renal
surgery (cryoablation, 8; partial nephrectomy, 15; metastectomy,
1; renal biopsy, 1; simple nephrectomy, 7; radical
nephrectomy, 6; cyst decortication, 2; nephroureterectomy,
7; donor nephrectomy, 19; and dismembered pyeloplasty,
8) and 26 patients underwent LESS pelvic surgery (varicocelectomy,
3; radical prostatectomy, 6; radical cystectomy,
3; sacral colpopexy, 13; and ureteral reimplant, 1). Mean
patient age was 54 years.
Mean operative time was 199 minutes. Estimated blood
loss was 136 mL. No intraoperative complications occurred.
Six patients required conversion to standard laparoscopy.
Mean length of hospitalization was 3 days. Mean Visual
Analog Pain Scale score at discharge was 1.5/10. At a mean
follow-up of 11 months, 9 Clavien Grade II (transfusion, 7;
urinary tract infection, 1; deep vein thrombosis, 1) and 2
Clavien Grade IIIb (recto-urethral fistula, 1; angioembolization,
1) surgical complications occurred.
Based on our initial experience that represents one of the
largest experiences in this technique worldwide, LESS urologic
surgery is safe, offers improved patient cosmesis and
decreased pain, and can be performed with a modicum of
laparoscopic skills. Its superiority compared to traditional
laparoscopy is currently speculative. As such, a prospective,
randomized trial is under way to better define its role.
Illustration of single-port retroperitoneoscopic kidney surgery.
Note that all instruments and scope are introduced through a
partial nephrectomy.