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Laparo-endoscopic single-site radical prostatectomy: Feasibility and technique ☆

View Article: PubMed Central

ABSTRACT

Background: As laparoscopy becomes a standard approach in many urological procedures, researchers strive to make minimally invasive surgery less invasive. Our objective was to apply recent innovations in equipment and surgical approaches to develop the technique and perform laparo-endoscopic single site radical prostatectomy (LESS-RP).

Methods: The technique for LESS-RP was derived by combining existing techniques of standard laparoscopic RP and developing techniques of urological LESS. This incorporated newly available low-profile trocars, flexible instruments and a flexible-tip laparoscope. The procedure was performed through a single 3-cm transverse infra-umbilical incision. LESS-RP was completed successfully via a single operative site without auxiliary needles or trocars. Perioperative variables and postoperative outcomes were recorded and measured.

Results: The operative time was 424 min and the hospital stay was 10 days because of a vesicourethral leak and ileus. The anastomotic leak resolved and the urethral catheter was removed at 4 weeks after surgery. The final pathology showed negative margins and Gleason 3 + 4 pT2c prostatic adenocarcinoma.

Conclusions: LESS-RP is feasible by replicating laparoscopic RP techniques and incorporating the LESS technique with the advent of flexible-tip laparoscopes and flexible instruments. After a learning curve has been overcome, this should be further tested prospectively to compare oncological and functional outcomes with laparoscopic and robotic-assisted RP.

No MeSH data available.


Flexible needle drivers make intracorporeal suturing and tying feasible during LESS.
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f0010: Flexible needle drivers make intracorporeal suturing and tying feasible during LESS.

Mentions: The patient was placed in a Trendelenburg position with low lithotomy stirrups and the arms tucked. Sequential compression devices were placed on both the lower extremities. A single 3-cm transverse infra-umbilical incision was made. Pneumo-insufflation was obtained using a Veress needle. A flexible-tip laparoscope (LTF Series, Olympus Surgical, Orangeburg, NY, USA), two 5-mm Anchorports (Surgiquest, Orange, CT, USA), and a 12-mm trocar were placed through separate fascial punctures within the single infra-umbilical incision site. Flexible instruments (Realhand, Novare, Cupertino, CA, USA) were used in addition to standard laparoscopic instruments. A 5-mm and a 10-mm flexible-tip laparoscope (LTF Series) were used during the procedure, with the 5-mm laparoscope reserved for use when 10-mm instruments were required. A surgical assistant was also present throughout the procedure to guide the laparoscope. The standard laparoscopic RP technique, as described previously [13], was adapted to a single operative site. The seminal vesicles were dissected posteriorly after incising the posterior peritoneum. An athermal technique was used to eliminate thermal injury to the pelvic plexus. A 10-mm disposable titanium clip applier was used for hemostasis, and the seminal vesicles were dissected to their tips. The space of Retzius was then entered by dividing the medial umbilical ligaments and urachal remnant. The endopelvic fascia was incised athermally and the levator musculature swept off the lateral aspect of the prostate. The puboprostatic ligaments were divided sharply. The dorsal venous complex was controlled and divided using a laparoscopic linear stapler. The bladder neck was incised using articulating monopolar scissors. The articulating instrument was critical to direct the tip of the instrument posteriorly and avoid incising into the base of the prostate. The lateral prostatic fascia was incised sharply, and after releasing the neurovascular bundles the vascular pedicles were clipped and divided. The prostatic apex was then dissected and the urethra was transected (Fig. 1). The specimen was immediately placed into an entrapment bag. The vesico-urethral anastomosis was completed with 3–0 poliglecaprone 25 sutures with intracorporeal knot tying (Fig. 2). Minimal leak was noticed upon irrigation at the end of the procedure. The specimen was placed in an entrapment bag and extracted through the infra-umbilical site after the fascial incisions were connected. A 10-F drain was placed through the same incision. No additional ports of any size were used for retraction, dissection, or suturing.


Laparo-endoscopic single-site radical prostatectomy: Feasibility and technique ☆
Flexible needle drivers make intracorporeal suturing and tying feasible during LESS.
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4374145&req=5

f0010: Flexible needle drivers make intracorporeal suturing and tying feasible during LESS.
Mentions: The patient was placed in a Trendelenburg position with low lithotomy stirrups and the arms tucked. Sequential compression devices were placed on both the lower extremities. A single 3-cm transverse infra-umbilical incision was made. Pneumo-insufflation was obtained using a Veress needle. A flexible-tip laparoscope (LTF Series, Olympus Surgical, Orangeburg, NY, USA), two 5-mm Anchorports (Surgiquest, Orange, CT, USA), and a 12-mm trocar were placed through separate fascial punctures within the single infra-umbilical incision site. Flexible instruments (Realhand, Novare, Cupertino, CA, USA) were used in addition to standard laparoscopic instruments. A 5-mm and a 10-mm flexible-tip laparoscope (LTF Series) were used during the procedure, with the 5-mm laparoscope reserved for use when 10-mm instruments were required. A surgical assistant was also present throughout the procedure to guide the laparoscope. The standard laparoscopic RP technique, as described previously [13], was adapted to a single operative site. The seminal vesicles were dissected posteriorly after incising the posterior peritoneum. An athermal technique was used to eliminate thermal injury to the pelvic plexus. A 10-mm disposable titanium clip applier was used for hemostasis, and the seminal vesicles were dissected to their tips. The space of Retzius was then entered by dividing the medial umbilical ligaments and urachal remnant. The endopelvic fascia was incised athermally and the levator musculature swept off the lateral aspect of the prostate. The puboprostatic ligaments were divided sharply. The dorsal venous complex was controlled and divided using a laparoscopic linear stapler. The bladder neck was incised using articulating monopolar scissors. The articulating instrument was critical to direct the tip of the instrument posteriorly and avoid incising into the base of the prostate. The lateral prostatic fascia was incised sharply, and after releasing the neurovascular bundles the vascular pedicles were clipped and divided. The prostatic apex was then dissected and the urethra was transected (Fig. 1). The specimen was immediately placed into an entrapment bag. The vesico-urethral anastomosis was completed with 3–0 poliglecaprone 25 sutures with intracorporeal knot tying (Fig. 2). Minimal leak was noticed upon irrigation at the end of the procedure. The specimen was placed in an entrapment bag and extracted through the infra-umbilical site after the fascial incisions were connected. A 10-F drain was placed through the same incision. No additional ports of any size were used for retraction, dissection, or suturing.

View Article: PubMed Central

ABSTRACT

Background: As laparoscopy becomes a standard approach in many urological procedures, researchers strive to make minimally invasive surgery less invasive. Our objective was to apply recent innovations in equipment and surgical approaches to develop the technique and perform laparo-endoscopic single site radical prostatectomy (LESS-RP).

Methods: The technique for LESS-RP was derived by combining existing techniques of standard laparoscopic RP and developing techniques of urological LESS. This incorporated newly available low-profile trocars, flexible instruments and a flexible-tip laparoscope. The procedure was performed through a single 3-cm transverse infra-umbilical incision. LESS-RP was completed successfully via a single operative site without auxiliary needles or trocars. Perioperative variables and postoperative outcomes were recorded and measured.

Results: The operative time was 424 min and the hospital stay was 10 days because of a vesicourethral leak and ileus. The anastomotic leak resolved and the urethral catheter was removed at 4 weeks after surgery. The final pathology showed negative margins and Gleason 3 + 4 pT2c prostatic adenocarcinoma.

Conclusions: LESS-RP is feasible by replicating laparoscopic RP techniques and incorporating the LESS technique with the advent of flexible-tip laparoscopes and flexible instruments. After a learning curve has been overcome, this should be further tested prospectively to compare oncological and functional outcomes with laparoscopic and robotic-assisted RP.

No MeSH data available.