RE:
INITIAL COMPLETE LAPAROENDOSCOPIC SINGLE-SITE SURGERY ROBOTIC ASSISTED
RADICAL PROSTATECTOMY(LESS-RARP)
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To the Editor:
Laparoendoscopic
single-site surgery (NOTES-LESS) has been gaining momentum in minimally
access urological surgery. The incorporation of the robotic interface
into the NOTES-LESS arena, proposes a symbiosis with promising future;
Haber et al. (1), presented their experience with experimental with NOTES
and robot in pigs for nephrectomies and pyeloplasties. Their results were
encouraging in terms of feasibility. More recently, Desai et al. (2) presented
an interesting work of transvesical radical prostatectomy (RP) in a cadaver
model. Our group has previously report on a transitional experience to
LESS-RP including both cadaver experimental and clinical experiences (3).
Previous detailed explanation and consent
of the procedure, we have performed LESS-RARP in a 69 years old patient
with prostatic cancer T1c. Patient’s PSA and Gleason score were
8.50 ng/mL and 3+3, respectively. Patient was fully continent preoperatively
and reported active sexual life. Operation was performed with daVinci®
interface and standard trocars (Figure-1). Ports were placed in a rhomboid
fashion with the endoscope in the upper corner (12 mm), a 5 mm trocar
in the lower corner for suction and traction purposes and 8 mm working
ports at either side, without need of any other instrument. Clashing between
instruments was verified externally and this hardened assistant’s
performance. Total operative time was 210 min. Dorsal venous control was
accomplished in 3 min. with one figure of eight stitch. Urethrovesical
anastomosis was performed in 35 min. by separate stitches. An antegrade
interfascial bilateral neurovascular bundle dissection was performed.
Bipolar energy and metallic clips were used for hemostasis. Blood loss
was 300 cc and final pathology reported a surgical specimen of 66 g, Gleason
score 3+4 with negative surgical margins. No perioperative complications
were observed.
RP has been previously assessed in NOTES-LESS
urological surgery. Desai et al. (2) presented an interesting work of
transvesical RP in a cadaver model. The procedure was performed in two
fresh male cadavers. They employed four laparoscopic transvesical trocars
and single-port device for their first and second cases, respectively,
using the daVinci-S robot (Intuitive Surgical, Sunnyvale, CA, USA). Both
operations were completed transvesically and robotically. There was no
need for additional ports. Operative time for the multi-port procedure
was 3 h and for the single-port procedure was 4.2 h. External conflict
with robotic interface was experienced as a technical difficulty with
the single-port procedure.
In the clinical arena, Kaouk et al. (4)
presented a series of single-port laparoscopic RP in 4 patients diagnosed
with prostate cancer. They treated patients with localized disease, no
previous pelvic surgery, and a body mass index < 35 kg/m2.
A single port device was placed transperitoneally through a 1.8-cm incision
located at the umbilicus without any other instruments or ports needed
to complete operations. Urethrovesical anastomosis was performed using
free-hand interrupted suturing and extracorporeal knot tying. This work
is an impressive publication verifying feasibility of this procedure with
the use of single port and articulated instruments. Kaouk et al have also
presented a previous experience in LESS-RARP using the R-port with adequate
results.
We report to our the first clinical report
of LESS-RARP. The procedure was successfully completed with the initial
approach and a change in port triangulation was a key point to accomplish
the task. Further evaluation of the technique is warranted.
REFERENCES
- Haber GP, Crouzet S, Kamoi K, Berger A, Aron M, Goel R, et al.: Robotic
NOTES (Natural Orifice Translumenal Endoscopic Surgery) in reconstructive
urology: initial laboratory experience. Urology. 2008; 71: 996-1000.
- Desai MM, Aron M, Berger A, Canes D, Stein R, Haber GP, et al.: Transvesical
robotic radical prostatectomy. BJU Int. 2008; 102: 1666-9.
- Barret E, Sanchez-Salas R, Kasraeian A, Benoist N, Ganatra A, Cathelineau
X, et al.: A transition to laparoendoscopic single-site surgery (LESS)
radical prostatectomy: human cadaver experimental and initial clinical
experience. J Endourol. 2009; 2. [Epub ahead of print]
- Kaouk JH, Goel RK, Haber GP, Crouzet S, Desai MM, Gill IS: Single-port
laparoscopic radical prostatectomy. Urology. 2008; 72: 1190-3.
- Kaouk JH, Goel R K, Haber GP, Crouzet S, Stein RJ. Robotic single-port
transumbilical surgery in humans: initial report. BJU. 2008 Sep 3. Epub
ahead of print.
Dr.
Eric Barret, Dr. Rafael Sanchez-Salas,
Dr. Xavier Cathelineau, Dr. Francois Rozet,
Dr. Marc Galiano & Dr. Guy Vallancien
Department of Urology
Institut Montsouris
Université Paris Descartes
Paris, France
E-mail: eric.barret@imm.fr |