The Surgical Management of Large Prostatic Adenoma

Introduction

Benign prostatic hyperplasia (BPH) is a prevalent disease, affecting 22% of men < 60 years old, and 45% of men 70-80 years old [1]. When BPH symptoms are refractory to medical management, surgical intervention is recommended. Optimal surgical management for large prostatic adenoma, defined as prostate mass > 100 g or volume > 80 cc, is controversial. While open simple prostatectomy (OSP) remains the gold-standard surgical management for severe BPH, the procedure is associated with significant morbidity, encouraging the use of other surgical options. This blog will discuss the surgical management of large prostatic adenoma, with emphasis on several alternatives to OSP, including bipolar TURP, holmium laser therapy, photoselective vaporization of the prostate (PVP), and robot assisted laparoscopic simple prostatectomy (RASP).

Open Simple Prostatectomy (OSP)

OSP is the gold standard surgical management for high volume (> 80 cc) prostatic adenoma. Advantages of this approach include more complete removal of prostatic adenoma under direct visualization, lower re-treatment rates, and no risk of TUR syndrome. A randomized controlled trial comparing transvesical open simple prostatectomy (TVP) with TURP for prostates > 80 cc demonstrated significant reduction in IPSS scores at 12 months post-op for the TVP group. Unfortunately, the peri-operative blood transfusion rate was 11% and 14% for the TVP and TURP arms, respectively (Figure 1) [2]. This morbidity associated with OSP has encouraged urologists to seek other alternatives for the management of large prostatic adenoma.

Figure 1: Complications for both TURP (n= 35) and Transvesical Open
Simple Prostatectomy (TVP) (n = 34). Ou et al. Urology 2010.

TURP

Monopolar TURP has been the gold standard surgical management for prostates 30-80 mL, but concerns regarding TUR syndrome and excessive bleeding prevent its routine use in larger prostatic adenoma. For this reason, many studies have focused on Bipolar TURP, which enables the use of normal saline irrigation with no risk of TUR syndrome. In a recent prospective, randomized trial comparing Bipolar TURP vs. OSP for prostates > 80 cc, Bipolar TURP was found to resect significantly less prostatic adenoma mass despite having similar pre-operative prostate size to the OSP arm. However, a significantly less hemoglobin drop, blood transfusion rate, and hospital stay was found in the Bipolar TURP arm [3].

Holmium Laser Therapy

Holmium laser therapy emits light at 2100 nm in pulses. This causes tissue water vaporization with limited (0.4 mm) tissue penetration. Because the procedure uses normal saline for irrigation, there is no risk for TUR syndrome manifested by dilutional hyponatremia. Laser settings commonly cited in the literature include 2-2.5 J and 40-50 Hz [4]. Several retrospective studies have found significant 6 month post-op reduction in IPSS scores for prostates greater than 75, 125, and 175 g [4-6]. Furthermore, these studies reported low peri-operative blood transfusion rates of 1.9-3.5%, which is significantly less than the reported OSP average blood transfusion rate of 8.5% or greater. For this reason, holmium laser therapy is often cited in the literature as having prostate “size independent” effectiveness.

Photoselective Vaporization of the Prostate (PVP)

Photoselective Vaporization of the Prostate (PVP) is commonly referred to as the Greenlight laser, as it vaporizes tissue at a wavelength of 532 nm. Because the laser is selectively absorbed by hemoglobin, the relatively fibrous prostatic capsule is resistant to absorption, making this procedure an attractive alternative to OSP. The current generation of the Greenlight laser is the 180 W XPS laser. The power has been increased from previous generations in order to improve adenoma removal and lower re-treatment rates. A multi-institutional prospective trial that looked at nearly 1,200 patients (2/3 with > 80 cc prostates; 1/3 with < 80 cc prostates) who underwent 180 W XPS laser therapy found that the larger prostate cohort maintained a mean IPSS reduction of 19 points at 6, 12, and 24 months post-op [7]. However, significantly more of the > 80 cc prostate cases had to be converted to TURP, most commonly due to bleeding that obscured the visual field. Therefore, PVP appears to be an effective, but imperfect alternative to OSP for large prostatic adenoma.

Robot assisted laparoscopic Simple Prostatectomy (RASP)

Robot assisted simple prostatectomy (RASP) appears to be a very attractive alternative to OSP, with the hope that it would produce the functional results of OSP while reducing the associated morbidity, including hospital length of stay, perioperative hemorrhage, and blood transfusion rates. The transvesical approach provides excellent visualization of the extent of the prostatic adenoma, while preventing injury to the ureteral orifices during incision of the bladder mucosa (Figure 2).

Figure 2: Transvesical RASP: Incision in bladder mucosa distal to the ureteral orifices.
Screen shot credit: Misop Han, M.D. Brady Urological Institute at Johns Hopkins Hospital.

Data from the Brady Urological Institute comparing RASP to OSP found reductions in estimated blood loss, blood transfusions, and hospital length of stay for the RASP arm (Figure 3). Although there was no significant difference in pre-operative prostate volume by transrectal ultrasound measurements, RASP had similar adenoma resection weights as compared to OSP. A review that looked at 13 RASP studies found an overall blood transfusion rate of 3.5% [8].

Figure 3. RASP vs. OSP Peri-operative Outcomes.
Brady Urological Institute at Johns Hopkins Hospital.

An edited video of a robot assisted laparoscopic simple prostatectomy performed at Johns Hopkins Hospital can be found below.

Key Points

• Open simple prostatectomy is the gold standard surgical management for large prostatic adenoma
• Bipolar TURP may remove less adenoma than OSP
• HoLEP has prostate “size independent” effectiveness
• PVP is effective but bleeding my obscure visualization
• RASP is an excellent alternative for severe BPH for those well versed in robotic radical prostatectomy

This blog was written by Bijan W. Salari, a medical student at Wright State University Boonshoft School of Medicine. Bijan recently finished a four-week sub-internship at the Brady Urological Institute and gave a presentation to the department on "The Surgical Management of Large Prostatic Adenoma" from which this blog is inspired. Bijan  is looking forward to a career in urology.

REFERENCES
1. Speakman et al. Burden of male lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) - focus on the UK. BJU Int. 2015 Apr;115(4):508-19. doi: 10.1111/bju.12745. Epub 2014 Oct 16.
2. Ou et al. A randomized trial of transvesical prostatectomy versus transurethral resection of the prostate for prostate greater than 80 mL. Urology. 2010 Oct;76(4):958-61. doi: 10.1016/j.urology.2010.01.079. Epub 2010 Apr 15.
3. Geavlete et al. Bipolar vaporization, resection, and enucleation versus open prostatectomy: optimal treatment alternatives in large prostate cases? J Endourol. 2015 Mar;29(3):323-31. doi: 10.1089/end.2014.0493. Epub 2014 Sep 17.

4. Krambeck et al. Holmium laser enucleation of the prostate for prostates larger than 175 grams. J Endourol. 2010 Mar;24(3):433-7. doi: 10.1089/end.2009.0147.
5. Matlaga et al. Holmium laser enucleation of the prostate for prostates of >125 mL. BJU Int. 2006 Jan;97(1):81-4.
6. Kuo et al. Holmium laser enucleation of prostate (HoLEP): the Methodist Hospital experience with greater than 75 gram enucleations. J Urol. 2003 Jul;170(1):149-52.
7. Hueber et al. Photoselective Vaporization of the Prostate for Benign Prostatic Hyperplasia Using the 180 Watt System: Multicenter Study of the Impact of Prostate Size on Safety and Outcomes. J Urol. 2015 Aug;194(2):462-9. doi: 10.1016/j.juro.2015.03.113. Epub 2015 Apr 4.
8. Patel et al. Robotic-assisted Simple Prostatectomy: Is there Evidence to go Beyond the Experimental Stage? Curr Urol Rep (2014) 15:443.

Diffusion of Robotics in Urology: Responsible Introduction of Surgical Innovation

The use of robotic surgery in urology began in 2001 with the advent of robot assisted radical prostatectomy (RARP). Since then, it has diffused throughout the field, providing an alternative to the open approach in numerous urologic procedures. However, the evidence for the utility and added benefits of the robotic approach is limited and varies among procedures. Given the fact that robotic-assisted procedures cost the patient an additional $1000 and the hospital nearly $100,000 annually, it is necessary to investigate the benefits of this technology and to determine for which procedures and which patients it is worth this increased cost. Furthermore, it is critical to assess whether the early introduction of this technology is safe for patients. Not only is the data supporting the use of robotics unclear, but also, in retrospect, the introduction of robotics may have led to unfavorable patient outcomes in certain settings. This blog will serve as overview of some of the early data regarding the use of robotics in the surgical management of three index cancers and will end with a brief discussion of safety during the initial diffusion of robotic prostatectomy.

    

RADICAL PROSTATECTOMY

Most of the initial data regarding RARP came from small, retrospective, single-center studies, most of which reported less blood loss, lower rates of transfusion, shorter length of stay and fewer short term complications. A recent prospective, multi-center, controlled trial from Sweden showed that RARP was associated with 500cc less blood loss, shorter length of stay by one day, and lower rates of reoperation during the initial hospital stay [1]. Therefore, at least in the short term, there seems to be good evidence for RARP improving perioperative outcomes.

Figure 1. RARP is associated with better short-term outcomes including less blood loss, shorter length of stay, and less rates of reoperation.  From Wallerstedt, et al. [1].

Data regarding long-term outcomes are more controversial. Based on numerous studies, it is difficult to interpret whether there is any benefit or drawback to achieving the "trifecta" of oncologic control, continence, and potency with robotic assistance. A recent prospective, non-randomized study from Sweden suggests that there may be some benefit to RARP with regard to potency, but no difference for oncologic control or continence [2]. Of note, the only randomized trial that sought to investigate this was terminated due to slow patient enrollment. Therefore, some evidence points to the benefits of RARP, some to its detriment, but most suggest equivalence between open and robotic.

 

PARTIAL NEPHRECTOMY

The use of robotics in partial nephrectomy (PN) is a different story. PN is the preferred surgical management of small renal masses (when technically feasible) because of its ability to preserve kidney function (i.e. nephron-sparing) with equivalent oncologic control. Minimally invasive PN has been shown to be associated with less blood loss, shorter length of stay, faster recovery, and less post-operative pain compared to the open flank incision [3]. Within the category of minimally invasive surgery, Pierorazio et al. showed that robotic assisted partial nephrectomy (RAPN) is associated with shorter operative time, less blood loss, and shorter warm ischemia time (WIT) [4]. Regarding complications, Mullins et al. found no difference in complication rates, but when stratified by Clavien grade, the RAPN cohort was more likely to have lower grade complications [5]. A meta-analysis comparing robotic vs. laparoscopic PN found no differences in operative times, blood loss, conversion rates, complications, or length of stay. However, RAPN was associated with shorter WIT, the key to renal preservation, which ultimately is the primary goal of PN [6].

Figure 2. RAPN is associated with shorter WIT.  From Aboumarzouk, et al. [6].

Robotic technology has led to an increased use of PN, due in part to the superior range of motion that aids in tumor excision and reconstruction under ischemic time constraints. This has been shown to be a real phenomenon, with a demonstrable increase in PN compared to radical nephrectomy in the years of robotic diffusion. [7] In addition, robotics has allowed urologists to tackle more complex renal tumors, such as tumors invading the large veins of the kidney and retroperitoneum (i.e. IVC thrombectomies), intrarenal, and posterior tumors, with comparable functional outcomes and less risk of conversion to radical nephrectomy [8-10].

 

RPLND

Retroperitoneal lymph node dissection (RPLND) is a treatment option for men with stage I and select stage II nonseminomatous germ cell tumors and is particularly useful for men who want to avoid long term surveillance or chemotherapy. Laparoscopic RPLND has been shown to have comparable oncologic outcomes with superior perioperative outcomes compared to open [11, 12]. The data regarding robotic RPLND is scant due to its nascency in the field, however a recent study shows that early on, robotic RPLND is comparable to laparoscopic in terms of perioperative outcomes [13]. Given the increased cost and risk of serious complications due to the intimacy with the great vessels during this procedure, the role of robotics in RPLND remains largely unknown at this point.

 

DIFFUSION AND PATIENT SAFETY

Given the variable and unclear data, particularly regarding RARP, how did robotics diffuse so rapidly and widely among urologists? First, it is important to note that in order to introduce new technology, one only needs a 510(k) clearance from the FDA. In the case of RARP, da Vinci received FDA clearance in 2000, the first RARP was in 2001, and the first population-based outcomes study was published in 2009. So many were performing RARP blindly without any population based data on efficacy or safety. Parsons et al. sought to retrospectively investigate if there was an effect on patient safety during this diffusion period using patient safety indicators (PSI). They found that in the year before the "tipping point," a set point indicating when RARP diffused from centers of excellence to more general urologists, there was a two-fold increase in PSI [14].

Figure 3. RARP during diffusion era is associated with a two-fold increase in PSI.  From Parsons, et al. [14].

These results highlight the importance of responsibility with regards to the introduction of new technology. Is a compromise to patient safety in the initial years of dissemination necessary? Does new technology always come with risk? How do we know when to stop pursuing a given technique? When is a reasonable time to assess whether it is inferior and causing more harm than good? Was RARP even worth this increased risk given its limited utility and increased cost? Finally, is the culprit here technology, or does innovation by nature have barriers at first?

 

SUMMARY

The role of robotics in urology today raises many questions regarding comparative efficacy, cost justification, and patient safety with innovation. Radical prostatectomy and partial nephrectomy illustrate a juxtaposition of results – RAPN seems to have succeeded while RARP has yet to show a demonstrable benefit other than less blood loss. It has also raised questions about patient safety during the dissemination of new technology and bears the question, how does an innovator responsibly report results while marketing and patient demand accelerate the innovation's diffusion? Moving forward, standardized training and credentialing programs as well as systematic reporting to non-industry groups could be instituted in order to diffuse innovation while keeping the patient first.

This blog was written by Kelly Harris, a medical student at Johns Hopkins Medical School.  Kelly recently finished a four-week sub-internship at the Brady Urological Institute and gave a presentation to the department on "The Diffusion of Robotic Surgery in Urology" from which this blog is inspired. Kelly is looking forward to a career in urology.

1. Wallerstedt A, Tyritzis SI, Thorsteinsdottir T, et al. Short-term Results after Robot-assisted Laparoscopic Radical Prostatectomy Compared to Open Radical Prostatectomy. Eur Urol 2015: 67:660-70
2. Haglind E, Carlsson S, Stranne J, et al. Urinary Incontinence and Erectile Dysfunction After Robotic Versus Open Radical Prostatectomy: A Prospective, Controlled, Nonrandomised Trial. Eur Urol 2015
3. Hung AJ, Cai J, Simmons MN, Gill IS. "Trifecta" in partial nephrectomy. J Urol 2013: 189:36-42
4. Pierorazio PM, Mullins JK, Eifler JB, et al. Contemporaneous comparison of open vs minimally-invasive radical prostatectomy for high-risk prostate cancer. BJU Int 2013: 112:751-7
5. Mullins JK, Feng T, Pierorazio PM, Patel HD, Hyams ES, Allaf ME. Comparative analysis of minimally invasive partial nephrectomy techniques in the treatment of localized renal tumors. Urology 2012: 80:316-21
6. Aboumarzouk OM, Stein RJ, Eyraud R, et al. Robotic versus laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol 2012: 62:1023-33
7. Patel HD, Mullins JK, Pierorazio PM, et al. Trends in renal surgery: robotic technology is associated with increased use of partial nephrectomy. J Urol 2013: 189:1229-35
8. Ball MW, Gorin MA, Jayram G, Pierorazio PM, Allaf ME. Robot-assisted radical nephrectomy with inferior vena cava tumor thrombectomy: technique and initial outcomes. Can J Urol 2015: 22:7666-70
9. Harris KT, Ball MW, Gorin MA, Curtiss KM, Pierorazio PM, Allaf ME. Transperitoneal Robot-Assisted Partial Nephrectomy: A Comparison of Posterior and Anterior Renal Masses. J Endourol 2014: 28:655-9
10. Curtiss KM, Ball MW, Gorin MA, Harris KT, Pierorazio PM, Allaf ME. Perioperative outcomes of robotic partial nephrectomy for intrarenal tumors. J Endourol 2015: 29:293-6
11. Bhayani SB, Ong A, Oh WK, Kantoff PW, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer: a long-term update. Urology 2003: 62:324-7
12. Steiner H, Peschel R, Janetschek G, et al. Long-term results of laparoscopic retroperitoneal lymph node dissection: a single-center 10-year experience. Urology 2004: 63:550-5
13. Harris KT, Gorin MA, Ball MW, Pierorazio PM, Allaf ME. A Comparative Analysis of Robotic versus Laparoscopic Retroperitoneal Lymph Node Dissection for Testicular Cancer. BJU Int 2015
14. Parsons JK, Messer K, Palazzi K, Stroup SP, Chang D. Diffusion of surgical innovations, patient safety, and minimally invasive radical prostatectomy. JAMA Surg 2014: 149:845-51

Journal Spotlight: Randomized Trial of Open and Robotic Radical Cystectomy

Robotic surgery disseminated rapidly over the past decade and is now the most common approach for radical prostatectomy for prostate cancer in the United States.  The dissemination of this technology was fueled by surgeon preference and a number of retrospective and case-series studies that demonstrate improvements in blood loss, convalescence, and hospital stays.[1,2]  However, randomized and/or controlled prospective studies were not performed before robotic surgery took over for prostate cancer.

There is growing interest in robotic surgery for bladder cancer.  The cystectomy (bladder removal) population is often an older, sicker population who undergoes a morbid, radical surgery.  In order to address the utility of robotic surgery for bladder cancer, researchers from MSKCC (Memorial Sloan Kettering Cancer Center) in New York City, reported the results of a small, randomized trial of open versus robotic radical cystectomy for the treatment of bladder cancer.  The results were shared as a Letter to the Editor in the July 24th edition of the NEJM (New England Journal of Medicine).

Bochner BH, Sjoberg DD, Laudone VP.  A Randomized Trial of Robot-Assisted Laparoscopic Radical Cystectomy.  N Engl J Med 2014; 371:389-390July 24, 2014DOI: 10.1056/NEJMc1405213

One-hundred eighteen (118) patients were randomly assigned to undergo open (60) or robotic surgery (58) by a number of experienced surgeons at MSKCC.  The study was designed to detect a difference in complication rates among the two types of surgery.  Given a historic complication rate of radical cystectomy of about 50%,[3] the researchers predicted robotic surgery should improve the complication rate by 20%.  The study was initially designed to enroll over 200 patients, but was stopped early when the complication rates were found to be similar at a pre-determined interim analysis.    

In fact the complication rate was 62% in the robotic group and 66% in the open group at 30 days; high-grade (severe) complications occurred in 22% and 21% respectively.  Important differences in the short-term analysis were:

• decreased blood loss in the robotic group (mean difference, 159 cm3)
• decreased length of surgery in the open group (mean difference, 127 minutes)

This communication was picked up by a number of medical and non-medical publications.  Given the recent skepticism regarding the use of robotic technology, as evidenced an increased reporting of complications in the gynecologic literature, and the increased associated costs with robotic technology,[4,5] a number of sources reflected on this report as a negative study. For instance, the Wall Street Journal ran with the headline, Surgical Robot Fails to Show Advantages in Treating Bladder Cancer, and stated, "This small study may cast further doubt on the benefits of Intuitive Surgical's da Vinci robot."[6]

While this study may not demonstrate a significant benefit to the robotic surgery, it does also not show any detrimental effects, increased complications or worse cancer outcomes for the patients undergoing robotic surgery.  In fact, while the robotic surgery may take longer, the significant lower blood loss may be a worthy trade-off.  In the contemporary radical cystectomy population, a group of patients that often receives chemotherapy before surgery and is subsequently anemic entering the operating room, upwards of 40% of patients will receive a perioperative blood transfusion.  This is especially significant, as recent studies indicate that blood transfusions may be linked to worse cancer outcomes in the bladder cancer population.[7]  Robotic surgery is another tool in the armamentarium of surgeons.  As found in other surgeries, outcomes are often surgeon- and experience-dependent,[8] and this study should not dissuade people from undergoing robotic surgery by an expert surgeon.  The authors and members of this study from MSKCC should be commended for running a successful study comparing a surgical innovation to standard-of-practice and should serve as a model for studies in the future.   

[1] Ficarra V, Cavalleri S, Novara G, Aragona M, Artibani W. Evidence from robot-assisted laparoscopic radical prostatectomy: a systematic review. Eur Urol. 2007;51:45-55; discussion 56. 
[2] Hu JC, Gu X, Lipsitz SR, et al. Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA. 2009;302:1557-1564
[3] Shabsigh A, Korets R, Vora KC, et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 2009;55:164-176
[4] Rabin RC. New Concerns on Robotic Surgeries.  The New York Times, September 9, 2013; D4. 
[5] Kolata G. Results unproven, robotic surgery wins converts. The New York Times. February 14, 2010; A1.
[6] Walker, J. Surgical Robot Fails to Show Advantages in Treating Bladder Cancer.  The Wall Street Journal.  July 23, 2014.

[7] Linder BJ, Frank I, Cheville JC, Tollefson MK, Thompson RH, Tarrell RF, Thapa P, Boorjian SA.

The impact of perioperative blood transfusion on cancer recurrence and survival following radical cystectomy. Eur Urol. 2013 May;63(5):839-45. doi: 10.1016/j.eururo.2013.01.004. Epub 2013 Jan 11.

[8] Klein EA, Bianco FJ, Serio AM, Eastham JA, Kattan MW, Pontes JE, Vickers AJ, Scardino PT.Surgeon experience is strongly associated with biochemical recurrence after radical prostatectomy for all preoperative risk categories.J Urol. 2008 Jun;179(6):2212-6; discussion 2216-7. doi: 10.1016/j.juro.2008.01.107. Epub 2008 Apr 18.

Faculty Spotlight: Stephen Schatz, Innovative Treatments of BPH

Benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms (LUTS) are incredibly common.  Approximately 40% of 50-year old men with have histologic evidence of BPH at autopsy, this number increases to 80% for 80-year men.  Over the same time period, mean prostate volume increases from an average baseline of 15-25 grams at age 50 to 25-40 grams at age 80.  In addition, the percentage of men with moderate-to-severe LUTS increases with age.[1]  When LUTS are bothersome, treatment options for BPH include medication and, when medications fail, surgery.

Stephen Schatz, MD

The traditional surgery for BPH is the transurethral resection of the prostate (TURP).   This operation has long been considered the "gold standard" for symptom relief.  But now, instead of chipping away at the prostate, says urologist Stephen Schatz, "we are doing far more procedures using either bipolar electrosurgical vaporization or laser vaporization techniques."  Essentially, vaporization destroys prostatic tissue using a high-energy source that coagulates as it destroys, preventing bleeding.

"Vaporization techniques are demonstrated to be safer than traditional TURP, with results that are entirely comparable" in terms of the durability and degree of symptoms relief, and retreatment rates are quite low.[2]  

With vaporization, the only significant downside is temporary worsening of irritative urinary symptoms (frequency, urgency and burning) immediately afterward.  But, Schatz says, "I have found this always gets better, and the long-term improvement is profound in most men.  It's a great alternative to long-term medical treatment," which takes longer to achieve an effect and does not provide as great a relief of symptoms.

Although Schatz performs all the surgical procedures, he prefers bipolar vaporization.  "I can see the prostate clearly as I work, without bleeding obscuring my view," he says.  Immediately afterwards, he adds, "the urine is almost always clear."  Only about 5% of patients stay overnight.  In addition, the rates of erectile dysfunction lower than with TURP because there is no electricity arcing outside the prostate and potentially injuring the cavernous nerves.

For men with BPH and low-risk prostate cancer...

Schatz and colleagues are even able to use vaporization on men with low-risk prostate cancer in Johns Hopkins' active surveillance program who are significantly bothered by LUTS.  "We continue to follow them regularly with biopsies and PSA tests," he says, "but the cancer doesn't get in the way of their treatment."

For men with very large prostate...

Schatz performs a simple prostatectomy - enucleation of the prostate, going in through a skin incision and through the bladder - robotically.  In a case series of more than 50 patients, Johns Hopkins urologists have reported outcomes that are comparable to the results from open surgery, but with clear decreases in perioperative blood loss.

For men who are poor candidates for surgery...

Schatz and interventional radiologist Mark Lessne are conducting a multicenter trial comparing prostatic artery embolization with traditional TURP, using very rigorous outcome measures, measuring prostates and performing urodynamics before and after, and tracking quality of life indices to see how patients respond.  The angiography procedure, done through the femoral artery, takes less than three hours and has "essentially no blood loss and no absorption of any fluids," Schatz says.  Symptoms improvement comes gradually as prostate tissue dies.  Click on the following link to see our prior blog entry on prostatic artery embolization.

Schatz suspects that within a few years, this treatment will be offered to men who "may not be candidates for even minimally invasive surgery, but who have significant symptoms not helped all that much by medications."

This blog entry is extracted and modified from the "Johns Hopkins Urology: News for Physicians from Johns Hopkins Medicine," Spring 2014.

[1] Roehrborn, Claus G., MD.  Benign Prostatic Hyperplasia : Etiology, Pathophysiology, Epidemiology, and Natural History [Book] Campbell-Walsh Urology, chapter 91, Pages 2570-2610.e10 Copyright © 2012, 2007, 2002, 1998, 1992, 1986, 1978, 1970, 1963, 1954 by Saunders, an imprint of Elsevier Inc.
[2] Teng J1, Zhang D, Li Y, Yin L, Wang K, Cui X, Xu D.  Photoselective vaporization with the green light laser vs transurethral resection of the prostate for treating benign prostate hyperplasia: a systematic review and meta-analysis.  BJU Int. 2013 Feb;111(2):312-23. doi: 10.1111/j.1464-410X.2012.11395.x. Epub 2012 Nov 13.

Laparoscopic Single Site (LESS) Surgery: Innovation in Urology

Mohamad E. Allaf, MD

Laparoendoscopic single-site surgery (LESS), or surgery through a single incision, has been utilized to perform every urologic surgery that can be accomplished by traditional laparoscopy. [1]  However, LESS is only routinely performed in approximately 10% of cases as it requires a unique laparoscopic skill set and technology. [2]

Mohamad E. Allaf, MD, Associate Professor of Urology, Oncology, and Biomedical Engineering and the Director, Minimally Invasive and Robotic Surgery at Johns Hopkins routinely performs LESS nephrectomies, both for living donor kidney transplants and for patients with diseased or cancerous kidneys.



See Dr. Allaf's video on LESS nephrectomy (below).

Here we review some of the new tools, technologies and approaches with LESS urological surgeries.

To successfully perform LESS, a surgeon may use a variety of LESS-instruments.  

Covidien Single Incision Laparoscopic (SILS) Instruments

These may include articulating instruments that attempt to recapitulate the triangulation of traditional laparoscopy by using surgeon-controlled intracorporal deflection.  These instruments allow the surgeon to keep his or her hands apart while focusing the instrument tips in the patient's body.[3]  They have full range of motion, however can have difficulty tying knots as the joint forces are not as strong as standard laparoscopic instruments and have a significant learning curve associated with them.[4,5]

Novare RealHand TM (Cupertino, CA, USA) demonstrated on Vimeo.

S-Portal TM Series (Karl Storz, Tuttlingen, Germany)

Pre-bent instruments restore triangulation may have an increased ease of use and shorter learning curve, but the surgeon is unable to adjust the deflection of the instrument in difficult cases.[6]

Surgeons also have the option to use needlescopic instruments, which are 3mm or smaller (see video below).  They can be used through a LESS port or "needle-sized" skin punctures.  They use traditional laparoscopic triangulation techniques and have been demonstrated to have excellent outcomes for patients undergoing adrenal surgery.[7]

New platforms are under development to make LESS easier to learn and incorporate into larger practice models.

The Magnetic Anchoring and Guidance System (MAGS) has a intra-abdominal, moveable magnet that is stabilized externally by a larger magnet on the abdominal wall.  The magnetic system allows spacing of instruments independent of the single port access site, improving triangulation and reducing clashing of instruments.

da Vinci single port system with curved robotic cannulas,
robotic camera and laparoscopic assistant port. [9]

Robot assisted LESS (RA-LESS)  has been demonstrated for radical prostatectomy, dismembered pyeloplasty and radical nephrectomy [8].  While safe and feasible, the current, large profile of the DaVinci robotic system, robotic arm collisions and unfamiliar camera angles prevent the widespread adoption of this technique.  A single port system has been developed for use with robotic technology and successful reports exist for RA-LESS cholecystectomy. [9]

This entry was written by Mark W. Ball, MD,  4th year resident at the Brady Urological Institute.  This entry is extracted from the chapter "Future Directions in LESS" which will appear in Atlas of Laparoscopic and Robotic Single Site Surgery [Jihad H. Kaouk (Editor), Robert J. Stein (Associate Editor), and Georges-Pascal Haber (Associate Editor)].








[1] Kaouk JH, Autorino R, Kim FJ, Han DH, Lee SW, Yinghao S, et al. Laparoendoscopic single-site surgery in urology: worldwide multi-institutional analysis of 1076 cases. Eur Urol 2011 Nov;60(5):998-1005.
[2] Irwin BH, Rao PP, Stein RJ, Desai MM. Laparoendoscopic single site surgery in urology. Urol Clin North Am 2009 May;36(2):223-35, ix.
[3] Autorino R, Cadeddu JA, Desai MM, Gettman M, Gill IS, Kavoussi LR, et al. Laparoendoscopic single-site and natural orifice transluminal endoscopic surgery in urology: a critical analysis of the literature. Eur Urol 2011 Jan;59(1):26-45.
[4] Jeong CW, Kim SH, Kim HT, Jeong SJ, Hong SK, Byun SS, et al. Insufficient joint forces of first-generation articulating instruments for laparoendoscopic single-site surgery. Surg Innov 2013 Oct;20(5):466-470.
[5] Tuncel A, Lucas S, Bensalah K, Zeltser IS, Jenkins A, Saeedi O, et al. A randomized comparison of conventional vs articulating laparoscopic needle-drivers for performing standardized suturing tasks by laparoscopy-naive subjects. BJU Int 2008 Mar;101(6):727-730.

[6] Stolzenburg JU, Kallidonis P, Oh MA, Ghulam N, Do M, Haefner T, et al. Comparative assessment of laparoscopic single-site surgery instruments to conventional laparoscopic in laboratory setting. J Endourol 2010 Feb;24(2):239-245.

[7] Gill IS, Soble JJ, Sung GT, Winfield HN, Bravo EL, Novick AC. Needlescopic adrenalectomy--the initial series: comparison with conventional laparoscopic adrenalectomy. Urology 1998 Aug;52(2):180-186.

[8] Kaouk JH, Goel RK, Haber GP, Crouzet S, Stein RJ. Robotic single-port transumbilical surgery in humans: initial report. BJU Int 2009 Feb;103(3):366-369.

[9] Kroh M, El-Hayek K, Rosenblatt S, Chand B, Escobar P, Kaouk J, et al. First human surgery with a novel single-port robotic system: cholecystectomy using the da Vinci Single-Site platform. Surg Endosc 2011 Nov;25(11):3566-3573.