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apid Communication

ingle-Port Transvesical Simplerostatectomy: Initial Clinical Report

ihir M. Desai, Monish Aron, David Canes, Khaled Fareed, Oswaldo Carmona,eorges-Pascal Haber, Sebastien Crouzet, Juan Carlos Astigueta, Roy Lopez,obert de Andrade, Robert J. Stein, James Ulchaker, Rene Sotelo, and Inderbir S. Gill

NTRODUCTION To present the initial report of single-port transvesical enucleation of the prostate in 3 patientswith large-volume benign prostatic hyperplasia.

ETHODS Single-port transvesical enucleation of the prostate was performed in 3 patients with large-volume (187, 93, and 92 g) benign prostatic hyperplasia. A novel single-port device (r-Port) wasintroduced percutaneously into the bladder through a 2.5-cm incision under cystoscopic guid-ance. After establishing pneumovesicum, the adenoma was enucleated in its entirety transvesi-cally under laparoscopic visualization using standard and articulating laparoscopic instrumenta-tion. The adenoma was extracted through the solitary skin and bladder incision after bivalvingthe prostate lobes within the bladder.

ESULTS Single-port transvesical enucleation of the prostate was technically feasible in all 3 cases. Theoperative time was 6, 1.5, and 2.5 hours, and the blood loss was 900, 250, and 350 mL. In patient1, who had previously undergone open suprapubic surgery, a bowel injury occurred during r-Portinsertion; the injury was recognized and repaired intraoperatively without sequelae. The urethralFoley catheter was removed on day 4, and all patients were voiding spontaneously with a minimalpostvoid residual volume and full continence.

ONCLUSIONS Transvesical single-port laparoscopic simple prostatectomy is technically feasible. Additionalexperience at our and other institutions is necessary to determine its role in the surgical managementof large-volume symptomatic benign prostatic hyperplasia. UROLOGY 72: 960–965, 2008. © 2008

Elsevier Inc.

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he surgical treatment of symptomatic benignprostatic hyperplasia (BPH) depends on the glandvolume and includes surgical enucleation, trans-

rethral resection, or energy-based ablation. In general,or the moderate- to large-volume adenoma, enucleationechniques (open, laparoscopic, or transurethral hol-ium:yttrium-aluminum-garnet enucleation) are pre-

erred because of greater intraoperative adenoma reduc-ion and long-term durable outcomes compared withransurethral ablative and resection procedures.

Laparoscopic and robotic simple prostatectomy haveeen reported with encouraging results as an alternativeo open simple prostatectomy in select patients withower urinary tract symptoms due to large-volume pros-atomegaly.1 More recently, the introduction of novelingle-port devices has enabled the performance of manyaparoscopic ablative and reconstructive procedures in airtually scarless fashion through a solitary intraumbilical

rom the Department of Urology, Glickman Urological and Kidney Institute, Clevelandlinic, Cleveland, OH; and Instituto Medico La Floresta, Caracas, VenezuelaReprint requests. Mihir M. Desai, M.D., Glickman Urological and Kidney Institute,

leveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail:

nesaim1@ccf.org

Submitted: May 10, 2008, accepted (with revisions): June 3, 2008

60 © 2008 Elsevier Inc.All Rights Reserved

ncision.2-4 We report our initial experience with single-ort transvesical enucleation of the prostate (STEP) per-ormed through a solitary suprapubic incision by way of aingle access port inserted directly into the bladder in 3atients with symptomatic BPH.

ATERIAL AND METHODS

ransvesical single-port simple prostatectomy was performed inpatients with large-volume BPH. The patients were aged 82,

0, and 78 years; the body mass index was 29, 26, and 26 kg/m2,nd the American Society of Anesthesiologists class was 2 in allpatients (Table 1). The prostate size, as assessed by preoper-

tive transrectal ultrasonography, was 187, 93, and 92 g, andhe baseline prostate-specific antigen level was 13.4, 9.6, and.4 ng/mL. Patients 1 and 2 underwent transrectal ultrasound-uided prostate biopsy to exclude prostate cancer. All 3 patientsad symptomatic lower urinary tract symptoms and desiredurgical therapy.

-Porte used a single port device (r-Port, Advanced Surgical Con-

epts, Wicklow, Ireland) for all 3 procedures. The r-Port con-ists of 2 parts: the retractor component and the valve compo-

ent. The retractor consists of an inner ring and 2 outer rings

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onnected by a pulley sleeve. Typically, during use for laparos-opy, the inner ring is introduced into the peritoneal cavitysing a special introducer. Subsequently, incremental pushingf the outer rings toward the skin and pulling the plastic sleeven the opposite direction cinches the 2 rings on either side ofhe abdominal wall creating an airtight seal.

echniquell procedures were performed under general anesthesia with

he patient in a modified low-lithotomy position. Initially,ystoscopy was performed and the prostate evaluated endoscop-cally. The bladder was filled with normal saline. The proposedite of the skin incision was marked such that it overlay theighest portion of the bladder with the aid of a hypodermiceedle inserted percutaneously and visualized cystoscopically.n approximately 2.5-cm skin incision was carried down to the

ectus fascia. The incision was located just below the umbilicusn the first patient but was located even lower (3-4 finger-readths above the symphysis pubis) in the subsequent 2 pa-ients (Fig. 1A). The bladder wall was identified and cleared ofny prevesical fat, and 2 stay sutures of 2-0 Vicryl were placed.he bladder wall was entered sharply between the stay sutures,nd the inner ring of the r-Port was inserted into the bladdernd deployed with the help of the introducer. The inner anduter rings were approximated by removing the slack on thelastic sleeve, thus cinching the abdominal and bladder walletween the rings of the r-Port in an airtight seal. The valve ofhe r-Port was inserted and the bladder insufflated with carbonioxide to create the pneumovesicum. The insertion and de-loyment of the r-Port was monitored cystoscopically (Fig. 1B).A U-shaped incision was made over the bladder mucosa

mmediately overlying the adenoma from the 3-o’clock to the-o’clock through the 6-o’clock position. Typically, a reddishone of mucosa is present immediately lateral to the internaleatus that serves as a reliable guide for creating the mucosal

ncision. The horizontal limb of the U-incision was made firstsing a hook electrode and cutting current to reach the ade-oma. The whitish prostatic adenoma was readily identified,nd the plane between the surgical capsule and the adenomaas created using the hook and suction cannula. The 2 limbs of

he U-incision were created, followed by completion of theircumferential mucosal incision (Fig. 2A). A 2-0 Vicryl suturen a CT-1 needle was placed through the adenoma for retrac-ion purposes (Fig. 2B). Small perforating vessels and tissuetrands between the surgical capsule and adenoma were system-tically divided using ultrasonic shears, enabling enucleation toroceed in a relatively avascular plane (Fig. 2C). The adenomaas thus enucleated until only the urethral mucosal attachment

Table 1. Demographic data

Variable Case 1

Age (y) 82BMI (kg/m2) 29ASA class 2Baseline PSA (ng/mL) 13.4Preoperative symptoms IPSS 25TRUS prostate size (cm3) 187Median lobe NoPrevious surgery Exploratory laparotom

BMI � body mass index; ASA � American Society of AnesthesioloSymptom Score; TRUS � transrectal ultrasound (determined).

emained. For the large prostate gland, a finger was introduced 4

ROLOGY 72 (5), 2008

hrough the r-Port ring to expedite the distal part of thenucleation. The urethral mucosa was divided sharply usingold endoshears (Fig. 2D). Trigonization was performed withnterrupted 2-0 Vicryl suture, and tied down with an extracor-oreal knot pusher (Fig. 2E). Hemostasis was confirmed, and a0F 3-way Foley catheter was inserted and the balloon inflatedo 40 mL and irrigated to confirm a clear and free return. Therostatic adenoma was extracted through the r-Port ring afterividing it intravesically into 2-3 pieces. The bladder openingas sutured using 3-0 Vicryl, and the fascia and skin were closed

n a standard fashion.

ESULTSn all 3 patients, the prostatic adenoma was enucleateduccessfully using this novel single-port transvesical tech-ique. The first patient had an inadvertent enterotomyuring port insertion that was subsequently recognizednd fixed intraoperatively by open conversion after thePH enucleation had been completed laparoscopically.able 2 details the perioperative data and functionalutcomes.The operative time was 6 hours, 1.5 hours, and 2.5 hours,

nd the estimated blood loss was 900, 250, and 350 mL inhe 3 cases. The solitary complication was an inadvertentnterotomy in patient 1. This patient had a history ofrevious exploratory laparotomy through a full midline in-ision for colon cancer and subsequent incisional herniaepair. The enterotomy occurred despite the r-Port beingnserted under direct vision and was recognized on success-ul completion of the BPH enucleation at the removal ofhe r-Port. Because of his previous bowel surgery, a decisionas made to extend the r-Port incision to confirm the

ntegrity of the remaining bowel and perform local resec-ion-anastomosis. A suprapubic catheter and a drainageube were placed for safety, and the patient recovered un-ventfully with a hospital stay of 3 days.

The duration of hospitalization was 3 days, 1 day, andday, and the Foley catheter was removed on postoper-

tive day 8 in patient 1 and postoperative day 7 inatients 2 and 3. All patients were voiding spontaneouslyithout a significant postvoid residual volume and were

ully continent. The postoperative peak urinary flow ratefter catheter removal in the consecutive cases was 19,

Case 2 Case 3

70 7826 26

2 29.6 3.4

19 2393 92

No Yes (predominant)Bilateral inguinal hernia No

; PSA � prostate-specific antigen; IPSS � International Prostate

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OMMENTor many decades, the choice of surgical therapy forymptomatic bladder outlet obstruction secondary toPH has been either transurethral resection or open

urgical enucleation. Traditionally, the choice betweenhese 2 procedures was primarily guided by the size of therostate and surgeon experience. This algorithm has beenade more complex in recent years by the availability of

ffective medical therapy for many patients and the spatef multiple procedures that have gained popularity, manyor only brief periods. At this writing, the procedures that

igure 1. (A) Diagrammatic representation of principles oirectly into bladder. Reprinted with the permission of Thell Rights Reserved. (B) Cystoscopic view showing internal

re in favor include transurethral resection of the prostate i

62

monopolar, bipolar), “Greenlight” vaporization using a0-100 W KTP laser, and holmium:yttrium-aluminum-arnet laser enucleation of the prostate using a 60-100 Wolmium:yttrium-aluminum-garnet laser. Table 3 con-ains a comparative summary of the various proceduresor BPH.

STEP is aimed at providing an effective minimallynvasive alternative to surgical enucleation for theedium to large-size prostate (�80 g). STEP has sev-

ral theoretic advantages. First, it enucleates the entiredenoma, akin to open surgery. Second, the urethral

EP. r-Port inserted through infraumbilical midline incisionland Clinic Center for Medical Art & Photography © 2008.of r-Port snuggly cinched inside bladder.

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nstrumentation is minimal, thereby minimizing the

UROLOGY 72 (5), 2008

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igure 2. (A) Circumferential mucosal incision made around bladder neck, starting posteriorly and then carried along lateralnd superior aspects (dotted line). (B) Stitch placed through prostatic adenoma after initial mobilization of adenoma fromapsule. Suture can then be grasped to provide traction during subsequent enucleation. (C) Adenoma progressivelynucleated under direct endoscopic visualization using ultrasonic shears to divide vascular attachments. Stitch used torovide traction. (D) Adenoma freed by sharply dividing urethral mucosa with endoshears. (E) Retrigonization performed byaking 3 interrupted sutures between posterior bladder neck mucosa and divided urethra. Reprinted with the permission of

he Cleveland Clinic Center for Medical Art & Photography © 2008. All Rights Reserved.

ROLOGY 72 (5), 2008 963

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isk of subsequent urethral strictures. Third, the pro-edure is performed without any irrigation fluid,hereby eliminating the sequelae of fluid absorptionnd potentially reducing the risk of infection. Fourth,leeding might be less because of tamponade fromarbon dioxide insufflation and enucleation under vi-ion, achieving adequate hemostasis. Finally, thenucleated adenoma can be extracted expeditiouslyhrough the single port by simply dividing the lobesnto a few large pieces.

Our experience with these initial 3 procedures is en-ouraging, and some technical issues were addressed.nsertion of the r-Port was relatively straightforward, andhe internal ring remained securely within the bladderhroughout the procedure in all 3 cases. The space avail-ble in the carbon dioxide-insufflated bladder was quite

Table 2. Perioperative data

Variable Ca

Operative time (h)EBL (mL) 9Transfusion YesComplications EnterotomyCatheter/drains Foley catheter

suprapubicHospital stay (d)Mean pain score (VAS) at discharge 3Catheterization duration (d)Incision

Location UmbilicusLength (cm)

Digital assistance for enucleation YesAdenoma weight (g) 2Maximal end-tidal CO2 (mm Hg)

EBL � estimated blood loss; VAS � visual analog scale; NA � n

Table 3. Comparison of various surgical approaches to BP

Variable TURP Open SurgeryLaRo

Suitability for largeglands

Operatordependent

Yes Yes

Amount ofadenomaremoved

�� ���

Operative time Sizedependent

Sizeindependent

Size

Blood loss �� ���Urethral

complications��� �

Irrigation sequelae ��� 0Specialized

instrumentsNo No No

Cost � �Incision No Long, single MulOutpatient

procedureNo No No

Routine drain No Yes YesRoutine SPT No Yes No

TURP � transurethral resection of prostate; PVP � photoseleenucleation of prostate; STEP � single-port transvesical enucleat

dequate for performing all steps of the procedure. Intra- d

64

esical visualization was excellent, and suction and irri-ation could be performed as and when required withoutosing exposure. The procedure was technically successfuln all 3 cases, and all patients voided after catheteremoval without a significant postvoid residual volume.

e had 1 major complication of an enterotomy duringnsertion of the r-Port despite using the open Hassonechnique. This was attributed to inserting the port at aigh location near the umbilicus and postoperative ad-esions from the patient’s previous laparotomy. For theubsequent cases, we inserted the port through an inci-ion approximately midway between the umbilicus andymphysis pubis.

Certain technical issues merit consideration. As men-ioned, the port should be inserted about 3-4 finger-readths above the symphysis pubis. This not only re-

Case 2 Case 3

1.5 2.5250 350

No No0 0

vesical drain, Foley catheter Foley catheter

1 11/10 0/10

7 7

Suprapubic Suprapubic3 3

Yes No65 45

NA NA

ilable.

scopic/Surgery

GreenlightPVP HoLEP STEP

No Operatordependent

Yes

� � ��� ���

pendent Sizedependent

Sizedependent

Sizeindependent

� �� ����� ��� �

0 �� �� 0Yes Yes Minimal

��� ��� ��No No 2 cmYes No No

No No NoNo No No

vaporization; HoLEP � holmium:yttrium-aluminum-garnet laserf prostate; SPT � suprapubic tube.

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ore accessible for finger enucleation, if necessary. Weelieve finger enucleation of the distal part of the ade-oma can be helpful to expedite enucleation of largedenomas and reduce the operative time. Once the vo-uminous adenoma at the prostatic base has been enucle-ted under laparoscopic vision, and its major blood sup-ly at the 4- and 7-o’clock positions controlled, the distalapical) part of the adenoma can be readily separatedrom the overlying surgical capsule digitally. Moreover,he finger can be introduced through the ring of the-Port by simply removing the valve, without having toemove the port itself. It is important not to pull thedenoma into the bladder but simply to separate thedenoma from the capsule during finger enucleation tovoid the potential for traction injury to the sphincter.nce the finger dissection has been completed, the r-Port

alve is reattached and the pneumovesicum re-estab-ished for incising the urethra at the prostatic apex andompleting the procedure.

Some concerns still remain with STEP. The possibilityf carbon dioxide absorption or even embolism if a majorenous sinus is opened exists. We measured the end-tidalarbon dioxide levels continuously during these cases andound no undue elevation. The second concern relates tohe potential for traction injury to the external sphincterue to pulling on the adenoma. We tried to enucleate the

land in situ and transected the urethra sharply with

ROLOGY 72 (5), 2008

cissors to prevent this injury. In the future, we propose toystoscopically incise the urethra circumferentially usingCollin’s knife or laser at the very outset of the proce-

ure, thereby further minimizing the potential for trac-ion injury to the urethra. All 3 patients were continentfter catheter removal. However, the continence resultseed to be assessed in a larger cohort of patients under-oing STEP.

ONCLUSIONSe report the initial experience and technical feasibility

f single-port transvesical simple prostatectomy usingneumovesicum and standard or articulating laparoscopicnstrumentation. Early results appear encouraging. Addi-ional studies are necessary to define its role in theurgical treatment of large-volume BPH (�80 g).

eferences. Sotelo R, Spaliviero M, Garcia-Segui A, et al. Laparoscopic retro-

pubic simple prostatectomy. J Urol. 2005;17:757-760.. Raman JD, Bensalah K, Bagrodia A, et al. Laboratory and clinical

development of single keyhole umbilical nephrectomy. Urology.2007;70:1039-1042.

. Desai MM, Rao PP, Aron M, et al. Scarless single port transumbili-cal nephrectomy and pyeloplasty: First clinical report. BJU Int.2008;101:83-88.

. Kaouk JH, Haber GP, Goel RK, et al. Single-port laparoscopic

surgery in urology: Initial experience. Urology. 2008;71:3-6.

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