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Natural Orifice Transluminal Endoscopic Surgery (NOTES) Partial Nephrectomy
Video of the Month In this issue we initiate the first “Video of the Month” selection by the AUA Audio-Visual Committee which will integrate articles published in an issue of The Journal of Urology® with videos from the 2009/2008 AUA Annual Meetings available in the AUA/BI DVD Library at (http://www.auanet.org/content/products/dvds.cfm#aua-bi-dvd). A commentary is provided to highlight the important viewpoints presented by the video as it relates to the articles. We hope readers will take advantage of this fast growing visual medium of education. Alexis E. Te and Benjamin Lee Chair and Vice Chair of the AUA Audio-Visual Committee
Natural Orifice Transluminal Endoscopic Surgery (NOTES) Partial Nephrectomy. B. R. Lee, U. Boylu, M. Oommen, G. Fifer, R. Thomas and V. Joshi One of the most rapidly evolving areas in the field of laparoscopy is laparo-endoscopic single site surgery (LESS) which comprises single port surgery and natural orifice transluminal endoscopic surgery. The goal is development of a completely incision-free operation, and the technique and technology of NOTES are presented in this video (http://dx.doi.org/doi:10.1016/ j.juro.2010.03.027). Several issues need to be refined before dissemination of the technology, including flexible/articulating instrumentation and endoscopes to overcome the limitations of a small working space, custom designed trocars to provide access, minimization of warm ischemia during partial nephrectomy (achieved in this video using a thulium laser without hilar clamping) and reliable closure of a controlled gastrotomy. In this issue of The Journal Jeon et al (page 1866) present their initial experience with 50 LESS procedures using a homemade single port device created from a surgical glove and wound retractor. They were able to perform advanced procedures such as single port partial nephrectomy, adrenalectomy and nephroureterectomy. While necessity and cost-effectiveness are the “mothers of invention,” the lack of rigidity and port angle stability compared to conventional trocars may add to the already considerable difficulty of the procedure, although the additional positioning options for the ports with this system may be somewhat of an advantage as well. The authors improved stability by using the abdominal wall as a fulcrum during instrument manipulation. These ergonomic issues are a significant part of the evolution of this technology. However, definitive evidence of any clinical benefit of LESS over standard laparoscopy is still lacking.
0022-5347/10/1835-1731/0 THE JOURNAL OF UROLOGY® © 2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
Another facet of partial nephrectomy which is highlighted in the video is the use of the thulium laser to minimize warm ischemia time. In a multi-institutional study on the impact of ischemia on renal function following laparoscopic partial nephrectomy Shikanov et al (page 1714) examine estimated glomerular filtration rate after 401 partial nephrectomies. Ischemia time (median 29 minutes) did not clinically impact global renal function, even in a case with warm ischemia time of 57 minutes. The authors make it clear that their conclusions are restricted to patients with 2 functioning kidneys, which likely masks to some degree the impact on renal function assessment. There has been significant discussion with regard to how long is too long to render the kidney ischemic during partial nephrectomy. The point of irreversible nephron death has been historically reported in the transplant literature, and there have been several studies of how to minimize renal ischemia time or resect renal masses off clamp. Only with the continuing quest to refine one’s technique can the field of urology move forward. Benjamin R. Lee Department of Urology Tulane University School of Medicine New Orleans, Louisiana
J. Stuart Wolf, Jr. Department of Urology University of Michigan Ann Arbor, Michigan
The 2009/2008 AUA Annual Meeting Video Abstract Sessions are available on DVD (http://www.auanet.org/content/products/dvds.cfm#aua-bi-dvd). Purchase sessions for $50 each or select a title from the “pay-per-view” list (Price: $10 per view). Trailers, which are about 30 seconds long, are provided to sample the quality of the video.
Vol. 183, 1731, May 2010 Printed in U.S.A. DOI:10.1016/j.juro.2010.03.027
www.jurology.com
1731
Natural Orifice Transluminal Endoscopic Surgery (NOTES) Partial Nephrectomy. B. R. Lee, U. Boylu, M. Oommen, G. Fifer, R. Thomas and V. Joshi One of the most rapidly evolving areas in the field of laparoscopy is laparo-endoscopic single site surgery (LESS) which comprises single port surgery and natural orifice transluminal endoscopic surgery. The goal is development of a completely incision-free operation, and the technique and technology of NOTES are presented in this video (http://dx.doi.org/doi:10.1016/ j.juro.2010.03.027). Several issues need to be refined before dissemination of the technology, including flexible/articulating instrumentation and endoscopes to overcome the limitations of a small working space, custom designed trocars to provide access, minimization of warm ischemia during partial nephrectomy (achieved in this video using a thulium laser without hilar clamping) and reliable closure of a controlled gastrotomy. In this issue of The Journal Jeon et al (page 1866) present their initial experience with 50 LESS procedures using a homemade single port device created from a surgical glove and wound retractor. They were able to perform advanced procedures such as single port partial nephrectomy, adrenalectomy and nephroureterectomy. While necessity and cost-effectiveness are the “mothers of invention,” the lack of rigidity and port angle stability compared to conventional trocars may add to the already considerable difficulty of the procedure, although the additional positioning options for the ports with this system may be somewhat of an advantage as well. The authors improved stability by using the abdominal wall as a fulcrum during instrument manipulation. These ergonomic issues are a significant part of the evolution of this technology. However, definitive evidence of any clinical benefit of LESS over standard laparoscopy is still lacking.
0022-5347/10/1835-1731/0 THE JOURNAL OF UROLOGY® © 2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
Another facet of partial nephrectomy which is highlighted in the video is the use of the thulium laser to minimize warm ischemia time. In a multi-institutional study on the impact of ischemia on renal function following laparoscopic partial nephrectomy Shikanov et al (page 1714) examine estimated glomerular filtration rate after 401 partial nephrectomies. Ischemia time (median 29 minutes) did not clinically impact global renal function, even in a case with warm ischemia time of 57 minutes. The authors make it clear that their conclusions are restricted to patients with 2 functioning kidneys, which likely masks to some degree the impact on renal function assessment. There has been significant discussion with regard to how long is too long to render the kidney ischemic during partial nephrectomy. The point of irreversible nephron death has been historically reported in the transplant literature, and there have been several studies of how to minimize renal ischemia time or resect renal masses off clamp. Only with the continuing quest to refine one’s technique can the field of urology move forward. Benjamin R. Lee Department of Urology Tulane University School of Medicine New Orleans, Louisiana
J. Stuart Wolf, Jr. Department of Urology University of Michigan Ann Arbor, Michigan
The 2009/2008 AUA Annual Meeting Video Abstract Sessions are available on DVD (http://www.auanet.org/content/products/dvds.cfm#aua-bi-dvd). Purchase sessions for $50 each or select a title from the “pay-per-view” list (Price: $10 per view). Trailers, which are about 30 seconds long, are provided to sample the quality of the video.
Vol. 183, 1731, May 2010 Printed in U.S.A. DOI:10.1016/j.juro.2010.03.027
www.jurology.com
1731