V2093 SPIDER™ PLATFORM FOR LESS UROLOGICAL SURGERY: FROM INITIAL LABORATORY EXPERIENCE TO FIRST CLINICAL APPLICATION

Vol. 185, No. 4S, Supplement, Wednesday, May 18, 2011

V2093 SPIDER™ PLATFORM FOR LESS UROLOGICAL SURGERY: FROM INITIAL LABORATORY EXPERIENCE TO FIRST CLINICAL APPLICATION Shahab Hillyer*, Bo Yang, Riccardo Autorino, Michael A White, Humberto Laydner, Fatih Altunrende, Rakesh Khanna, Greogry Spana, Cleveland, OH; Wahib Isac, cleveland, OH; Robert J. Stein, Georges P Haber, Jihad Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: The SPIDER is designed to allow multiple instruments to be manipulated through a single cannula. Flexible instrument delivery tubes are used to guide surgical instruments to the operative field. Aim of this video is to describe initial laboratory experience and to report the first clinical urological LESS application using this novel surgical platform. METHODS: After a dry lab session by conducting training standardized tasks, different kidney procedures (partial nephrectomy, nephrectomy and pyelopasty) requiring both extirpative and reconstructive surgical steps were performed in four male pigs. Then, a cyst decortication was performed in a 64-year-old lady presenting with a symptomatic 15 cm left renal cyst. RESULTS: During the porcine partial nephrectomy selective arterial clamping was accomplished by placing a vessel loop tourniquet and renorrhaphy performed using knotless barbed sutures using SPIDER needle drivers. Porcine nephrectomy was performed using SPIDER monopolar hook and Maryland dissectors and the clip applicator to manage the pedicle. Porcine pyeloplasty was done by using two SPIDER needle drivers. For the clinical case, a 2-cm periumbilical incision was done to insert the SPIDER by using a Hasson technique. Given limited working space, the SPIDER was then re-inserted through a GelPoint device. Difficulty was found, especially for retraction and suction, due to lack of precision and strength of movements. Operative time was 180 minutes and blood loss was minimal. Hospital stay was 36 hours. Twenty-six mg of morphine equivalents were used for analgesia and VAPS score at discharge was 1.5/10. Radiological control demonstrated resolution of the cyst. CONCLUSIONS: The SPIDER platform offers the advantages of intuitive maneuverability of the instruments into the abdominal cavity, restored triangulation without any external instrument clashing, and no significant gas leakage. Nevertheless, further refinements are awaited to define the application of this system for LESS urological surgery. Source of Funding: Spider

V2094 SMALL INCISION ACCESS RETROPERITONEOSCOPIC TECHNIQUE (SMART) FOR PYELOPLASTY Ali Serdar Go¨zen*, Giovannalberto Pini, Michael Schulze, Jens Rassweiler, Heilbronn, Germany INTRODUCTION AND OBJECTIVES: Laparoscopic pyeloplasty for UPJ obstruction has been demonstrated to be safe and effective. In an attempt to further reduce surgical morbidity and better cosmetic results new technical developments with transperitoneal access are introduced. In this video we share our experience of performing a retroperitoneal pyeloplasty with SMART. METHODS: 26 years old female presented with right flank pain. Kidney sonography revealed a right hydronephrosis and a scintighrapy 45% shared function of this kidney. A retrograde ureterogram was performed and pigtail catheter was placed. Doppler sonograpy demonstrated crossing aberrant lower pole vessels. Retroperitoneal space was created with specially designed 5 mm balloon trocar. An improved 5mm 30°optic, HD wide-view camera system, a 5 mm Optic port, two 3mm working ports, and special developed 3 mm instruments (Storz®) are used. The ports are triangulated like in a standard retroperitoneal technique and a retroperitoneal Y-V pyeloplasty was performed. RESULTS: The operation time was 58 minutes; no intraoperative or postoperative complications were occurred. Blood loss was

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minimal. No stitch was necessary for the trocar wounds and no analgesics were needed during the postoperative period. Drain was removed on the 3th day and the patient was discharged from the hospital during the same day. The wound healing was almost scarless. CONCLUSIONS: The SMART procedure for UPJ obstruction seems like safe and effective in experienced hands. The advantages of SMART are minimum access trauma, less postoperative pain and optimal cosmetic result. Source of Funding: None

V2095 FEASIBILITY OF TRANSRECTAL NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES) NEPHRECTOMY IN THE PORCINE MODEL Ryan Kopp*, Wassim Bazzi, Sean Stroup, Ithaar Derweesh, San Diego, CA INTRODUCTION AND OBJECTIVES: Natural Orifice Transluminal Endoscopic Surgery (NOTES) utilizes ports of entry to the peritoneal cavity instead of incisions on the abdominal wall. We examined the feasibility of transrectal NOTES nephrectomy in the porcine model. METHODS: After obtaining approval from our Institutional Animal Care and Use Committee, 3 female pigs (45 Kg) underwent transrectal NOTES nephrectomy (2 right-side, 1 left). Our current protocol is to perform a hybrid approach to NOTES procedures. Pneumoperitonuem was created by a 12mm trocar was inserted periumbilically through which a laparoscope was advanced to obtain intraabdominal visualization. A horizontal incision was made 2cm above the dentate line and a submucosal tunnel was created in the posterior rectal wall and pre-sacral space. A dual-channel gastroscope was gradually advanced through the submucosal tunnel and into the retroperitoneum to the level of the kidney using air insufflation. A window in the peritoneum was created and mobilization of the kidney was completed. Transumbilically applied laparoscopic 45 mm stapler was used to transect the ureter and renal hilum. A specimen extraction bag was deployed transrectally and the specimen was delivered intact, prior to sutured closure of the transrectal incision. RESULTS: Transrectal NOTES nephrectomy was successfully performed in all cases. Mean operative time was 180min (30min for rectal access). Estimated blood loss was 50ml. No intra-abdominal injuries were noted on necropsy. CONCLUSIONS: In this initial report on feasibility of transrectal NOTES approach for nephrectomy,the procedures were performed with minimal blood loss and intact specimen extraction. Survival studies are requisite to assess for sterility, and short and long-term complications. We hypothesize this approach to be of utility as an alternative to transvaginal access. Source of Funding: None

V2096 LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR FOREIGN BODY SIMULATING RENAL CANCER Roberto Sanseverino*, Giorgio Napodano, Olivier Intilla, Umberto Di Mauro, Mario Iacone, Nocera Inferiore, Italy INTRODUCTION AND OBJECTIVES: We report the case of a 61 year old male presenting with an upper pole right renal mass suggestive of renal cell carcinoma which resulted to be a retained surgical gauze. METHODS: The case of a patient with a history of previous nephrolithotomy 30 years before, with subsequent Percutaneous nephrolitotomy and ESWL, who presented with flank pain. Abdominal Ultrasound and CT-scan were suggestive of malignant renal mass of right upper pole kidney. A right transperitoneal laparoscopic radical nephrectomy was planned. After performing renal biopsy, we noticed a gauze