Mini-laparoscopy advances: Where does urology fit?

Mini-laparoscopic surgery is progressing from a diagnostic to a therapeutic approach that may offer advantages over robotic and traditional surgery.

That was the message from the Euro-American Multispecialty Summit, held in February in Orlando, FL.

Today’s mini-laparoscopic surgery does not require trocars, and the 2- to 3-millimeter instruments result in smaller incisions than with traditional laparoscopy. 

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Urology Times asked urologists Timothy Charles Brand, MD, and J. Stuart Wolf, Jr., MD, what they think this means to the specialty. General surgeon Richard M. Satava, MD, weighs in on how mini-laparoscopy’s evolution might impact the future of medicine.

Dr. Brand, a Lieutenant Colonel, Medical Corps, U.S. Army, and urology residency director at Madigan Army Medical Center, Tacoma, WA, discusses the new developments and their possible impact on urology. He said these are his opinions and not the opinions of the Department of Defense or U.S. government.

UT: What are the specific new developments in mini-laparoscopy for urologists?

Dr. Brand: Even though the technology has been around for a while, the recent changes in instrumentation seem to be what’s leading to more adoption. There has been very little done with mini-laparoscopy in urology specifically. Most of the cases, so far, have been in general surgery and [gynecology].

I think there is potentially an opportunity for urologists to consider using this technology; in particular, in the field of pediatric urology, with a possible example being a laparoscopic orchidopexy. There’s probably potential for pyeloplasties for ureteropelvic junction obstructions because there is no sizable specimen in those cases-it’s just a reconstructive surgery. Those cases are frequently in children and often in younger females who have greater concern about the risk of scarring with bigger incisions. There are a handful of studies looking at feasibility of mini-laparoscopy in urologic applications (ie, a paper published online in the World Journal of Urology [May 28, 2015], and J Endourol 2014; 28:951-7), but these data have been non-randomized and small series.

NEXT: Advantages over traditional laparoscopy

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UT: Does mini-laparoscopy offer advantages over traditional laparoscopy?

Dr. Brand: [Cosmesis and minimal scarring] seem to be the biggest potential advantages. There may be less pain, as well, although a lot of that is really conjecture. The data are not there.

UT: How does mini-laparoscopy compare to robotics?

Dr. Brand: The incisions are a little smaller than with the robot. It would be cheaper to use than the da Vinci, and it would afford haptic feedback to the surgeon, as the surgeon is using the laparoscopic instruments.

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UT: What disadvantages are there to the technique?

Dr. Brand: The biggest difference between this and the robotic approach is that you don’t have wristed instruments, so you don’t have the degree of freedom with the instrumentation that you have with the robot. [That freedom] is especially nice when you’re talking about sewing, which is required on something like pyeloplasty.

I haven’t actually seen the view that you get with mini-laparoscopic cameras, but the view with the robot is particularly good. With the robot, there are two separate visual feeds, one for each eye, so you get 3-dimensional or stereoscopic view with the robot.

NEXT: What is the learning curve?

UT: What is the learning curve?

Dr. Brand: [Brazilian researcher] Gustavo L. Carvalho MD, PhD, who spoke at the Euro-American Multispecialty Summit and will soon publish a paper on mini-laparoscopy in the Journal of the Society of Laparoscopic Surgeons, reported on the biggest development and the reason why mini-laparoscopy seems to be resurfacing after its initial introduction in the mid-1990s. There is instrumentation now that is low-friction. Basically, the biggest difference is that there’s not a cannula seal that’s necessary to maintain pneumoperitoneum. My understanding is that the tolerances of the trocar and the instruments are so close and exact that the instruments are able to slide through the trocar with minimal friction and maintain a pneumoperitoneum without a seal.

As far as the learning curve goes, at least based on this study from Dr. Carvalho, the learning curve approximates what you would see with standard laparoscopic instrumentation-5-mm instrumentation. But it appears to be significantly easier, with a shorter learning curve, than what you would see with the prior generations of the mini-laparoscopy instrumentation.

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UT: Is mini-laparoscopy ready for use in urology?

Dr. Brand: I think it is not quite ready. I think it deserves evaluation and trial, potentially, in pediatric urology for orchidopexy and possibly for pediatrics and young adults and otherwise for pyeloplasty for UPJ obstruction. And for the time being, there are not great data to support its use in urology, but it deserves a closer look.

NEXT: Cosmesis only advantage of mini-lap, Dr. Wolf says

Dr. Wolf, a member of the Urology Times Editorial Council who is professor of urology and associate chair for surgical services in the department of urology at University of Michigan, Ann Arbor, shares his thoughts about mini-laparoscopic surgery and this press release by the Society of Laparoendoscopic Surgeons (SLS).

UT: What do you think about this evolution in laparoscopic surgery?

Dr. Wolf: Mini-laparoscopic surgery is not new; it is just that recently the instruments have been improved to the point that they are almost as effective as regular-sized instruments. The advantage of mini-laparoscopy-and, in fact, the only advantage-is cosmetic.

The improved appearance of the incision made for a 2-mm instrument or a 3-mm port, compared to that for a 5-mm port, is amazing. I never would have believed it, but then I started doing some mini-laparoscopic procedures myself. The incision for the 5-mm port leaves a small but noticeable scar; the 2- and 3-mm incisions are virtually undetectable when they have healed well.

Nonetheless, I don’t think that the some of the claims in the press release, specifically claims about decreased pain and faster healing, are substantiated by data. Cosmesis, alone, is a fine reason to offer mini-laparoscopic surgery. I don’t think that mini-laparoscopic surgery decreases pain or speeds healing.

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UT: Where do you think it will be most useful in urology and why?

Dr. Wolf: Mini-laparoscopic surgery is most useful in reconstructive procedures that don’t require removal of a specimen. In my experience, young to middle-aged women are the most concerned about cosmesis. So, that would make the best procedures for mini-laparoscopic surgery in urology to be laparoscopic pyeloplasties, ureteral reimplantations, and other reconstructive procedures in young to middle-aged women. I have very limited experience with laparoscopic surgery in children, but I think that the mini-laparoscopic approach would be of value in that population too.

I should point out, with regards to extirpative surgery (where a larger incision has to be made for specimen extraction so the procedure cannot be entirely mini-laparoscopic), that there might still be an advantage to one or two of the ports being mini-laparoscopic ones. We have used this approach in young women undergoing nephrectomy for benign disease. The 12-mm port needed for staples and large clips is placed below the pubic hairline (this port site is enlarged slightly for specimen extraction), a 5-mm port is placed in the base of the umbilicus for the video-laparoscope, and then two 3-mm ports are used for working ports. These small and strategically placed incisions greatly improve cosmesis.

UT: Do you think it’s too early to tout it as safer and a therapeutic, rather than diagnostic, approach in the specialty?

Dr. Wolf: There have already been several series of mini-laparoscopic pyeloplasty reported at meetings and in publications, and there have also been reports of adrenalectomy and donor nephrectomy using mini-laparoscopic instruments. We need a wider experience to better assess the role of mini-laparoscopic surgery in urologic practice.

NEXT: Transition noninvasive surgery is happening

Dr. Satava, an SLS board member and professor emeritus of surgery, University of Washington Medical Center, Seattle, said the transition from minimally invasive surgery to noninvasive surgery, based on Directed Energy for Diagnosis and Therapy (DEDAT) technologies, is in progress.

“The transition began about 15 years ago with the emergence of ‘intelligent’ energy-based systems in which both diagnosis and therapy occur instantaneously, such as ultrasound (eg, Doppler/3-D ultrasound for diagnosis and high-intensity focused ultrasound [HIFU] for therapy). It is a matter of record that these technologies were actually first used in urology, such as in lithotripsy,” Dr. Satava said.

“Around the same time, radiologists were beginning to combine their energy-based diagnostics (x-ray, ultrasound, terahertz, etc., imaging) with the therapeutic applications, which they referred to as ‘image-guided surgery.’ In addition, other energy-based therapies, such as photonics (lasers), began combining both diagnosis and therapy. For example, Barrett’s esophagus was diagnosed with spectral analysis and then ablated with specific wavelengths of photonic (laser) energy.”

While multiple disciplines began applying limited DEDAT uses, there was no real recognition within the general and specialty surgical communities of the importance of these advances, Dr. Satava said.

Along with advances in energy came new energy-based modalities, including femtosecond lasers, cold atmospheric plasma, molecular probes, genetic engineering, and cellular surgery, which, for the first time, used energies at the molecular level.

“Another advance was in the area of controlling metabolism, specifically to be able to create ultra-hypometabolic states (like hibernation and suspended animation). The result of these experiments were the realization that new surgical ‘tools’ existed to perform ‘surgery’ at the molecular level,” he said.

So, where are we now? About halfway through the transition from minimally invasive to noninvasive (or DEDAT) surgery, Dr. Satava says.

“A few technologies… are emerging out of the laboratory and experimental/clinical trials and are ready for mainstream clinical adoption-with urology leading the pack by using HIFU for prostate lesions and lasers for BPH,” Dr. Satava said. “Just as laparoscopy and robotics have carved out specific niches in which these technologies have a decided advantage, so, too, the new DEDAT technologies will increase in share, from a few percent to a large percent over the next 20 years.

“At this time, it is unlikely that open and MIS will go away entirely, but 50 or more years from now, it is entirely possible that a majority of surgical procedures will be performed with DEDAT.”

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