Matthieu Durand and Prof. Jean Amiel (L to R)

The European Association of Urology is holding its annual meeting in Paris this week. Our team has won first prize for best oncology abstract for the work presented in “Real-time, in vivo multiphoton microscopy imaging is a promising tool to identify prostate tissue during rat survival surgery.” This work was presented by Matthieu Durand who spent a year working at Cornell in New York. The full abstract can be found here and is reproduced below.

Multiphoton microscopy is a novel imaging modality that can differentiate various structures while performing prostate cancer surgery. This technology has the potential to reduce morbidity and complications during robotic prostate surgery.
Real-time, in vivo multiphoton microscopy imaging is a promising tool to identify prostate tissue during rat survival surgery
Durand, M.1, Aggarwal, A.2, Robinson, B.3, Srivastava, A.4, Sooriakumaran, P.4, Mtui, J.4, Brooks, D.4, Flomenbaum, D.4, Sterling, J.2, Mukherjee, S.2, Leung, R.4, Tewari, A.K.4
1Academic Hospital of Nice, Dept. of Urology, Nice, France, 2Weill Medical College of Cornell University, Dept. of Biochemistry, New York, United States of America, 3Weill Medical College of Cornell University, Dept. of Surgical Pathology, New York, United States of America, 4Weill Medical College of Cornell University, Dept. of Urology, New York, United States of America
Introduction & Objectives

Extraprostatic extension of prostate cancer is a microscopic phenomenon; therefore, it is not possible to differentiate cancerous cells from nerves during surgery. This can result in the incomplete removal of the cancer and/or postoperative impotence due to damage or excision of the nerves. In vivo multiphoton microscopy (MPM) is a novel technology that has shown promise in visualizing prostatic structures and adjacent nerves in an ex vivo setting. We investigated its role in an animal model, to discover whether it could be used in an in vivo setting.
Material & Methods

We used a custom-built MPM, consisting of an Olympus BX61WI upright frame and a modified Bio-Rad MRC 1024 scanhead. We used Sprague Dawley rat models, ex vivo and then in vivo for in-situ MPM imaging to assess its ability for identifying the anatomy of the prostatic tissue; we also examined the imaged tissue for signs of phototoxicity. A cocktail of ketamine and xylazyne was used as general anesthesia to keep the rat asleep and decrease body movement during imaging. Open surgical exposure of the prostate was performed to image the right prostatic lobe and the left lobe was used as an internal control. After image acquisition, the rat’s abdominal cavity was closed and the rat removed from the stage back to the husbandry unit for recovery. The rat was monitored for at least 15 days to check for signs of distress. Finally, the rat was euthanized and the whole prostate was processed for histological analysis to look for phototoxicity effects and to provide correlation between MPM ‘virtual’ histology and the gold standard.
Results

MPM was correctly able to identify anatomical structures of the rat prostatic tissue, as seen in figure 1. No tissue damage was observed either during imaging, or in the histopathology slides prepared from the imaged specimens.
Conclusions

Real-time, MPM imaging is feasible and safe without damaging tissue structures or being life-threatening in rat models. This novel technology may in the future be translated to human subjects via intra-operative use of a multiphoton endoscope currently being developed by our collaborators.

Our group at the LeFrak Center for Robotic Surgery and the New York Presbyterian Hospital/Weill Cornell Medical Center Institute of Prostate Cancer have published two new papers reviewing Laparoendoscopic Single Site (LESS) surgery. These publications will appear in upcoming issues of European Urology and the British Journal of Urology International. The references can be found on our publications page. Single site surgery could have large implications in prostate cancer treatment as well as other organ systems.

Laparoscopic or ‘keyhole’ surgery has developed in an effort to reduce the complications associated with large incisions during ‘open-access’ surgery. Over the last 15 years the results of this approach have been unanimous across a variety of procedures, demonstrating intra- and postoperative benefits which, for example, have led to a quicker recovery with less blood loss, hospital stay, scar pain and hernia formation.

Recently, an extension of this principle of ‘minimal invasion’ has been proposed in the form of LaparoEndoscopic Single-Site (LESS) surgery. Here, instead of operating through several small (e.g. 1-2cm) incisions, a slightly larger single incision (e.g. 3-5cm) is used to provide access for all the operating instruments. This incision is still smaller than the open incision, and can be concealed within the umbilicus with good cosmetic effect.

However, it remains to be seen whether the same surgical results can be achieved when using several instruments via a single access device. Such an approach complicates triangulation of laparoscopic instruments, because the instruments have to enter the body at the same point, thus making the technique challenging even in expert hands. Nevertheless, proof of principle has been demonstrated by several groups describing the safe implementation of various single-site procedures, particularly for operations involving the kidney.

In order to overcome the spatial limitations single-site surgeons have benefited from the creative use of flexible and pre-bent instruments. One further advance is being trialled through the incorporation of robotics. Since the advent of robotic technology, surgeons have been able to overcome the restrictions of traditional ‘keyhole’ surgery while providing the same intra- and postoperative benefits when compared to traditional open surgery. Furthermore, the robotic approach benefits from superior  ergonomics and Endowristed instruments which can somewhat alleviate the spatial constraints of operating through a single site using laparoscopic equipment. Unfortunately current robotic technology has not been designed for this use, and external arm clashing still restricts single site procedures.

In the future, urologists may be able to benefit from in vivo micro-robots that will allow the manipulation of organs from inside the body. The use of magnetic anchors might also go some way to freeing up space at the point of access, using for example external magnets to hold internal cameras.

However, the final promise in minimally invasive surgery is Natural Orifice Transluminal Endoscopic Surgery (NOTES), with its scarless technique, which occurs via operating through a natural orifice (such as the mouth or vagina). It naturally follows that this ‘indirect’ pathway to abdominal organs is even more difficult to navigate compared to LESS surgery, and such procedures are very much at the experimental stage.

It remains to be seen whether NOTES, LESS, or any of these future developments will prove their clinical superiority over standard laparoscopic methods.

British Journal of Urology International abstract can be found here.

European Urology abstract can be found here.

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