LARP – three instrument techniques to reduce costs
Reviewed by Gokul Vignesh Kanda Swamy

The cost of laparoscopic radical prostatectomy (LARP) is high because of both the initial installation cost and, more importantly, high running costs. The main reason for the latter is the limited number of usage of the instruments; generally, each instrument is used 10 times. Cutting down on the instruments is obviously a good way of reducing running costs and studies have shown exclusion of high energy devices (such as PK dissectors, bipolar graspers or robotic LigaSure™) has reduced costs by 40%. Potentially, another 12% can be saved if only one needle driver is used. The present standard in most UK centres is the five instrument technique – monopolar scissors, bipolar forceps, prograsp, and two needle drivers. The authors have vast experience and have progressed sequentially to a four instrument technique dropping one needle holder and then to a three instrument technique using monopolar scissors, prograsp and one needle driver only. The needle driver is used all along in the fourth arm for retraction (without grasping tissues) but for two steps it is swapped to first arm – DVC stitch and urethra-vesical anastomosis. This article explains a step by step approach of how to make use of this technique very well. They do recognise minimal drawbacks in technical aspects but no increased operative time, blood loss, complications or outcomes. They have now performed more than 1000 procedures with this technique. However, no comparative data on the above measures are provided between the four and five instrument techniques. From a cost point of view this is definitely appealing. 

Reducing costs for robotic radical prostatectomy: three-instrument technique.
Ramirez D, Ganesan V, Nelson RJ, Haber GP.
UROLOGY
2016; [Epub ahead of print].