Guiding Principles
Laparoscopic surgery and other minimally invasive surgeries are rapidly changing how we take care of our patients. This development has led to the formation of the Carolinas Laparoscopic & Advanced Surgery Program (CLASP). Founded at Carolinas Medical Center in 1998, CLASP emphasizes minimally invasive applications for surgery, with focus upon the primary missions of Carolinas HealthCare System:

• Patient Care
• Education
• Research

Because McKay Urology shares these priorities, the surgeons from McKay and CLASP collaborate effectively in a multi-disciplinary approach. In fact, CLASP is truly a multi-disciplinary center, involving not only urology, but also trauma, surgical oncology, gastroenterology, gynecology, thoracic surgery, and orthopedic surgery. This multi-disciplinary approach has resulted in substantial improvements in patient care, and has advanced the field of urology, as well as many other disciplines.

Patient Care
For urology patients in particular, McKay Urology and CLASP combine medicine and technology to improve patient care and enhance patient comfort. Compared with open surgery, the benefits of laparoscopic surgery include:

• Shorter hospital stay
• Less pain
• Quicker recovery

In fact, CLASP data indicates that hospital stays following laparoscopic surgery are usually half as long as open operations. The incidence of morbidity, which refers to the occurrence of complications resulting from surgery, is substantially less in laparoscopic surgery. Recovery also takes about half the time it would if the procedure were performed through open surgery.

Accordingly, McKay Urology and CLASP collaborate to provide the following types of care for patients with a variety of diseases of the kidneys, including:

• Renal cell cancer
• Nonfunctional kidneys
• Transitional cell cancer
• Renal cysts
• Renin-mediated hypertension
• Polycystic kidney disease

Through 2003, McKay Urology and CLASP surgeons have collaborated on nearly 300 laparoscopic procedures for kidney patients alone, and the team averages over 50 per year.

The primary procedure performed by Dr. Chris Teigland and Dr. Kent Kercher is the radical laparoscopic nephrectomy for kidney cancer. When facing this procedure, patients often ask:

• How long will I be in the hospital?
• What are the chances that I will have complications?
• What are the chances that they won't be able to perform the procedure laparoscopically?
• How long will it take for me to recover?

CLASP experience has shown that laparoscopic nephrectomy results in fewer hospital days, fewer complications (such as blood loss), and more rapid recovery than open surgery. Dr. Kercher supports these conclusions in the department's ongoing study¹ of the laparoscopic nephrectomy results at CMC. Between August 1998 and September 2002, the Departments of Surgery, Urology, and Transplantation performed 118 laparoscopic nephrectomies and 92 open nephrectomies. Those patients undergoing laparoscopic surgery spent an average of two full days less in the hospital. The percentage of cases involving transfusion/blood loss was over 50% less in laparoscopic procedures. In addition, only two cases that began laparoscopically were converted to open surgery. For live kidney transplant donor patients in particular, return to normal activities, such as driving, was an average of 22 days sooner in cases performed laparoscopically. Clearly, the laparoscopic procedure offers patients many advantages compared with open surgery.

The CLASP program has established CMC as one of the nation's leading centers for laparoscopic and minimally invasive surgeries-comparing very favorably with the world's best institutions. For example, the University of Maryland has the most experience of any institution in the world in laparoscopic donor nephrectomy (kidney removal for transplantation). Compared with the University of Maryland, CMC has experienced a significantly lower percentage of cases that involved:

• Conversions to Open Operations
• Transfusions
• Major Intra-Operative Complications
• Major Post-Operative Complications

This is a major accomplishment, considering the fact that the University of Maryland experience is recognized as the benchmark for laparoscopic donor nephrectomy.

Beginning around 1990, laparoscopy was widely adopted for general surgery. As technology and surgical techniques have advanced, laparoscopy and minimally invasive surgery have been applied to more complex procedures that would have only been done through open surgery in the past. Two primary examples from the field of urology are the removal of the kidney (nephrectomy) and the removal of the prostate (prostatectomy). Both procedures are very complex operations when done laparoscopically. That is why CLASP and McKay Urology collaborate in a multi-disciplinary approach to laparoscopic and minimally invasive surgery for urology patients.

In fact, CLASP and McKay Urology are partners in a dedicated, team approach involving surgeons, oncologists, radiologists, and urologists. This team cares for many patients who would not be candidates for surgery at another institution. However, if such a patient comes to CMC, he can receive comprehensive care. For example, someone with metastatic kidney cancer may have his kidney removed; be managed by one of our specialized orthopedic oncologists; and then, if necessary, he may have systemic therapy such as immunotherapy with Interleukin-2-all at a single institution. By design, this dedicated, multi-disciplinary team approach ensures continuity of care.

Taking a team approach is especially important in CLASP's collaboration with urologic surgeons (because of the complexity of the procedures). For example, CMC performs over 100 kidney removals each year. Instead of working with many urologic surgeons and dividing the number of cases among them, CLASP surgeons partner with two urologic surgeons-Dr. Chris Teigland and Dr. Pierce Irby-and collaborate on all the laparoscopic nephrectomies performed by the faculty at Carolinas Medical Center. Because of this partnership between CLASP and McKay Urology, all the cases are concentrated within that team. While Dr. Teigland focuses primarily in the area of cancer/malignancy, Dr. Irby focuses primarily on the benign diseases of the kidney. Dr. Kercher provides added expertise in laparoscopic surgery, working with Dr. Teigland or Dr. Irby, depending on the indication for surgery.

Education
In addition to patient care, education is another fundamental priority of the CLASP initiative. Because of the clear benefits of laparoscopy and other minimally invasive and technology-based surgeries, resident surgeons and attending surgeons throughout the region and the country have been eager to learn these techniques. To meet this demand, CLASP began by educating physicians within the Carolinas HealthCare System, including Dr. Chris Teigland and Dr. Pierce Irby at McKay Urology. Since then, CLASP has broadened its curriculum in specific laparoscopic techniques for surgeons who come from the Southeast, throughout the United States, and around the world. To date, more than 1,000 physicians from 30 states, 4 countries, and 41 academic institutions have attended CLASP courses.

Specifically, CLASP educates general surgeons who are already out in practice, and did not have an opportunity to learn laparoscopic procedures during their residency. CLASP also educates and collaborates with other surgeons in particular sub-specialties, including:

• Urologic surgeons
• Neurosurgeons
• Surgical Oncologists
• Orthopedic Surgeons
• Gynecologists

The educational objective of CLASP is to advance the field of laparoscopic surgery by teaching other surgeons the techniques that are relevant to their area of specialization. Members of the CLASP faculty are also available to proctor surgeries for doctors who have recently learned the laparoscopic technique. In these cases, members of the CLASP faculty travel to other hospitals across the region, scrub in, and guide the surgeons through the latest laparoscopic and minimally invasive surgical techniques.

Research
In addition to patient care and education, the third fundamental priority for CLASP is research. CLASP conducts laboratory research to better understand the physiology of laparoscopy and other minimally invasive procedures. In other words, CLASP researchers study the impact of laparoscopy and minimally invasive procedures on the structure and function of the affected organs and organ systems. For example, researchers consider such issues as: the effect of carbon dioxide exposure to a kidney that is harvested for transplant; or, the functional characteristics of the remaining kidney following the removal of a cancerous kidney. These are two of many questions that CLASP researchers are studying currently in their ongoing laboratory research.

In addition, CLASP conducts clinical research, analyzing data from actual cases. Researchers focus on how CLASP data compares with that of other leading institutions. For example, CLASP researchers compare results from laparoscopic urology procedures with results from the Cleveland Clinic, which is the largest center for laparoscopic urology.

CLASP's clinical research does not involve experimental research on patients. Instead, it involves examining the data and analyzing the outcomes. By doing so, CLASP continuously seeks to improve its practices and optimize patient outcomes. For example, CLASP's clinical research may identify a certain group of patients who have higher complication rates for a given procedure than other groups. Knowing this enables CLASP surgeons to counsel patients who belong to a particular group, and to explain the specific risks that may apply to them in undertaking the procedure, based on experience and analysis. Additionally, the surgeon can help the patient understand why he is at risk. This allows the surgeons to educate each patient about the risks, benefits, and potential options available for management of his or her particular disease process. It also enables CLASP to analyze and modify its practices in order to minimize complications and risks for a given group of patients. In this way, CLASP's research directly benefits patients and their doctors.