PRESENT TREND/SCOPE OF LAPAROSCOPYON UROLOGICAL
AJIT M VAZE
Hon. Urologist and Andrologist,
Jaslok Hospital, Sir HN Hospital, Lilavati Hospital and Research Centre, Mumbai.
Laparoscopy, though 1st done in 1977 by
Wickham for laparoscopic ureterolithotomy, has seen several twist and tips.
In 1991, ralph clayman, did 1st transperitoneal laparoscopy. However the initial
enthusiasm whithered within 3/4 year but finally in last 4-5 year has emerged
more strongly and it will not take more time now, to emerge as a separate subspeciality.
The skilled laparoscopic urologist now can effectively replace many incisional
procedures, its potential is limited only by the urologist imagination. The
way, in which this speciality is increasing, method of urological practice will
change dramatically. Laparoscopy has dual advantage of endoscopic surgery and
the open surgery can do ablative and reconstructive surgery of various organs,
this transfer benefit of early recovery, less hospital stay and early recuperation.
It would not be exaggeration to state, after ESWL therapy in 1983, laparoscopic
surgery is very close on its heel.
1st urologic application was localization of undescended testis in adult by
Cortesi 1976, wick hau than performed laparoscopic Ureterolithotomy in 1979.
Schussler in 1991 described laparoscopic Pelvic lymph node dissection in staging
cancer of prostate. 1st transperitoneal nephrectomy was done in 1992 by Ralph
Clayman. Dr. DD Gaur in 1993, described retroperitoneoscopic laparoscopic surgery.
In 1995 Rakte and Covouss 1st described laparoscopic donor nephrectomy.
There are two types of laparoscopy.
Advantages of retroperitoneal approach:
1.It can be done safely even in patients, who have undergone multiple intraperitoneal
2.Less port sites are needed as retraction can be done from one trocar only
as bowel retraction is not needed.
3.Less operative time in transperitoneal approach; more time is required as
the position of the patient has to be changed from supine to lateral position
after creation of pneumoperitoneum and mobilization of gut is required before
exposing the kidney.
4.Less operative complication with transperitoneal approach; there is risk of
injury to intraperitoneal organs like bowel and spleen during retraction.
5.No risk of development of intraperitoneal adhesions at a later date.
DISADVANTAGES OF RETROPERITONEAL APPROACH
1.Less working space available for dissection and there is difficulty in dissecting
large hydronephrotic kidneys and large renal tumours. However some authors have
not found it true in all cases and modifications have been suggested for such
2.Longer learing curve.
3.Although there are certain advantages and disadvantages of both the approaches,
in a particular patient, the ideal approach should be individualized. Both the
approaches are safe and complementary to each other and sometimes even combined
access can be used.
INDICATIONS AND CONTRAINDICATIONS
Before undertaking any laparoscopic procedure the patient should be explained
the risk of the procedure. This risk includes common general risks (wound infection),
uncommon risks (vascular and enteric injury) and catastrophic risks (death).
The patient should clearly understand that the procedure can be converted to
open surgery at any point of time. List of indications and contraindications
are mentioned in Tables 1 and 2.
OVERVIEW OF ESTABLISHED LAPAROSCOPIC UROLOGICAL PROCEDURES
Although many urological procedures have now been performed laparoscopically
there are some which have almost established themselves in routine practice
now. Such common procedures include renal cyst decortication, simple nephrectomy,
radical nephrectomy, ureterolithotomy, pelvic lymph node dissection, surgery
for stress urinary incontinence, surgery for undescended testis and recently
donor nephrectomy. The other interesting areas emerging are laparoscopic radical
prostatectomy, radical cystectomy and urinary diversions.
A. Adrenal gland
Laparoscopic approach to adrenal gland has been used for various benign adrenal
diseases. Laparoscopic surgery for malignant adrenal diseases is still controversial.
Current indication, for laparoscopic adrenalectomy include non functioning adenomas,
phaeochromocytoma, Cushing’s disease, aldosteronoma, angiomyolipoma and medullary
cysts of adrenal gland open surgery is recommended for large (6 cm) functioning
adrenal neoplasms and malignant neoplasm. Gasman et al reported retroperitoneoscopic
adrenalectomy in eight patients. Five patients had aldosteronoma and three patients
and Cushing’s syndrome. The average adrenal tumour size was 31 mm (Range 20
to 40). The average operating time was 84 minutes (range 45 to 140), and average
hospital stay was 2.4 days (range 1 to 4). The average blood loss was 65 ml.
No patient required conversion to open surgery. No complication was reported.
We have performed 18 adrenalectomies in patients with phaeochromocytoma, Conn’s
disease, and myelolipoma and adrenal cyst with good results.
B. Kidney and Ureter
1. Simple nephrectomy and nephroureterectomy : I have performed nephrectomy
and nephroureterectomy for nonfunctioning kidneys due to benign disease in about
200 patients since 1994. The indications have included non functioning kidney
due to pelviureteric junction obstruction, stone disease, renovascular hypertension,
and tuberculosis. These also included patients of various congenital disorders
like horseshoe kidney, ectopic kidney, vesicoureteric reflux and megaureter.
Our conversion rate has been 8.5%. We have been able to complete the procedure
successfully even in patients on nephrostomy, patients with pyonephrosis and
previously operated cases. The speciman was removed intact by extending one
of the port site incision to avoid the cost of various organ entrapment sacs
and tissue morcellators, beside saving on operating time.
2. Radical nephrectomy : The indications for removal of those kidneys harbouring
malignancy are clear now. These organs are best removed intact by extending
the port site incision. This allows adequate staging and grading of the tumour
and reduces the risk of tumours spillage or tract seeding. In general, patients
with tumours 8 cms and without renal vein or caval involvement, are considered
candidates for laparoscopic nephrectomy. Location of tumour in relation to kidney
is not a factor to consider in removal of kidney. Ono et al have compared the
results of open and laparoscopic radical nephrectomy in a group of 100 patients
treated from 1992-1998. Sixty patients underwent laparoscopic and forty patients
underwent open surgery. There was only one conversion in laparoscopic group.
The calculated blood loss was less than in open surgery. There was faster recovery
and shorter hospital stay in the laparoscopic group. Abbou et al reviewed 58
consecutive patients of radical nephrectomy. 29 underwent open radical nephrectomy.
The laparoscopic radical nephrectomy group had significantly less operative
blood loss, required less pain medication, had shorter hospital stay and had
less complication rate as compared to open radical nephrectomy group. They recommend
that laparoscopic approach is effective and safe for tumours less than 5 cms.
In our centre, we are carrying out comparison of retroperitoneoscopic radical
nephrectomy with open surgical nephrectomy as a pilot study and have performed
over 17 cases with successful outcome.
3. Stone disease : With the development of extracorporeal shock wave lithotripsy
(ESWL) and percutaneous nephrolithotomy (PCNL) the indications of open surgery
have shrunken considerably. In those patients in whom there is an indication
of open surgery laparoscopic approach has been performed in our department and
these were the cases where open surgery was contemplated otherwise. This is
an area, where there is great scope in our country, especially for patients
presenting with large size stone. However, a comparative study is required between
PCNL, and laparoscopy with long-term followup. Similarly, nonfunctioning kidneys
due to stone disease can be nephrectomized laparoscopically without any doubt.
4. Chyluria : Operative lymphatic disconnection is indicated once conservative
measures and sclerotherapy fail to cure the patient. We have performed pyelolymphatic
disconnection in seven patients and have been successful in all of them. The
average operative time was 114 mts (range 95-145 mts) and blood loss was 125
ml. There were no major complications. This is another appropriate indication
for retroperitoneoscopic management.
C. Laparoscopic lymphadenectomy
Retroperitoneal lymphadenectomy for testicular tumour is being done effectively
and successfully. Pelvic lymphadenectomy can be performed safely and expeditiously.
For prostate cancer it is now being performed by both accessing extraperitoneally
and transperitoneally. It has been shown in many studies that the staging effectiveness
of laparoscopic approach is comparable to open procedure. It also has role for
other pelvic malignancies.
D. Laparoscopic surgery for female urology
1. Incontinence procedure : Initial reports of the laparoscopic bladder neck
suspension have suggested success rate similar to other traditional bladder
neck suspension procedures. The currently accepted theory of continence is that
increase in urethral closure pressure during stress manoeuvres arise because
the urethra is compressed against the Hammock-like supporting layer, rather
than the urethra being truly intrabdominal. Delancey suggested that the treatment
of female stress urinary incontinence should focus on reconstructing this supporting
tissue, not on elevating or repositioning the bladder. Stone investigators have
suggested that patients with anatomic stress incontinence may also have an element
of intrinsic sphincteric dysfunction, which may compromise the results of the
bladder neck suspension procedure. Several investigators have advocated the
use of the sling urethropexy for all patients with sui to improve long-term
success rates of surgical intervention. At the present juncture isolated laparoscopic
bladder neck suspension has got limited role. Exclusively in patients with anatomical
2. Laparoscopic sling urethropexy : For patients presenting with type 2 sui,
the widely accepted technique for surgical management has been the sling urethropexy.
The sling procedure can be performed laparoscopically. Urethra is dissected
including periurethral tissue and sling is applied laparoscopically. Continued
clinical evaluation of these patients is being maintained in an effort to determine
the long-term efficacy of this surgical procedure for sui.
3. Laparoscopic management of vaginal prolapse : Massive eversion of the vagina
is one of the most disturbing, frustrating, and embarrassing disorders confronting
the modern woman. The incidence of the massive vaginal erosion is not well established,
but it probably occurs in about 0.5% of patients who have undergone vaginal
or abdominal hysterectomy the laparoscopic approach to surgical management affords
the patient a minimally invasive procedure which can duplicate the technique
used at open surgery to attach the vaginal vault to the hollow of the sacrum
with either autologous (fascia lata, rectus fascia, cadaveric, etc.) or synthetic
(gortex, mersilene, or marlex mesh, etc) materials. The laparoscopic sacrocolpopexy
technique involves a transperitoneal approach to the pelvis.
4. Laparoscopic repair of vesicovaginal and vesicoureteric fistula : vesicovaginal
fistula is a commonly encountered problem in our country. Simple supratrigonal
VVF can be repaired laparoscopically by separating both bladder and vagina.
Interrupted sutures can be applied on either side. An omental twig can be interposed
in between. Similarly vesicouterine fistula can also be repaired laparoscopically
by separating bladder from uterus and interposing omentum in between to prevent
recurrence and make sure shot repair. Author has experience of reconstructing
both the conditions laparoscopically.
E. Paediatric urology
Laparoscopy has firmly established itself in children with nonpalpable testis.
The role is to localize an intra-abdominal testis in the hope of improving incision
placement and avoiding intra-abdominal exploration. Laparoscopy has been successful
in localizing or identifying the non-palpable testis in 85-100% patients. Laparoscopy
has been described for intersex patients. It allows complete visualization of
pelvic structure, gonadal biopsies can be taken or gonadectomy can be done in
patients where indicated. It is safe to say that anything that can be done in
adults can be done in children. However it need to be carefully addressed to
various disease processes. A great deal of debate exist over the performance
of nephrectomy in small children. Pyeloplasty has been performed in children
adrenal laparoscopic surgery has not been aggressively pursued in children at
this point. Laparoscopic pyelolithotomy, pelvic node dissection, cystoprostatectomy,
appendicovesicostomy, ileal conduit, ileal vaginal reconstruction, bladder diverticulectomy,
ureteroneocystomy have all been done in selected children. Author has reported
retroperitoneal approach for nephrectomy, nephroureterectomy and nephrectomy
with isthumusectomy in 11 children without and conversion. It was concluded
that it is safe and effective in children.
F. Role of hand-assisted laparoscopy in urologic practice
Had assisted laparoscopy addresses many of the contemporary concern of urologist
who are contemplating performing renal laparoscopy. The return of tactile feel,
finger dissection, and vascular control will facilitate laparoscopic renal surgery
for many urologists. Hand assistance may shorten the learning curve and minimize
intraoperative complications by allowing less-experienced laparoscopists to
dissect rapidly and efficiently and to control problematic bleeding more easily.
The lack of abundant "Training" cases has limited many urologists
from embracing urologic laparoscopy. Hand assistance allows urologists to attempt
more challenging procedures sooner, thereby increasing their caseload. Similarly,
hand assistance enables experienced laparoscopist to tackle more complex procedures
with greater confidence than they would have while using conventional laparoscopy
alone. Cost remains a concern among all practitioners of minimally invasive
surgery. It remains a challenge to create a cost scenario in which laparoscopic
nephrectomy has to be equal to its open counterpart. Prolonged operative time
has been a critical element in the increased cost of laparoscopic nephrectomy.
Devices such as the pneumodissector, endohand, and endostitch were all created
to hasten tissue dissection and shorten operative times. Hand assistance has
been quoted in shortening operating room times. Despite this benefit, enthusiasm
for hand assistance must be tempered. Urologist must consider the restrictions
of the template on port placement, curtailment of operating space as a result
of having a hand in the abdomen. The time required to set up the device, and
the cost. Yet in cases requiring intact specimen removal where an incision must
be made (laparoscopic live-donor nephrectomy or radical nephroureterectomy),
hand assistance offers significant benefits during the procedure. The first
hand-assisted live donor nephrectomy has recently been reported. Similarly,
conversion to hand assistance can be beneficial if there is lack of progression
of the dissection during a standard laparoscopic procedure. It is clear that
hand assistance belongs in the arsenal of the practising urologic laparoscopist.
G. Laparoscopic surgery in renal transplantation
The major disadvantage of living donors is that a health person must undergo
a major surgical procedure. It is also of paramount importance that surgery
poses minimum risk to the healthy patient. The disincentives associated with
donation include factors such as prolonged hospitalization, postoperative pain
and the cosmetic results of major abdominal surgery. The other major indication
for laparoscopic surgery in renal transplant patients is in the management of
posttransplant lymphocoeles. The technique of laparoscopic live-donor nephrectomy
in humans was first developed by Ratner et al in 1995. Since then several investigators
have reported their experience with this procedure. Laparoscopic live-donor
nephrectomy has resulted in decreased hospital stay, less postoperative analgesic
requirements and an earlier return to normal activities. Both the transperitoneal
and retroperitoneal approaches can be used to do laparoscopic live-donor nephrectomies.
As advocated by Johnson et al the risk of complications can be minimized by
1.Identifying the correct plane between the mesocolon and retroperitoneal structures
by tracing the gonadal vein as it crosses the iliac vein to the renal vein.
2.Keeping the ureterogonadal vessels complex intact throughout the length of
the graft ureter in order to prevent the risk of ureteral ischaemia.
3.Confine renal vein dissection medial to the gonadal and adrenal vein origin
so as to prevent injury to the renal pelvis.
4.Transect the lateral attachments and the ureter after the pedicle is free.
This minimizes the likelihood of torsion of the renal pedicle and urine is kept
out of the field. Conversion to open surgery may be indicated if there is uncontrolled
bleeding, trauma to adjacent organs, difficult anatomy, renal ischaemia during
the procedure and prolonged dissection time. The author has experience of retroperitoneoscopic
donor nephrectomy and the technique is described below.
The preparation for the patient is similar to the transperitoneal procedure
and the patient is positioned in the standard kidney position. A 2 cm incision
is made a little below and posterior to the tip of the 12th rib down the thoracolumbar
fascia into the retroperitoneal space and the retroperitoneal space created
using blunt finger dissection. As with the transperitoneal approach the patient
is kept volume expanded and the retroperitoneal space is insufflated to a pressure
of 15 cms of water. This is in order to ensure good renal blood flow. The second
10 mm cannula is introduced in line with the first port, a little above the
iliac crest in order to avoid hindrance to the manoeuvreability of the cannula
by the bone. A third 10 mm cannula is introduced in the line with the first
inserted under vision. In the midaxillary line two centimeters below the costal
margin. During insertion of this thirds port, special care needs to be taken
to prevent the trocar from traversing the peritoneum. A fourth port is inserted
posteriorly later in the procedure. Initially the kidney is mobilized within
the Gerota’s fascia, which is then incised posteriorly. And the renal pedicle
is dissected starting posteriorly. The renal artery and vein are freed from
their adventitial attachments. The ureter is mobilized within the periureteral
sheath along with the gonadal vessels. The rest of the kidney is dissected free
from within the Gerota’s fascia. Prior to transection of the ureter and the
ligation of the renal vascular pedicle the primary port site incision is enlarged
as for a flank incision down to muscular layers except thoraco-lumbar fascia,
so that following ligation the kidney can be delivered with minimum delay. Once
the kidney is freed all around and the ureter transected the pedicle is ligated
and the kidney delivered. Mannitol, frusemide and heparin are given as in all
cases of donor nephrectomy. It is important to dissect the kidney completely
without undue traction on the renal pedicle. On the delivery of the kidney subsequent
management is similar to that discribed for the transperitoneal route. The overall
performance of the allograft, measured by posttransplant serum creatinine, urine
output, incidences of acute tubular necrosis, rejection episodes and ultimate
graft survival appear to be similar to the kidney obtained by open surgery.
H. Posttransplant lymphocoele
The other major indication of laparoscopic surgery in the management of transplant
patients is in the treatment of persistent lymphocoeles. The reported incidence
of lymphocoele formation in recipients of renal allografts is of the order of
0.5% to 18.1%. Large and symptomatic lymphocoeles may cause hydronephrosis,
impaired renal function, ipsilateral leg swelling, oedema overlying the graft,
venous and arterial obstruction and infection. Routine post-operative ultrasound
is the best method of detection of the lymphocoele, the first line of management
of symptomatic lymphocoeles is percutaneous drainage. It is however associated
with prolonged catheter drainage, risk of infection and protein loss from the
lymph and a high recurrence rate (50-80%). Laparoscopic internal drainage of
the lymphocoele was first reported by McCullough et al in 1991. Since then the
over all success rate of the procedure is around 88%. The procedure of laparoscopic
internal drainage of the lymphocoele is done via the transperitoneal approach
after the placement of a Foley catheter and nasogastric tube. Pre-operatively
the sac may be filled with methylene blue in order to delineate the lymphocoele
better at surgery. The ports are inserted at the umbilicus, right mid-clavicular
line just below the umbilicus and the third port in the hypogastrium. After
the lymphocoele is identified as a bulge any adhesions over it are removed,
its wall incised and the fluid aspirated. A part of the wall is then removed
and the omentum fixed around the edge of the cavity. This procedure should be
avoided if the lymphocoele is infected. Injury to the transplanted ureter can
occur during the procedure especially if the lymphocoele is located posteriorly
There are a few complications which may be encountered during laparoscopic procedures.
Subcutaneous emphysema. Pneumomediastinum, pneumopericardium, pneumothorax may
result be cause of the need for CO2 insufflation for these procedures. Gill
et al reviewed the complications of laparoscopic nephrectomy done between June
1990 and July 1993 at five centres of USA. The procedure was done in 185 patients.
A total of 30 patients (16%) had 34 complications. Access related complications
included two cases of hernia formation at the trocar site, abdominal wall haematoma
and one trocar injury to a hydronephrotic kidney. Intra-operative complications
included five cases of vascular injury, one splenic laceration and one pneumothorax.
Postoperative complications involved the gastrointestinal tract in six cases,
cardiovascular system in six, genitourinary tract in four, respiratory system
in four and musculoskeletal system in two. Miscellaneous complications occurred
in three patients. Open surgical intervention was required electively in eight
patients and on an emergency basis in two. The incidence of complications decreased
with experience 71% occurred during the initial 20 cases at each institution.
In our series of 356 patients who underwent various laparoscopic procedures
at our institute, there were 11.4% complications rate and 11.1% conversion rate,
which includes our initial learning curve and wrongly chosen cases such as xanthogranulomatous
pyelonephritis, genitourinary tuberculosis, medially located pelvic kidneys,
severe pyonephrosis with dense perirenal adhesions due to urolithiasis. Peritoneal
rents during port placement occurred in 13 (5.4%) patients. Excessive bleeding
occurred in seven patients. The causes were common iliac artery injury, slipped
clip from the renal venous stump, injury to gonadal vessels and trocar injury
to renal vein. Only two patients with gonadal vessels and trocar injury could
be managed endoscopically and the other five patients required conversion to
open surgery. Seven patients have persistent fever in the post operative period.
The cause of fever was a retroperitoneal collection in three patients while
the other four had pleural effusion, basal atelectasis, subcutaneous abscess
at the port site and urinary tract infection. One patient developed a port site
hernia following nephrectomy for a pyonephrotic kidney.
Laparoscopic urologic surgery has advanced from ablative to reconstructive surgery.
Though, only few centres are doing these procedures worldwide but gradually
picking up all over. More advanced laparoscopic procedures like pyeloplasty,
radical prostatectomy, radical cystectomy, urethral sling, sacrocolpopexy, ileal
loop conduit and other urologic bowel surgery are being done by only few surgeons.
However, these techniques are being adopted now. It is also important to evaluate
these procedures as what is possible laparoscopically does not mean it is reasonable.
Before taking up these procedures, one should be properly trained and it requires
patience and skill as learning curve is often steep long. Thus, it is evident
that there is substantial scope of laparoscopic urologic surgery. The time is
ripe for the urologist to learn and practice this art of surgery. With the skills
of endoscopic surgery and experience of endovision camera, I for one don’t see
any reason, why urologist cannot take up laparoscopic surgery. Dedication, training,
perseverence are required. The next century is going to be an era of minimally
invasive surgery. Therefore do not miss the opportunity to learn this new art
to benefit your patients.
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