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Laparoscopic Surgery in Urology

Durga D Gaur
 

Introduction
There was not much laparoscopic activity in the field of urology during the decade preceding 1991. However, during the past decade there was meteoric rise in the activity and there was hardly any urological procedure which was not performed laparoscopically. Two historical events are responsible for this surge in urological laparoscopic activity. One of them was the report of the first laparoscopic nephrectomy by Clayman et al in 19911 and other the publication of the balloon technique of retroperitoneoscopy by Gaur in 1992.2 This is revealed by the fact that the number of urological laparoscopic articles published in the world literature during the following decade was about 40 times more compared to the previous decade.

However compared to gynaecology and general surgery, the urological laparoscopic activity was much less. This was due to the fact that except in undescended testis, all urological organs are placed retroperitoneally and therefore comparatively difficult to access. Consequently, while the role of laparoscopy in gynaecology and general surgery soon got established, its role for most of the urological procedures remained a subject for debate for many years.

Indications
Laparoscopic urological procedures performed at many centres are:
1. Orchidopexy
2. Renal biopsy
3. Varicocoelectomy
4. Colposuspension for stress urinary incontinence
5. Simple renal cyst decortication
6. Rovsing’s operation for polycystic kidneys
7. Nephropexy
8. Nephrectomy for benign non-functioning kidneys
9. Pyelolithotomy
10. Ureterolithotomy

All these above mentioned laparoscopic procedures are comparatively simple and can be performed in less than 2 hours. In experienced hands there are minimal complications and the patients can be discharged the same day or the following day.

Laparoscopic procedures being performed at the specialized centres are:
1. Adrenalectomy
2. Pyeloplasty
3. Partial nephrectomy
4. Radical nephrectomy
5. Radical nephrectomy with excision of cuff of bladder
6. Ureteral reconstructive surgery
7. Bladder diverticulectomy
8. Partial cystectomy
9. Simple cystectomy
10. Radical cystectomy
11. Cystoplasty
12. Total reconstruction of the bladder
13. Excision of seminal vesicular cyst
14. Excision of cyst of prostatic utricle
15. Radical prostatectomy
16. Repair of urogenital fistula
17. Pelvic lymphadenectomy
18. Para-aortic lymphadenectomy
19. Renal lympholysis for intractable chyluria

All these procedures require a lot of learning experience, take more than 2 hours and have a higher initial complication rate. In experienced hands complication rate is minimal and the patients can be discharged in one to 5 days.

Retroperitoneal or transperitoneal approach
As most urological organs are placed in the retroperitoneum, the retroperitoneoscopic approach provides a direct and easy access to these organs and should be considered as the procedure of choice. As the peritoneal cavity is not transgressed, there is less risk of damage to the bowel or any other intraperitoneal structure. The only disadvantage of retroperitoneoscopy is that due to limited working space, excision of large solid tumours and reconstructive procedures of the kidney, ureter or urinary bladder especially in the presence of adhesions are difficult to perform.

We have performed more than 500 laparoscopic urological procedures with minimum complication rate and very low conversion rate.

Future perspectives
There is a great scope for improving skills in performing laparoscopic reconstructive procedures. All these procedures require lot of suturing which has to be mastered. Breda et al have suggested two tier systems where in most of the simple urological procedures can be performed at level one centre and major complex laparoscopic work can be performed at referral centres.3

Improvement in technology like intraoperative ultrasound, cryotherapy,4 computer generated assistance for pelvic lymphadenectomy,5 hydro dissectors,6 pneumodissectors,7 electrosurgical snare,8 and fibrin glue9 have made laparoscopic surgery simpler. Use of radiofrequency ablation of tumours under ultrasound control gives a new dimension.10 Use of robotic surgery particularly for suturing and telementoring has simplified laparoscopic procedures.11 Laparoscopic radical prostatic surgery has been performed.12

Current status
Laparoscopic urological surgery is a well established specialty and is a good alternative for open surgery in experienced hands.

References

  1. Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopic nephrectomy: Initial case report. J Urol 1991; 146 : 278-81.
  2. Gaur DD. Laparoscopic operative retroperitoneoscopy: Use of a new device. J Urol 1992; 148 : 1137-9.
  3. Breda G, Nakada SY, Rassweiler JJ. Future developments and perspectives in laparoscopy. Eur Urol 2001; 40 (1) : 84-91.
  4. Martin SF, Gill IS. Laparoscopic ultrasonography. J Endourol 2001; 15 (1) : 87-92.
  5. Bainville E, Chaffinjon P, Cinquin P. Computor generated visual assistance during retroperitoneoscopy. Comput Biol Med 1995; 25 (2) : 165-71.
  6. Shekarriz H, Shekarri B, Upadhyay J, et al. Hydrojet assisted laparoscopic partial nephrectomy: Initial experience in a porcine model. J Urol 2000; 163 (3) : 1005-8.
  7. Seifman BD, Wolf JS Jr. Technical advances in laparoscopy: hand assistance, retractor and pneumodissector. J Endourol 2000; 14 (10) : 921-8.
  8. Elashry OM, Wolf JS Jr, Rayala HJ, et al. Recent advances in laparoscopic partial nephrectomy: Comparative study of electrosurgical snare electrode and ultrasound dissection. J Endourol 1997; 11 (1) : 15-22.
  9. Cadeddu JA, Corwin TS, Traxer O, et al. Hemostatic laparoscopic partial nephrectomy: Cable-tie compression. Urology 2001; 57 (3) : 562-6.
  10. Paulter SE, Pavlovich CP, Mikityansky I, et al. Retroperitoneoscopic guided radiofrequency ablation of renal tumours. Can J Urol 2001; 8 (4) : 1330-3.
  11. Lee BR, Png DJ, Liew L. Laparoscopic telesurgery between the United States and Singapore. Ann Acad Med Singapore 2000; 29 (5) : 665-8.
  12. Gill IS, Ukimura O, Rubinstein M, et al. Lateral pedicle control during laparoscopic radical prostatectomy: Refined technique. Urol 174 (3) : 850-3.

 
Associate Professor, Department of Urology, Bombay Hospital, Mumbai.
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