腹腔镜泌尿外科

Laparoscopic Urological Surgery

                               
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Laparoscopic Urological Surgery

If someone had been to name the three revolutionary innovations within the good reputation for surgery, most of these will be the discovery regarding antisepsis, the development of anesthesia, and the advent of minimally invasive surgery. The best objective involving minimally invasive surgery would be to existing an alternative choice to open surgery with equal rewards and reduced morbidity. Traditional laparoscopy provides the advantages of reduced postoperative pain, reduced convalescence, and enhanced cosmesis. Cortesi documented the very first use of laparoscopy for urology surgery as a diagnostic tool in a patient with undescended testes in 1976, but its use for any therapeutic procedure wasn't noted till Clayman completed the first laparoscopic nephrectomy within 1990. This novel method, which reproduces the actual concepts associated with open up surgery, has dramatically improved patient final results by just changing the surgical method.

Basic approach

Laparoscopic entry with regard to urologic programs might be received via several routes viz. transperitoneal, retroperiponeal and extraperitoneal. The problem of the optimum surgical approach within urologic laparoscopy is still controversial and several unanswered queries still remain. Earlier experience with urologic laparoscopy consisted almost exclusively of transperitoneal procedures. For many surgeons, this method continues to be gold standard for the operative strategy from the higher urinary tract.

The justifications justifying this particular view are
1. A bigger operating area and thus a simpler entrapment of huge surgical specimens.
2. More familiar anatomic attractions, thus the training curve is shorter.
3. Anteriorly situated tumors, crossing vessels during pyeloplasty, are managed easier.

Although trans-peritoneal physiology may be more common in order to general surgeons, Urologists are well familiar with retroperitoneal anatomy. Retroperitoneal laparoscopy does not appear to be much more technically challenging than the transperitoneal counterpart. The actual retroperitoneal strategy has also been claimed to have smaller surgical duration. Avoiding the opening from the peritoneal cavity could also ameliorate postoperative comfort and diminish postoperative sequels such as
intraperitoneal adhesion formation.

The arrival of hand-assisted laparoscopy offers provided a new minimally invasive alternative for the treating a number of renal conditions needing surgical intervention. Hand-assisted laparoscopy uses a unique approach that combines the facets of open up surgery along with those of conventional laparoscopy, expanding the indications for laparoscopy and also bridging the gap between open surgery and conventional laparoscopy. Hand-assisted laparoscopy may represent the pragmatic choice for that established urologist in practice, to whom a formal laparoscopic training is unrealizable. Insertion from the non-dominant hand into the operative field enables the surgeon to beat some of the obstacles related to conventional laparoscopy, for example loss of proprioception, tactile sensation, as well as spatial orientation. Arguments against HAL is the price of the port, and the 7 cm incision necessary to place this port even in patients not really requiring retrieval of a big specimen. Other drawback of the HAL approach is that it does not assistance to acquire and maintain superior laparoscopic abilities, which are essential for complicated reconstructive procedures for example pyeloplasty or radical prostatectomy.

Specific applications for benign diseases:

Laparoscopic simple nephrectomy

Virtually all harmless urologic problems happen to be impacted with laparoscopic surgery. Because Clayman’s first laparoscopic nephrectomy within 1990, laparoscopic simple nephrectomy is just about the most common urologic laparoscopic procedure. All benign conditions requiring nephrectomy happen to be handled laparoscopically. Although laparoscopic removals of small atrophic kidneys are ideally suited to the actual less experienced surgeon, simple nephrectomy remains among the great misnomers within urologic surgery. Simple by no means equates to uncomplicated nephrectomy, specifically in situations by which dense inflammation as well as fibrosis could pose immense challenges toward surgical dissection. Patients with xanthogranulomatous pyelonephritis, tuberculous nephritis, and prior renal surgery should be reserved for probably the most experienced laparoscopic surgeons. These sufferers ought to be counseled concerning the increased probability of problems and possible open conversion.

Donor nephrectomy

Open donor nephrectomy has been a viable and safe option for more than 30 years but carries the morbidity of the relatively huge open incision and a long convalescence period. Insufficient living donor continues to be the main cause of ever increasing waiting list of renal transplantation recipients. Ratner within 1995 carried out the very first laparoscopic live donor nephrctomy, extracting the kidney via a 9 inch midline incision. Inside next 11 years, LDN became the gold standard. Success of the operation has influenced favourably to helping the willingness to donate and thus helping the donor pool. Ratner reported a greater than 100% rise in live related renal transplants in their center because beginning the laparoscopic donor nephrectomy.

Adrenalectomy

There has been a rise in detection of adrenal incidentalomas. NIH consortium recommends excision of such masses if related to biochemical proof of pheochromocytoma, size more than 6 cm, masses more than 4 cm with rapid growth rate, or radiographic findings consistent with adenoma. Laparoscopic adrenalectomy was initially tagged by Gagner in 1992. Lots of data has since gathered to aid the use of transperitoneal or retroperitoneal laparoscopic approach for adrenalectomy as opposed to open surgery. The arguments against laparoscopic approach are longer operating time and higher hospital charges. Laparoscopic approach is overwhelmingly preferred approach for smaller adrenal masses including partial adrenalectomy. Only presumed adrenal cortical carcinomas continue to be approached open. At centers such as ours, where our experience continues to grow, LA is recognized as superior to open adrenalectomy for many extirpative adrenal surgeries.

Pyeloplasty

Ureteropelvic junction obstruction can be characterized by a functionally significant impairment regarding urinary transport, caused by obstruction in the area where the ureter joins the renal pelvis. Nearly all cases tend to be congenital; however, acquired conditions at the degree of the UPJ could also existing with symptoms and also signs of obstruction. Till recently, open up pyeloplasty and endoscopic techniques happen to be the primary surgical options with the intent of open complete excision, or endoscopic incision from the obstruction. Endoscopic antegrade or even retrograde visually managed incision of the ureteropelvic junction obstruction, or even radiologically managed incision don't share the high effectiveness that results from open-surgical dismembered pyeloplasty. The development of laparoscopy has allowed non-invasive reconstructive surgery that mirrors open surgical methods. In the hands of experienced surgeons, laparoscopic pyeloplasty offers a less invasive option to open surgery with decreased morbidity, shorter hospital stay, and faster convalescence.

Lymphocele

Lymphocele complicates 1 to 12% of patients following renal transplantation. Lymphocele also complicates 1 to 10% of sufferers after pelvic lymphadenectomy, because done for proste cancer. Treating option is either percutaneous drainage as well as sclerotherapy, or even transpertoneal laparoscopic marsupialization from the lymphocele. Treatment with percutaneous drainage and sclerotherapy has high morbidity and a high recurrence rate. Hsu reported 91% success in support of 6% recurrence after treating 81 lymphoceles with laparoscopic marsupialization. Laproscopic treatment of pelvic and post transplant lymphoceles has become a preferred approach to management.

Female Urology

Repair of vaginal vault prolapse remains a surgical challenge irreapecive of abdominal, vaginal, and combined procedures being used to fix the problem. The ideal operation remains elusive with regard to outcomes, morbidity, and economics. Being an extension from the abdominal approach, laparoscopy is constantly on the gain favor being an access method, so that as a surgical advancement. Recent studies highlight a number of laparoscopic processes for restoration of apical support that demonstrate feasibility and encouraging results. Further studies are essential to determine when the minimally invasive nature of laparoscopy can duplicate or surpass standard abdominal and vaginal approaches to repair of pelvic organ prolapse.

Vericocele

Vericocele is found in upto 15% of normal population, but the incidence is really as high as 40% in males with subfertility. Traditional approached for vericocele were retroperitoneal and inguinal. Microsurgical technique has lately been used for vericocele repair to decrease complications like hydrocele and damage to testicular artery, and to decrease the number of cases of vericocele recurrence. Laparoscopic vericocelectomy promised to become a cosmetic method to deal with vericocele with lesser complications than conventional approaches due to inherent optical enlargement and good vision.

Renal biopsy

Percutaneous renal biopsy might be contraindicated in some patients because of obesity, coagulopathy, solitary kidney or failed previous percutaneos biopsy. Options during these situations include open surgical biopsy, CT guided biopsy, transvenous biopsy and laparoscopic guided biopsy. Knowledge about laparoscopic renal bopsy has provided an abundant biopsy tissue compared to CT or transvenous biopsy with minimal morbidity in patients wherever percutaneous biopsy was contraindicated.

Oncologic applications

In addition to the general benefits of MIS, using laparoscopic procedures for oncologic applications must prove no compromise within the oncologic charge of the disease, whether positive surgical margins, incidence of intraoperative seedings while retrieving the specimen, or long term oncologic control. Histopathological margin positivity has not been higher with laparoscopic oncologic procedures. Long term oncologic control information is gradually appearing, and seems to be equivalent to open surgery. There's been concern regarding seeding in urologic laparoscopy. In an international survey, the information from 19 institutions performing laparoscopic oncologic procedures was collected for 2,604 radical nephrectomies, 555 partial nephrectomies, 559 nephroureterectomies, 3,665 radical prostatectomies, 1,869 pelvic lymph node dissections and 479 retroperitoneal lymph node dissections. There were no cases of seeding from renal cell cancer despite over 3,400 procedures reported, and also the utilization of morcellation in 40% of the radical nephrectomies.

Nephrectomy and nephroureterectomy

Laparoscopic radical nephrectomy has significant smaller incision having a quick postoperative recovery with less minor and major complication rates than open surgical counterpart. Mean loss of blood is less with LRN. MIS benefits have certainly improved the caliber of life during these patients. As mentioned earlier there's little risk of peritoneal contamination and port site metastasis after LRN for RCC despite morcellation of specimen before removal. Seems like, as stated earlier, that port-site seeding associated with LRN is an extremely rare and unlikely event, provided that strict surgical technique is applied as well as an entrapment sac is used for specimen removal.

Though morcellation cuts down on the retrieval incision further, consensus seems to be emerging that malignant specimens be removed intact in a specimen bag without morcellation. Significant data is available these days regarding LRN oncologic efficacy. Five year overall disease specific and acturial survival is similar to open surgery in various retrospective series, which is expected since laparoscopic technique adheres to same surgical principles. Since an incision is needed to retrieve the intact specimen, hand assisted laparoscopic surgery continues to be popular for LRN. HAL has been said to facilitate difficult dissection and reduce operative time, even for larger renal tumors.

Partial nephrectomy

For the incidental small renal lesion, elimination of the entire kidney by open radical nephrectomy or minimally invasive techniques may end up being more detrimental in the long run by leaving behind a limited nephron mass. Several studies have indicated that disease-free survival and oncologic connection between partial nephrectomy are equal to radical nephrectomy in carefully selected patients Regardless of the advantages laparoscopic partial nephrectomy enjoys over conventional open surgery when it comes to perioperative morbidity, blood loss, operative time, and hospital stay, the chance of bleeding and technical difficulty of intracorporeal laparoscopic suturing has prevented the widespread use of laparoscopic partial nephrectomy. There is also a concern for prolonged warm ischemia some time and subsequent renal dysfunction.

A number of adjuncts to dissection and hemostasis like hand assistance, harmonic scalpel, argon beam coagulator, fibrin glue and radiofreuency power make significant transformation in past few years. Accessibility to laparoscopic instruments for vascular control and application of intracorporeal cooling has additionally widened the scope of LPN further. While traditionally useful for absolute indications and only restricted to elective indications where the primary tumor was 4 cm or less within the presence of the normal contralateral kidney, more recent reports suggest that large and locally advanced (pT2) tumors can also be managed effectively with nephron sparing techniques. Reports from Cleveland Clinic group implies that 4% of their total LPN number of 525 patients were locally advanced. LPN might be performed with a mean blood loss of 199 ml (range 100-800), mean warm ischemia time of 29 minutes and mean OR time of 3 hours.

Prostate cancer

Laparoscopic Radical prostatectomy is of major interest to Urologists especially considering the incidence and clinical significance of prostate cancer. The process comprises several steps of challenging dissection where the preservation of delicate erectile nerves and external sphincter has to be coupled with safe tumor excision. The intervention ends with vesicourethral anastomosis, which is considered probably the most difficult reconstructive procedure in urologic laparoscopy. LRP has gradually be a standardized procedure, and it is now routinely performed all over the world. Data in the literature and available experience demonstrates that oncologic and functional results with LRP seem similar to those of classic open radical retropubic prostatectomy (RRP). In a comparison of LRP with RRP (n 180), the entire positive surgical margin rates were similar (16.9% vs. 20%), however RRP had a greater positive apex margin rate. With anatomical nerve sparing technique of LRP, 76% of previously potent man reported potency after 12 months. Continence rates were similar to RRP. Minimal bleeding, reduced blood transfusion rates, shorter hospitalization, and shorter recovery time are
some unquestionable advantages of LRP.

Robotic assisted laparoscopic prostatectomy has became popular recently, and never without reasons. Accessibility to examples of freedom using the Robotic arms and also the accessibility to 3D vision have successfully transferred the RRP skills to a laparoscopic environment. Loss of blood is significantly less, out of the box postoperative pain. Continence and potency data have been favorable. Although likely to be restricted to advanced urologic laparoscopic centers, LRP and RALP established to be a viable surgical alternative to RRP for treating localized prostate cancer.

Laparoscopic cystectomy and urinary diversion

Open radical cystectomy remains the defacto standard for nonmetastatic muscle invasive bladder cancer. Regardless of being first described by Parra in 1992 for benign disease, and later used for invasive carcinoma in 1995 by Sanchez, use of laparoscopic cystectomy has been uncommon. Extensive experience of radical prostatectomy and urethrovesical anastomosis has grown the interest of urologists of late, including the utilization of robotic assisted techniques. Laparoscopic radical cystectomy has been described as a feasible procedure and is still being evaluated. Gerullis and colleagues from Germany have described recently their initial knowledge about laparoscopic cystectomy with extracorporeal assisted urinary diversion in 34 patients with mean operating time of 244min, the mean blood loss of 325ml, along with a transfusion rate of 5.9%. All procedures were completed laparascopically without conversion to spread out techniques, and without major complications, during or after the surgery.

Urinary Diversion following cystectomy may be performed using an Ileal conduit, which could be performed laparascopically with assistance or performed pure laparascopically. Orthotropic neobladder has additionally been described, with both extracorporeal suturing as well as pure laparascopically.

RPLND

Danger of missing low risk metastatic disease in additional than 30% patients despite undetected nodes on CECT abdomen proved the value of RPLND in nonseminomatous testicular tumors. Early open RPLND had significant morbidity during these young patients. With an increase of awareness regarding the disease pass on pattern, the modified unilateral lymphadenectomy templates have significantly reduced morbidity with preserved ejaculation without compromising the efficacy. Laparoscopic RPLND using four trocars is a low morbidity alternative to open lymphadenectomy and it has been utilized in Oncology Institutions with laparoscopic skills with comparative lymph node positivity. Laparoscopic RPLND has probably the greatest impact in decreasing morbidity over similar open procedures. Typical hospital stays of a day with laparoscopy vs. Five days with open surgery, and convalescence of 2 weeks versus 8 weeks, respectively, are essential differences between the two types of procedures.