Advances in Urological Laparoscopy

A Comparison Between Laparoscopic and Robot-Assisted Laparoscopic Pyeloplasty in Patients with Ureteropelvic Junction Obstruction

Background

The aim of this study is to compare the results of laparoscopic pyeloplasty and robot-assisted laparoscopic pyeloplasty in patients with ureteropelvic junction obstruction.

Methods

Between March 2008 and May 2019, the patients who underwent retroperitoneal laparoscopic or robotic-assisted laparoscopic pyeloplasty in our institution were retrospectively reviewed.

Results

Thirteen patients underwent laparoscopically, and 12 patients underwent robotic surgery. The significant difference was found in median operative time between laparoscopic group (296 minutes) and robotic group (199 minutes) (P = 0.001). The median time for drain removal in laparoscopic group was longer than robotic group (3 vs. 2 days, respectively, P = 0.029).

Conclusion

Laparoscopic and robot-assisted laparoscopic pyeloplasty is safe and excellent success rates in patients with ureteropelvic junction obstruction. However, our experience study suggested that robotic surgery improves a total operative time, decreases drain removal time and less intraoperative blood loss than laparoscopic approach.

Learning curve of laparoscopic nephrectomy: a prospective pilot study

Background

Learning curve of laparoscopic nephrectomy (LN) is mainly affected by two main factors: plotting performance and experience. However, there is paucity in the literature addressing the number of cases required to adopt LN. Herein, we aimed to assess the learning curve of LN for various renal disorders and number of cases required to adopt the technique. Between September 2015 and December 2017, consecutive patients undergoing LN for various renal diseases were enrolled in this study. Patients were divided into two groups, the first 20 cases (group A) and subsequent 20 cases (group B). All procedures were performed by a single trainee urologist under supervision of an expert endourologist. Learning curve was assessed using operative time and incidence of complications.

Results

A total of 40 patients were included in this pilot clinical study. Mean age was 38.2 ± 16.3 years. The mean operative time for patients in group B was significantly lower than the mean operative time for patients in group A (108.5 vs. 139.3 min, p < 0.05). However, there were no significant differences between both groups in terms of intraoperative blood loss (86 vs. 104 ml; p = 0.081), conversion to open surgery (5% vs. 10%; p = 0.256) and postoperative complications (5% vs. 15%; p = 0.09) for group B and group A, respectively. Similarly, there was no significant difference between both groups in terms of hospital stay (42 ± 8 vs. 46 ± 11 h p = 0.01). The trainee surgeon reached a plateau after 22 cases.

Conclusions

Our study suggests that a minimum of 22 LN procedures are needed in order to adopt the technique of laparoscopic nephrectomy. Learning curve of LN is mainly affected by number of performed procedures within a short period of time.

Comparative Study of Retroperitoneal Laparoscopic Versus Open Ipsilateral Nephrectomy After Percutaneous Nephrostomy: A Multicenter Analysis

Purpose: To investigate the feasibility of retroperitoneal laparoscopic ipsilateral nephrectomy of a benign nonfunctional kidney after percutaneous nephrostomy, and to compare this method with open surgery. Materials and Methods: Data from 70 patients who underwent simple nephrectomy from January 2014 to October 2018 at three large centers were retrospectively analyzed. All patients underwent percutaneous nephrostomy because of renal or ureteral calculi with severe hydronephrosis or pyonephrosis. Simple nephrectomy was performed via retroperitoneal laparoscopic surgery (retroperitoneal laparoscopic group; n = 33) or open surgery (open group; n = 37). The retroperitoneal laparoscopic and open groups were compared regarding preoperative variables (age, sex, location of surgery, hypertension, diabetes, BMI, preoperative serum creatinine level, American Society of Anesthesiologists (ASA) grade, fistula duration, fistula size, number of fistulae, and urinary tract infection), and perioperative variables (operation time, intraoperative blood loss, postoperative drainage volume, catheter indwelling time, gastrointestinal function recovery time, duration of bedrest, duration of postoperative hospitalization, postoperative hemoglobin decline, perioperative transfusion, and postoperative complications). Results: The retroperitoneal laparoscopic group included more patients with hydronephrosis, while the open group included more patients with pyonephrosis. There were no significant differences between the two groups in age (P = .813), sex (P = .729), location of surgery (P = .345), hypertension (P = .271), diabetes (P = .394), BMI (P = .798), preoperative serum creatinine level (P = .826), ASA grade (P = .820), fistula duration (P = .108), fistula size (P = .958), number of fistulae (P = .925), urinary tract infection (P = .111), or operative time (P = .851). The retroperitoneal laparoscopic group had significantly lesser intraoperative blood loss (P = .007), postoperative drainage volume (P = .008), shorter catheter indwelling time (P = .002), gastrointestinal function recovery time (P < .001), duration of bedrest (P < .001), and duration of postoperative hospitalization (P < .001), and lesser postoperative hemoglobin decline (P = .035) compared with the open group. Conclusions: Retroperitoneal laparoscopic ipsilateral nephrectomy is feasible for a benign nonfunctional kidney after percutaneous nephrostomy. The surgical method should be selected based on the surgeon's experience and the specific situation of the patient.

Robot-assisted laparoendoscopic single site adrenalectomy: A comparison of 3 different port platforms with 3 case reports

RATIONALE

Laparoscopic adrenalectomy is currently the standard of care for adrenal lesion. Minimal invasive laparoscopic surgery such as laparoendoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) have been developed to improve cosmetic outcomes and reduce postoperative pain. However, there are still some problems related to instruments and port limitation during LESS surgery. Robot-assisted laparoscopic surgery may help to overcome these problems, and port platforms selection is an important issue.

PATIENT CONCERNS

Three cases received robot-assisted LESS adrenalectomy due to adrenal tumor were enrolled. Blood loss, hospital stay, and analgesia injection were compared.

DIAGNOSES

Preoperative evaluations were done in a usual manner. Benign tumors were suspect for two patients, while metastatic tumor could not be excluded for the other patient with prior malignancy history. The pathology reports were all benign adrenal cortical adenoma after operation.

INTERVENTIONS

Three different port platforms, Da Vinci Single-Site Surgical Platform, GelPOINT, and homemade glove port were used. Trans-peritoneal approach was used for two patients, while the other one received trans-retroperitoneal approach. The advantage and disadvantage of different port platforms were discussed.

OUTCOMES

All patients underwent the operation smoothly without major complications or conversion to open surgery. Blood loss amount was small, hospital stay was short, and only one patient received one single dose of opioid analgesia injection after the surgery.

LESSONS

The main problems of LESS are the loss of a working triangle and the limitations of the instruments. Robot-assisted LESS may help surgeons overcome part of these problems. Many different port platforms are available, and based on our initial experience, we believe that the GelPoint may be a more suitable platform, for it maintains the endo-wrist function of the Da Vinci instruments, and allows the surgeon to design the position of ports freely to minimize external and internal collision.

Combined laparoendoscopic single-site ureterolithotomy and flexible cystoscopy in the treatment of concurrent large upper ureteral and renal stones

OBJECTIVE

The aim of this study was to present the authors' experience with technical recommendations for the treatment of concurrent large upper ureteral and renal stones.

METHODS

Between September 2014 and March 2016, laparoendoscopic single-site surgery (LESS) ureterolithotomy with renal stone extraction or holmium laser lithotripsy under flexible cystoscopy was performed on 15 patients who had concurrent upper ureteral and renal stones. The ureteral stone was treated with LESS ureterolithotomy. After the ureteral stone had been removed, a flexible cystoscope was inserted through one of the laparoscopic ports into the renal pelvis and collecting systems. Renal stones were extracted with a stone basket or broken by a holmium laser and then removed. The perioperative and postoperative data were collected and analyzed retrospectively. Patients were followed up postoperatively for evidence of long-term side-effects.

RESULTS

Nine patients underwent LESS ureterolithotomy and flexible cystoscope-assisted renal stone extraction. Six patients underwent concomitant holmium laser lithotripsy because of larger renal stones. All procedures were completed successfully. The ureteral stones were 15-23 mm in diameter and the renal stones were 4-20 mm in diameter. The mean surgery time was 156 min. Estimated blood loss was 70 ml. Complete stone clearance was confirmed by postoperative imaging in all patients. The median length of hospital stay after surgery was 9.1 days. No intraoperative or postoperative complications occurred during a mean follow-up of 10.2 months.

CONCLUSIONS

LESS ureterolithotomy with renal stone extraction or holmium laser lithotripsy under flexible cystoscopy can be considered an effective treatment for patients with concurrent large ureteral and renal stones.

Open Versus Laparoscopic Adrenalectomy for Adrenocortical Carcinoma: A Meta-analysis of Surgical and Oncological Outcomes

PURPOSE

This study was designed to determine the role of laparoscopic adrenalectomy (LA) in the surgical management of adrenocortical carcinoma (ACC).

METHODS

A systematic literature review was performed on January 2, 2015 using PubMed. Article selection proceeded according to PRISMA criteria. Studies comparing open adrenalectomy (OA) to LA for ACC and including at least 10 cases per each surgical approach were included. Odds ratio (OR) was used for all binary variables, and weight mean difference (WMD) was used for the continuous parameters. Pooled estimates were calculated with the fixed-effect model, if no significant heterogeneity was identified; alternatively, the random-effect model was used when significant heterogeneity was detected. Main demographics, surgical outcomes, and oncological outcomes were analyzed.

RESULTS

Nine studies published between 2010 and 2014 were deemed eligible and included in the analysis, all of them being retrospective case-control studies. Overall, they included 240 LA and 557 OA cases. Tumors treated with laparoscopy were significantly smaller in size (WMD -3.41 cm; confidence interval [CI] -4.91, -1.91; p < 0.001), and a higher proportion of them (80.8 %) more at a localized (I-II) stage compared with open surgery (67.7 %) (odds ratio [OR] 2.8; CI 1.8, 4.2; p < 0.001). Hospitalization time was in favor of laparoscopy, with a WMD of -2.5 days (CI -3.3, -1.7; p < 0.001). There was no difference in the overall recurrence rate between LA and OA (relative risk [RR] 1.09; CI 0.83, 1.43; p = 0.53), whereas development of peritoneal carcinomatosis was higher for LA (RR 2.39; CI 1.41, 4.04; p = 0.001). No difference could be found for time to recurrence (WMD -8.2 months; CI -18.2, 1.7; p = 0.11), as well as for cancer specific mortality (OR 0.68; CI 0.44, 1.05; p = 0.08).

CONCLUSIONS

OA should still be considered the standard surgical management of ACC. LA can offer a shorter hospital stay and possibly a faster recovery. Therefore, this minimally invasive approach can certainly play a role in this setting, but it should be only offered in carefully selected cases to avoid jeopardizing the oncological outcome.

Laparoendoscopic single-site pyelolithotomy with use of a carter-thomason needle grasper

PURPOSE

To study the feasibility and safety of the procedure, we present our early experience with laparoendoscopic single-site (LESS) pyelolithotomy performed by use of a Carter-Thomason needle grasper.

MATERIALS AND METHODS

Four patients underwent LESS pyelolithotomy for the removal of renal pelvic stones. The patients' mean age was 57.8 years, and their mean body mass index was 23.01. We used a homemade single-port device made with a surgical glove that was inserted into a 2.5-cm periumbilical incision. The operation was performed transperitoneally by using a Carter-Thomason grasper. After removal of the stone, a double-J stent was placed in situ, and laparoscopic intracorporeal suturing was performed. No additional ports were used.

RESULTS

All surgeries were completed successfully without conversion to conventional laparoscopy or open surgery. The mean operative time was 124.5 minutes, and the mean estimated blood loss was 255.2 mL. There were no significant complications, except in one patient who required a blood transfusion. The mean duration of hospital stay was 8.3 days. The mean stone size was 3.9 cm. Chemical analysis of the stones showed that three patients had calcium-containing stones and one patient had a uric acid stone. Postoperative radiologic study showed a stone clearance rate of 100%.

CONCLUSIONS

Our results, albeit limited, showed that LESS pyelolithotomy is a feasible and safe procedure. Especially with the use of a Carter-Thomason needle grasper, this operation can be performed without an additional port.

Transumbilical laparoendoscopic single-site ureterolithotomy for large impacted ureteral stones: initial experiences

Purpose

We presented our initial clinical experiences with transumbilical laparoendoscopic single-site (LESS) ureterolithotomy for large, impacted ureteral stones.

Materials and Methods

Between March 2009 and November 2009, seven LESS ureterolithotomies were performed at our institute. During the operation, we made a single 2 cm incision at the umbilicus and a homemade port by using a small wound retractor (Alexis®, Applied Medical, Rancho Santa Margarita, USA), a surgical glove, and conventional trocars. The operation was performed in the same manner as conventional laparoscopic surgery. The mean maximal stone diameter was 21.9 mm (range, 16.0-27.0 mm). There were six cases of upper ureteral stones and one case of a mid-ureteral stone. Perioperative and postoperative parameters were evaluated.

Results

The mean operative time was 197.1 min (range, 150-270 min). No transfusions were required. The mean postoperative hospital stay was 3.3 days (range, 2-6 days). The mean pain intensity on a visual analogue scale (VAS) on postoperative day 2 was 26 mm (range, 0-80 mm), and the mean cosmetic VAS at 6 weeks after the operation was 0 mm. The mean time for patients to return to their baseline activities was 4.0 days (range, 3-7 days). In six cases, all stones were completely removed on the basis of postoperative radiologic evaluation. There were no cases of major complications, including internal organ injury, urinary leakage, or urinary tract infection.

Conclusions

Transumbilical LESS ureterolithotomy can be considered as an alternative treatment option with minimal invasiveness and good effectiveness for large, impacted ureteral stones.

Urologic laparoendoscopic single-site surgery

Laparoendoscopic single-site surgery (LESS) probably represents the next evolutionary step in laparoscopic surgery. Although most urologic procedures are feasible by the LESS approach, significant challenges in terms of intraoperative ergonomics and requirement for laparoscopic skill are present. New, specially designed instruments and ports represent a solution for combating ergonomic problems during surgery. Documentation of the advantages of LESS over other approaches is currently lacking, as comparative clinical trials are scarce in the literature; in the absence of such information, the technique has been accepted at centers of laparoscopic expertise. Thus, further prospective randomized clinical trials are necessary to fully characterize the outcomes of LESS.

Perioperative outcomes in patients undergoing conventional laparoscopic versus laparoendoscopic single-site pyeloplasty

OBJECTIVES

To compare the outcomes of laparoendoscopic single-site (LESS) surgery with conventional laparoscopic pyeloplasty (CLP) before LESS can be widely accepted. LESS surgery is a novel technique for performing laparoscopic pyeloplasty through a single incision.

METHODS

Fourteen patients undergoing less pyeloplasty were matched 2:1 with regard to age and side of surgery to a previous cohort of 28 patients who underwent CLP. All patients underwent surgery for symptomatic ureteropelvic junction obstruction and/or delayed urinary excretion based on functional imaging. Intracorporeal suturing was aided through a 5-mm instrument placed in the eventual drain site.

RESULTS

No difference was observed between the LESS and CLP cohorts in regard to preoperative characteristics. Postoperatively, no difference was noted between LESS and CLP cases in regard to length of stay (77 vs 74 hours; P = .69), morphine equivalents required (34 vs 38; P = .93), minor postoperative complications (14.3% vs 14.3%; P = 1.0), or major postoperative complications (21.4% vs 10%; P = .18). Median operative times (207 vs 237.5 minutes; P <.001) and median estimated blood loss (30 vs 72.5 mL; P = .002) were lower in patients undergoing LESS. Detailed follow-up imaging revealed a success rate of 96% for CLP at 14.6 months (86% follow-up) and 100% for LESS at 6.8 months (71% follow-up).

CONCLUSIONS

Although LESS pyeloplasty is feasible, all measured perioperative outcomes are similar to CLP. Further studies are needed to better define the appropriate role of LESS surgery in urology.

Laparoendoscopic single-site surgery in urology: where have we been and where are we heading?

One-port, single-incision laparoscopy is part of the natural development of minimally invasive surgery. Refinement and modification of laparoscopic instrumentation has resulted in a substantial increase in the use of laparoendoscopic single-site surgery (LESS) in urology over the past 2 years. Since the initial report of single-port nephrectomy in 2007, urologists have successfully performed various procedures with LESS, including partial nephrectomy, pyeloplasty, orchiectomy, orchiopexy, ureterolithotomy, sacrocolpopexy, renal biopsy, renal cryotherapy, and adrenalectomy. Further advancements in technology, such as magnetic anchoring and guidance systems, and robotic instrumentation, may allow broader application of this emerging surgical technique. Future research is required to determine the intraoperative and postoperative benefits of LESS in comparison with standard laparoscopy.

Devices for laparoendoscopic single-site surgery in urology

The quest to make minimally invasive techniques even more 'minimal' has generated a drive within the surgical community to explore novel ways of achieving this. This has led to surgeons attempting to either decrease the number of trocars placed through the abdominal wall or eliminate them completely. This led to the evolution of several approaches, including natural orifice translumenal endoscopic surgery (NOTES), single incision laparoscopic surgery (SILS), single port access surgery and one port umbilical surgery (OPUS) or E-NOTES. The most recent consensus on nomenclature involves the term laparoendoscopic single-site surgery (LESS). The transition from multiple port access surgery to single port access surgery represents a paradigm shift in reconstructive and extirpative surgery and is a testament to the recent advances in surgical technology. Successful LESS involves the use of articulating or bent instrumentation via a single large-caliber trocar or small, adjacent trocars. Advances in technology have led to the development of new laparoscopic access ports (R-Port and Quadriport by Advanced Surgical Concepts, Wicklow, Ireland; and Uni-X Single Port, PNavel Systems, Cleveland, OH, USA) capable of permitting several instruments to be inserted through multiple channels incorporated in, and as part of, a larger single port. The development of articulating and bent instrumentation permits triangulation intracorporeally despite the close proximity of several instruments via a single port. Currently, commercially available instruments can be broadly divided into articulating laparoscopic graspers and shears (Real Hand, Novare Surgical Systems, Cupertino, CA, USA; and Autonomy Laparo-angle, Cambridge Endo, Framingham, MA, USA), endoshears (Cambridge Endo), and laparoscopic needle drivers (Cambridge Endo). Despite the preliminary optimistic results in the outcomes of LESS, an experienced laparoscopic skill set is essential for the safe and effective completion of surgery.

[Comparative analysis of renal graft function after open vs. laparoscopic nephrectomy: experimental model]

INTRODUCTION

Living donor renal transplant reports a higher patient and graft survival in comparison to cadaver donor and represents a good alternative facing the current lack of organs for transplant.

GOALS

To analyze comparatively in an experimental model (pig) the influence of ischemia-reperfusion and functional outcome of renal graft retrieved by open Vs laparoscopic nephrectomy.

MATERIAL AND METHODS

30 lab pigs were nephrectomized (left kidney): 15 by laparoscopy and 15 by open surgery, as living donors, in a model of renal autotransplant. Renal blood flow (RBF) was measured by means of an electromagnetic probe and creatinine levels during the first week after the implant.

RESULTS

Comparative analysis of RBF during the immediate 60 min after unclamping showed a significant reduction of average RBF in laparoscopic group in comparison to open group (p < 0.001), with a more evident reduction of RBF in the laparoscopic group during the 5-min period after unclamping (p < 0.001) and a progressive recuperation of RBF during the 1st hour, slowest in laparoscopic group. Creatinine levels in the first week after the transplant decreased progressively from 1.3 to 0.8 mgrs/dl in the open group and from 2 to 1.1 mg/dl in laparoscopic group (p < 0.001).

CONCLUSIONS

Renal grafts retrieved by laparoscopy presents a more evident ischemia-reperfusion syndrome shown by a lower average RBF after unclamping and a significant deterioration of renal function during the first week after transplant.

Retroperitoneoscopic adrenalectomy: an early institutional experience

OBJECTIVE

To review our initial experience with the retroperitoneoscopic approach, which is rapidly becoming the procedure of choice for paediatric adrenalectomy. Swift access to the vascular pedicle makes this approach ideal for adrenal surgery where haemodynamic instability is a common feature.

METHOD

Patients were placed in a fully prone position and the locations of the 12th rib, iliac crest and paravertebral muscles were marked. A 10-mm incision was made lateral to the para-vertebral muscle, halfway between the iliac crest and costal margin. A retroperitoneal working space was created around the kidney using a homemade balloon. A 10-mm Hasson port was then inserted. A 5-mm working port was placed lateral to the tip of the 12th rib and, if necessary, a second was inserted medial to the camera port. Dissection was performed with diathermy and/or Harmonic Scalpeltrade mark and the adrenal vessels were divided between clips. The specimen was retrieved in an endopouch through the 10-mm port.

RESULTS

Over 16 months, six adrenalectomies were performed in five patients (three boys and two girls); two right, two left and one bilateral. Median age at surgery was 8 years. Presentation was with hypertension (n=2), Cushing's syndrome (n=2) and abdominal pain (n=1). Median operative time was 154 min. A single-instrument port adrenalectomy was performed in three patients. Histopathological diagnosis included adrenal cyst (n=1), cystic phaeochromocytoma (n=1), adrenal cortical tumour (n=2) and central Cushing's disease (n=1). All were completely resected. All patients remain symptom free with a median follow up of 17 months.

CONCLUSION

These cases represent our initial institutional experience with retroperitoneoscopic adrenalectomy. The senior reporting surgeons have already surmounted the general learning curve for laparoscopy, and this experience has proved vital to expand our repertoire with encouraging early results. This is our technique of choice as it provides a superior view of the adrenal gland and vessels, with good intraoperative haemodynamic stability.

Peritoneal dialysis catheter placement—is laparoscopy an option?

Peritoneal dialysis (CAPD) is the preferred and gentlest type of dialysis in patients with end-stage renal disease (ESRD). One of the most frequent complications following peritoneal dialysis catheter (P-catheter) placement is malfunction owing to displacement, which frequently entails major problems for the patient, including reoperation and the risk of having to switch to haemodialysis. Consequently, to ensure optimal P-catheter function and reduce patient morbidity, it is essential to develop and assess new surgical techniques for dialysis catheter placement. The objective of this survey is to describe and assess a laparoscopic-assisted procedure for P-catheter placement.

MATERIAL AND METHODS

Survey of laparoscopic-assisted P-catheter placements performed during a one-year period. The study describes the operative procedure, catheter function and complications. Furthermore, a comparison with open surgery performed in the period is made.

RESULTS

One of nine P-catheters inserted using laparoscopic-assisted surgery under general anaesthesia was displaced while four of 13 P-catheters inserted using traditional open surgery under local anaesthesia were displaced. The five displaced catheters were subsequently fixed laparoscopically under general anaesthesia.

CONCLUSION

Laparoscopic P-catheter placement is uncomplicated, quick and reduces P-catheter displacement frequency. Drawbacks include costly equipment and the need for general anaesthesia. Future follow-up will reveal whether laparoscopically placed P-catheters yield longer-lasting and better-functioning catheters than traditionally placed P-catheters.

Enterocistoplastia de ampliación laparoscópica: experiencia inicial

OBJECTIVE

To analyze the initial experience of our group in the realization of the augmentation enterocystoplasty by laparoscopyc approach.

METHODS AND PATIENTS

We describe the augmentation enterocystoplasty technique with ileal segment completely achieved by laparoscopyc approach. We present the cases of two patients suffering from hyperreflexic bladder refractory to medical treatment who underwent this surgery. In both cases the technique was realized without intraoperative complications although it was needed a surgical time of 6 and 4.5 hours respectively. The results after 12 and 5 months were satisfactory in both patients, obtaining a low pressure bladder with a good continence.

CONCLUSIONS

Laparoscopyc augmentation enterocystoplasty is a complicated technique that requires a great experience, mainly in laparoscopyc suture. It reproduces completely the open surgery and it offers all the advantages inherent to the laparoscopyc surgery.

Laparoscopic partial cystectomy for a vesical leiomyoma

A 47-year-old woman presented with gross hematuria and urinary frequency for 6 months. The tumor located at the dome of bladder was resected by transurethral resectoscope. The pathology revealed leiomyoma; however, her symptoms did not improve after the endoscopic procedure. We performed transurethral mucosal incision for circumscribing the margin of tumor and transperitoneoscopic partial cystectomy to treat the patient successfully.

Outcomes of hand-assisted laparoscopic nephroureterectomy for managing upper urinary tract transitional cell carcinoma—China Medical University Hospital experience

OBJECTIVES

To report our experience with hand-assisted laparoscopic nephroureterectomy (HALNU) to treat upper urinary tract transitional cell carcinoma (TCC). In addition, we report the treatment of 4 patients with upper urinary tract TCC and synchronous superficial urinary bladder TCC by HALNU and simultaneous transurethral resection of bladder tumor (TURBT).

METHODS

We retrospectively reviewed 33 patients who had undergone HALNU. Recovery was evaluated according to the Eastern Cooperative Oncology Group performance status. Four patients had concomitant superficial urinary bladder cancer and underwent simultaneous TURBT at the beginning of surgery. We compared our data with those of our open surgery group and previously published data.

RESULTS

Partial recovery had occurred by 1 week and complete recovery by 4 weeks postoperatively. Conversion to open surgery was required in 2 (6%) of the 33 patients. The complication rate was 24% (8 of 33) without any mortality. The recurrence rate of urinary bladder TCC was 6% (2 of 33). Both patients with recurrent tumor were treated successfully by TURBT and bacille Calmette-Guérin instillation. All 4 patients with synchronous superficial urinary bladder TCC had undergone simultaneous transurethral resection of bladder tumor, and all 4 were disease free at the last follow-up visit.

CONCLUSIONS

Hand-assisted procedures are appropriate for surgeons with limited experience with laparoscopic surgery. In our study, the convalescence of patients was excellent, and the postoperative results were compatible with those of previous studies. To treat upper urinary tract TCC with synchronous urinary bladder TCC, HALNU and TURBT together seems to be a safe and efficient technique.

Development of Laparoscopic Surgery and Training Facilities in Europe: Results of a Survey of the European Society of Uro-Technology (ESUT)

OBJECTIVE

The European Society of Uro-Technology (ESUT) conducted a survey in order to assess the application of laparoscopy and the facilitation of training programs within Europe.

METHODS

A total of 430 urologists and residents from European countries answered the ESUT survey during the XVIIIth Annual EAU Meeting in Madrid in 2003. The survey constituted of 11 questions of which nine with dual response (Y/N) options. Two questions, evaluating the importance of different training methods and different reasons not to be involved in laparoscopy, were assessed by means of a Likert type scale.

RESULTS

Laparoscopy was performed in 71% of urological departments. The majority (85%) of departments where no laparoscopy was performed, intended to establish it in the future. Two thirds of respondents believed laparoscopy would replace open surgery in the next 5 to 10 years. The access to training facilities was insufficient for 44%. Different methods of training were considered to be of equal importance. Among the reasons for not being involved in laparoscopic surgery a high variability was identified.

CONCLUSIONS

Laparoscopy is performed in the majority of urological departments in Europe. While there is a strong believe in the prominent role of laparoscopy in the mid-long future, access to training is still needed.

Laparoscopic adrenalectomy for pheochromocytoma

We reviewed 10 cases of laparoscopic adrenalectomy for pheochromocytoma and compared the results with those of a recent series of 11 patients who underwent open adrenalectomy. Of the 10 cases, the tumor was removed successfully in all cases except in one case with laparoscopy that required open laparotomy. A pair of laparoscopic coagulating scissors was utilized in all except the initial two cases. In the laparoscopy group (excluding the initial two cases and the case that required conversion to open surgery), mean operative time and blood loss were 145 min and 55 ml, respectively. No significant difference was observed in mean operative time between the laparoscopy group and the open surgery group (165 min for open surgery). Mean blood loss of the laparoscopy group was significantly less than that of the open surgery group (330 ml for open surgery, P = 0.01). Mean intervals to first ambulation and oral intake, and postoperative hospital stay of the laparoscopy group, tended to be less than those of the open surgery group, although no statistical significance was observed (2.3 versus 3.2 d, 2.9 versus 3.6 d, and 12 versus 14 d, respectively). We conclude that laparoscopic adrenalectomy for pheochromocytoma is equally effective and less invasive than open adrenalectomy and should be considered the therapy of choice even for pheochromocytoma.

Critical care and the urologic patient

Changing concepts of disease management, expanding indications for invasive therapy to elderly patients, together with technologic advances have changed the management of various urologic diseases. Although minimally invasive surgery may have reduced the need for ICU care, we are faced with new and unique treatment problems.

Current laparoscopic practice patterns in urology: results of a survey among urologists in Germany and Switzerland

OBJECTIVES

A survey was performed to assess the current practice patterns in laparoscopy among urologists in Germany and Switzerland.

METHODS

Using the database directory of the German and Swiss Urological Association urological departments were identified. A detailed questionnaire was designed and sent by postal service. Responding questionnaires were analyzed.

RESULTS

The overall response rate was 64%. Fifty-four percent of respondents in Germany and 33% in Switzerland already perform laparoscopy; another 50% and 56% are planning to introduce laparoscopy. Thirty-six percent think that laparoscopy is economical and 77% await shortening of hospital stay. Major concerns are: Economical aspects, lengthy learning curve, investment, and lack of scientific data. The number of laparoscopic procedures during 12 months was registered for 19 indications. More than 40 procedures for one indication are performed by only 6% of the departments.

CONCLUSIONS

The survey reveals an increasing number of departments performing laparoscopy and broad acceptance of the technology but combined with some major concerns. Currently only a minority of the departments perform more than 40 procedures for one indication suggesting that at present laparoscopy is mainly a center-based technology.

Multilayered small intestinal submucosa is inferior to autologous bowel for laparoscopic bladder augmentation

PURPOSE

Bladder augmentation is most commonly performed with ileum. However, porcine small intestinal submucosa has been reported as a substitute for bowel for incorporation into the urinary tract. We assessed the feasibility and long-term 12-month results of laparoscopic bladder augmentation with ileum or multilayered small intestinal submucosa (Cook Biotech, Spencer, Indiana) in a porcine model.

MATERIALS AND METHODS

We performed laparoscopically assisted hemicystectomy and bladder augmentation in 24 female Yucatan mini-pigs using an ileal segment (12) or multilayered small intestinal submucosa (12). The followup protocol included anesthetic bladder capacity, renal ultrasonography and serum chemistry. At 3, 6 and 12 months, respectively, 4 animals per group were scheduled for sacrifice and pathological analysis.

RESULTS

Despite longer anastomotic time in the multilayered small intestinal submucosa group (120 versus 91 minutes, p = 0.026) total operative time was similar in the 2 groups. In each group bladder capacity increased with time but by 12 months bladder capacity was significantly better in the bowel than in the small intestinal submucosa group (825 versus 431 cc, p = 0.016). At 3 months pathological evaluation revealed that the multilayered regenerated bladder patch had shrunken and by 6 months it was replaced by dense calcified scar tissue. Long-term 6 and 12-month bladder capacity in the small intestinal submucosa group was the result of the regeneration of native bladder with exclusion of the whole multilayered patch in the majority of cases.

CONCLUSIONS

Laparoscopic bladder augmentation using multilayered small intestinal submucosa produced functional and pathological results inferior to those of bowel at 12-month followup in a porcine model.

[Endoscopic surgery in urology]

At this moment in time, endourology is incorporating extraluminal endoscopic techniques (laparoscopy, lumboscopy, retziuscopy), which the urologist is expected to master. The current advanced stage of development of intraluminal endoscopic surgery is mainly due to the most recent technological achievements (miniaturization of the lens, the use of more versatile materials and new energy sources). In the current cystourethroscopic procedures, compact endoscopes and flexible cystoscopes play an important role. The most important of these new techniques include tissue vaporisation procedures, interstitial application of substances or energies, low-pressure transurethral resection and percutaneous vesical surgery. Upper endoluminal procedures have been the ones to most benefit from modern technological developments. The most important features of present day ureterorenoscopes and their clinical applications are studied and also those of percutaneous nephroscopy (lithiasis, neoformations and others). In a review on the current situation of extraluminal endoscopy, a wide range of laparoscopic techniques--applicable to adrenal regions, kidneys, ureters, retroperitoneal and lymphatic systems, testicles and sperm ducts, bladder and prostrate gland--are discussed as well as the indications, advantages and drawbacks involved and the preferential surgical approaches.

Endoscopic partial cystectomy for bladder leiomyoma using retroperitoneoscopic and transurethral procedures

Retroperitoneoscopic partial cystectomy was performed to remove a leiomyoma in the right wall of the bladder in a 58-year-old man. The tumor was initially circumscribed with a mucosal incision using a transurethral resectoscope, and once the bladder wall had been penetrated with the resectoscope, the remaining procedures were performed retroperitoneoscopically. The bladder wall was closed using a retroperitoneoscopic suturing technique. Endoscopic partial cystectomy using both a transurethral incision and a retroperitoneoscopic resection is technically feasible in the treatment of small bladder tumors.

Early repeated exploration after laparoscopic urologic surgery: comparison of clinical, radiologic, and surgical findings

OBJECTIVES

To correlate the clinical scenarios and radiographic findings with the operative findings in patients who underwent repeated exploration to define a management strategy. Postoperative complications after laparoscopy may cause diagnostic challenges because of atypical presentation.

METHODS

We retrospectively reviewed the records from 1226 urologic laparoscopic procedures between July 1993 and July 2000. We compared the clinical, radiologic, and surgical findings of patients who underwent repeated exploration within the first month after laparoscopy.

RESULTS

During the study period, 9 patients (0.7%) were taken back to the operating room for repeated exploration. The median time for the appearance of symptoms was the second postoperative day. Eight patients were evaluated by computed tomography (CT) and one by both renal Doppler ultrasonography and MAG-3 renal perfusion scan. Repeated operations were laparoscopic in 4 and open in 5 patients. In all the patients evaluated by CT scan, the radiologic findings were consistent with the surgical findings. In the patients who underwent diagnostic laparoscopy because of the severity of clinical findings, despite negative CT findings, no abnormality was discovered at exploration. In 1 patient who was not evaluated by CT, duodenal perforation was detected at exploration.

CONCLUSIONS

Clinical findings may not be sufficient for the decision of repeated operation for patients acutely ill after laparoscopy. CT findings correlated well with the findings at exploration. In cases in which no abnormality is detected by CT, it appears reasonable to withhold surgical exploration unless the clinical situation deteriorates.

Multi-institutional study of complications in 1085 laparoscopic urologic procedures

OBJECTIVES

To assess the incidence of the complications in laparoscopic urologic procedures with regard to clinical presentation, etiology, and treatment.

METHODS

From January 1994 to December 2000, 1085 laparoscopic procedures were performed at three institutions in 1075 patients (702 men, 373 women). A referent surgeon for laparoscopy was at each institution. The major procedures were radical prostatectomy (n = 232), different types of nephrectomy (n = 171) and nephroureterectomy (n = 15), adrenalectomy (n = 130), pyeloplasty (n = 61), pelvic lymph node dissection (n = 130), genitourinary prolapse repair (n = 86), bladder neck suspension (n = 104), and treatment of benign kidney pathologic findings (lithiasis, cysts, and diverticula, n = 55). The complications were listed by incidence and etiology according to the procedure attempted.

RESULTS

A total of 75 complications (6.9%) occurred in this multi-institutional series. The mortality rate was 0.09%, and the conversion rate was 2.1%. Vascular (n = 7) and visceral injuries (n = 11) occurred in 24% of complications. Hematomas (n = 10), urinomas (n = 8), and wound infections (n = 7) at the trocar sites were the most frequent postoperative surgical complications. Pulmonary disorders (n = 9) and urinary infections (n = 9) were predominant in the postoperative medical problems.

CONCLUSIONS

Even though it appears to be minimally invasive, laparoscopy remains major surgery, with serious complications possible. These complications should be preventable with better mastery of the different steps of the procedures. Increased knowledge of the possible complications is essential for urologists in laparoscopic training and may help them improve their learning curve.

Should laparoscopy be the standard approach used for pelvic lymph node dissection?

Involvement of the pelvic lymph nodes in patients with prostate cancer worsens the overall prognosis of this common disease entity. Prior radiographic staging techniques, including fine-needle aspiration, are limited by a poor sensitivity and are not reliable. The gold standard for the evaluation of pelvic lymph nodes in men with prostate cancer involves performing a lymphadenectomy. Historically, this procedure was performed using an open surgical technique. Unfortunately, this invasive procedure is associated with significant morbidity. In response, modern surgical technology has provided newer, less invasive techniques, including laparoscopic pelvic lymphadenectomy (LPLND). Improved detection of localized prostate cancer through the institution of screening protocols and early detection programs has decreased the number of patients presenting with lymph node involvement. Various clinical indicators, including prostate-specific antigen, grade, and stage, have been used to improve the selection of "high-risk" patients that are appropriate candidates for pelvic lymph node dissection. The technique of LPLND is a valid option in the armamentarium for staging of prostate cancer. The laparoscopic approach provides the same staging accuracy as the open surgical technique and is superior with respect to morbidity. LPLND is limited to patients who present with a high risk of advanced prostate cancer. In addition, the urologist must accept the additional training, financial expense, and "learning curve" associated with this technique.

Laparoscopic ultrasonography

The use of laparoscopic ultrasonography (LUS) allows visualization of tissues beyond the two-dimensional laparoscopic picture, enhancing the amount and quality of information available to the surgeon. Linear-array transducers with frequencies of 7.5 to 10 MHz are typically used for LUS, employing B-mode scanning and color Doppler capability on probes with articulating tips. In general surgery, LUS has become a common adjunct to the intraoperative staging of upper gastrointestinal malignancy to determine resectability, avoiding unnecessary laparotomy. In urology, LUS appears to be a promising adjunct for four current procedures: difficult pelvic lymphocele marsupialization, renal cyst decortication, nephrolithotomy and other renal stone surgery, and cryotherapy of renal masses. The role of LUS during varicocelectomy is limited, and enthusiasm for this procedure is waning. Laparoscopic ultrasonography is a critical adjunct to renal cryoablation, a developmental procedure that currently lacks long-term data but is promising as therapy for small, incidentally detected renal masses. It appears that as laparoscopic urologic procedures continue to expand, so will the application of this promising operative imaging modality.

Urologic laparoscopy: the future is now

Recent interest in urologic laparoscopy is a welcome renaissance of minimally invasive procedures that provide superior benefit to patients. It behooves the urologist to avoid complacency and embrace the resurgence of laparoscopy. Dedicated pursuit and perseverance will facilitate the evolution and future of urologic laparoscopy.

Retroperitoneal minilaparoscopic nephrectomy in the rat model

OBJECTIVES

Development of small animal models for laparoscopic surgery is important for basic pathophysiologic and oncologic studies, instrument development, and surgical training. Although transperitoneal laparoscopy has been described in the rat, the technical feasibility of the retroperitoneoscopic approach for major renal surgery has not been reported previously. Herein, we describe the development of a rat model for retroperitoneal minilaparoscopic nephrectomy.

METHODS

Sixteen male Sprague-Dawley rats underwent a three-port bilateral retroperitoneoscopic nephrectomy using 2 and 3-mm instruments and optics exclusively. After developing the technique in 10 animals, the study was conducted in 6 animals. Following retroperitoneal balloon dilation and CO(2) pneumoretroperitoneum (mean 4.5 mm Hg), nephrectomy was accomplished by intracorporeal en bloc ligation of the renal pedicle. To prevent peritoneal entry, the anterior surface of the kidney was mobilized subcapsularly. Volume of the created retroperitoneal space and peritoneal integrity were confirmed by a contrast x-ray study. Intraperitoneal pressure was monitored constantly during the procedure.

RESULTS

Mean surgical time was 74.5 minutes (range 60 to 95) and estimated blood loss was less than 1 mL. Mean volume of the retroperitoneal space was 8.4 mL after initial balloon dilation, and 11.5 mL after nephrectomy. Mean weight of the excised kidneys was 1. 4 g. Inadvertent peritoneotomy occurred during 3 of 12 study nephrectomies. Complications included renal artery hemorrhage leading to death in 1 animal and renal vein injury in 1 animal.

CONCLUSIONS

Laparoscopic retroperitoneal nephrectomy in the rat model is technically feasible. This novel small animal model can be used for further studies of the retroperitoneal laparoscopic approach.

Management of hemorrhage during laparoscopy

Bleeding can be a complication of laparoscopic procedures commonly performed by urologists, such as pelvic node dissection and nephrectomy, and is often difficult to manage. Hemorrhage also can occur as a result of Veress needle or trocar placement, and there are specific strategies for the management of these injuries. Laparoscopic clip appliers, laparoscopic staplers, laparoscopic suturing, various energy sources (monopolar and bipolar electrocautery, laser, ultrasonic dissectors, and argon beam coagulators), and topical agents (gelatin foam, cellulose, collagen, and fibrin sealant) can be used to obtain hemostasis. Converting to laparotomy to obtain hemostasis may be necessary in some cases. Proper patient selection is important for lowering the risk of hemorrhage.