Advances in Urological Laparoscopy:

Survey of urologic laparoscopic practice patterns in Saudi Arabia

BACKGROUND AND PURPOSE

Laparoscopic surgery is taking a greater role in the management of many urologic diseases. We performed a survey whose aim was to define laparoscopic practice patterns among urologists in Saudi Arabia.

MATERIALS AND METHODS

In March 2009, detailed questionnaires about urologic laparoscopic practice patterns were distributed to 352 urologists who were working in Saudi Arabia. The questions related to age, residency training, and amount of laparoscopy performed.

RESULTS

The overall response rate was 42%. A total of 21% of certified urologists in Saudi Arabia performed no laparoscopy, 24.8% devoted less than 5% of their practice time, and 54.3% devoted 5% or more of their practice time to laparoscopic surgery. Of the respondents, 27.5% stated that they had adequate training during residency to perform laparoscopy. Both age and time in practice were inversely related to the amount of time devoted to laparoscopy (P = 0.001). Of those who were affiliated with a university, 70% devoted more than 5% of their operative time to laparoscopy. Urologists in the Ministry of Health were the least to perform a significant volume of laparoscopy. The two most important reasons mentioned for performing laparoscopy were a faster recovery period and reduced morbidity. The main laparoscopic procedures, according to the proportion of urologists who perform laparoscopic surgery, were varicocelectomy, 38%; simple nephrectomy, 27%; renal cyst decortications, 23%; adrenalectomy, 20%; radical nephrectomy, 20%; pyeloplasty, 18%; and orchidopexy, 17%.

CONCLUSIONS

Urologic laparoscopic practice in Saudi Arabia is still in its early stages. Accordingly, more laparoscopic procedures should be implemented in the local training programs.

Laparoscopic Ileocystoplasty: An Experimental Study in Pigs

BACKGROUND AND PURPOSE

Bladder dysfunction may lead to urinary incontinence and progressive kidney deterioration. When clinical treatment fails, bladder augmentation is the operation of choice in most cases. The purpose of this study was the standardization of the technique of videolaparoscopic ileocystoplasty in a porcine model and demonstration of a tutor-supervised learning curve.

MATERIALS AND METHODS

The study was conducted on 15 Large-White male pigs (20-25 kg) that underwent ileocystoplasty with 15 cm of distal ileum shaped into a using extracorporeal technique and laparoscopic ileovesical anastomosis. Operative time, ileovesical anastomosis time, intraoperative complications, and extravasation after anastomosis were evaluated. To assess the learning curve, the animals were divided into three groups of five: group I (operated on in collaboration with a tutor), group II (treated under the supervision of tutor), and group III (without the tutor's collaboration or supervision).

RESULTS

Total surgical time and ileovesical anastomosis time revealed significant differences (P < 0.05) between groups I and III (70% reduction) as well as between groups II and III (64% reduction).

CONCLUSIONS

Laparoscopic ileocystoplasty in pigs is feasible without special laparoscopic material. Ten initial procedures with a tutor's help were important for technique acquisition and mastery. A sharp increase in efficiency occurs between the tenth and fifteenth procedures. These procedures should be executed at least ten times in the presence of the tutor to enable the surgeon to overcome the learning curve.

Hand-Assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Nonseminomatous Testicular Cancer

PURPOSE

We describe our initial experience with hand-assisted laparoscopic retroperitoneal lymph node dissection for nonseminomatous testicular cancer.

MATERIALS AND METHODS

Between April 2002 and December 2004, 10 patients with testicular tumor were operated on, 6 on the right side and 4 on the left side. Eight patients were in clinical stage I, one patient was in clinical stage IIA, and one patient was in clinical stage IIB disease. Depending on the tumor site, a 6-7 cm mid-lower or -upper laparotomy was done, the HandPort (Smith and Nephew, Andover, MA) was placed in the abdominal wall, and the left hand of the surgeon was inserted into the abdomen. Four laparoscopic ports were also inserted. The ascending or descending colon was mobilized completely. The retroperitoneal lymph nodes were dissected and removed according to the modification of Weissbach and colleagues.

RESULTS

The average operative time was 258 min (range, 150-432 min). One patient required re-operation because of postoperative bleeding. The average postoperative hospital stay was 3.5 (range, 3-10) days. Patients with stage IIA or IIB disease on histopathology received 2-3 courses of combined chemotherapy. Antegrade ejaculation was preserved in all patients. During follow-up that ranged from 9 to 36 months, there was no local recurrence or distant metastasis.

CONCLUSION

Hand assistance makes the laparoscopic operation simpler, faster, and safer. A 6-7 cm muscle-splitting incision should be advantageous for patients compared to the xyphopubic laparotomy of the open procedure. To our knowledge this is the first report on hand-assisted laparoscopic retroperitoneal lymph node dissection.

Synthetic Torso for Training in and Evaluation of Urologic Laparoscopic Skills

BACKGROUND

The expanding use of advanced minimally invasive surgical techniques demands more advanced training methods, objective measures of resident performance, and more realistic and anatomically correct training models.

MATERIALS AND METHODS

A new synthetic torso for urologic laparoscopy training was developed and assessed. The trainer, Lapman, was based on the Visible Human Model and has the exact shape of a human torso. The torso models the outer shape of the body and the abdominal and pulmonary cavities. Animal or synthetic models of the abdominal organs may be placed in the abdominal cavity. An abdominal wall provides access and seals the cavity and can be replaced after repeated punctures with laparoscopic instruments. The thoracic cavity connects to a pneumatic pump to simulate breathing. In order to render realistic mechanic properties, the torso is cast of materials with elastic properties similar to those of soft tissue and incorporates a synthetic skeleton. These similar mechanical properties and the thoracic insufflation create realistic ventilatory motion simulation.

RESULTS

Twenty-five individuals--medical students, residents, and attending urologists--participated in a study comparing Lapman with a standard training box. Lapman presented several advantages over the traditional training box, specifically with regard to internal and external views and the incorporation of a realistically shaped abdominal wall. A significant and recurrent theme was the value of the synthetic wall as a tool to gain a greater appreciation of the importance of port placement. Study participants at all levels of training appreciated that Lapman gives a more realistic approximation of the operative procedure.

CONCLUSIONS

The novelty of the trainer consists in its anatomic shape, realistic mechanical properties, and ventilatory simulation. This paper reports on its design, construction, and preliminary tests.

Laparoscopic pyeloplasty for ureteropelvic junction obstruction: Outcome of initial 12 procedures

BACKGROUND

Open pyeloplasty has been the gold standard for surgical treatment of ureteropelvic junction (UPJ) obstruction, enjoying a long-term success rate exceeding 90%. Unfortunately, this procedure requires a muscle incision that entails some degree of morbidity. We have, therefore, investigated the feasibility of laparoscopic pyeloplasty for UPJ obstruction and report here the outcomes of our early cases. The median follow up is 25 months (range, 12-42 months).

METHODS

Between March 1999 and September 2001 we performed laparoscopic pyeloplasty on 12 ureters in 11 patients presenting with symptomatic hydronephrosis, secondary to a short stenosis of the UPJ or to ventrally crossing vessels; bilateral pyeloplasty was performed as a single procedure in one patient. We performed dismembered Anderson-Hynes pyeloplasty, Fenger plasty and Y-V plasty in eight, two and two ureters, respectively. All procedures were carried out transperitoneally.

RESULTS

The procedure was completed successfully in all cases. Crossing vessels were noted in six of 12 ureters (50.0%). Mean operative time and blood loss in 11 patients (including one bilateral case) were 272.8 min (range, 175-480 min) and 96.4 mL (range, 20-340 mL), respectively. Postoperative complications were noted in two patients (18.2%): one instance of prolonged urine leakage and one anastomotic re-stricture. Eleven of 12 ureters (91.6%) demonstrated a patent UPJ on excretory urography and/or improvement of renal function on diuretic renography at a minimum follow up of 12 months.

CONCLUSION

Although the procedure requires advanced laparoscopic skills, it can be safely and successfully completed as frequently as the conventional open procedure. Laparoscopic pyeloplasty seems to be a valuable alternative to open pyeloplasty for UPJ obstruction.

Comparison of surgical stress between laparoscopy and open surgery in the field of urology by measurement of humoral mediators

BACKGROUND

Recently, laparoscopic procedures have become more common in urological surgery, and are suggested to be less stressful compared with open surgery; however, little data on objective evaluation of surgical stress after laparoscopic surgery are available. The objective of this study was to compare surgical stress between laparoscopic and open surgery in the field of urology by measurement of humoral mediators.

METHODS

Blood samples were obtained from 25 patients who underwent laparoscopic surgery (laparoscopic radical prostatectomy, 10; retroperitoneoscopic nephrectomy or nephroureterectomy, seven; laparoscopic adrenalectomy, five; and hand-assisted laparoscopic radical nephrectomy, three) and 10 who underwent open surgery (retropubic radical prostatectomy, four; radical cystectomy, three; and radical nephrectomy, three), 48 h before surgery, during surgery, and 24, 48 and 96 h after surgery. Serum levels of interleukin (IL)-6, IL-10 and granulocytic elastase in these samples were measured, and the results were analyzed with respect to several clinical factors.

RESULTS

In both groups, IL-6 and granulocytic elastase levels increased during surgery and reached maximum levels 24 h after surgery; the increase in granulocytic elastase tended to be prolonged compared with that of IL-6. Changes in IL-10 levels in the open surgery group were similar to those of IL-6 and granulocytic elastase levels, whereas IL-10 levels in the laparoscopic surgery group reached a maximum level during surgery and then decreased to the same level as at 48 h before surgery, on the first postoperative day. The maximum levels of these three mediators in the laparoscopic surgery group were significantly lower than those in the open surgery group. IL-6 was closely associated with the interval of fasting and duration of hospitalization after surgery.

CONCLUSION

Although the present study was based on retrospective and non-randomized analysis, the findings suggest that serum levels of IL-6, IL-10 and granulocytic elastase are useful as objective markers of surgical stress, and that laparoscopic surgery is markedly less stressful than open surgery.

Urology practice patterns after residency training in laparoscopy

PURPOSE

Laparoscopic training has been incorporated into many urology residency programs. Although the impact of laparoscopic training courses has been examined, the impact of residency training in laparoscopy on subsequent urology practice patterns has not been assessed.

MATERIALS AND METHODS

Urologists completing their residency from 1977 through 1999 at Tulane University and the University of California-San Diego were sent anonymous questionnaires in September 2000. The questionnaires evaluated practice demographics, operative experience in laparoscopy during residency, and the role of laparoscopy in the urologist's current practice. Factors impacting the decision to perform or not perform laparoscopy were evaluated.

RESULTS

Sixty-one former residents (67%) responded to the questionnaire. Urologists were more likely to perform laparoscopic procedures if they had been trained during their residency (69%) than if they had no experience during residency (34%; p < 0.025). Intensity of laparoscopic experience in residency did not appear to correlate with ongoing practice, with 73% of residents having <15 cases during residency training continuing to perform laparoscopy compared with 67% of residents doing 15 to 80 laparoscopic cases. Urologists who had been trained in laparoscopy during residency cited the need for more training (47%) and inadequate case volume (47%) as reasons for not currently performing laparoscopy. Among those who had received residency training, the most common reasons given were inadequate case volume (61%) and increased operative time (57%).

CONCLUSIONS

This survey suggests that laparoscopic procedures are more likely to be performed by physicians who have received training during residency. As the number of urologists who have been trained in laparoscopy during residency increases, shifts in practice patterns will continue to evolve, along with advances in urologic laparoscopy.

Minimally invasive extraperitoneal lymphadenectomy: clinical validation of an original technique

PURPOSE

To validate an original technique described for pelvic node dissection.

PATIENTS AND METHODS

A series of 192 patients were included in this study. The surgical technique we reported in 1987 is based on the use of a special retractor called the pelvioscope. The incision is the classical MacBurney incision on the right and its equivalent on the left. After the division of the muscles, the peritoneum is mobilized medially, and the pelvioscope is introduced. The node resection is then performed with classical surgical instruments.

RESULTS

In total; 151 bilateral, 20 unilateral right, and 21 unilateral left node dissections have been performed. In one case, dissection was not possible on both sides, and in two cases, the dissection was not complete on one side (patients previously operated on). The average intraoperative time was 69 minutes for a unilateral procedure and 103 minutes for a bilateral procedure. The mean number of pelvic lymph nodes removed was 5.6 on each side. The overall rate of complications was 7.3%.

CONCLUSION

The effectiveness of this minimally invasive surgery is clear, and the morbidity is low.

Laparoscopic partial nephrectomy and wedge resection for the treatment of renal malignancy

The widespread use of abdominal ultrasonography, CT, and MRI has led to an increase in the number of incidentally detected renal masses, some of which are malignant. Numerous studies suggest that partial nephrectomy or wedge resection of these lesions yield cure rates similar to those obtained with radical surgery. Laparoscopic nephron-sparing surgery is one of the more challenging minimally invasive surgical techniques, and its use is largely restricted to specialized medical centers. The techniques and available results are described.

Indications, technique, and results of laparoscopic pelvic lymphadenectomy

Despite considerable clinical research, there is still controversy about the optimal management of the pelvic lymph nodes in men with prostate cancer. This article reviews the creation and application of selection criteria for laparoscopic pelvic lymphadenectomy and describes the various techniques.

Laparoscopic partial nephrectomy in the pig: comparison of three hemostasis techniques

BACKGROUND AND PURPOSE

Control of intraoperative bleeding is the main technical difficulty encountered during laparoscopic partial nephrectomy. The objective of this study was to compare the efficacy and morbidity of three renal parenchymal hemostasis techniques: high-frequency bipolar electrical current, high-frequency unipolar spray electrical current, and ultrasound during laparoscopic partial nephrectomy performed in pigs without vascular control.

MATERIALS AND METHODS

A standardized laparoscopic transperitoneal right lower-pole partial nephrectomy was performed in 27 pigs with a mean weight of 65 +/- 5 kg. The pigs were divided into three groups according to the technology used: Group 1 = bipolar electrical current, Group 2 = unipolar spray electrical current, and Group 3 = ultrasound. Intravenous urography was performed on the 28th day. The kidneys were then removed for histologic examination, and the pigs were sacrificed. The criteria evaluated were intraoperative and postoperative complications, blood loss, renal function, and thickness of the parenchymal lesions induced. The Kruskal-Wallis nonparametric test for comparison of medians was used for statistical analysis of the data (P < 0.05). Data from pigs that died before the end of the study were excluded from the analysis.

RESULTS

All partial nephrectomies were performed laparoscopically, and all pigs were alive at the end of the operation. The postoperative complication rate was 11% (N = 3): two pigs died before the end of the study, one from hemorrhage on Day 6 (Group 2), and the other from prolonged reflex ileus with sacrifice of the pig on Day 7 (Group 3). One pig developed an asymptomatic urinoma (Group 2). Blood loss was significantly lower when ultrasound was used (P = 0.026). Global renal function was not significantly altered in the various groups. The median thickness of tissue necrosis and fibrosis detected in the scar zone was 6 mm (range 4-10 mm) and was similar in the three groups.

CONCLUSION

Partial nephrectomy can be performed by laparoscopy without vascular control in the pig. Coagulation by ultrasound appears to present an advantage in terms of limitation of blood loss compared with coagulation by bipolar or unipolar spray electrical currents without presenting any benefit in terms of preservation of the renal parenchyma.

Laparoscopic transverse hemicystectomy with ileocystoplasty in a porcine model

BACKGROUND AND PURPOSE

The ideal replacement for bladder tissue is yet to be described, although multiple alternatives have been studied. Currently, enterocystoplasty, despite its limitations, is considered the gold standard for bladder augmentation. This study evaluated the feasibility, safety, and morbidity of laparoscopic ileocystoplasty in a large-animal model.

MATERIALS AND METHODS

In eight minipigs, laparoscopy was performed using four ports. A segment of ileum was delivered through a 3-cm umbilical incision and detubularized and refashioned using standard open surgical technique. Laparoscopic hemicystectomy was then performed, followed by laparoscopic suturing of the ileal patch to the bladder. The bladder was drained with a Foley catheter, but no pelvic drain was placed. All animals were followed for for a minimum of 3 months. Preoperative and postoperative evaluation included measurement of bladder capacity, ultrasound imaging of the kidneys, blood counts, and serum electrolyte and creatinine measurements. Two of the animals were sacrificed at 3 months and one at 6 months, and the bladders were harvested.

RESULTS

Eight animals underwent ileocystoplasty without intraoperative or postoperative complications. The average operating and anastomosis time was 250 minutes and 96 minutes, respectively. All animals had normal preoperative blood values that remained normal during follow-up. Bladder capacity decreased initially to 71% of the baseline volume and then increased to 83% and 117% at 3 and 6 months. One of three animals sacrificed was noted to have a right midureteral stricture.

CONCLUSIONS

We developed a reliable laparoscopic technique for ileocystoplasty that may extend the advantages of laparoscopy, including better cosmesis and reduced risk of postoperative adhesions, to bladder augmentation.

Unilateral laparoscopic retroperitoneal lymphadenectomy for clinical stage I nonseminomatous testicular cancer

Since June 1993, unilateral laparoscopic retroperitoneal lymph-node dissection (LRPLND) has been performed in six patients with clinical Stage I nonseminomatous germ-cell tumors (NSGCT). All of the patients had undergone prior radical orchiectomy. The testicular cancer was left-sided in three cases and right-sided in three cases. Preoperative staging by means of tumor marker assessment, CT scan of the chest and abdomen, and chest radiography was unremarkable for metastatic disease. All procedures were accomplished without any complications in a mean time of 325 minutes (275-420 minutes). The estimated perioperative and postoperative blood loss was minimal, and none of the patients required blood transfusion. In the case of the first patient, the hospital stay was 18 days because of a widespread subcutaneous emphysema. In the remaining five cases, the average hospitalization was 4.8 days (range 4-6 days). The patients resumed normal activities within 12 to 27 days (mean 16.16 days) postoperatively. The mean number of lymph nodes removed was 6.8 (range 5-9). Histologic examination of these nodes revealed microscopic metastases from embryonal carcinoma in two patients, both of whom were subjected to adjuvant chemotherapy. The mean follow-up period is 27.1 months (range 12-42 months). To date, no relapses have been observed. In accordance with other reports, we believe that LRPLND is both feasible and effective. However, larger and more comprehensive studies with long-term follow-up are required to determine whether this approach is reliable and definitely superior to standard open surgery in the management of clinical Stage I NSGCT.

A review of our first 100 cases of laparoscopic nephrectomy: defining risk factors for complications

OBJECTIVE

To present the complications from our first 100 cases of laparoscopic nephrectomy, a technically demanding procedure requiring lengthy experience, and to define the risk factors.

PATIENTS AND METHODS

Indications for laparoscopic nephrectomy included patients requiring nephrectomy for benign pathology and those requiring nephroureterectomy for upper tract transitional cell carcinoma confined to the upper ureter and/or renal pelvis. All patients were operated on by one surgeon (D.A.T.) via a transperitoneal route and data on diagnosis, outcome and complications collected prospectively.

RESULTS

The overall complication rate was 18%, of which 3% were major and 15% minor complications. Five cases were converted to open surgery electively. Complications and conversions were associated with a history of pyonephrosis, previous renal surgery, staghorn calculi, polycystic kidney disease, and xanthogranulomatous pyelonephritis. While there was no discernible decline in the decrease in complications with experience, operative duration decreased from a mean of 204 min for the first 20 cases to 108 min for the last 20. Complications and conversions were more closely associated with diagnosis than with the surgeon's experience.

CONCLUSION

Laparoscopic nephrectomy and nephroureterectomy can be undertaken for a variety of indications with reasonable complication and conversion rates. Although inflammatory conditions increase the difficulty of these procedures, we feel that patients requiring nephrectomy for benign disease should be offered a trial of laparoscopic surgery.

Initial experiences with the retroperitoneal approach for endoscopic nephrectomy with the patient in the prone position

Retroperitoneal endoscopic nephrectomy with the patient in the prone position was performed in 12 patients. Indications for this procedure were end-stage kidneys with ureteropelvic junction stenosis or distal ureteric obstruction, nonfunctional kidneys with drug resistant renin-mediated hypertension, and distal ureter malignancy. The retroperitoneal area was exposed using an open surgical technique in combination with the use of a liquid-filled dissection balloon. Removal of kidney tissue was performed with a morcellator through one of the ports. On average, the operating time was 210 min (range 160-480 min) to complete a one-sided nephrectomy. No major complications occurred. Mean hospital stay in this series was 6.6 days, and the follow-up period was uncomplicated in all cases. Retroperitoneal endoscopic nephrectomy with the patient in the prone position is an acceptable alternative to open nephrectomy in selected indications.

Laparoscopic adrenalectomy for bilateral pheochromocytoma: a case report

We report a case of bilateral (2.4-cm left and 6.5-cm right) adrenal pheochromocytoma in a 27-year-old man that was treated by laparoscopic adrenalectomy. The patient had no evidence of multiple endocrine neoplasia, type II. The left adrenalectomy was performed first, with the patient in a semilateral position, and then the patient was turned before the procedure was begun on the right side. His postoperative convalescence was uneventful, and he continues corticosteroid replacement therapy. Transperitoneal laparoscopic adrenalectomy can be a safe procedure for bilateral pheochromocytoma, if the patients are carefully selected and the procedures are performed by experienced laparoscopists.

Laparoscopic urologic surgery outcome assessment

Laparoscopic surgery is an evolving technique that began to be applied widely in urology in the early 1990s. We have conducted an ongoing multicenter study of laparoscopic urologic surgery to identify any changes in utilization, complications, and short- and long-term outcomes. Laparoscopic urologic surgical procedures were assessed in three successive phases: retrospective initial experience [P1] (before 1991), and prospectively, an intermediate phase [P2] (1991-1992) and a late phase [P3] (1993-1994). The late phase group was followed for 1 year through 1995 to identify any delayed complications. In the P1 group, 114 patients are included; 105 underwent laparoscopic pelvic lymph node dissection (LPLND), 7 underwent laparoscopic variocele ligation (LVL), and 2 underwent other procedures. The complication rates in P1 are 21% (total): 10.5% (major) and 10.5% (minor). The P2 group includes 148 patients; 132 underwent LPLND, 10 underwent LVL, and 6 underwent other procedures. The complication rates decreased to 16.2% (total): 6% (major) and 10.1% (minor). The latest group (P3) includes 326 subjects; 245 had LPLND, 39 had LVL, and 42 had other procedures. More improvement in outcome is shown in this phase with a 7.98% total complication rate: 0.92% major and 7.05% minor. In addition, other parameters such as operative time and hospital stay show improvement through the successive phases. There were no significant long-term complications in the latest study group. This study demonstrates a continual improvement in outcome and changes in utilization patterns as urologists become more experienced with laparoscopic surgery. The complexity of the procedures performed has increased with a decrease in the complication rates overall.