Robotic assisted laparoscopic pyeloplasty

Dismembered pyeloplasty is the gold standard treatment for adult ureteropelvic junction obstruction with published success rates consistently over 90%. The morbidity of the open flank incision required for dismembered pyeloplasty led to experimentation with other less invasive modalities such as endopyelotomy and laparoscopic techniques. Modern laparoscopic pyeloplasty series demonstrate success rates equivalent to those of their open counterparts with improved postoperative convalescence. The requirement of complex intracorporeal reconstruction has limited widespread application of laparoscopic pyeloplasty. The daVinci surgical robotic platform offers features that improve intracorporeal reconstruction and suturing thereby flattening the learning curve of laparoscopic pyeloplasty for residents, fellows, and novice laparoscopists. Multiple variations in robotic technique exist but short term outcomes and convalescence appear equivalent to open and laparoscopic pyeloplasty. Complications related to robotic assisted laparoscopic pyeloplasty are minimal and usually self-limiting. The indications for robotic pyeloplasty have expanded to include difficult cases such as those who have failed previous therapy for ureteropelvic junction obstruction including failed endopyelotomy or previous pyeloplasty. The appeal of robotic technology is tempered somewhat by its high cost compared to standard laparoscopic techniques but it is hoped that overall costs will decrease with time.

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.

A transperitoneal laparoscopic approach to endourology

Although endoscopic methods have become the preferred means of management for many diseases facing the genitourinary surgeon, a laparoscopic approach might be considered comparable or advantageous in select circumstances. In the literature, laparoscopists reporting their work have favored the transperitoneal approach; however, there are clear advantages and disadvantages to both transperitoneal and retroperitoneal laparoscopy. Intracorporeal suturing remains the most time-consuming aspect of reconstructive surgery, and research emphasis has been on suturing devices and novel anastomotic techniques. Laparoscopic pyeloplasty is efficacious and should be considered, particularly in the case of a capacious renal pelvis, crossing vessel, or failed previous endopyelotomy. Laparoscopic pyelolithotomy is uniquely suitable for patients with aberrant anatomy, such as a horseshoe kidney, and may be performed concurrently with pyeloplasty for ureteropelvic junction obstruction. The use of laparoscopic extravesical ureteral reimplantation awaits further development in both open and subtrigonal injection techniques. Its use in colposuspension is undetermined and requires further study as suturing technology improves. During laparoscopic exploration, it is possible to address intraoperative injuries to the ureter and bladder laparoscopically. In summary, laparoscopic surgery of the urinary tract is a "work in progress," but it offers promise for some of the most challenging of circumstances. As the technology advances and the clinical experience widens, the indications and contraindications for these techniques will be better established.

Laparoscopic repair of incisional and parastomal hernias after major genitourinary or abdominal surgery

BACKGROUND AND PURPOSE

Abdominal wall or parastomal hernias following major genitourinary or abdominal surgery are a significant surgical problem. Open surgical repair is difficult because of adhesion formation and poor definition of the hernia fascial edges. Laparoscopic intervention has allowed effective correction of these abdominal wall hernias.

PATIENTS AND METHODS

From November 1997 to June 2000, 14 male and 3 female patients underwent laparoscopic abdominal wall herniorrhaphy at our institution. Of these, 13 patients received incisional and 4 parastomal hernia repair. All hernia defects were repaired using a measured piece of Gore-Tex DualMesh. A retrospective review of each patient's history and operative characteristics was undertaken.

RESULTS

All repairs were successful. No patient required conversion to an open procedure, and there were no intraoperative complications. The average operative time was 4 (range 2.5-6.5) and 4.3 (range 3.75-5.5) hours in the incisional and parastomal group, respectively. The average hospital stay was 4.9 days (range 2-12) for the incisional group and 3.8 (range 3-4) days for the parastomal group. To date, two patients experienced a recurrence of incisional hernias, at 5 and 8 months postoperatively. No recurrences have developed in the parastomal hernia repairs at 2 to 33 months.

CONCLUSION

Laparoscopic repair of abdominal wall incisional or parastomal hernias provides an excellent anatomic correction of such defects. Adhesions are lysed under magnified laparoscopic vision, and the true limits of the fascial defects are clearly identified. The DualMesh is easy to work with and has yielded excellent results. A comparison with open repair with respect to perioperative factors and long-term success is currently under way.

Morbid obesity and the prone position: a case report

An improperly positioned prone patient can experience serious impairment of cardiopulmonary function. However, with appropriate preparation, even an extremely obese patient can safely tolerate the prone position.

Laparoscopic management of bladder pheochromocytoma

Pheochromocytoma primarily involving the bladder is an uncommon pathologic finding. Patients may present with transient hypertension associated with palpitations and diaphoresis on micturition. A case of bladder pheochromocytoma treated by laparoscopic partial cystectomy is presented. The management principles of bladder pheochromocytoma for our specific case are discussed. Successful treatment requires that the correct diagnosis and tumor location be made in conjunction with the obligatory preoperative preparation of the patient.

Laparoscopic partial nephrectomy and wedge resection

Partial nephrectomy is a more challenging operation than radical or simple nephrectomy, primarily because of the risk of complications such as bleeding. This problem is even more troublesome with minimally invasive approaches because of the dearth of effective hemostatic instruments and supplies. The location of the lesion determines whether a transperitoneal or a retroperitoneal route will be employed. Centrally located or anterior renal lesions generally are approached transperitoneally whereas peripheral lateral or posterior lesions are accessed by retroperitoneoscopy. The Harmonic Scalpel with slow cutting and high coagulation settings is useful for incising the renal capsule and parenchyma. The argon beam coagulator is helpful to stop any persistent bleeding. The few reported series of laparoscopic partial nephrectomy indicate considerably longer operative times than are needed for open surgery and hospitalization of upwards of 5 days, largely to monitor drainage and urine leakage. It is hoped that this advanced laparoscopic technique will become more user friendly with further developments in techniques and instrumentation to provide patients with the expected benefits of minimally invasive surgery.

Laparoscopic lymph node dissection: pelvic and retroperitoneal

The application of laparoscopic procedures to the field of urology continues to expand at a rapid rate. The initial animal studies performed in the late 1980s were brought into the clinical arena by 1990. The first widely accepted procedure was laparoscopic pelvic lymph node dissection for the staging of prostate cancer. Since that time, numerous laparoscopic procedures have been developed and accepted. Herein we discuss laparoscopic pelvic lymph node dissection for the staging evaluation of cancer of the prostate with possible applications to the bladder, urethra, and penis. The technique of laparoscopic retroperitoneal lymph node dissection has been used for cancer of the testes and will also be described. The indications and a brief review of the postoperative results will also be discussed for each malignancy.

Survey of neuromuscular injuries to the patient and surgeon during urologic laparoscopic surgery

OBJECTIVES

Laparoscopy may be complicated by neuromuscular injuries, both to the patient and to the surgeon. We used a survey to estimate the incidence of these injuries during urologic laparoscopic surgery, to assess risk factors for these injuries, and to determine preventive measures.

METHODS

A survey of neuromuscular injuries associated with laparoscopy submitted to 18 institutions in the United States was completed by 18 attending urologists from 15 institutions.

RESULTS

From among a total of 1651 procedures, there were 46 neuromuscular injuries in 45 patients (2.7%), including abdominal wall neuralgia (14), extremity sensory deficit (12), extremity motor deficit (8), clinical rhabdomyolysis (6), shoulder contusion (4), and back spasm (2). Neuromuscular injuries were twice as common with upper retroperitoneal as with pelvic laparoscopy (3. 1% versus 1.5%). Among patients with neuromuscular injuries, those with rhabdomyolysis were heavier (means 91 versus 80 kg) and underwent longer procedures (means 379 versus 300 minutes), and those with motor deficits were older (means 51 versus 42 years of age). Of the surgeons, 28% and 17% reported frequent neck and shoulder pain, respectively.

CONCLUSIONS

Although not common, neuromuscular injuries during laparoscopy do contribute to morbidity. Abdominal wall neuralgias, injuries to peripheral nerves, and joint or back injuries likely occur no more frequently than during open surgery, but risk of rhabdomyolysis may be increased. Positioning in a partial rather than full flank position may reduce the incidence of some injuries. Measures to reduce neuromuscular strain on the surgeon during laparoscopy should be considered.

Laparoscopic practice patterns among North American urologists 5 years after formal training

PURPOSE

We assessed urologist laparoscopy practice patterns 5 years after a postgraduate training course in urological laparoscopic surgery. Results were compared to findings from similar studies performed on the same cohort at 3 and 12 months after training.

MATERIALS AND METHODS

Between January 1991 and November 1992, 11, 2-day university sponsored, postgraduate laparoscopic surgery training programs were held. A survey was mailed to the 322 North American participants in the summer of 1997 to determine current laparoscopic use and experience.

RESULTS

Of the 166 respondents (51% response rate) 53.6% (89) had performed 1 or more laparoscopic procedures in the previous year, compared to 84% 1 year following course completion. Of the respondents 37% believed their laparoscopic experience was sufficient to maintain skills compared to 66% at 1 year. Of the respondents 6% had performed more laparoscopic procedures while 82% had performed fewer than anticipated. Reasons cited for decreased use included decreasing and/or lack of indications, increased cost, decreased patient interest, higher complication rates, decreased institutional support and increased operative time. Respondents practicing in academic or residency affiliated centers, or those who had completed residency after 1980 were more likely to have performed more procedures than anticipated (p = 0.044) compared to community based colleagues.

CONCLUSIONS

Laparoscopic use by urologists trained in the postgraduate setting is decreasing. Few respondents are maintaining the skills acquired during the original training course. Decreased use appears to be multifactorial.

Retroperitoneal and pelvic extraperitoneal laparoscopy: an international perspective

OBJECTIVES

To assess technical preferences and current practice trends of retroperitoneal and pelvic extraperitoneal laparoscopy.

METHODS

A questionnaire survey of 36 selected urologic laparoscopic centers worldwide was performed.

RESULTS

Twenty-four centers (67%) responded. Overall, 3988 laparoscopic procedures were reported: transperitoneal approach (n = 2945) and retroperitoneal/extraperitoneal approach (n = 1043). Retroperitoneoscopic/extraperitoneoscopic procedures included adrenalectomy (n = 74), nephrectomy (n = 299), ureteral procedures (n = 166), pelvic lymph node dissection (n = 197), bladder neck suspension (n = 210), varix ligation (n = 91), and lumbar sympathectomy (n = 6). Mean number of total laparoscopic procedures performed in 1995 per center was 41 (range 5 to 86). Major complications occurred in 49 (4.7%) patients and included visceral complications in 26 (2.5%) patients and vascular complications in 23 (2.2%). Open conversion was performed in 69 (6.6%) patients, electively in 41 and emergently in 28 (visceral injuries, n = 16; vascular injuries, n = 1 2). Retroperitoneoscopy/extraperitoneoscopy is gaining in acceptance worldwide: in 1993, the mean estimated ratio of transperitoneal laparoscopic cases versus retroperitoneoscopic/ extraperitoneoscopic cases per center was 74:26; however, in 1996 the ratio was 49:51.

CONCLUSIONS

Retroperitoneoscopy and pelvic extraperitoneoscopy are important adjuncts to the laparoscopic armamentarium in urologic surgery. The overall major complication rate associated with retroperitoneoscopy/extraperitoneoscopy was 4.7%.

Laparoscopic retroperitoneal lymphadenectomy for cancer of the testis

Laparoscopic retroperitoneal lymph node dissection (RPLND) is a technically advanced procedure that has been undertaken for the management of low-stage nonseminomatous germ cell testis tumor. Although it has been shown to be an effective staging technique, its role as a therapeutic operation is currently unknown. Laparoscopic RPLND requires longer operative times but offers the patient all the advantages of minimally invasive surgery, such as less postoperative pain and shorter hospitalization and convalescence. The role of laparoscopic RPLND for the evaluation of residual abdominal masses following chemotherapy is currently being examined.

Laparoscopic adrenalectomy: the preferred choice? A comparison to open adrenalectomy

PURPOSE

We compare the effectiveness and efficiency of laparoscopic adrenalectomy to open surgical management of adrenal disorders.

MATERIALS AND METHODS

A retrospective comparison was undertaken of 21 patients who underwent transperitoneal laparoscopic adrenalectomy between April 1996 and May 1997 with 17 patients who underwent open adrenalectomy between October 1994 and January 1996. Any patient suspected of having primary adrenal carcinoma and/or an adrenal lesion larger than 6 cm. was excluded from the study.

RESULTS

Patient demographics were matched well. Mean laparoscopic surgical time was 79 minutes longer than for open surgery. After overcoming the learning curve, the surgical time decreased by 59 minutes in the last 10 laparoscopic adrenalectomies. All laparoscopic intraoperative complications were managed without the need for open surgical conversion. Postoperative characteristics demonstrated significant benefits in the laparoscopic group (p=0.001) with respect to days to return to full diet (1.7 versus 4.6), analgesic pain requirements and days of hospitalization (2.7 versus 6.2).

CONCLUSIONS

Laparoscopic adrenalectomy offers significant postoperative benefits to patients with benign adrenal disease requiring surgical intervention. The surgical time is longer than that for open adrenalectomy but there was an encouraging reduction in time after overcoming the laparoscopic learning curve. Laparoscopic adrenalectomy is an excellent choice for tumors smaller than 6 cm. Its role for larger lesions and/or primary adrenal carcinoma is currently under investigation.

Needlescopic adrenalectomy--the initial series: comparison with conventional laparoscopic adrenalectomy

OBJECTIVES

To report the initial series of needlescopic transperitoneal adrenalectomy and to compare the results with a contemporary series of conventional transperitoneal laparoscopic adrenalectomy performed at the same institution.

METHODS

Fifteen patients underwent needlescopic adrenalectomy over a 4-month period. Outcome data were retrospectively compared with 21 conventional laparoscopic adrenalectomies performed over the preceding 12-month period at the same institution. The needlescopic technique included three subcostal ports (two, 2 mm; one, 5 mm) and one umbilical port for ultimate specimen extraction (10/12 mm). The laparoscopic technique included four subcostal ports (all 10/12 mm). Endoscopic transperitoneal adrenalectomy was completed by the standard technique in both groups.

RESULTS

Baseline demographics were comparable between the needlescopic (n = 15) and laparoscopic (n = 21) groups. The needlescopic group had a shorter surgical time (169 versus 220 minutes, P = 0.05), less blood loss (61 versus 183 mL, P = 0.002), and shorter hospital stay (1.1 versus 2.7 days, P < 0.001). Convalescence averaged 2.1 weeks in the needlescopic group and 3.1 weeks in the laparoscopic group (P < 0.001). No significant complications occurred in either group. One patient in the needlescopic group was converted to conventional laparoscopy because of marked obesity; hospital stay in this patient was 2 days.

CONCLUSIONS

Reported herein is the initial series of needlescopic adrenalectomy. Compared with conventional laparoscopy, needlescopic adrenalectomy results in an overnight hospital stay, rapid recovery, and excellent cosmesis. However, prior experience with conventional laparoscopy is essential before embarking on needlescopic surgery.

Increased intra-abdominal pressure during pneumoperitoneum stimulates endothelin release in a canine model

Prolonged pneumoperitoneum during laparoscopic surgery has been associated with oliguria in clinical experimental studies. Although the pathophysiology of this oliguria is thought to be renal parenchymal and venous compression, the role of the potent vasoconstrictor endothelin (ET) has not been studied. The purpose of this study was to investigate the effect of pneumoperitoneum on endothelin release and renal function in a canine model. Two groups of dogs were studied during pneumoperitoneum (Group 1, N = 7) or isolated left renal vein compression (Group 2, N = 6). Urine and plasma samples were collected for urine output, glomerular filtration rate (GFR), urine sodium, and plasma endothelin measurements. In Group 1, GFR fell significantly (p < 0.05) by 49% from a control of 0.88 +/- 0.12 mL/min per gram of kidney weight. Urine volume fell by 79% (p < 0.05) from a control value of 0.014 +/- 0.003 mL/min/gkw. Sodium excretion was decreased by 88%. Sodium reabsorption was significantly enhanced during pneumoperitoneum (99.56 +/- 0.15% v 98.44 +/- 0.25%). Arterial plasma ET concentrations were elevated by 8% during the first 20 minutes of pneumoperitoneum (30.8 +/- 3.6 v 33.3 +/- 3.4 pg/mL; p < 0.05). In Group 2, left renal vein compression resulted in a 31% decrease (p < 0.05) in GFR in the left kidney and a 25% decrease in the right kidney. Urine volume fell by 67% in the left kidney and 40% in the right. Renal venous ET concentrations also increased after renal vein compression. Although the mechanism by which oliguria occurs during pneumoperitoneum is not fully understood, the ET concentration was elevated. Because ET can decrease RBF, GFR, and sodium excretion, it may contribute to the oliguria observed during long periods of pneumoperitoneum.

Effect of laparoscopic pelvic lymph node dissection on the natural history of D1 (T1-3, N1-3, M0) prostate cancer

OBJECTIVES

Reports of abdominal wall tumor implantation after laparoscopic procedures have raised questions regarding the safety of laparoscopic surgery when applied to patients with malignancies. Our objective was to determine if laparoscopic pelvic lymph node dissection (LPLND) had a negative effect on tumor behavior and clinical outcome in men with Stage T1-3, N1-3, M0 (D1) prostate cancer.

METHODS

Fifty-two men were retrospectively identified at four institutions who had pelvic nodes positive for metastatic prostate adenocarcinoma at LPLND and at least 1 year of follow-up. Operative and clinical records were reviewed to determine morbidity, adjuvant treatment, onset of hormone-resistant disease, and survival.

RESULTS

During a mean follow-up of 3.1 years, there were no cases of trocar site tumor implantation. There were four perioperative complications, including enterotomy, epigastric vessel injury, abscess, and symptomatic lymphocele formation. There were three deaths from prostate cancer (5.8%) occurring 3 to 4 years after LPLND. For the 45 men treated with early androgen ablation, the 5-year biochemical prostate-specific antigen and clinical progression free rates were 45% and 55%, respectively.

CONCLUSIONS

Abdominal wall tumor implantation after LPLND for prostate cancer was not demonstrated, even in patients who developed hormone-resistant disease. LPLND in men with Stage D1 disease did not alter short-term disease progression. Longer follow-up in a larger cohort is necessary to determine if LPLND will have an impact on the 5 and 10-year disease progression and survival rates for patients with Stage D1 prostate cancer.

Hip and knee replacement as a relative contraindication to laparoscopic pelvic lymph node dissection

PURPOSE

We investigated the effect of lower extremity joint prostheses on subsequent laparoscopic pelvic lymph node dissection.

MATERIALS AND METHODS

We reviewed the records and pathology studies of 5 patients who underwent laparoscopic pelvic lymph node dissection subsequent to total hip or knee replacement from 1990 through 1995.

RESULTS

Four of the 5 laparoscopic operations were complicated, 3 were unsuccessful in obtaining bilateral pelvic lymph nodes and 2 required conversion to an open procedure. Examination of the lymph nodes revealed sinus histiocytosis in the 4 cases in which nodal tissue was removed.

CONCLUSIONS

The increased risk of complications in certain patients with lower extremity joint prostheses may contraindicate attempted laparoscopic pelvic lymph node dissection.

Laparoscopic nephrectomy of a horseshoe kidney

The role of laparoscopic surgery in the treatment of benign renal diseases continues to evolve with the development of equipment and refinement of techniques. A minimally invasive approach to the treatment of these lesions offers several advantages, including shorter convalescence. We describe the first laparoscopic nephrectomy involving a horseshoe kidney.

Technique of laparoscopic adrenalectomy

Laparoscopic adrenalectomy by the transperitoneal route has been shown to be a safe and effective approach to select adrenal pathology. Although the specific indications will continue to be refined, it is clear that for adrenal masses of 6 cm or less, laparoscopy provides excellent access with little additional risk to the patient. In addition there appears to be an improved postoperative course when compared with open adrenalectomy. This latter point, however, requires careful prospective studies to confirm this impression objectively. The operative times are longer by the laparoscopic approach, but undoubtedly these times will decrease with increasing experience and improved laparoscopic instrumentation.

Laparoscopic pelvic lymph node dissection following definitive radiotherapy for carcinoma of the prostate

PURPOSE

Laparoscopic pelvic lymph node dissection is an effective and minimally invasive approach to the clinical staging of adenocarcinoma of the prostate. We report our experience with this technique in patients in whom full course pelvic radiotherapy had failed and who were being considered for salvage local therapy.

MATERIALS AND METHODS

In 14 patients disease was staged by transperitoneal laparoscopic pelvic lymph node dissection performed for persistent adenocarcinoma of the prostate at least 20 months (average 49.5) following external beam radiotherapy and/or brachytherapy. All patients were healthy, had no evidence of metastatic disease and were considered to be candidates for salvage therapy.

RESULTS

A total of 13 patients underwent successful laparoscopic pelvic lymph node dissection while 1 sustained an enterotomy requiring conversion to open surgery. The normal surgical planes were more difficult to dissect, with the obturator lymph node packets appearing smaller and more fibrotic than in nonirradiated patients, yielding an average of 7.1 total nodes. Average operative time was 167 minutes and postoperative hospitalization was comparable to reported series of nonirradiated patients. Four patients (28%) with metastatic pelvic lymph nodes underwent subsequent orchiectomy. Nine patients with negative lymph nodes underwent ultrasound guided transperineal placement of radioactive gold or palladium seeds. One patient underwent salvage radical retropubic prostatectomy.

CONCLUSIONS

Laparoscopic pelvic lymph node dissection following full course pelvic irradiation is technically feasible, albeit more difficult than in nonirradiated patients. This approach appears to be an excellent minimally invasive technique for the clinical restaging of persistent adenocarcinoma of the prostate in patients being considered for salvage therapy.

Role of laparoscopic surgery in pediatric urology

OBJECTIVES

In our clinic, laparoscopy was introduced in 1987 for the exploration of non-palpable testes and since 1991 it has also been applied with therapeutic aims. We present our experience with this minimally invasive technique in pediatric patients.

PATIENTS AND METHODS

Between May 1987 and September 1996, 219 laparoscopic procedures were performed in children. All children received general anesthesia. Positioning of the patient on a rotatable and tiltable operating table is very important.

RESULTS

All laparoscopic interventions were well tolerated in children. The operative time for exploration of a nonpalpable testis ranged from 10 to 30 min, and for varix ligation from 15 to 30 min. In nephrectomy and nephroureterectomy cases 80-150 min were required. The excision of the urachal remnant and the drainage of lymphocele took between 30 and 70 min. No immediate postoperative complications were observed. Mobilization and oral intake were routinely carried out on the day of surgery. The children required little or no postoperative pain medication.

CONCLUSION

Laparoscopy has been found to be the most reliable diagnostic tool in evaluating nonpalpable testes within the pediatric population. This approach enables subsequent therapy of laparoscopic orchiectomy, primary laparoendoscopic orchidopexy, or laparoscopically assisted two-stage Fowler-Stephens maneuver. Laparoscopic varix ligation is a simple and highly effective treatment modality for the pubescent male with a symptomatic varicocele. To date, the recurrence rate is 1.8% based on 80 patients followed for over 1 year. Fenestration of lymphoceles following renal transplantation has been found to be as efficaciously treated with laparoscopy as with open surgery. Laparoscopic nephrectomy and/or nephroureterectomy are technically demanding procedures and should only be performed by an experienced laparoscopic surgical team to minimize the complication rate. At the present time, the intraoperative costs of laparoscopic surgery are greater than with open surgery due to the use of disposable instrumentation and longer operating room times. However, minimally invasive surgery continues to gain a greater and more important role in the field of pediatric urology.

Sequential laparoscopic bladder diverticulectomy and transurethral resection of the prostate

The surgical treatment of prostatic obstruction associated with a clinically significant bladder diverticulum has classically combined open diverticulectomy with relief of the bladder outlet obstruction. This report demonstrates that this result may be efficiently achieved by performing transurethral surgery followed immediately by laparoscopic excision of the diverticulum. As assessed by a retrospective comparison with four open bladder diverticulectomies combined with transurethral resection of the prostate, laparoscopic diverticulectomy markedly reduces the postoperative and convalescence period. The overall financial saving that ensues may benefit both the patient and the healthcare system. Sequential laparoscopic bladder diverticulectomy and transurethral resection of the prostate illustrates the increasing possibilities of minimally invasive surgery.

Comparative financial analysis of laparoscopic pelvic lymph node dissection performed in 1990-1992 v 1993-1994

In 1994, it was reported that laparoscopic pelvic lymph node dissection (L-PLND) was US $1350 more expensive than open pelvic lymph node dissection (O-PLND) for the staging of prostate cancer. Despite the lower postoperative expenses associated with L-PLND, the intraoperative expenditures were 52% higher, primarily because of the prolonged operating time and the cost of disposable instrumentation. The objective of the present study was to determine if, with increasing laparoscopic experience and a more competitive surgical supply market, the intraoperative as well as the overall hospital expenses would diminish. The study population consisted of 105 men who underwent staging L-PLND for cancer of the prostate. Group I was composed of 50 patients who underwent surgery between 1990 and 1992, and Group II consisted of 55 patients operated on in 1993 and 1994. All hospital-related expenses were reorganized into preoperative, intraoperative, and postoperative and subsequently corrected for inflationary changes to a base year of 1993-1994. The total overall expenses of the two groups were similar, differing by only $65. Despite a lowering of preoperative and postoperative expenses in the 1993-1994 group by 112% and 31%, respectively, the intraoperative expenses were still $571 higher. The operative time decreased by 19 minutes in the contemporary group, but the expense of surgical supplies continued to increase up to $910 (104%) more than the 1990-1992 group. It is hoped that the use of "laparoscopic kits" as well hospital equipment consortiums will help slow the escalating costs of surgical care. However, it is the responsibility of the laparoscopic surgeon to demonstrate that these procedures are as safe, efficient, and cost-effective as their open counterpart.

Carbon dioxide homeostasis during transperitoneal or extraperitoneal laparoscopic pelvic lymphadenectomy: a real-time intraoperative comparison

The primary goal of this study was to evaluate differences in carbon dioxide metabolism between patients undergoing transperitoneal or extraperitoneal laparoscopic pelvic lymph node dissection (L-PLND) for staging of adenocarcinoma of the prostate (CaP). Eighteen candidates undergoing L-PLND were divided between the transperitoneal (N = 12) and extraperitoneal (N = 6) approaches. End-tidal partial pressure of CO2 (PeCO2) and minute volume of expired CO2 (VCO2) were considered indicators of CO2 absorption. These two parameters were monitored intraoperatively utilizing a metabolic cart and Ohmeda Rascal-II. The cardiostimulatory effect of increasing serum CO2 and the ventilatory countermeasures used to correct the iatrogenic hypercapnia associated with CO2 insufflation were also measured. With the exception of the region of CO2 insufflation, the operative procedure and perioperative care were identical for the two groups. Preoperative patient characteristics were similar. The mean time of CO2 insufflation was 136 minutes for the transperitoneal group and 120 minutes for the extraperitoneal group. The absorption of CO2 was significantly greater and more rapid during extraperitoneal L-PLND. This may be attributable to more profound CO2 absorption from the parietal peritoneal surface compounded by subcutaneous CO2 emphysema. Disruption of microvascular and lymphatic channels during the development of the extraperitoneal working space facilitates direct CO2 absorption into the intravascular space. A minor increase in heart rate and systolic blood pressure was noted during CO2 insufflation. In all but one patient (extraperitoneal group), hypercarbia and acidemia were prevented by an increased ventilatory rate. The potential dysrhythmogenicity of hypercarbia may contraindicate the extraperitoneal approach in patients with cardiopulmonary disease.

Laparoscopic urethral sling for treatment of intrinsic sphincter deficiency

The surgical treatment of intrinsic sphincter deficiency, or Type III genuine stress urinary incontinence, has traditionally been accomplished by sling cystourethropexy, the placement of an artificial urinary sphincter, or periurethral injection. We developed a laparoscopic approach for the performance of a sling cystourethropexy as an alternative to the open approach and herein describe our experience. We have found that a laparoscopic sling cystourethropexy is feasible, but at the present time, we have been unable to demonstrate any significant advantages to the patient in terms of decreased cost or convalescence compared with the open vaginal sling cystourethropexy.

Laparoscopic marsupialization of pelvic lymphoceles

Pelvic lymphoceles are a known complication of urologic surgery. Often, these are small and asymptomatic and require no specific therapy. When large or symptomatic, the treatment of choice is controversial, but includes needle aspiration, percutaneous drainage, sclerotherapy, open surgical marsupialization or, most recently, laparoscopic marsupialization. The laparoscopic technique described herein has been performed successfully by many urologists and is accepted as a standard laparoscopic procedure. Because of its efficacy and its low morbidity, laparoscopic marsupialization may be considered a first-line treatment for pelvic lymphoceles.

Laparoscopic urethral sling for the treatment of intrinsic urethral weakness (type III stress urinary incontinence)

The treatment of intrinsic urethral weakness (type III stress urinary incontinence) has traditionally been accomplished by the performance of a sling cystourethropexy, the placement of an artificial urinary sphincter, or periurethral injection. Herein we describe our experience using laparoscopy to perform a sling cystourethropexy.

Laparoscopically assisted penile revascularization for vasculogenic impotence

Young patients with impotence and cavernous arterial insufficiency resulting from trauma-induced arterial occlusive disease are ideal candidates for microvascular arterial bypass surgery. To avoid the long abdominal incision required to harvest the inferior epigastric artery, a laparoscopic approach was used. We report a case of laparoscopically assisted penile revascularization for vasculogenic impotence.

Laparoscopic partial nephrectomy: initial experience and comparison to the open surgical approach

During an 18-month period, 6 laparoscopic partial nephrectomies were attempted, 4 of which were successful. The surgical technique was modified and improved between cases aided by new laparoscopic instrumentation, such as the argon beam coagulator and the 7.5 MHz. ultrasonic sector scanning system. In a retrospective comparison between laparoscopic and open partial nephrectomy, estimated blood loss was 525 ml. for the former versus 708 ml. for the latter procedure. However, operating time was more than 2 hours longer with the laparoscopic approach. The major advantages of the laparoscopic procedure appear to be a more rapid return to full diet, less postoperative pain and less requirement for parenteral narcotics. Despite the small size of this series and limited followup data, convalescence may be shortened by 4 weeks after laparoscopic partial nephrectomy. Patients with benign diseases of the kidney, especially with a duplicated collecting system, who require partial nephrectomy may be considered candidates for the laparoscopic approach. The advantages to the patient, however, may be offset by the technical demands on the surgeon.

Laparoscopic urologic surgery. The financial realities

Since 1990, laparoscopic surgery has gained an important role in the specialty of urology. This article provides a financial analysis of the three most common urolaparoscopic procedures compared with their open surgical counterpart. The intraoperative costs of laparoscopic surgery are more expensive, but the postoperative expenses are less compared with open surgery. The financial ramifications of a shorter period of convalescence following laparoscopic surgery must be considered.

Laparoscopic approaches to the treatment of intrinsic urethral weakness (type III stress urinary incontinence)

The treatment of intrinsic urethral weakness (Type III stress urinary incontinence) has traditionally been accomplished by the performance of a sling cystourethropexy or the placement of an artificial urinary sphincter. As experience with operative laparoscopy continues to increase, the possibility of performing these procedures from a laparoscopic approach becomes realistic. We report our experience with the laparoscopic performance of a sling cystourethropexy and placement of an artificial urinary sphincter in the canine model. On the basis of initial results, we believe these techniques are feasible in human subjects.

Laparoscopic excision of urachal cyst

The treatment of choice for persistent urachal anomaly is radical surgical excision intended to prevent complications, notably malignancy in a retained remnant. We report a case of the radical laparoscopic excision of an infected urachal cyst. This effective alternative to an open technique has the advantages inherent in minimally invasive surgery.

Comparative financial analysis of laparoscopic versus open pelvic lymph node dissection for men with cancer of the prostate

Laparoscopic pelvic lymph node dissection has been applied as a minimally invasive staging technique for men with prostate cancer. This procedure has been shown to shorten markedly postoperative hospitalization, decrease analgesic requirements and shorten convalescence period compared to open pelvic node dissection. However, the laparoscopic procedure takes longer to perform and many disposable instruments are used, thus increasing the cost. We determine the overall cost of laparoscopic versus open pelvic lymph node dissection. Between January 1989 and April 1992, 61 men underwent only staging pelvic lymph node dissection for cancer of the prostate at a single university teaching hospital. Of these patients 11 and 50 underwent open and laparoscopic pelvic lymph node dissection, respectively. Information from the hospital business office was reorganized into preoperative, intraoperative and postoperative expenses. All individual charges were transformed up or down to the dollar amounts of the 1990 to 1991 fiscal year so as to correct for inflationary changes. Preoperative costs were not significantly different between the 2 operative approaches. Intraoperative expenses were 52% greater if laparoscopic pelvic lymph node dissection was performed and can be explained by the longer operative times and use of disposable instrumentation. However, the postoperative period lasted an average of 1.61 days following laparoscopic pelvic lymph node dissection. Postoperative nursing and analgesic requirements were significantly more for patients undergoing open pelvic lymph node dissection. The overall postoperative costs following open pelvic lymph node dissection were 280% more expensive than for the laparoscopic procedure. The overall total costs were approximately $1,250 more for laparoscopic pelvic lymph node dissection. Wages lost or earned during this period and rapid return to normal activity following laparoscopic pelvic lymph node dissection would, in our opinion, justify this additional cost.

Laparoscopic partial nephrectomy: initial case report for benign disease

On February 12, 1992, a laparoscopic partial nephrectomy was performed on a woman with a lower-pole caliceal diverticulum containing a stone. By incorporating the laparoscopic argon beam coagulator and a tourniquet device, the procedure was completed in 6 hours and 10 minutes. The postoperative course and period of convalescence was markedly improved over that expected from open surgery. This laparoscopic intervention demonstrates the expanding horizons of minimally invasive surgery and the remarkable development of new laparoscopic devices.

Peptidergic nerves in the ureter

Vasoactive intestinal peptide (VIP) and substance P were demonstrated in the pig ureter by immunohistochemical techniques. Nerves containing these materials were related mainly to the smooth muscle layer in the normal and obstructed ureter. In isolated ureteral segments, VIP caused relaxation at doses exceeding 0.18 micrograms/ml, with no significant difference seen in the effect on normal and obstructed ureter. Vasoactive intestinal polypeptide may play a role in the regulation of ureteral smooth muscle tone.

Laparoscopic nephrectomy in crossed fused renal ectopia

Operative laparoscopy offers the patient a minimally invasive alternative to open surgery. We have recently performed a laparoscopic nephrectomy of the upper moiety of a crossed fused renal ectopia. The procedure lasted approximately six hours, and the patient was discharged on postoperative day 3. He was able to resume normal physical activity in one week. This case demonstrates the advantages of minimally invasive surgery.

Relationship of symptoms of prostatism to commonly used physiological and anatomical measures of the severity of benign prostatic hyperplasia

In previous studies the severity of symptoms of prostatism in men with benign prostatic hyperplasia have not correlated well with prostate size, degree of bladder trabeculation, uroflowmetry or post-void residual volume. As part of a prospective cohort study of benign prostatic hyperplasia treatment effectiveness in 4 university-based urology practices, we correlated symptom severity and these commonly used measures of disease severity. Symptom severity was quantified using the American Urological Association symptom index. Analyses were based on 198 outpatients completing a standardized evaluation (84 of these men have completed 6 months of followup after treatment with prostatectomy, balloon dilation, terazosin or watchful waiting). At baseline, symptom severity was not correlated with uroflowmetry, post-void residual, prostate size and degree of bladder trabeculation. However, symptom severity was much more strongly related to overall health status than the other measures. Reduction in symptoms with treatment did correlate with improvements in uroflowmetry. This poor baseline correlation with symptoms may reflect unreliability in measurement of the physiological/anatomical variables. Alternatively, these parameters may be measuring different pathophysiological phenomena.

Laparoscopic surgical training: effectiveness and impact on urological surgical practice patterns

Urological interest in laparoscopic surgical techniques has dramatically increased during the last several years. However, the extent to which these methods are being used and the impact of training courses on clinical use are unclear. We assessed urologist practice patterns subsequent to a formal training course in urological laparoscopic surgery. On 5 dates between January and October 1991, a total of 163 urologists participated in a 2-day, university sponsored, laparoscopic surgery training seminar. Instruction consisted of 8 hours of didactic lectures including 2 live video cases, 4.5 hours of simulation and 4.5 hours in a live animal laboratory. Three months after the course the participants were mailed a questionnaire inquiring as to the interval laparoscopic surgery experience. Practice demographics, additional training, equipment availability, number of laparoscopic surgery candidates identified, percentage of overall surgical case load, patient inquiries, cases performed and complications were assessed by the questionnaire. Descriptive and correlative information was then derived from the data set. A total of 105 course participants (64%) responded to the questionnaire and 64 had engaged in some form of additional training following the course. During the 3 months since course completion respondents had identified an average of 4 candidates for laparoscopic surgery, which represented a mean of 2.5% of the total case load. Specific patient inquiries averaged less than 1 per physician within 3 months. During this same interval respondents had performed a total of 156 laparoscopic procedures (1.7 per urologist). Of the participants 45% had not performed their first case and 32% had performed more than 1 laparoscopic procedure. A total of 11 complications was reported (7.2%) and in 7 instances the surgeon was required to convert to an open approach. Veress needle placement was perceived as the most difficult aspect of the technique (22% of the respondents). Training subsequent to the course was the best predictor of clinical use. Of those who responded 88% believed that their future use of laparoscopy would increase. This survey suggests that subsequent to training, laparoscopic techniques are being rapidly and safely used by urologists. However, in the current state of development the impact of laparoscopic surgery on global urological practice patterns appears to be small.

Inverted V peritoneotomy significantly improves nodal yield in laparoscopic pelvic lymphadenectomy

We compared the nodal yield and volume of target tissue removed in 3 groups of patients undergoing laparoscopic pelvic lymphadenectomy as a staging procedure for carcinoma of the prostate. With the exception of the type of peritoneotomy used to expose the obturator fossa, surgical management of all patients was identical. Results were evaluated in patients undergoing linear peritoneotomy (40), inverted V peritoneotomy (14) or both procedures (28, 1 approach on each side). Significantly more tissue was removed from patients in the inverted V group (16.3 +/- 8.3 cm.3) compared to the linear peritoneotomy group (7.2 +/- 5.7 cm.3, p = 0.004). This resulted in a significant increase in nodal yield in patients in the inverted V group (11.0 +/- 4.1) relative to the linear peritoneotomy group (6.8 +/- 5.2, p = 0.003). In terms of the volume of tissue removed and the number of nodes obtained, combination patients had values intermediate to those in the other groups (11.6 +/- 10.5 cm.3 and 8.8 +/- 5.6 nodes, respectively). The right-to-left ratio of nodes and tissue volume was reversed in the combination group relative to the other 2 groups. Operative time was significantly decreased for the inverted V technique compared to the linear peritoneotomy approach (p = 0.01). No difference in operative blood loss of complications was identified. The improved exposure obtained with this technique appears to result in a more complete lymphadenectomy without increased risk of complications.

Laparoscopic varix ligation

Varicocele, dilated veins in the pampiniform plexus, is frequently a contributing factor in male infertility. We performed outpatient laparoscopic varix ligation in 14 patients (5 bilaterally) with clinically evident varices and persistent oligospermia and/or asthenospermia. The spermatic artery was identified and preserved in all but 1 varix ligation. Mean interval to resumption of preoperative activity levels was 3.4 days. On average, patients consumed 8.4 tablets of acetaminophen (325 mg.) with codeine (30 mg.) during the recovery period. The procedure is effective and decreases postoperative morbidity.