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.

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 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.

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.

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.

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 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.

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 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.

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.

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.

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.