LAPAROSCOPY UPDATE
SAKTI DAS, MD, FACS
After a decade of evolution, laparoscopic urology seems to have reached its zenith and yet it continues to soar through the relentless scientific pursuit of our pioneers and dedicated stalwarts, bringing us to newer shores of achievement. Laparoscopy has successfully ventured into almost all the urologic surgical domains and has evolved as a better alternative to orthodox open surgery. As I look back, it has been an exciting and eventful journey punctuated by poignant epochs of discoveries, developments, and rare disenchantments. These developments can be grouped into three distinct categories: new techniques, new tasks or indications, and new technologies.
New Techniques. In the domain of new techniques, hand-assisted laparoscopy continues to make strides and gain popularity amongst urologists. Interestingly, a technique that was developed and utilized exclusively for transperitoneal laparoscopy has now been extended to retroperitoneoscopic procedures as well by our colleagues in Japan and South Korea [1,2]. The relative ease of hand assistance entices the neophytes. However, we must use it judiciously for select indications only, where intact specimen retrieval necessitates an open incision. It should not be used indiscriminately in situations where standard trocar-only laparoscopy is feasible. Reports of the use of hand-assisted laparoscopy for simple procedures such as renal cyst unroofing and simple nephrectomy are disconcerting. I am also concerned about the 4-5% incidence of incisional hernia reported in the literature, which corroborates my personal experience in hand-assisted laparoscopy [3]. Such incidence of incisional hernia is unacceptable. Therefore, critical closure of this small incision with unabsorbable sutures using interrupted full-thickness closure is strongly recommended.
The technique of laparoscopic radical prostatectomy is evolving through different modifications espoused by different institutions. The transperitoneal versus the extraperitoneal approach to this procedure, as well as several nuances of seminal vesicle dissection and nerve-sparing techniques, are being developed. There is not yet a consensus about urethrovesical anastomosis using the standard multiple interrupted sutures or the two running sutures.
The other areas of technique innovation have focused on the complex intracorporeal surgeries that entail difficult dissection, hemostasis, and suturing. The reconstructive surgeries on the urinary tract involve thin-walled urothelium and connective tissues necessitating the use of finer suture material. Compared to the general surgeons, urologists are relying more on freehand intracorporeal suturing techniques than the mechanical suture devices. Mastering intracorporeal suturing is therefore indispensable for advanced urologic laparoscopy.
New Indications or Tasks. The new indications for the Year 2002 are essentially the expansion and improvement upon what we initiated in 2001. There certainly is a profusion of laparoscopic radical prostatectomies being carried out and accepted as a preferred modality in various centers around the world. The feasibility of this procedure is now well established. Significantly less blood loss and earlier achievement of continence are proven benefits of laparoscopic radical prostatectomy [4]. Recognition of early difficulties and limitations has led to modifications that are reducing the margin-positive rates close to that achieved with open radical prostatectomy. We eagerly await the long-term results of PSA negativity and survival statistics that need vigilant surveillance to prove the ultimate efficacy of this exquisite procedure.
The feasibility of simple and radical cystectomy has already been proven through sporadic reports in the last decade, but progress was limited by the difficulty of performing urinary diversion with the laparoscope [5]. With progressive experience in laparoscopic intestinal anastomosis and enterocystoplasties enhanced by our intracorporeal suturing expertise, various urinary diversions using completely intracorporeal maneuvers are now accomplished with an increasing level of comfort. This has led to the performance of laparoscopic radical cystectomy at several institutions. All varieties of urinary diversion, from ileal loop to orthotopic neobladder and continent cutaneous diversions, have been done. The group at Norfolk has reported on ten patients with laparoscopic radical cystectomy and orthotopic Mainz pouch diversion done entirely intracorporeally with an impressive 100% continence rate [6].
It is encouraging to note that some of the minor indications and simpler procedures have resurfaced and their efficacy has been reaffirmed. The Johns Hopkins group has proven with their large series of 74 patients that laparoscopic renal biopsy is the way to go in patients in whom percutaneous biopsy is difficult or contraindicated [7]. Similarly, the Washington University group, in their seven years’ experience of 29 patients with adult polycystic kidney disease, has observed that in patients with debilitating pain, extensive laparoscopic cyst decortication can provide long-term, durable pain relief without any adverse effect on renal function [8].
We applaud the endeavors of the Cleveland Clinic group in pushing the envelope to the extreme through exotic indications of complex laparoscopic urologic surgeries. These include laparoscopic ileal ureter, complex partial nephrectomies [9] with repair of the collecting system as needed, anatrophic nephrolithotomy, repair of renal artery aneurysms, etc., all of which have been performed successfully in clinical situations. In laboratory animal studies, they have proven the feasibility of laparoscopic renal autotransplantation, splenorenal bypass, and inferior vena caval and atrial thrombectomy. We eagerly await application of these exquisite procedures to suitable clinical situations in the near future. Truly, the indications of laparoscopic urology are limited only by our imagination. I envision a day when our open incision surgeries will be limited only to extracoelomic organs such as the penis, urethra, and scrotum.
New Technology. New technologies continue to aid in the progress of laparoscopic urology. For the purpose of thermal destruction of small, localized, renal cell cancers, cryoablation seems to offer consistently good results up to the available three-years follow-up by the Cleveland group. In contrast, the radiofrequency ablation requires improvement in performance and vigilance in followup, because a significant 20-30% of tumors are showing either histologic evidence of tumor persistence or CT-enhancing lesions during follow-up. We eagerly await the performance of new modalities such as laparoscopic high-intensity, focused ultrasound and ferromagnetic rod placement that are showing promising results in the laboratory.
For hemostatic sealing of blood vessels and collecting systems, two new technologies show promise in the laboratory: (1) Fibrin sealant powder with lyophilized human fibrinogen and thrombin applied as a dry spray and the other more exciting method, (2) bio-degradable synthetic polyethylene glycol lactide copolymer that forms a firm gel when applied to a cut surface and activated by green xenon light [10] (Figure 1). With hilar vascular control embellished by the use of various hemostatic sealants and suture closures, the majority of partial nephrectomies is coming to the domain of laparoscopic urology similar to the acceptance of laparoscopic radical nephrectomy as the standard of care for larger renal cell carcinomas.
In vascular clipping-stapling technology, the locking hemostatic Weck clips have proven extremely reliable and are definitely cost effective. The larger 13-mm clips are applicable to almost all the renal vessels, thereby effectively replacing the expensive vascular stapling devices (Figure 2). These clips also allow relatively more generous lengths of renal vessels during laparoscopic donor nephrectomy.
Of course, the most revolutionary recent technologic event is the interaction of intelligent, intuitive robotic devices in laparoscopic urology. This year, several institutions have reported their encouraging experience with robotic laparoscopic radical prostatectomy with a sprinkling of other procedures such as pyeloplasty, adrenalectomy, and donor nephrectomy [11]. At present, the Zeus System by Computer Motion and the da Vinci Robotic System by Intuitive Surgical, Inc. are competing for the lucrative market share. Although conceptually similar, both systems have disparate features that provide different strengths and weaknesses to the users. The unquestionable advantage is the ease of complex dissection and intracorporeal suturing provided by robotic assistance. The evolution of robotics continues with the development of suction and retraction instruments, the addition of auxiliary robotic arms, MR-compatible robotic instruments for image-guided robotic surgery, and hopefully, instruments for proprioception and haptic feedback. The future of robotics is charged with exciting possibilities; and with robotic assistance, laparoscopic urology is poised to take the quantum leap into new-age surgery.
It is evident that the invigorating interest and enthusiasm for laparoscopy is infectious in our urologic specialty. Our new generation of residents, after two years of preliminary surgical rotation, is arriving with a backbone of basic laparoscopy through their experience in a handful of laparoscopic cholecystectomies. With that compost already in ground, their expertise is ready to blossom with further nurturing in laparoscopic urology. At the same time, laparoscopy is too good and too ubiquitous to be sequestered into a separate subspecialty in urology. It must be ingrained and incorporated into our urologic residency training. And that, is what we see happening. The writing is on the wall and we welcome the revolution.
Figure 1. Ex-vivo hydrogel application to porcine kidney. Note: hydrogel cap adherent to amputated kidney surface.
Figure 2. Weck Hem-o-lok hemostatic clips.
This article is a synopsis of Dr Das’s presentation at Endo Expo 2002.
Address reprint requests to: Sakti Das, MD, FACS, 4860 Y St, Ste 3500, Sacremento, CA 95817, Telephone: 916 734 6491, Fax: 916 734 8094, E-mail: saktidas@aol.com
Sakti Das, MD, graduated in medicine from the University of Calcutta, India and completed his postgraduate training in surgery in New Delhi, India; and in the United Kingdom, he continued his training and became a fellow of the Royal College of Surgeons of Edinburgh. Dr Das completed his residency in urology at UCLA Medical Center. Currently a Professor of Urology at the University of California Davis School of Medicine, his primary focus is on laparoscopic urology. Dr Das has helped with the development and propagation of urologic laparoscopy.
References
1. Araki I, Tsuchida T, Endo S, et al. Retroperitoneoscopic hand assisted radical nephrectomy and total nephroureterectomy for renal cell cancer and renal pelvic cancer [abstract]. J Urol. 2002;167(suppl 4). Abstract V68.
2. Yoon SJ, Cho SP, Lee JB, et al. Hand assisted retroperitoneal laparoscopic nephroureterectomy with bladder cuffing after both pre- and retro-peritoneal ballooning [abstract]. J Urol. 2002;167(suppl 4). Abstract V70.
3. Strup S, Hubosky SG, Trabulsi EJ, et al. Complications of hand assisted laparoscopic Nephrectomy: a review of 118 consecutive cases at a single institution [abstract]. J Urol. 2002;167(suppl 4). Abstract 674.
4. Guilloneau B, Vallencien G. Laparoscopic radical prostatectomy: the Montsouris Experience. J Urol. 2000;163:1643-1649.
5. Sanchez de Badajoz E, Gallego Perales JL, Reche Rogado A, et al. Laparoscopic Cystectomy and ileal conduit: case report. J Endourol. 1995;9:59-62.
6. Turk I, Deger S, Winkelman B, et al. Laparoscopic radical cystectomy with continent Urinary diversion (rectal sigmoid pouch) performed completely intracorporeally. J Urol. 2002;165:1863-1866.
7. Ramakumar S, Shetye KR, Fugita OE, et al. Laparoscopic renal biopsy: nine year. Experience [abstract]. J Urol. 2002;167(suppl 4). Abstract 88.
8. Lee D, Andreoni C, Rehman J, et al. Laparoscopic cyst decortication in patients with Autosomal dominant polycystic kidney disease (ADPKD): long term impact on pain, Hypertension and renal function [abstract]. J Urol. 2002;167(suppl 4). Abstract 86.
9. Gill IS, Desai MM, Kaowk JH et al: Laparoscopic partial nephrectomy for renal tumor: Duplicating open surgical technique. J Urol. 2002;167:469-471.
10. Ramakumar S, Colegrove PM, Nelson JR, et al. Photopolymerized PEG-lactide hydrogels: an effective means for hemostasis during laparoscopic partial nephrectomy. J Urol. 2002;167(suppl 4). Abstract 7.
11. Menon M, Shrivastava A, Tewari A, et al. Laparoscopic and robot assisted radical Prostatectomy: establishment of structured program and preliminary analysis of outcome. J Urol. 2002;168:945-949.
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