Laparoscopic Urological Procedure
Laparoscopic surgery, also called minimally invasive surgery (MIS), or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5–1.5 cm) as opposed to the larger incisions needed in laparotomy. Keyhole surgery makes use of images displayed on TV monitors to magnify the surgical elements. Laparoscopic surgery includes operations within the abdominal or pelvic cavities, whereas keyhole surgery performed on the thoracic or chest cavity is called thoracoscopic surgery.
There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include reduced pain due to smaller incisions and less blood loss, shorter hospital stay, better cosmetic results and shorter recovery time. Patients are able to go back to work within 1-2 weeks.
Specific applications for benign diseases:
Laparoscopic simple nephrectomy
Virtually all harmless urologic problems happen to be impacted with laparoscopic surgery. Because Clayman’s first laparoscopic nephrectomy within 1990, laparoscopic simple nephrectomy is just about the most common urologic laparoscopic procedure. All benign conditions requiring nephrectomy happen to be handled laparoscopically. Although laparoscopic removals of small atrophic kidneys are ideally suited to the actual less experienced surgeon, simple nephrectomy remains among the great misnomers within urologic surgery.
Open donor nephrectomy has been a viable and safe option for more than 30 years but carries the morbidity of the relatively huge open incision and a long convalescence period. Insufficient living donor continues to be the main cause of ever increasing waiting list of renal transplantation recipients. Ratner within 1995 carried out the very first laparoscopic live donor nephrctomy, extracting the kidney via a 9 inch midline incision. Inside next 11 years, LDN became the gold standard.
There has been a rise in detection of adrenal incidentalomas. NIH consortium recommends excision of such masses if related to biochemical proof of pheochromocytoma, size more than 6 cm, masses more than 4 cm with rapid growth rate, or radiographic findings consistent with adenoma. Laparoscopic adrenalectomy was initially tagged by Gagner in 1992. Lots of data has since gathered to aid the use of transperitoneal or retroperitoneal laparoscopic approach for adrenalectomy as opposed to open surgery. The arguments against laparoscopic approach are longer operating time and higher hospital charges.
Ureteropelvic junction obstruction can be characterized by a functionally significant impairment regarding urinary transport, caused by obstruction in the area where the ureter joins the renal pelvis. Nearly all cases tend to be congenital; however, acquired conditions at the degree of the UPJ could also existing with symptoms and also signs of obstruction. Till recently, open up pyeloplasty and endoscopic techniques happen to be the primary surgical options with the intent of open complete excision, or endoscopic incision from the obstruction. Endoscopic antegrade or even retrograde visually managed incision of the ureteropelvic junction obstruction, or even radiologically managed incision don’t share the high effectiveness that results from open-surgical dismembered pyeloplasty.
Lymphocele complicates 1 to 12% of patients following renal transplantation. Lymphocele also complicates 1 to 10% of sufferers after pelvic lymphadenectomy, because done for proste cancer. Treating option is either percutaneous drainage as well as sclerotherapy, or even transpertoneal laparoscopic marsupialization from the lymphocele. Treatment with percutaneous drainage and sclerotherapy has high morbidity and a high recurrence rate. Hsu reported 91% success in support of 6% recurrence after treating 81 lymphoceles with laparoscopic marsupialization. Laproscopic treatment of pelvic and post transplant lymphoceles has become a preferred approach to management.
Repair of vaginal vault prolapse remains a surgical challenge irreapecive of abdominal, vaginal, and combined procedures being used to fix the problem. The ideal operation remains elusive with regard to outcomes, morbidity, and economics. Being an extension from the abdominal approach, laparoscopy is constantly on the gain favor being an access method, so that as a surgical advancement. Recent studies highlight a number of laparoscopic processes for restoration of apical support that demonstrate feasibility and encouraging results.
Vericocele is found in upto 15% of normal population, but the incidence is really as high as 40% in males with subfertility. Traditional approached for vericocele were retroperitoneal and inguinal. Microsurgical technique has lately been used for vericocele repair to decrease complications like hydrocele and damage to testicular artery, and to decrease the number of cases of vericocele recurrence.
Percutaneous renal biopsy might be contraindicated in some patients because of obesity, coagulopathy, solitary kidney or failed previous percutaneos biopsy. Options during these situations include open surgical biopsy, CT guided biopsy, transvenous biopsy and laparoscopic guided biopsy. Knowledge about laparoscopic renal bopsy has provided an abundant biopsy tissue compared to CT or transvenous biopsy with minimal morbidity in patients wherever percutaneous biopsy was contraindicated.
In addition to the general benefits of MIS, using laparoscopic procedures for oncologic applications must prove no compromise within the oncologic charge of the disease, whether positive surgical margins, incidence of intraoperative seedings while retrieving the specimen, or long term oncologic control. Histopathological margin positivity has not been higher with laparoscopic oncologic procedures. Long term oncologic control information is gradually appearing, and seems to be equivalent to open surgery. There’s been concern regarding seeding in urologic laparoscopy. In an international survey, the information from 19 institutions performing laparoscopic oncologic procedures was collected for 2,604 radical nephrectomies, 555 partial nephrectomies, 559 nephroureterectomies, 3,665 radical prostatectomies, 1,869 pelvic lymph node dissections and 479 retroperitoneal lymph node dissections. There were no cases of seeding from renal cell cancer despite over 3,400 procedures reported, and also the utilization of morcellation in 40% of the radical nephrectomies.
Nephrectomy and nephroureterectomy
Laparoscopic radical nephrectomy has significant smaller incision having a quick postoperative recovery with less minor and major complication rates than open surgical counterpart. Mean loss of blood is less with LRN. MIS benefits have certainly improved the caliber of life during these patients. As mentioned earlier there’s little risk of peritoneal contamination and port site metastasis after LRN for RCC despite morcellation of specimen before removal. Seems like, as stated earlier, that port-site seeding associated with LRN is an extremely rare and unlikely event, provided that strict surgical technique is applied as well as an entrapment sac is used for specimen removal.
For the incidental small renal lesion, elimination of the entire kidney by open radical nephrectomy or minimally invasive techniques may end up being more detrimental in the long run by leaving behind a limited nephron mass. Several studies have indicated that disease-free survival and oncologic connection between partial nephrectomy are equal to radical nephrectomy in carefully selected patients Regardless of the advantages laparoscopic partial nephrectomy enjoys over conventional open surgery when it comes to perioperative morbidity, blood loss, operative time, and hospital stay, the chance of bleeding and technical difficulty of intracorporeal laparoscopic suturing has prevented the widespread use of laparoscopic partial nephrectomy.
Laparoscopic Radical prostatectomy is of major interest to Urologist in East Delhi especially considering the incidence and clinical significance of prostate cancer. The process comprises several steps of challenging dissection where the preservation of delicate erectile nerves and external sphincter has to be coupled with safe tumor excision. The intervention ends with vesicourethral anastomosis, which is considered probably the most difficult reconstructive procedure in urologic laparoscopy. LRP has gradually been a standardized procedure, and it is now routinely performed all over the world. Data in the literature and available experience demonstrates that oncologic and functional results with LRP seem similar to those of classic open radical retropubic prostatectomy (RRP). In a comparison of LRP with RRP (n 180), the entire positive surgical margin rates were similar (16.9% vs. 20%), however, RRP had a greater positive apex margin rate.
Laparoscopic cystectomy and urinary diversion
Open radical cystectomy remains the defacto standard for nonmetastatic muscle-invasive bladder cancer. Regardless of being first described by Parra in 1992 for benign disease, and later used for invasive carcinoma in 1995 by Sanchez, use of laparoscopic cystectomy has been uncommon. Extensive experience of radical prostatectomy and urethrovesical anastomosis has grown the interest of urologists of late, including the utilization of robotic-assisted techniques. Laparoscopic radical cystectomy has been described as a feasible procedure and is still being evaluated. Gerullis and colleagues from Germany have described recently their initial knowledge about laparoscopic cystectomy with an extracorporeal assisted urinary diversion in 34 patients with a mean operating time of 244min, the mean blood loss of 325ml, along with a transfusion rate of 5.9%.
The danger of missing low-risk metastatic disease in additional than 30% patients despite undetected nodes on CECT abdomen proved the value of RPLND in nonseminomatous testicular tumors. Early open RPLND had significant morbidity during these young patients. With an increase of awareness regarding the disease pass on a pattern, the modified unilateral lymphadenectomy templates have significantly reduced morbidity with preserved ejaculation without compromising the efficacy. Laparoscopic RPLND using four trocars is a low morbidity alternative to open lymphadenectomy and it has been utilized in Oncology Institutions with laparoscopic skills with comparative lymph node positivity.