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OBJECTIVE: The standard surgicaltreatment of upper tract TCC remains nephroureterectomywith excision of a cuff of bladder. However, laparoscopicnephroureterectomy (LNU) has been shown to be associatedwith reduced perioperative morbidity, a shorter hospitalstay, and a reduced requirement for transfusion than opennephroureterectomy (ONU). The objective of this articleis to review experience and outcome following laparoscopicnephroureterectomy for upper tract TCC.METHOD: A literature search of PubMed(www.ncbi.nlm.nih.gov/PubMed/) was performed andarticles reporting technical aspects and outcome oflaparoscopic nephroureterectomy for upper tract TCCwere reviewed.RESULTS: The published data show that outcomesreported following LNU in terms of cancer control arecomparable to ONU, at least in the short to medium term.Despite concerns about port site recurrences there wereno incidences of this in the 125 patients undergoing LNUin the reviewed reports. An interesting observation wasthat a high percentage of the tumours are Grade 2 or 3when TCC affects the upper tract, unlike TCC of the bladder where the majority of tumours are of low gradeand stage.CONCLUSION: Laparoscopic nephroureterectomy isa safe treatment option for patients with upper tract TCC.The shorter hospital stay and faster overall recovery isobviously of benefit to the patient, but importantly thelonger-term tumour control appears to be equivalent tothat following open nephroureterectomy.
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OBJECTIVES: To review the current sta-tus of the Laparoscopic Radical Prostatectomy in Europe (LRP).METHODS: The published peer reviewed articles on the experience of the European groups performing Laparoscopic Radical Prostatectomy.RESULTS: Three different approaches have been described for LRP, two of them transperitoneally (early dissection of seminal vesicles or of the prostatic apex) and one totally extra peritoneally. Results in terms of per operative performances and immediate outcomes seem to be comparable with the exception of the bleeding and the transfusion rate that seem higher in the transperitoneal approach with early dissection of the prostatic apex. Conversion rates have been described up to 5% but it is rare after the 20 first cases; after the learning curve has been overcome the complication rate varies between 10%and 17%. Being a novel technique, all the series have a short median follow-up of around one year. The one-year continence rates are comparable to the ones described with the classical open approach, as it is the potency rate.The rate of positive margins bounces between 2 and 49% depending mainly on case selection. A long and steady learning curve burdens the technique in terms of complications.CONCLUSIONS: LRP is feasible, teachable and repro-ducible. Although no comparative series with the open approach are available yet, functional and oncological results seem to be comparable to the ones reached after open Retropubic Radical Prostatectomy.
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OBJECTIVES: Laparoscopic surgery ingeneral is handicapped by the reduction of the range ofmotion from six to four degrees of freedom. This has amajor impact on technically difficult procedures such aslaparoscopic radical prostatectomy. Solutions for thisproblems include the understanding of the geometry oflaparoscopy with sophisticated training programs, but liealso in newly developed surgical robots, computersimulatorsand telementoring. This article evaluates thevalue of these alternatives based on own experiences andan analysis of the current literature.METHODS: Own experiences with robot-assistedsurgery include 406 laparoscopic radical prostatectomiesusing a voice-controlled camera-arm (AESOP) as well as6 telesurgical interventions with the Da Vinci-system.Additionally, substantial experimental studies have beenperformed focussing on the geometry of laparoscopy andnew training concepts such as perfused pelvitrainers andcomputersimulation. Moreover, the current literature ofthe last 10 years on telesurgery and telementoring hasbeen reviewed.RESULTS: The geometry of laparoscopy includes theangles between the instruments which have to be in arange of 25° to 45°; the angles between the instrument andthe working plane that should not exceed 55°; and theangle between the shaft of the needle holder and the needlewhich has to be adapted according to the anatomicalsituation in range of 90 to 110°. 3-D-systems did not yetproved to be effective due to handling problems such asshutter glasses, video-helmets or reduced brightness. Atthe moment, there are only two robotic surgical systems(ZEUS, Da Vinci) in clinical use for telesurgery, of whichonly the Da Vinci provides stereovision and all six degreesof freedom (DOF). In the meantime, more than 200laparoscopic radical prostatectomies have been performedwith this system. Until now, however, there was no evidenceof any advantages over the conventional laparoscopicapproach. The ZEUS in combination with thetelecommunication system SOKRATES is the only deviceenabling to realize telemanipulation and telementoringover long distances (i.e. transatlantic).CONCLUSION: Robotic surgery represents a turningpoint of surgical research. However, broad use of roboticsystems is limited mainly because of the high investmentand running costs. Whereas there will be a clear role ofaudio-visual telementoring in future training concepts,the need of telemanipulation / telesurgery has not yet beenclarified. New technological concepts promote thedevelopment of hand-held mechanical manipulators (i.e.6-DOF-needle-holder) used in combination with monotaskingcomputerized robots (i.e. AESOP) resulting in asignificant cost reduction.
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OBJECTIVES: Primary objective of thepresent article is to evaluate the surgical efficiency of thelaparoscopic retroperitoneal lymph node dissection inclinical stage I and II testis tumor. Secundary objective isthe description of the technique used by the author.METHODS: A description of the author's experienceand review of the litterature in terms of feasibility,oncological results and quality of life.RESULTS: Once the learning curve has been overcome,the operative time is in the range of that open surgery withlower morbidity and complications. Ejaculation can bepreserved in virtually all patients by means of a templatedissection. With a mean follow-up of almost four yearsoncologic long-term outcome is not compromised by thelaparoscopic approach.CONCLUSIONS: In clinical stage I testis tumorlaparoscopic retroperitoneal lymph node dissection canbe used as a diagnostic measure with the same long termresults as the open procedure. In stage II disease removalof residual tumor can also be achieved by laparoscopy.
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OBJECTIVES: To evaluate our own experience with laparoscopic bladder neck suspension. The laparoscopic procedure is performed by anchoring a mesh from the vagina to the ligament, thus creating tension. This technique has several characteristics that make it very attractive: it is easy to learn, operating times are short and it is a commonly indicated procedure.METHODS: We present a series of 72 women with history of urinary stress incontinence to whom a laparoscopic bladder neck suspension was indicated.RESULTS: The procedure was completed in 69 patients, with a mean operative time of 40 minutes. Mean hospital stay was 1.6 days (Range 1 to 5 days). Continence rate was 82% after a median follow up of 31 months. 12 patients recurred after the operation, 7 of them recurred in the first 2 months and 5 had previous surgical history; this makes us think whether the technique was not adequately performed or the indication for treatment was not suitable.CONCLUSIONS: We believe that, although it is necessary a longer follow-up, laparoscopic bladder neck suspension can be considered a good alternative in the treatment of urinary stress incontinence.
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OBJECTIVES: To review all differentsteps in the process of learning laparoscopic surgery,presenting the guidelines that surgeon and his/her teamshould follow to successfully complete the process.METHODS: We describe two levels of training: Basic,that is initiated with handling of instruments in simulators,and Advanced, which culminates with the practice ofspecific procedures in animal models.RESULTS: At the basic level eye-hand coordination isacquired through exercises under direct vision inmechanical simulators. Later on, the use of optic andcamera will allow to achieve eye-hand-TV monitorcoordination. To use experimental and organic tissuespermits to practice organic dissection and suture.Training at the advanced level is performed in researchanimals and makes up team work. Animal species selection,team composition, and anatomical protocol are of utmostimportance to successfully complete the second phase.CONCLUSIONS: Training in laparoscopic surgery is acomplex process that implies surgeon's interaction withthe rest of the team. Basic and advanced training must beavailable for all team members in order to assuresatisfactory results in the difficult initial phase that shouldbe mentored by an expert in laparoscopic surgery.
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OBJECTIVES: To review the developmentof laparoscopic varicocelectomy from our initialdescription in 1986 based in the first pioneering works ofK. Semm and to describe our latest microlaparoscopictechnique that uses 3 mm instruments.METHODS: We use 3 mm reusable trocars with aspecially designed telescope and instruments. One port isin the umbilicus the others are in the flanks at this level.Spermatic vessels are identified by firm traction of thetesticle. The peritoneum is incised transversally at thislevel to dissect and ligate the two or three veins usuallyfound here. To shorten operation time and improve resultsthe vascular bundle is ligated en-bloc and when it is bulky,we divide it into two smaller bundles before tying the knot.RESULTS: Field of vision and image brightness isadequate and allows the operator to suture with greatprecision and ease. Large angular movements of the 3 mmtelescope should be made with its trocar. Image brightnessdepends on the proximity of the lens to the structure beinginspected; it worsens when the lens is withdrawn evenslightly. Reusable 3 mm instruments can be used hundredsof times and with care they have sufficient strength to permit tying tight even en-bloc ligatures of vascularbundles. Operating times are between 20 and 25 minutes,bilateral operations need about 10 minutes more. Woundsmade by the 3 mm trocars are usually self-closing andrarely need a stitch.CONCLUSIONS: Many authors confirm that since wefirst described the technique 15 years ago laparoscopicvaricocelectomy is a safe, quick and easy minimal invasiveprocedure, less expensive than open techniques or occlusionunder radiological control. The Palomo retroperitonealapproach using en-bloc ligatures of the vascular pediclelaparoscopically shortens operative times, the percentageof failures is minimum and postoperative testicular volumesand sperm counts increase. The microlaparoscopictechnique not only reduces surgical aggression, but alsothe risk of complications is less and it does not increaseoperative difficulty or operation time.
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- OBJECTIVES: To analyse the experienceof our own group and other reference groups withlaparoscopic pelvic lymphadenectomy since 1990regarding different aspects: Technical details, results,complications, and establishment of its current indicationsfor prostate cancer treatment.METHODS: We report a retrospective statisticalanalysis of a series of lymphadenectomies over a 10 yearperiod with a total of 202 cases (69 laparoscopic and 133open surgical) analysing different lymph node invasionrisk factors.RESULTS: Elevated PSA and Gleason resulted in morelymph node infiltration being the cutting point in 40 and7 respectively.CONCLUSIONS: Laparoscopic lymphadenectomyprovides equal diagnostic reliability than the traditionaltechnique. Currently we perform laparoscopiclymphadenectomy in prostate cancer for T3 tumours(independently of PSA or Gleason score) and in < T3 withPSA≥ 40, Gleason ≥ 8, and in cases with Gleason 7 andPSA >20.
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OBJECTIVES: To review indications, results and endourologic alternatives to the pyeloplasty technique.METHODS: We describe the surgical technique proposed by Schluesser et al., which was applied to 9 patients in our series. Another 4 patiens undewent a simple laparoscopic pyelolisis.RESULTS: Results obtained with laparoscopic dismembered pyeloplasties are completelly comparable with those obtained with the conventional Anderson Hynes Pyeloplasty. Outcomes were very favourable in 7 / 9 patients in the series; another one shows a discrete improvement and the other one did not return for control. Is does not happen the same with pyelo-ureterolysis. Two of them had a good outcome, other two remain the same, and another one has not had his control yet.CONCLUSIONS: After 8 years, laparoscopic pyeloplasty has consolidated as the elective technique in cases of recoverable hydronephrosis, secondary to crossing vessels or which have a redundant renal pelvis.A few important modifications to the technique have been proposed; exceptions are that it can also be done by retroperitoneoscopy and that in some cases equally good results may be obtained with the Fenger´s laparoscopic pyeloplasty.
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OBJECTIVE: The safety and success of antegrade endopyelothomy in the treatment of ureteropelvic junction (UPJ) stenosis have been documented in numerous literature reports over the last decade. We show a new available alternative to the way incision is performed. METHODS: Endopyelothomy with modified laparoscopic scissors was performed in 18 patients; 12 presented with primary obstruction and 6 with secondary obstruction. 3 mm laparoscopic scissors with one end sharpened and adapted for this technique are introduced through a nephroscope. A small puncture through the renal pelvis wall is made in the posterolateral position using the scissors' end. After that, scissors are opened under permanent endoscopic control as far as to visualization of the peripielyc space, continuing then with the internal edge of the scissors down to the UPJ. Visual control allowed us to coagulate any vessel and to avoid the bigger calibre ones. At the end of the procedure an endopyelothomy stent was placed over the safety guide wire. RESULTS: Results were good in 17 patients (94%); symptomatic relief and adequate pass of contrast to proximal ureter were observed in the remaining case, although pyelocalicilar dilation was not improved. Three vessels adjacent to the UPJ (16.6%) were discovered through the performed pyelotomy incision. Operative times were lower than 2 hours. Blood losses were minimal and patient recovery uneventful allowing hospital discharges within 48 hours. CONCLUSIONES: To use 3mm laparoscopic scissors allows to perform endopyelothomy without changing endoscopes, precisely cutting due to retroperitoneum visualisation, and offers the chance to coagulate small calibre vascular elements and to avoid those of bigger size.
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OBJECTIVES: Nephrectomy is probablythe most widely accepted procedure for the application oflaparoscopic techniques in urology. The great advantagesof laparoscopy over conventional approaches have justifiedits indication for different renal extirpative procedures:atrophy, renal carcinoma, transitional cell carcinoma,policystic kidney disease, living kidney donation fortransplantation and partial nephrectomies. The objectiveof this article is to describe the techniques and advantagesof laparoscopic nephrectomy through a retroperitoneoscopicapproach, demonstrating that it is an effectiveoption for the majority of cases in which extraction of thekidney is required.METHODS: Between January 1991 and January 2001107 patients with different renal conditions were treatedat the Instituto Docente de Urología (IDU) usingtransperitoneal (36 patients) or retroperitoneal (71patients) laparoscopic access. Indications for laparoscopicapproach included atrophy, living donation, renal carcinoma,urothelial tumour, policystic kidney disease andpartial nephrectomy.RESULTS: Nephrectomy trough a transperitonealapproach was completed in 33 (91.6%) of 36 patients,being necessary to convert to conventional surgery in theremaining 3 cases (8.3%). Retroperitoneoscopic approachwas successful in all cases (100%).CONCLUSIONS: The retroperitoneoscopic approachis a simple procedure that allows its implementation in themajority of patients in which there is an indication fornephrectomy. Retroperitoneoscopy provides a rapidrecovery, minimal analgesic needs, and a short hospitalstay. Finally, retroperitoneoscopic approach represents alogical evolution for conventional flank incisions, providingfamiliarity with surgical field landmarks and managementto those urologists that incorporate this new technicalmodality.
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OBJECTIVES: To describe the techniqueand preliminary results of the laparoscopic cystectomy aswell as to review current indications and limitations of anouvel surgical approach for a clasical operation.METHODS: A careful description of the key points ofthe technique of laparoscopic cystectomy and creation ofan ileal conduit is provided. Operative and inmediatecomplications of this operation in a preliminary series of11 patients are described.RESULTS: Laparoscopic cystectomy is proven feasiblewith a mean operative time of 7.3 hours and minimal bloodloss (median 330 cc.). Transfusion was requiered in twopatients and the rate of major complications is in thisseries for 18%. Minor complications account for 27% ofthe series. Mean hospital stay was 7 days.CONCLUSIONS: Laparoscopic cystectomy can beperformed safely although a high level os skill is needed.The precise role of the technique has yet to be described and for the moment being, and till oncological results willbe confirmed remains under evaluation.
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OBJECTIVES: To describe the complications of laparoscopic surgery in general but also specifically in the field of Urology and then analyze the preventive measures that must be taken in order to minimize these complications.METHODS: At first we outline the absolute and the relative contraindications of laparoscopic surgery in ge-neral. Then we describe the various intra and postoperative complications seen in laparoscopic surgery and finally we discuss the complications reported specifically in Urological laparoscopic procedures.RESULTS AND CONCLUSIONS: The applications of laparoscopic surgery in Urology grows every day. The main complications are vascular injuries and visceral lesions but the complications rate disminishes as surgeons improve in their learning curve.
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OBJECTIVES: To establish urologicalpathologies in which video-assisted laparoscopy would beindicated as an alternative to conventional surgery.METHODS: From 1995 to December 2000 weperformed 106 urological laparoscopic procedures in 99children six months to 16 years old (mean age of 7 years).The indications for laparoscopy were: a) Diagnosticindications in 60 patients (n) / 65 procedures (p) includingintrabdominal testis (n=28, p=33) and renal biopsy (n=32,p=32); b) Therapeutical indications in 33 patients (n) / 34procedures (p) consisted of varicocelectomy (n=5, p=7),orchiectomy (n=1, p=1), closure of patent processusvaginalis (n=2, p=4), retroperitoneoscopic nephrectomy(n=16, p=18), renal cyst excision (n=2, p=2),marsupialization of symptomatic giant lymphocele afterrenal trasplantation (n=2, p=4), and c)Retroperitoneoscopic approach before open access in 6patients / 7 procedures.RESULTS: The laparoscopic approach was effective in100% and 94,2% of diagnostic and therapeutic procedures,respectively. Conversion to an open approach was requiredin two procedures because of peritoneal perforation duringretroperitoneoscopic nephrectomy in one case and bleedingafter retroperioneoscopic renal biopsy in the other.Previous retroperitoneal surgery is not a contraindicationfor retroperitoneoscopy. There were no postoperativecomplications with intraoperative morbidity of 2,8%.Overall average hospital stay was 1,4 days.CONCLUSIONS: Minimally invasive surgery plays animportant role in management of pediatric urology patients.Nowadays, there are procedures in pediatric urology thatcan be considered established indications for laparoscopicor retroperitoneoscopic approaches.
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OBJECTIVES: To review indications,techniques and results of laparoscopic adrenalectomy.METHODS: We retrospectivelly review our experiencewith 8 cases of transperitoneal laparoscopic adrenalectomy(2 feochromocytomas, 4 aldosteromas, 1 myelolipomaand 1 non functioning adenoma).RESULTS: Mean operative time was about 3 hours,with an mean estimated blood loss of 200 cc. MeanHospital stay was 2.5 days, complication rate was 10%,being conversion to open surgery between 5 and 10%.CONCLUSIONS: Laparoscopic adrenalectomy is theoperation of choice for functioning adrenal tumours andfor incidentally diagnosed tumours ≤ 6 cm that haveincreased in size in successive radiographic examinations.
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OBJECTIVE: Hand-assisted laparoscopicsurgery has recently been introduced in order to help easethe learning process associated with standard laparoscopicsurgery. It has various urological applications in themanagement of malignant and benign disease of thekidney. The purpose of this study is to review theapplications and the success rate associated with handassistedlaparoscopic surgery.METHODS: A comprehensive literature review of handassistedurological surgery was performed using MEDLINEsearch.RESULTS: Hand-assisted laparoscopic nephrectomyhas been performed for benign and malignant disease,donor renal transplant, and nephron sparing surgery withgood success. Patients who undergo the hand-assitedprocedure seem to have less perioperative morbidity thanthose who undergo an open procedure. This approachminimized the warm-ischemia time in renal transplantation.CONCLUSION: Hand-assisted nephrectomy is a usefultool facilitating the learning process in laparoscopy.
