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Dr. Sreejoy Patnaik

Shanti Omni Super Speciality Hospital Cuttack LAPAROSCOPY IN UROLOGY

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LAP- ENDO

History of Lap. UrologyThe first laparoscopic Nephrectomy was performed in 1990 by Clayman

The procedure had an operative time of seven hours and required a 1-unit transfusion and a six-day inpatient hospital stay.

Challenges of Uro lap. surgeryTechnically, more demandingSpecialized teamSlightly more expensive, use of consumablesAdvantages outweigh the challenges

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Laparoscopic SurgeryKey hole surgery

Latest development of Urology

Obvious advantages over conventional open surgery

Smaller wound

Less pain

Quicker recovery, discharge, early return to work

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Laparoscopic Urological SurgeryRevolutionary development in last 2 decades.

Experienced centres

Improves Patients peri-operative quality of life

Provides excellent view due to magnification less tissue trauma & minimal blood loss.

Approaches The 3 three commonly used approaches are

Transperitoneal approachRetroperitoneal approachHand assisted approachEndoscopic Procedures

Transperitoneal approachWider availabilityWorking spaceBetter identification of important landmarksIntestinal Injury ?

Retroperitoneal approachRestricted rapid accessRenal pedicle identification.Reduce the incidence of ileusInjury to the intraperitoneal contents

Hand assisted approachImproved tactile feedbackBridge between open surgeryLap Gelport TMLap Disc TM

ENDOSCOPIC APPROACHESCYSTOSCOPY- TURP/BNI/TURBT/OIUURETEROSCOPY-RIGID URETETROSCOPY URSFLEXIBLE URETEROSCOPY- RIRSPCNL- BY RIGID NEPHROSCPEMINI PERC - RENAL STONES

Laparoscopic Urological ProceduresCommonest procedures performed :-

Ablative Procedures: Urolithiases:Simple nephrectomy PyelolithotomyPartial nephrectomy UreterolithomyRenal cyst marsupilisation CystolithotomyRadical nephrectomy Urachal Cyst excisionRadical cystectomyRadical prostatectomy

Reconstructive Procedures:PyeloplastyLower ureteric reconstructionsBoari flap reconstructionUreteric reimplanation/Psoas hitchIleal ureter implantationOrchipexyDonor nephrectomy

Simple NephrectomyNon functioning KidneyPre renal transplant nephrectomy

Transperitoneal approach Pneumoperitoneum - open technique or closed technique. Ports are inserted in a strategic manner. Preoperative CT Scan) if done helps in determining the location of the kidney and deciding the location of port placement. Other parameters which determine the site of port placement are extent of truncal obesity and body mass index (BMI).

Positioning

Lateral decubitus positionNear the edge of the tableLower limb is flexed

Technique

Left side colon is reflectedIliac bifurcationSuperiorly the splenorenal Renocolic ligamentsIdentify the ureterGonadal vesselsUreter is lifted Psoas landmark

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(B) Retroperitoneal approach

Gaur etal15mm incision petit triangleLumbodorsal fasciaBalloon dilator

(C) Hand assist approach

Insert a non dominantHand assist device is inserted Right lower quadrant midway between umbilicus and anteriorsuperior iliac

Laparoscopic Radical NephrectomyT2 & T3a tumors.T1 tumors contraindicated with IVC thrombus

Technique

TransperitonealLumbar & adrenal veins are doubly clipped & cut.

Results

Advantage short hospitalLow analgesiaComparableOpen laparoscopic approach is a standard of care in T1 & T2. Renal thrombus is feasible

Laparoscopic partial nephrectomy

Small renal masses Lesions in a solitary kidneyBilateral renal lesionsTechnique- Pneumoperitoneum

- Ports similar to simple nephrectomy

- Ureteric catheter placed per-urethrally - to instill methylene blue- Identify the pelvicalyceal system prior to suturing- Colon reflected and the ureter is lifted off the psoas muscle

- Dissection proceeds to the renal hilum- Renal hilum dissected & satinsky applied - Renal tumor is cut with cautery or harmonic

- Preferred scissors for excising the tumor should be with wide jaws.

- Pelvicalyceal system is closed followed by the cortical defect- An indwelling ureteric catheter or alternatively a double J stent is placed for 48hours.

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PyeloplastyPUJ ObstructionRGP prior to positioning the patient5Fr pigtail catheter is inserted into the pelvicalyceal system

Technique

30 degree Scope - pelvis is identified bulges outDismembered Anderson hynes Pyeloplasty is preferred crossing vessel is suspectedY-V plasty is preferred

The important steps of this procedure are

PyelotomySpatulation of the ureterPyelotomy is closed a 3-0/4-0 vicrylV stitch as anterior layer easier step to start , followed by posterior layer.

Donor NephrectomyDo no harm to the donor is the dictum

Technique

Port placement mirrors that of simple nephrectomyCT angiography plays a pivotal role for strategic port placement.Ureter should be lifted of the psoas in toto as an ureterogonadal packet.Dissection of the artery should be a thermal and should be kept to the minimum.Topical papvarine instillation on the vessel helps in relieving spasmUpper pole should be separated from the spleen securing the adrenal veinGraft should be adequately perfused by intravenous infusion of mannitiol and furosemide prior to retrievalRetrive the graft through a pfannesteil incision

Laparoscopic ureteral reimplanationSupine position a 11mm trocar for camera insertion umbilicusUreter is lifted transected as distally as possibleThe bladder is filled with 200ml salineLateral and anterior peritoneum incised a boari flap is preferredSpatulated ureter and the bladder flap are anastomosed in a tension free manner with 4-0 polygalactin suturesA stent is kept indwelling for 6weeks after the surgery

Laparoscopic stone removalProcedure performed transperitoneal or a retroperitoneal approachPlacement of a stent ureteric catheterUreter lifted of the psoas The ureter is slingedUsing a cold knife the ureter is incisedSpoon may be used for retrieving the stoneStone may be entrapped in a bag for removalUreterotomy is closed with a 3-0 absorbable suture and a drain is placed.

Advanced Laparoscopic Procedures

Laparoscopic ileal interposition

Laparoscopic retroperitoneal lymph node dissections

Laparoscopic radical cystectomy (LRC)Laproendoscopic single site surgery (LESS)

Simple nephrectomyPyeloplastyReconstructive proceduresUreteroneocystostomyLESS donor nephrectomyTechnically feasible procedureSteep learning curve

Robot Assisted Laparoscopic UrologyProstatectomy ,Pyeloplasty, Nephrectomy & Ureter reconstructionsDonor nephrectomyAdrenalectomyAdvantages:Robotic platform Da Vinci SiHigh definition visual magnificationBetter range of motion Additional arm for retractionA unprecedented range of accuracy and dexterityIts increased range of freedomProperty of motion scalingProcedures requiring intracorporeal suturingSmall spaces pelvisThe cost benefit ratio is likely to be a driving force in further development and application of this technology

Laparoscopic NephrectomyBenign, non functioning kidneyRenal cell carcinoma Almost all tumours can be removed laparoscopically

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Laparoscopic Nephrectomy

LAP - URETEROLITOTOMY

LAP. PYELOLITHOTOMYVIDEO

LAP PARTIAL NEPHRECTOMYVIDEO

LAP RADICAL NEPHRO-URETECTOMYVIDEO

LAP URACHAL CYSTECTOMYVIDEO

Laparoscopic Prostatectomy5 small incisions

Completely mimick all the principles of open surgery

Extraperitoneal approach, avoiding contact with intestine

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Laparoscopic Prostatectomy4-5 hours surgery

Less blood loss, minimal blood transfusion requirement

Magnification allowing more accurate dissection and preservation of continence and erection

Hospital stay of 2nights, early removal of urinary catheter.

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Laparoscopic radical prostatectomy

Inverted fan shaped manner Endopelvic fascia incisedDorsal vein securedVas deferens &Dissected secured hem-o-lokThe lateral detrussor pillars are secured with clipsThe urethra is dissected be to gain maximum length Posterior reconstruction stich RoccoThe van velthowen technique (bidirectinal running suture) technique with 3-0 monocrylSatisfactory oncologic outcome

Radical Prostatectomy

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ROBOTIC PROSTATECTOMY

Laparoscopic Prostatectomy v/s Robotic prostatectomyAssistance from robot in suturing

3d view

High capital and recurring cost

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What is new in laparoscopy in urology?Almost all urological procedures can be done laparoscopically

Reproducible, similar if not better results than open surgery

What is the standard of care?

Laparoscopic urological surgeriesProcedureStandard of CareCurrent OpinionLaparoscopic Radical NephrectomyYesProven long term results for tumour upto 7cmLaparoscopic radical nephroureterectomyYesReplaces openLaparoscopic marsupilazation of kidney cystYesReplaces openLaparoscopic adrenalectomyYesReplaces openLaparoscopic pyeloplastyNot yetVery promising, awaiting long term results

Laparoscopic urological surgeriesProcedureStandard of careCurrent opinionLaparoscopic radical prostatectomyNoDivided (laparoscopic, robotic assisted laparoscopic, open)Laparoscopic varicocelectomyNoDivided (open microscope)Laparoscopic extra peritoneal herniorraphyNoPromising, awaiting long term resultsLaparoscopic ureterolithotomyNoAdvantage over open, but other options availableLaparoscopic partial nephrectomyNoAt best, similar to openLaparoscopic radical cystectomyNoAt best, similar to open

Laparoscopic retroperitoneal lymp node dissection NoPromising, Development stageLaparoscopic reimplatation of ureterNoEarly development stageLaparoscopic augmentation cysto plastyNoEarly development stage

SummarySurgery is moving towards minimally invasive surgery.

Urology - ESWL, Endoscopy, Percutaneous & Laparoscopy.

More than one or a combination of MIS modalities may be used.

Endoscopic and Per cutaneous procedures almost treat all the urolithiases, prostatic and bladder diseases.

Robotic Surgery is the future for dealing with Prostate and Bladder.

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