Needlescopic urology: current status

ADVANCEDUROLOGICLAPAROSCOPY

0094-0143/01 $15.00 + .00

NEEDLESCOPIC UROLOGY: CURRENT STATUS Inderbir S. Gill, MD, M C h

Laparoscopy has significantly impacted on contemporary urologic surgery. Increasing experience with this minimally invasive technology has expanded the current indications to include procedures that were earlier thought to be beyond the realm of the laparoscopic surgeon. Primarily, the advantages of minimally invasive surgery stem from the smaller skin incisions and decreased "trauma of access," thereby lowering surgical morbidity. Conventional laparoscopic instrumentation comprises trocars and instruments ranging in size from 5 to 12 mm. The recent availability of 2-mm instrumentation and optics has triggered the emergence of needlescopic surgery. Initially limited to diagnostic purposes in gynecologic surgery,1,3, 5 needlescopic techniques are now implemented for definitive therapeutic procedures as well. 9 The initial clinical experience with 2-mm needlescopic instrumentation in various therapeutic urologic procedures, including adrenalectomy, was recently reported from the author's center21, 21 This article presents an overview of the author's experiences with the safety, efficacy, and practicality of incorporating needlescopic (2 mm) technology into various urologic laparoscopic procedures (Table 1). The various 2m m instruments and scopes currently available are discussed along with clinical urologic applications, including adrenalectomy, orchiopexy, bladder cuff excision during nephro-

ureterectomy, renal cyst marsupialization, and lymphocelectomy. The use of 2-mm ins t r u m e n t s as an a d j u n c t to c o n v e n t i o n a l laparoscopy is described. The advantages, limitations, and future potential of minilaparoscopic technology are discussed. DEFINITION

Because needlescopic surgery is still in its infancy, its definition remains a matter of debate?, 17 Questions include whether all ports need to be 2 m m exclusively, or whether a judicious and logical combination of mostly 2-mm ports and a larger-sized port is acceptable. The author believes that the term needlescopic surgery has a different connotation Table 1. CLEVELAND CLINIC EXPERIENCE WITH NEEDLESCOPIC SURGERY (N=65) Clinical Application

Adrenalectomy Nephrectomy/nephroureterectomy Orchiopexy/orchidopexy Renal cystectomy Lymphocele marsupialization Pelvic lymphadenectomy Exclusively needlescopic (N = 18) Orchiopexy/orchiectomy Renal cystectomy Lymphocele marsupialization

Number of Patients

30 12 14 3 3 3 12 3 3

From the Section of Laparoscopic and Minimally Invasive Surgery, Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio

UROLOGIC CLINICS OF NORTH AMERICA VOLUME 28 ° NUMBER 1 • FEBRUARY2001

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for reconstructive versus ablative procedures. During needlescopic reconstructive surgery, 'wherein no surgical specimen needs to be extracted, 2-ram instrumentation should be used exclusiw~ly, however, for needlescopic ablative procedures, in which a specimen needs to be extracted, one larger skin incision is ultimately imperative. There would be no rationale in performing an entire transperitoneal ablative procedure exclusively with 2mm instrumentation and then making a skin incision to either extract intact or morcellate the specimen. A superior operative strategy -would be to make a small 1.2-cm incision at the outset and use it to intraoperative advantage by placing a 10-mm laparoscope for superior visualization. From a cosmetic point of view, the optimal location to conceal such an incision is within the umbilicus. Such incorporation of one larger port is an accepted component of needlescopic ablative general surgery during cholecystectomy, splenectomy, appendectomy, and adrenalectomy. A current concession to this strict definition involves the use of one 5-ram port for the interchangeable use of various essential 5-mm instruments (hook electrode, suction-aspirator, clip appliers), the 2-mm versions of which are unavailable at this time. Anticipated future developments are expected to render the use of this 5-mm port unnecessary. 6,~

similar to the outer diameter of a 14-gauge angiocatheter needle (Fig. 1). Currently available 2-ram needlescopic instruments include a single-action grasper, a double-action graspe~, scissors, hook scissors, a probe, and a suction-irrigator (Fig. 2). 2~ In addition to these reusable instruments, a disposable 2-ram endoshears with an electrocautery attachment is also available. The 2-ram needlescopic instrument that the author employs most c o m m o n l y is the single-action grasper, which is adequate for the retraction of bulky tissues, such as a kidney during laparoscopic nephrectomy. Another preferred 2-ram instrument is the disposable electrosurgical scissors (US Surgical, Norwalk, CT). The manufacturer recommends that the coagulation current setting for this scissors not exceed 30 W. Because the shaft of the scissors is quite flexible, the scissors are adequate only for dissection of fine tissue, such as during pediatric orchiopexy or excision of renal cyst walt. The author does not use the scissors for the division of major vascular structures and tissues. Because of their small diameter, these delicate 2-ram instruments lack tensile rigidity and bend easily when stressed with laterally applied forces, x~ The intracorporeal excursion of the tip of a 2-ram instrument is less than the surgeon's hand movement. This characteristic results in exaggerated extracorporeal movements when compared with those required for a conventional laparoscopic instrument. The weaker grasping capability of the

iNSTRUMENTATION

Needlescopic instruments and ports have an outer diameter of 2 mm or less, which is

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Figure 1. A, The 2-mm needlescope is shown inserted within a 2-mm port. B, The 2-mm Veress (US Surgical Corp., Norwalk, CT) needle trocar is compared with a 14-gauge angiocatheter needle.

NEEDLESCOPIC UROLOGY: CURRENT STATUS

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Figure 2. Currently available 2-mm needlescopic instruments: probe (A); reusable scissors (B); hook scissors (C); single-action grasper (D); double-action grasper (E); suction-irrigator cannula (F). (From Soble JJ, Gill IS: Needlescopic urology: incorporating 2 mm instruments in laparoscopic surgery. Urology 52:187, 1998; with permission.)

delicate jaws of the needlescopic grasper makes tissue manipulation somewhat more cumbersome. In addition to their decreased technical capability, an adequate selection of 2-ram instruments is currently lacking. A needlescopic clip applicator and hook electrode are currently not available. The 2-ram electrosurgical scissors are not adequate for major tissue dissection. Because of its small-bore lumen and resultant poor flow characteristics, the 2-ram suction irrigator is inadequate to aspirate blood and maintain a clean surgical field. Evacuation of electrocautery-induced smoke through a 2-ram port is virtually non~ existent w h e n an instrument occupies the port. The 2-ram technology confers significant cosmetic advantages. Because of its extremely small diameter, no formal skin incision is necessary when inserting a needlescopic port; instead, only a needle puncture, similar to that required for a 14-gauge angiocatheter needle, is necessary. The r o u g h e n e d nonsmooth external surface of the 2-ram trocar provides a tight seal with the abdominal wall, eliminating the need for any retention sutures. On removal of a needlescopic port, subcuticular suturing is not necessary, and a single Steri-strip provides adequate closure. MINILAPAROSCOPES

Image transmission through a scope can be achieved by either the rod-lens or the fi~ beroptic system. Although the rodqens system provides superior image quality, it does not lend itself well to miniaturization because it is unable to provide clear images at smaller diameters. The fiberoptic system, using fused

quartz fiberoptic technology, in which each scope contains 30,000 to 50,000 tiny quartz threads (pixels), can transmit a relatively bright image through a small diameter scope. Another advantage of the fiberoptic system is that these scopes are only semirigid, allowing a certain degree of bending without damage to the fibers. Fiberoptic technology is the basis for the 1.9-ram needlescope (Fig. 3); however, the resultant image has a smaller size and lesser magnification than that achieved with the conventional laparoscope. Image resolution and contrast reproduction, especially at the periphery, are currently suboptimal. Because of the limited focal distance, the needlescope must be placed close to the target structure, with a resultant glare effect owing to light reflection. Only a straight-viewing (0°) needlescope is currently available. Minilaparoscopes with a marginally larger diameter of 3.3 mm and using the rod-lens system are available. In comparison with the 1.9-ram needlescope, the 3.3-ram minilaparoscope has superior resolution, a wider viewing angle, increased depth of view, and is available with a 0 °, 30 °, and 45 ° viewing angle. Although the image quality of current needlescopes and minilaparoscopes is somewhat inferior to that obtained with larger conventional laparoscopes (Fig. 4), their diagnostic capability is comparable. 4 Currently available minilaparoscopes include the following: Storz microendoscope, diameter, 1 m m (Karl Storz, Culver City, CA); Medical Dynamics m i c r o e n d o s c o p e / m i c r o - o p t i c a l catheter, diameter, 1.8 m m (Medical Dynamics, Englewood, CO); Pixie microendoscope, diameter, 1.9 m m (Origin MedSystems, Menlo

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Figure 4. Comparison of endoscopic views of an intra-abdominal testis as seen through a tO-mm laparoscope (A), a 5-mm laparoscope (B), and a 2-mm needlescope (C). (From Soble JJ, Gill IS: Needlescopic urology: Incorporating 2 mm instruments in laparoscopic surgery, Urology 52:187, 1998; with permission.)

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NEEDLESCOPIC UROLOGY: CURRENT STATUS

Park, CA); Microlap, diameter, 2 mm (Imagyn, Laguna, CA); Minisite, diameter, 2 mm (US Surgical, Norwalk, CT); and Hopkins II telescope, diameter, 3.3 m m (Karl Storz, Culver City, CA). The first five of these miniaturized laparoscopes employ fiberoptic technol~ ogy and cannot be autoclaved; therefore, they require gas or glutaraldehyde sterilization. 5 The last mentioned endoscope employs the rodqens system. These miniscopes are compatible with standard videoendoscopic equipment and cameras as used for conventional laparoscopy.

CLINICAL APPLICATIONS Adrenalectomy

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Figure 5. Needlescopic right adrenalectomy: port placemerit. Note: The 10-mm 45 ° laparoscope is placed at the umbilicus (From Gilt IS, Soble J J, Sung GT, et al: Needlescopic adrenalectomy--the initial series: Comparison with conventional laparoscopic adrenatectomy. Urology 52:180, 1998; with permission.)

In nonobese patients (body mass index

[BMI] -<35) with a small- to medium-sized (-< 5 cm) adrenal tumor wlho are candidates for transperitoneal endoscopic adrenalectomy, the needlescopic technique, partially incorporating 2-ram instrumentation and optics, is the author's preferred approachF ~

Right Adrenalectomy A needlescopic (2 mm) port with an in situ Veress needle introducer is inserted into the abdomen just below the costal margin in the anterior axillary line. ,H P n e u m o p e r i t o n e u m (15 m m Hg) is established, and a 1.%mm needlescope is inserted to confirm safe peritoneal access. Under needlescopic visualization, a 10/12-mm trocar is inserted at the superior umbilical crease. The needlescope is removed, and a 10-mm, 45 ° laparoscope is introduced. Two additional secondary ports are placed (Fig. 5)--a 2-ram port lateral to the xiphoid at the costal margin, and a 5-mm port at the lateral border of the rectus abdominis, two to three fingerbreadths below the costal margin. The surgeon works through the lateral 2-ram and 5-ram ports while the assistant retracts the liver by a 2-ram grasper inserted through the medial 2-mm port. Extreme care must be taken while retracting the liver and gall bladder with the 2-mm instrument. The specific technique of needlescopic right adrenalectomy is identical to that performed by conventional laparoscopy. The posterior parietal peritoneum is incised parallel to, and 1 cm below, the inferior edge of the liver, extending from the paracolic gutter up to the inferior vena cava medially. The adrenal gland is identified immediately below this peritone-

otomy and retracted laterally. Protecting the adrenal gland with a piece of Surgicel during lateral retraction guards against trauma to the adrenal parenchyma, which can result in persistent hemorrhage. Dissection between the adrenal gland and the vena cava identifies the right adrenal vein. A 5-mm clip applier introduced through the 5-mrn port is used to secure the adrenal vein, which is then divided. Dissection along the superomedial and inferomedial aspects of the adrenal gland secures the adrenal branches of the inferior phrenic vessels and the renal hilar vessels, respectively. The adrenal gland, en bloc with the periadrenal fat, is mobilized from the undersurface of the liver and the upper pole of the kidney, respectively. The tail of the adrenal gland, occasionally supplied by a sizeable blood vessel, is mobilized, freeing the specimen completely. The 10-ram laparoscope is removed and the needlescope reinserted. A 10-mm Endocatch bag (US Surgical, Norwalk, CT) is inserted through the umbilical port u n d e r needlescopic visualization to entrap and extract the specimen intact by the umbilicus. After hemostasis is confirmed, fascial closure of the umbilical port incision is performed with a Carter-Thomason device (Inlet Medical, Eden Prairie, MN) u n d e r needlescopic visualization. All ports are r e m o v e d u n d e r needlescopic visualization. The 10-mm and 5-mm port site incisions are closed with subcuticular sutures (4-0 Vicryl), whereas each 2-ram port-site puncture hole is closed with a single Steri-strip.

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Figure 6. Needlescopic left adrenalectomy: port placement. A 10/12-mm port is placed at the umbilicus, a 2* mm port at the midaxillary line at the costal margin, a 5mm port at the midclavicutar line two finger-breadths below the costal margin, and a 2-mm port at the lateral border of the left rectus muscle at the costal margin.

Left Adrenalectomy The initial Veress needle is inserted lateral to the lateral border of the rectus abdominis muscle approximately three fingerbreadths below the costal margin} ~ Similar to the technique on the right side, pneumoperitoneum is established, the needlescope is inserted, and an umbilical port (10/12 mm) is inserted

under needlescopic visualization. A 10-ram, 45 ° laparoscope is inserted, and three secondary ports are placed (Fig. 6). Technical maneuvers during a left adrenalectomy include incision of the line of Toldt and formal mobilization of the splenic flexure and descending colon, with medial retraction of the spleen and pancreas. Dissection along the superior border of the left renal vein identifies the left main adrenal vein (Fig. 7), which is controlled with 5-ram clips and divided. Multiple aortic branches to the adrenal gland are clip occluded and divided to free the adrenal gland circumferentially.

Results To date, the author and his colleagues have performed over 30 needlescopic adrenalectomies. In no patient was open conversion necessary; however, in four patients, the needlescopic approach was converted to conventional laparoscopy for the following reasons: morbid obesity (BMI = 34.1), large adrenal mass (6 cm), and hemorrhage from a peripheral adrenal vessel (n = 2). The author's recent retrospective nonrandomized comparison of needlescopic (n = 15) and conventional laparoscopic (n = 21) adrenalectomy supported the finding of decreased morbidity

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Figure 7. Needlescopic left adrenalectomy: dissection of the left main adrenal vein. Note: T-incision is made along the line of Toldt. If adequate mobilization of the spleen is performed initially, the spleen remains retracted away from the operative field by gravity alone. Extreme care must be taken while retracting any intra-abdominal organ (spleen, liver, colon) with a 2-mm instrument. (From Gill IS, Soble J J, Sung GT, et al: Needlescopic adrenalectomy--the initial series: Comparison with conventional laparoscepic adrenalectomy. Urology 52:180, 1998; with permission)

NEEDLESCOPIC UROLOGY: CURRENT STATUS

associated with the needlescopic approach (Table 2). 11 The needlescopic surgery was associated with decreased blood loss (P = 0.0002), shorter hospital stay (P < 0.0001), and quicker convalescence (P < 0.0001). Alt h o u g h the surgical time was s o m e w h a t shorter in the needlescopic group (P = 0.0005), this difference is not a true advantage of the needlescopic technique but reflects increasing experience and comfort with endoscopic adrenalectomy. Needlescopic (2 mm) visualization is used only at specific points during the procedure: during confirmation of primary port placement, during insertion of the 10/12-mm umbilical port, during the occasional use of an Endo-GIA vascular stapler or 10-mm clip applier through the umbilical port for securing a larger adrenal vein, during specimen entrapment, during extraction, during Carter-Thomason fascial closure of the umbilical port, and during exit. Most of the endoscopic procedure is performed under visualization afforded by the umbilical-located 10-mm, 45 ° laparoscope. In comparison with conventional laparoscopy, needlescopic adrenalectomy differs in two important aspects: (1) the need for the surgeon to become comfortable with the flimsier 2-mm instrumentation, and (2) the need to recognize that the angle of visualization of the adrenal bed provided by the umbilically located, 10-mm, 45 ° laparoscope is different from that afforded by a 10-mm, 30° laparoscope placed in a subcos-

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tal location d u r i n g the conventional technique. For an experienced laparoscopic adrenal surgeon, the learning curve for needlescopic adrenalectomy is approximately five to ten cases. Because of the current lack of availability of 2-mm versions of essential instruments, such as an adequate suction-aspirator, hook electrode, robust electrosurgical scissors, and clip applier, one 5-mm port is employed for the surgeon's dominant hand to allow interchangeable use of these 5-mm instruments. During conventional laparoscopic adrenalectomy, four larger (5-10 mm) ports are placed along the subcostal margin, 22 which result in larger scars and, frequently, postoperative complaints about subcostal pain. During the needlescopic technique, the only 10/12-mm port is inserted at the umbilicus. Only smaller ports (two, 2 mm; one, 5 mm) are located in the subcostal area, resulting in considerable cosmetic and analgesic advantages.

Outpatient Adrenalectomy The decreased morbidity and excellent patient satisfaction afforded by the needlescopic technique have allowed the author and his colleagues to explore the possibility of outpatient adrenalectomyd Fourteen selected patients have undergone endoscopic adrenalect o m y on an outpatient basis. Each patient

Table 2. NEEDLESCOPIC VERSUS CONVENTIONAL LAPAROSCOPIC ADRENALECTOMY: RETROSPECTIVE, NONRANDOMIZED COMPARISON

Parameter Age (years) Sex (% male) Weight (kg) Height (cm) Adrenal side (% right) Diagnosis Aldosteroma Nonfunctional a d e n o m a Pheochromocytoma Metastatic tumor Surgical time (minutes) Blood loss (mL) Specimen weight (g) Oral intake (days) Hospital stay (days) Convalescence (weeks) Complications Open conversion

Needlescopic Surgery (N = 15)

Laparoscopic Surgery (N = 21)

60.4 + 11.3 79% 88.97 _+ 16.7 173 + 9.4 53%

52.2 + 12.7 48% 88.1 + 14 171.4 + 9.7 25%

9 3 2 1 168.7 (130-210) 61.4 (20-200) 41.6 (6.8-108.0) 0.3 (0-1) 1.1 (<23 h o u r s - 2 days) 2.1 + 1.02 1 (8%) 0

16 3 0 2 220.4 (114-400) 183.1 (30-500) 15.7 (6.6-55.0) 0.3 (0-1) 2.7 (2-9) 3.1 + 1.9 6 (29%) 0

P Value 0.06 0.07 0.48 0.75 0.14 ----0.05 0.002 0.001 -<0.001 <0.001 0.2 --

Adapted from Gill IS, Soble JJ, Sung GT, et al: Needlescopic adrenalectomy--the initial series: Comparison with conventional laparoscopic adrenalectomy. Urology 52:180, 1998; with permission.

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fulfilled all of the following preoperative and perioperative inclusion criteria: informed consent, age 70 years or less, BMI <-- 40, adrenal tumor less than 5 cm, no pheochromocytoma, the laparoscopic procedure is uncomplicated and finished by noon, perioperative hemodynamic stability, and postoperative pain controlled with oral analgesics. In the initial nine patients, the average patient age was 53 years, the tumor size was 2 cm, the surgical time was 2.3 hours, blood loss was 53 mL, and postoperative analgesia required 6 mg of morphine sulfate and 32 mg of ketorolac. The postoperative hospital stay averaged 416 minutes (range, 300-570 minutes). Except for one patient with a delayed local abscess, no patient was rehospitalized, s In addition to the previously mentioned advantages, needlescopic adrenalectomy is financially advantageous vis-a-vis open surgery. ~3 On comparing the financial records of 15 patients undergoing needlescopic adrenalectomy with the records of 15 contemporary patients undergoing open adrenalectomy, the needlescopic technique resulted in a 17.9% decrease in total hospital costs. Although the needlescopic approach was 18.1% more expensive intraoperatively, postoperative costs were 63.4% lower than for open surgery. 13 Nephroureterectomy: Retrieval of Distal Ureter and Bladder Cuff Laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma is rapidly evolving into a preferred treatment alternative compared with open surgery22, 2o Although the technique of laparoscopic nephrectomy is standardized, the optimal technique for en bloc removal of the distal ureter and bladder cuff is a matter of debate. The author and his colleagues have recently described a novel technique involving two suprapubic transvesical needlescopic (2 mm) ports to facilitate cystoscopic detachment of the bladder cuff. Details of this technique, which is contraindicated in patients with concomittant b l a d d e r tumors, have been published previously, m Briefly, two 2-mm ports are inserted suprapubically into the bladder, and a 2-mm endoloop tie is positioned around the targeted ureteric orifice. Constant wall suction is employed to both 2-mm ports to minimize the chances of intraoperative fluid extravasation. A ureteric catheter is cystoscopically inserted through the open endoloop into the targeted ureter. A 2-mm su-

prapubic grasper is inserted to retract the diseased ureteric orifice tautly in an anteromedial direction. Using a resectoscope with a Collin's knife, a precise bladder cuff is detached full-thickness from the detrusor (Fig. 8). Continued anteromedial traction by the suprapubic grasper allows cystoscopic dissection of the distal-most 3 to 4 cm of intact ureter into the bladder. The mobilized ureter is occluded with the previously placed endoloop tie, and the 2-mm ports are removed. A urethral Foley catheter is left indwelling, and the patient is repositioned for performance of a retroperitoneal laparoscopic nephroureterectomy. This novel technique has inherent disadvantages and advantages. Disadvantages include a learning curve, primarily owing to the 90 ° separation between the plane of manipulation of the suprapubic 2-mm instruments and the transurethral resectoscope, the potential for fluid extravasation, and the need for 1 week of Foley catheterization to allow healing of the posterior cystotomy. Significant advantages of the technique include the excision of a bladder cuff identical to that obtained b y conventional open surgery, the elimination of local spillage of urine from the ipsilateral kidney, and intraoperative confirmation that the entire at-risk ipsilateral ureteral urothelium and bladder cuff have been excised. 10

Results

Among the 42 patients undergoing laparoscopic radical nephroureterectomy for pathologically confirmed upper tract transitional cell carcinoma at the a u t h o r ' s center, the novel technique described p r e v i o u s l y was employed in 20 patients. 12 Mean operating time for this m a n e u v e r was 59 minutes (range, 35-120 minutes). Significant fluid extravasation into the retroperitoneal space dev e l o p e d in one patient, necessitating open drainage. One week postoperatively, the cystogram confirmed watertight healing in 19 patients. In one elderly diabetic male patient with peripheral vasculopathy, the 1-week cystogram identified mild extravasation, necessitating continued indwelling Foley catheterization for an additional week. Pathologic examination revealed negative surgical margins at the bladder cuff edge in all 20 patients. Over a mean follow-up of 11 months, no patient has experienced a local or port-site recurrence.

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Figure 8. Transvesical needlescopic-assisted technique for bladder cuff and distal ureter during laparescopic radical left nephroureterectomy. Circumferential full4hickness detachment of the bladder cuff from the detrusor muscle with an electrocautery Collin's knife is demonstrated, Cystoscopic dissection is carried into the perivesical fat until 3 cm to 4 cm of the intact extravesical ureter are mobilized into the btadder. Arrow denotes direction of the suprapubic traction applied on the ureter. The prepositioned 2-ram Endeloop (US Surgical, Norwalk, CT) tie and the retrogradely-inserted ureteral catheter are shown (FromGill IS, Soble J J, Miller SD et al: A novel technique for management of the en bloc bladder cuff and distal ureter during laparoscopic nephroureterectomy. J Urol 161:430, 1999; with permission).

Cryptorchidism Surgery A l t h o u g h laparoscopy is becoming the standard approach at many centers for managing the undescended testicle) 5 one drawback has been the large size of the conventional 5-mm and 10-ram laparoscopic ports relative to the small size of the pediatric abdomen. Needlescopic (2 ram) instrumentation and optics address this concern adequately.

Technique An exclusively needlescopic three-port transperitoneal technique is employed? A 2mm primary port is inserted at the superior umbilical crease. The area of the internal inguinal ring is inspected bilaterally with the 1.9-ram needlescope to visualize the testicular vessels and vas deferens. If blind-ending testicular vessels are clearly seen, a diagnosis of ipsilateral anorchia is established, and the

procedure is terminated. Alternatively, if the vessels exit a closed internal ring, the presence of a high inguinal testicle or an inguinal testicular remnant must be suspected. In this event, or if an intra-abdominal or peeping testicle is identified, additional needlescopic dissection is necessary. Two secondary 2-mm ports are inserted, each lateral to the rectus muscle at the level of the umbilicus. For exploration of the vessels exiting a closed internal ring, a peritoneotomy is made at the internal ring, and the vas and vessels are followed into the inguinal canal. If an inguinal testicle can be identified, needlescopic orchidopexy is performed. If the vas and vessels cannot be traced to their inguinal termination, a small inguinal incision is made to remove a distal testicular remnant or to perform an orchidopexy, as necessary. Identification of an intra-abdominal or peeping testicle usually requires performance of a needlescopic orchidopexy. The technique

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of the needlescopic procedure 9 is the same as the one used in conventional laparoscopy, as described by Jordan and colleagues. 15 Briefly, the essential steps include creation of an inverted-V peritoneotomy over the internal ring, division of the gubernaculum (Fig. 9), preservation of any longqooping vas, meticulous freeing of the testicular vessels proximally beyond the iliac vessels, creation of a subdartos pouch in the ipsilateral hemiscroturn, and rerouting of the testicle to the scrotum in a more direct course medial to the medial umbilical ligament. Such a neo-internal ring is created by retrogradely guiding a curved hemostat through the scrotal incision, anterior to the pubic tubercle and into the abdominal cavity just medial to the medial umbilical ligament under needlescopic visualization (Fig. 10). The testicle is delivered into the scrotum and secured in the subdartos pouch in standard fashion, and needlescopic ports are removed. Each needlescopic port site is secured with a single Steri-strip, and no sutures are necessary.

placement of the testicle. The mean surgical time was 110 minutes (range, 60-118 minutes), and blood loss was 6 mL (range, 0-20 mL). All of the procedures were performed exclusively needlescopically, and the patients were routinely discharged on an outpatient basis. At 6- to 12-months follow-up, the 2m m skin puncture sites were barely visible, and all eight operated testicles were noted to be well positioned in the scrotum. 9 Needlescopic orchidopexy has n o w replaced the open technique at the author's center as the procedure of choice for the pediatric peeping or intra-abdominal testis. A d v a n tages of the endoscopic technique include the atraurnatic, high retroperitoneal mobilization of the testicular vessels, which may be superior to that achieved open surgically, and the precise creation of a medially located neointernal ring under magnified visualization. In the author's opinion, the laparoscopic procedure minimizes traction on, and avoids overskeletonization of, the spermatic cord.

Results

Lymphocele

In the author's initial experience with 12 procedures, there were 8 orchidopexies, including 2 bilateral, 2 orchiectomies, and 2 diagnostic examinations with attempted excision of testicular remnant. All eight orchidopexies were successful with good scrotal

Although infrequent, symptomatic pelvic lymphoceles may occur following renal transplantation or peNic lymph node dissection. Laparoscopy using conventional 5-ram and 10-mm instrumentation has emerged as the standard definitive treatment for most pa-

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Figure 9. Needlescopic left orchiopexy. Following an inverted-V peritoneotomy at the internal inguinal ring, the testis is retracted cephalad. The gubernaculum is divided distally, taking care to avoid any long-looping vas that may be present.

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the umbilicus. In the author's experience with three patients, the mean surgical time was 105 minutes, blood loss ranged from 10 to 200 mL, and one patient was converted to conventional laparoscopy to achieve hemostasis at the parenchymal cut edge of the cyst wall. Additionally, over a follow-up of 6 months, one patient (33%) had a recurrence of the renal cyst, which was treated secondarily with conventional laparoscopy.

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Figure 10, Transfer of the mobilized gonad from the intraperitonealty-located needlescopic grasper to the scrotallyqnserted hemostat, for subsequent placement in the subdartos pouch. The three-port transperitoneal needlescopic approach is shown.

tients with symptomatic pelvic lymphocelesJ4 Although the pelvic lymphocele is usually located deep in the pelvis, thereby requiring considerable dissection, occasionally, it is superficially located and readily accessible. In these select cases, needlescopic lymphocelectomy can be performed. A three-port transperitoneal approach is employed, and a window of the lymphocele wall is excised at its most readily visible bulging part. In the author's experience with three patients, the mean surgical time was 118.3 minutes, blood loss ranged from 10 to 50 mL, and all procedures were performed on an outpatient basis.

Renal Cyst For the occasional patient with an anteriorly located, readily visible symptomatic renal cyst who is deemed a candidate for laparoscopic excision, the needlescopic technique may be employed. A four-port transperitoneal technique is performed, and the renal cyst is marsupialized after mobilizing the ipsilateral colon. Because the cyst wall must be removed at the end of the procedure, and because an argon beam coagulator may be necessary, one 5-mm port m a y be placed at

Perhaps one of the foremost applications of needlescopic instrumentation is its use as an adjunct to conventional laparoscopy. During the p e r f o r m a n c e of a conventional laparoscopic procedure, where there is a need to retract various tissues, or to aid the performance of a laparoscopic running suture line by placing traction on the suture, a 2-mm instrument can be readily employed in lieu of a larger port. There may be some hesitation on the part of the surgeon to place an additional larger (5 ram) port for this purpose. Because a 2-mm port requires no formal skin incision but only a skin puncture, it can be readily employed without any significant cosmetic disadvantage. 2 The author has replaced a 5-ram port wifl~ a needlescopic port for lateral retraction of the kidney during radical nephrectomy, live-donor nephrectomy, and nephroureterectomy. Other reconstructive procedures wherein a needlescopic port may be efficacious include laparoscopic enterocystoplasty, pyeloplasty, sacral colpopexy, and cross-trigonal Cohen ureteral reimplantation/ Needlescopic visualization can be emp l o y e d to enhance safety w h e n obtaining transperitoneal laparoscopic access in the setting of a previously operated abdomen, in lieu of the open (Hasson) technique. The author obtains pneumoperitoneum by inserting a 2-mm port (Veress needle) in a safe quadrant of the abdomen, distant from the previously operated site. Pneumoperitoneum is achieved and a 1.9-mm needlescope inserted to visualize the peritoneal cavity. Conventional laparoscopic trocars can then be inserted reliably u n d e r vision in a p l a n n e d manner into adhesion-free areas.

Experimental Techniques Needlescopic and minilaparoscopic instrumentation can be employed for training and

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research purposes in small animal models. The author and his colleagues have recently d e v e l o p e d a rat m o d e l of retroperitoneoscopic nephrectomy using 2-mm and 3-mm instrumentation exclusively. 16 After gently creating a retroperitoneal space with a small Foley balloon, three minilaparoscopic ports are inserted. The renal hilum is dissected and secured en bloc with an intracorporeally placed 3-0 suture tie. The kidney is then circumferentially freed without compromising the peritoneal membrane. Future projects involving minilaparoscopic reconstructive techniques in the rat model, possibly involving robotics, are proposed. LIMITATIONS AND ADVANTAGES

Currently available 2-mm instrumentation and scopes lack the versatility and durability of their conventional laparoscopic counterparts. 21 The 2-mm instruments are flimsier, less sturdy, and have suboptimal grasping power. A 2-mm suction-aspirator, hook electrode, and needle driver are currently unavailable. Furthermore, the 2-mm electrosurgical scissors are adequate only for performing dissection of delicate tissues, such as during cryptorchidism surgery. The image resolution and clarity provided by the minilaparoscope and needlescope are inferior to that of the 5-mm laparoscope, which is inferior to that of the 10-mm laparoscope. Nevertheless, in the author's experience, the visualization afforded by the needlescope is adequate for the limited applications listed herein. Needlescopic technology does afford the advantages that can be expected from miniaturization. A clear advantage is the superior cosmetic result. Despite the trend toward decreased analgesic requirements, a shorter hospital stay, and abbreviated convalescence in various reports, TM18 a prospective randomized comparison with conventional urologic laparoscopy has not yet been performed. SUMMARY

Technological miniaturization is an emerging trend that encompasses virtually all surgical subspecialt!es. Minimization of surgical t r a u m a while maximizing surgical cure through gradual progression from maximally invasive to minimally invasive to ultimately

noninvasive technologies must be the goal. Needlescopic techniques represent a natural evolution and sophistication of conventional laparoscopy. At the author's center, needlescopic techniques have been used to particular advantage in four specific clinical applications: adrenalectomy, pediatric orchiopexy, detaching the bladder cuff during laparoscopic nephroureterectomy, and as an adjunctive needlescopic port for retraction purposes during conventional laparoscopic surgery. Given the urologist's natural facility with small-diameter endoscopes, the specialty is uniquely positioned to take a leadership position in this emerging field. Increased experience and careful comparisons with conventional laparoscopy will determine the true role of needlescopic technology in the armamentarium of the urologic surgeon. References 1. Bauer O, Devroey P, Wisanto A, et ah Small diameter laparoscopy using a microlaparoscope. Hum Reprod 10:1461-1464, 1995 2. Borer JG, Retik AB, Atala A, et ah Pediatric retroperitoneoscopic nephrectomy using 2 millimeter instrumentation [abstract no. 604]. J Urol 159:158, 1998 3. Dorsey JH, Tabb CR: Minilaparoscopy and fibre-optic lasers. Obstet Gynecol Clin North Am 18:613, 1991 4. Faber BM, Coddington CC IIh Microlaparoscopy: A comparative study of diagnostic accuracy. Fertil Steril 67:952-954, 1997 5. Fuller PN: Microendoscopic surgery: A comparison of four microendoscopes and a review of the literature. Am J Obstet Gynecol 174:1757-1762, 1996 6. Gill IS: Reply to letter to the editor: Needlescopic surgery. Urology 53:1071, 1999 7. Gill IS, Desai M, Ross J: Laparoscopic transvesical cross-trigonal Cohen ureteral reimplantation. J Endourol 13:FP6-2(A43), 1999 8. Gill IS, Hobart MG, Schweizer D, et ah Outpatient adrenalectomy. J Urol 163:717-720, 2000 9. Gill IS, Ross JH, Kay R: Needlescopic surgery for cryptorchidsim the initial series. Am J Pediatr Surg 35:1426, 2000 10. Gill IS, Soble JJ, Miller SD, et ah A novel technique for management of the en bloc bladder cuff and distal ureter during laparoscopic nephroureterectomy. J Urol 161:430, 1999 11. Gill IS, Soble JJ, Sung GT, et ah Needlescopic adrenalectomy--the initial series: Comparison with conventional laparoscopic adrenalectomy. Urology 52:180-186, 1998 12. Gill IS, Sung GT, Hobart MG, et al: Laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma: Cleveland Clinic experience. 164:1513, 2000 13. Hobart MG, Gill IS, Schweizer D, et al: Financial analysis of needlescopic versus open adrenalectomy J Urol 162:1264-1267, 1999 14. Hsu T, Gill IS, Grune MT, et ah Laparoscopic marsu-

NEEDLESCOPIC UROLOGY: CURRENT STATUS

15. 16. 17. 18. 19.

pialization of lymphocele in 81 patients: Multi-institutional analysis. J Urol 163:1096-1099, 2000 Jordan GH, Winslow BH: Laparoscopic single stage and staged orchiopexy. J Urol 152:1249, 1994 Kaouk JH, Gill IS, Meraney AM, et al: Retroperitoneal microlaparoscopic nephrectomy in the rat model. Urology, in press Lee BR, Kavoussi LR, Goh PMY: Letter to the editor: Needlescopic surgery. Urology 53:1071, 1999 Palter SF, Olive DL: Office microlaparoscopy under local anesthesia for chronic pelvic pain. J Am Assoc Gynecol Laparosc 3:359-364, 1996 Risquez F, Pennehoaut G, McCorvey R, et al: Diag-

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nostic and operative microlaparoscopy: A preliminary multicentre report. Hum Reprod 12:1645-1648, 1997 20. Shalhav A, Dunn M, McDougall EM, et ah Laparoscopic radical nephroureterectomy for upper tract TCC: The emerging standard. Urol Clin North Am, in press 21. Soble JJ, Gill IS: Needlescopic urology: Incorporating 2 mm instruments in laparoscopic surgery. Urology 52:187, 1998 22. Winfield HN, Hamilton BD, Bravo EL: Technique of laparoscopic adrenalectomy. Urol Clin North Am 24: 459, 1997 Address reprint requests to Inderbir S. Gill, MD, MCh Section of Laparoscopic and Minimally Invasive Surgery Department of Urology, A-100 The Cleveland Clinic Foundation 9500 Euclid Avenue Cleveland, Ohio 44195