Laparoscopic And Robotic Surgery Will Replace Open Urological Surgery In Near Future

Review Article

LAPAROSCOPIC AND ROBOTIC SURGERY WILL REPLACE OPEN UROLOGICAL SURGERY IN NEAR FUTURE Ritesh Mongha and Anant Kumar Department of Urology and Renal Transplantation,Indrapastha Apollo Hospitals,Sarita Vihar,New Delhi 110076, India. Correspondence to: Dr Anant Kumar, Senior Consultant, Department of Urology and Renal Transplantation, Indrapastha Apollo Hospitals,Sarita Vihar,New Delhi 110076, India. e-mail: [email protected] Today, almost all open urological surgery can be performed by minimally invasive surgery. In the new millennium, the old craft of open surgery has an ever-diminishing role in the treatment of urologic disease. Urologists have many tools at their disposal like endoscopes, laparoscopes, percutaneous tools and recently robot to take of their patients without inflicting much pain, discomfort and morbidities. Among all, laparoscopy has made tremendous impact in urology. Robotic surgery has strengthened the minimally invasive surgery as more and more complex cases can be done with relative ease and efficiently. Key words: Laparoscopy, Urology, Minimally access surgery

INTRODUCTION THE early application of laparoscopy was largely limited to diagnostic purposes. In the surgical arena, laparoscopy was first made popular by the gynecologists for procedures like tubal ligation and pelvic inspection. However, it was not until the mid-1980s that laparoscopy moved from gynecology into the realm of general surgery. Laparoscopy in urology paralleled, to a large extent, the changes in general surgery. Up until the late 1980s, laparoscopy had limited applications in urology. Evolution of laparoscopy was rapid after that. The first laparoscopic Nephrectomy was performed in 1991 [1], laparoscopic live donor Nephrectomy 1995 [2], and the first robotic radical prostatectomy in 1998 [3]. Various multi-institutional studies which compared laparoscopic procedures with their open surgical counterparts, have shown that, laparoscopic surgery has equivalent efficacy combined with distinct advantages like

lesser blood loss, reduced morbidity, minimal inflammatory reaction, post-op adhesions and pain, better cosmesis, faster recovery, and shorter length of hospital stay [4]. Laparoscopy has thus moved into the mainstream of urologic practice. Robotic surgery has further improved the minimal surgery and made it possible to those procedures which were difficult and complex by many laparoscopic surgeons. Laparoscopy and robotic assisted surgery have evolved in last 15 years and Tables 1 to 4 summarize its current position. LAPAROSCOPY AND ROBOTICS PROCEDURES Laparoscopic adrenalectomy The adrenal gland’s unique location in the retroperitoneal makes it amenable to various laparoscopic

Table 1. Indications for urologic laparoscopy procedures done routinely in many centers Kideny

Ureter

Adrenal

Testes

Nephrectomy

Nephroureterectomy

Adrenelectomy

Orchiopexy

•

simple

• live donor •

radical

Renal cysts

Ureterolithotomy

Pyeloplasty

Lymphocele

Orchidectomy

145

Apollo Medicine, Vol. 6, No. 2, June 2009

Review Article

Table 2. Procedures done only at major centers Kidney

Ureter

Bladder

Prostate

Retroperitoneal Lymph Node

Partial nephrectomy

Ureterolysis

Partial cystectomy

Radical Prostatectomy

Lymph node Dissections

Retrocaval ureter

VVF & UVF repair

Pyelolithotomy

Ureteric re-implantation Augmentations Diverticulectomy Urachus excision

Table 3. Procedures not established Bladder

Surgery for stress incontinence

Retroperitoneal Lymph Node [RPLN]

Urinary conduit

Procedentia

RPLN dissections

Urinary diversion

Cystocele

Radical cystectomy

Rectocele

Neobladders

Colposuspension

decreased by 50%, and the time to full convalescence has been reported to be markedly less than with open removal. In early series, the mean operative times were greater than 300 minutes. However, with advances in techniques, experience, and equipment, current operative times have decreased dramatically [4,6,7].

Table 4. Robotic assisted laparoscopic surgery Commonly performed procedures

Done in major centers

Radical prostatectomy

Partial nephrectomy

Pyeloplasty

Cystectomy with diversion

Pelvic floor prolapse

VVF & UVF, RPLND

Laparoscopic transperitoneal donor nephrectomy

approaches. Gasman and coworkers (5) reported their experience using the lateral retroperitoneal approach. Reported operative times ranged from 45 to 160 minutes, with an average of 97 minutes. Diameters of the excised glands ranged from 26 mm to 4 cm. Contraindications to retroperitoneal laparoscopy included adrenal glands 5 cm or larger as it could be cancerous with periadrenal infiltration and previous lumbar incisions. Laparoscopic nephrectomy The postoperative results of the laparoscopic Nephrectomy are comparable to that of open surgery with much less pain and shorter convalescence. Postoperative pain requirements are approximately four times less than with traditional open incisions. Hospital stays have been Apollo Medicine, Vol. 6, No. 2, June 2009

Laparoscopic living donor Nephrectomy was first performed by Ratner and associates in 1995, as a means to diminish the disincentives to organ donation by decreasing the morbidity [8]. When compared with open nephrectomy for transplantation, the laparoscopic approach results in a shorter hospital stay, lower postoperative analgesic requirements, a faster return to activities of daily living, and an earlier return to employment. Laparoscopic donor nephrectomy has not been shown to have adverse affects on allograft function or survival [9-12]. Renal biopsy Ultrasound-guided percutaneous needle biopsy, under local anesthesia, is the current standard for obtaining renal tissue. Unfortunately, there is a 5% rate of significant hemorrhagic complications, and as many as 5% to 20% of

146

Review Article

cases yield inadequate tissue for accurate diagnosis. For these patients, laparoscopic renal biopsy offers the advantages of open biopsy with the decreased morbidity of a two-port outpatient procedure especially in patients with single kidney. Renal cystic disease The laparoscopic approach to renal cystic disease has been found to be effective in decompression and pain control. Laparoscopic decortication for symptomatic ADPKD is technically feasible and less morbid than open surgery,but its indication is still evolving [13]. Nephropexy Patients who are markedly symptomatic and have documented changes in the kidney position from the supine to the erect position may benefit from the effective and less morbid treatment of laparoscopic nephropexy [14]. Pyelolithotomy, ureterolithotomy and anatrophic nephroloithotomy Individuals to be considered for this approach includes those in who presently accepted procedures have failed (ESWL, percutaneous or ureteroscopy), patients with unusual anatomy such as the pelvic kidney, and patients with stones resistant to fragmentation such as those of cystine composition. Successful laparoscopic transperitoneal pyelolithotomy has been reported in ectopic kidneys with stones from 2 to 4 cm [15,16]. Large ureteric stones and pelvic stones are good indications for laparoscopy. Laparoscopy has also been tried for stag horn calculus by extended pyelolithotomy and anatrophic nephroloithotomy. LAPAROSCOPY FOR RENAL MALIGNANCY Laparoscopic Radical Nephrectomy Reports have clearly shown it to be less morbid than open surgery. The reported 5-year survival of patients indicates that the cancer-free survival is comparable to that seen after open radical nephrectomy. Gill and associates [17] compared a series of 53 laparoscopic radical nephrectomy to 34 open radical nephrectomy. In the 53 laparoscopic radical nephrectomies for tumors with a mean size of 4.6 cm (range 2 to 12 cm), the mean specimen weight was 484 g. All specimens were removed intact. Minor complications occurred in eight patients (17%,) and major complications requiring conversion to open surgery occurred in two patients (4%). The laparoscopic approach was found to have less blood loss (P<0.001), a shorter hospital stay (P<0.001), lower analgesic requirements (P<0.001), and shorter

convalescence (P <0 .005) compared with open radical nephrectomy. Complications were seen in 13% of the laparoscopic patients and in 24% of the open surgical candidates. Similar results have been reported by other investigators comparing open and laparoscopic radical nephrectomy [18,19]. Partial Nephrectomy - Nephron-sparing surgery (NSS) Laparoscopic NSS for small solid renal masses can be performed safely utilizing innovative modalities to achieve hemostasis. This technique closely approximates the surgical goals of open NSS as an effective means of managing small renal tumors. Novel hemostatic techniques may allow increased applications. In a current publication from cleaveland clinic for both procedures have almost similar results [20]. Robotic partial nephrectomy is also becoming popular and more such surgeries are being attempted. Laparoscopic pyeloplasty It is one of the procedures which have almost replaced open pyeloplasty in majority of the centers. Results are comparable to open operation with minimal morbidity. Robotic pyeloplasty is also becoming very popular [21,22]. OTHER APPLICATIONS OF LAPAROSCOPIC SURGERY Laparoscopic pelvic lymph node dissection Comparative studies of laparoscopic versus open PLND demonstrate intraoperative times similar to those with laparoscopy after the learning curve is overcome. Complication rates of LPLND are not significantly different from those of open PLND. As with most other laparoscopic procedures, there is a marked benefit with laparoscopy in the postoperative period for pain control requirements, hospitalization, and overall convalescence. Laparoscopic retroperitoneal tomy for cancer of the testis

lymphadenec-

Some centers have reported small series of laparoscopic RPLND for nonseminomatous stage I testis tumors [23]. Laparoscopic RPLND may be considered a staging technique for patients with stage I cancer of the testis. Its ultimate role in the algorithm that defines the management of cancer of the testis is still to be determined. There are some selected centers in Europe who are doing RPLND for stage 1 and II as well as for post chemotherapy residual mass excision. Laparoscopic varicocelectomy

147

The role of laparoscopic varicocelectomy remains Apollo Medicine, Vol. 6, No. 2, June 2009

Review Article

controversial[24] and is replaced by microsurgical inguinal approach, which has excellent results. Laparoscopic radical prostatectomy It is one of the most difficult operations performed laparoscopically all over the world. It is feasible and mimics the open surgical results. With regard to the oncological results, as compared to RRP, surgical positive margin rates are marginally higher. Surgical morbidity, continence rates from experienced laparoscopic surgeons are compared with those of experienced open surgeons [25]. Blood loss and transfusion rates are lower with LRP than with RRP. The Montsouris group averaged a blood loss of only 262 mL with a 0% transfusion rate in their most recent 60 patients [25]. Length of hospital stay for LRP is also similar to that for RRP. However sexual dysfunction rate is higher in laparoscopic group [26]. Robotic prostatectomy Now more than 60 % of all radical prostatectomy in USA are being done robotically as it is easier to learn and can be performed with ease and efficiency. Its results are similar or better than open radical prostatectomy. Many urologists could not perform or learn laparoscopic surgery for the complex procedures, but could learn robotic surgery very quickly and could perform most of the operations with very good results. Laparoscopic lymphocele ablation Intervention is necessary for lymphoceles that displace the bladder; obstruct the pelvic veins and lower-extremity lymphatics, causing edema; or compress a transplant ureter. Laparoscopic ablation of lymphoceles demonstrates comparable efficacy and reduced morbidity compared with open surgical drainage [27]. It has become one of the preferred procedures for this entity. OTHER APPLICATIONS Laparoscopic partial and simple cystectomy These are performed primarily for benign disease of the bladder. Such procedures may be aided by combined laparoscopic and cystoscopic approaches to locate and excise bladder lesions. Here robotic has better role as suturing is easier , quicker and better. Laparoscopic radical cystectomy Gill and colleagues [28] reported a series of seven patients on whom they performed laparoscopic radical Apollo Medicine, Vol. 6, No. 2, June 2009

cystectomy and ileal conduit urinary diversion exclusively by intracorporeal techniques. Experience with intracorporeal suture placement and knot tying is critical to accurate ureteroileal anastomoses. After seven cases, the operative time, as expected, is lengthy (6.5 to 8 hours), but it is expected to decrease with experience. Laparoscopic Radical Cystectomy (LRC) with Urinary Diversion it takes longer time requires significant laparoscopic expertise, more expensive and long-term data are not available. So, the role is not as yet established. Presently most of the surgeons are removing bladder laparoscopically and doing ileal conduit by open method, which does not make much sense. One can give a little bigger incision and do the whole operation by open method. Robotic surgery has a definite role here as diversion or continent pouch can be easily performed by robotic rather than laparoscopy. Again partial and radical cystectomy are not easier by robotic than laproscopic way. Laparoscopic bladder diverticulectomy Diverticula that involve the lateral, dome, or anterior regions of the bladder are easily accessible to dissection and repair by laparoscopic techniques [29]. Laparoscopic bladder augmentation Many reports demonstrate that laparoscopic bowel manipulation followed by bladder augmentation-with or without the creation of a catheterizable stoma-is both safe and feasible [30,31]. Furthermore, early follow-up has demonstrated satisfactory results. However, these procedures are technically demanding, with long operative times (5 to 10 hours), and perioperative outcomes have not been compared with those of standard open techniques. Until an advantage in morbidity is demonstrated with equal efficacy, these procedures should be offered only to selected patients. Again robotic assisted surgery has been found by many easier, better and simpler for any pelvic surgery of bladder and prostate. Whenever suturing is to be done robotic has scored over the laparoscopy. Pediatric laparoscopic and robotic surgery Laparoscopic procedures in paediatric urology are gaining popularity, with an increasing number of centers performing advanced surgery. Indications have expanded from diagnostic to ablative surgery and more recently to reconstructive procedures. Since pediatric tissues are small and delicates and sutures are 5 and 6 zero, robotic assisted surgery has become more popular among pediatric urologists.

148

Review Article

Laparoscopy in the management of impalpable testicle Diagnostic laparoscopy is a very helpful, minimally invasive technique in the diagnosis of impalpable testes especially when ultrasonography and/or computed tomography are not informative. In addition, orchiectomy and orchiopexy can be done for with intra-abdominal testes. Therefore, the laparoscopy has an important role in the diagnosis and treatment of impalpable testes. Lap orchiopexy is in fact an easier and simpler procedure in comparison to open method. Dismembered pyeloplasty remains a challenging procedure limited to few centers, with excellent midterm results. Usually children above the age of two are taken up for lap Pyeloplasty, but some pediatric urologist has reported smaller series for children below two years also. Now most of the pediatric pyeloplasty in USA are done with the help of robot and results are better as many more urologists could do it. Laparoscopic adrenal surgery has been extended to neuroblastoma in selected cases. Laparoscopic transvesical ureteric re-implant is now feasible, and opens a new era in bladder surgery. However this is still limited to a few centers. Ureteric tailoring and reimplantation is being done by few centers [32]. Robotic has a bigger role to play in these indications as the tissues are small and delicate in children and more precise surgery can be done with robotic assistance. Other rare procedures done by lap or robotic assisted In addition, there are many case reports showing that almost all urological procedures could be done laparoscopically like renal artery aneurysm [33], auto transplantation on [34], retrocavel ureter [35], freeing the ureter from retroperitoneal fibrosis and omental wrapping [35], laparoscopic ureteral reimplantation with extracorporeal tailoring for megaureter [32], uretero-calycostomy, lap prostatectomy for BPH [37] and excision of urachal carcinoma [38]. Difference between lap vs. robotic Laparoscopy need dexterity and advance skill. One should use both hands simultaneously to do complex procedures. Due to two D vision, depth perceptions are not good and often makes suturing difficult. It is also difficult when space and vision is limited. However

robotic has many advantages as it has three D vision and one can move instrument in 7 directions which may not even possible by hand. There is no intentional tremor and surgeon is not tired as he is sitting on console. Complex procedures like radical prostate, rad cystectomy, diversion, augmentation, partial nephrectomy and pyeloplasty were become popular after the advent of robotic surgery. Suturing even in deep pelvis is very easy and can be done by any surgeon. Where laparoscopy and robotic surgery is not possible Procedures not being done laparoscopically are penile, urethral and scrotal surgeries as these structures are superficially located. In urological trauma, laparoscopy can be used for inspection and staging. In major reconstructive surgery which involves lot of suturing usually open surgery is preferred. However in future with robotics, absorbable staplers and adhesive devices all reconstructive surgeries may be performed with minimal invasion. CONCLUSION There is sufficient evidence in the literature that laparoscopic approaches result in equivalent surgical outcomes with decreased convalescence when compared to traditional open surgical procedures. Indeed, it is becoming increasingly clear that the objectives of almost all aspects of open retroperitoneal surgery, be it of the kidney, ureter, adrenal gland, prostate or lymph nodes, can now be achieved laparoscopically with far less injury and pain to the patient. Minimally invasive surgery is superseding open surgery at major medical centers throughout the world. In the new millennium, the old craft of open surgery has an ever-diminishing role in the treatment of urologic disease. Unfortunately, clinical practice demonstrates that applications of these techniques have yet to be widely employed. The primary reasons are lack of adequate physician training mechanisms and additional cost of the laparoscopic approach. Hopefully, the development of surgical simulators and telementoring systems will help urologists gain experience in this minimally invasive alternative. The length of operative procedure and use of disposable equipment is the primary factor responsible for the increased cost of laparoscopic surgery. The reduced hospital stay has not compensated for these expenses. Thus far, there has not been adequate financial analysis to assess the full impact of decrease in post-hospital convalescence. These individual and employee savings may significantly shift the cost advantage to the laparoscopic approach.

149

Apollo Medicine, Vol. 6, No. 2, June 2009

Review Article

Robotic urology has opened a new armamentarium for the laparoscopic surgeons as it has seven degree of movements, surgeon operating in sitting position with minimal fatigue and no procedure related injury. Suturing and dissection is more efficient due to better dexterity, ergonomics and good vision. REFERENCES 1. Clayman RV, Kavoussi LR, Soper NJ, et al: Laparoscopic nephrectomy. N Engl J Med 1991; 324:1370. 2. Ratner LE, Ciseck LJ, Moore RG, et al: Laparoscopic live donor nephrectomy. Transplantation 1995; 60:1047. 3. Menon M, et al. Robotic assisted laparoscopic radical prostatectomy. J Urol 1998 :168(3): 945. 4. Baba S, Nakagawa K, Nakamura, et al. Experience of 143 cases of laparoscopic surgery in urology-clinical outcome in comparison to open surgery. Jpn J Urol 1996; 87: 842-850. 5. Gasman D, Droupy S, Koutani A, et al. Laparoscopic adrenalectomy: The retroperitoneal approach. J Urol 1998;159:1816-1820.

Laparoscopic pyelolithotomy in a pelvic kidney: A case report and review of the literature. JSLS 1997; 1: 163-165. 17. Gill IS, Schweizer D, Hobart MG, et al. Retroperitoneal laparoscopic radical nephrectomy: The Cleveland Clinic experience. J Urol 2000;163:1665-1670. 18. McDougall EM, Clayman CR, Elashry OM: Laparoscopic radical nephrectomy for renal tumor: The Washington University Hospital experience. J Urol 1996;155:11801185. 19. Clayman RV, Elbahnasy A, Elashry O, et al. Laparoscopic vs. open radical/total nephrectomy for renal cell carcinoma. (Abstract 1280.) J Urol 1997; 157(Suppl): 328A. 20. Gill IS, et al. Comparative Analysis of Laparoscopic Partial Nephrectomy vs. Open Partial Nephrectomy J Urol 2003: 170; 64-68. 21. Mandhani A, Kumar D, Kumar A, et al. Steps to reduce operative time in laparoscopic dismembered pyeloplasty for moderate to large renal pelvis. Urology 2005; 66(5): 981-984.

6. Rassweiler JJ, Stock C, Frede T, et al. Transperitoneal and retroperitoneal laparoscopic nephrectomy in comparison with conventional nephrectomy. Urologe A 1996; 35: 215-222.

22. Mandhani A, Kumar D, Kumar A, Kapoor R, Dubey D, Srivastava A, Bhandari M. Safety profile and complications of transperitoneal laparoscopic pyeloplasty: A critical analysis. J Endourol 2005; 19(7): 797-802.

7. Rassweiler JJ, Fornara P, Weber M, et al. Laparoscopic nephrectomy: The experience of the laparoscopic working group of the German Urologic Association. J Urol 1998a;160: 18-21.

23. Nelson JB, Chen RN, Bishoff JT, et al. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular tumors. Urology 1999; 54: 1064-1067.

8. Ratner LE, Ciseck LJ, Moore RG, et al. Laparoscopic live donor nephrectomy. Transplantation 1995; 60:1047.

24. Jarow JP. Varicocele repair: Low ligation. Urology 1994; 44: 470-472.

9. Ratner LE, Kavoussi LR, Sroka M, et al. Laparoscopic assisted live donor nephrectomy-a comparison with the open approach. Transplantation 1997c;63: 229-233.

25. Guillonneau B, Cathelineau X, Barret E, et al. Morbidity of laparoscopic radical prostatectomy: Evaluation after 210 procedures. J Urol 2000; 163:140.

10. Sosa JA, Albini TA, Powe NR, et al. Laparoscopic vs. open live nephrectomy: A multivariate patient outcome analysis. Transplantation 1998; 65(12): S85.

26. Ong AM, Sul M, Varkarakis I, et al. Nerve sparing radical prostatectomy: effects of hemostatic energy sources and the recovery of cavernous nerve function in a canine model. J Urol. 2004;172:1318-1322.

11. Fabrizio MD, Ratner LE, Montgomery RA, Kavoussi LR. Laparoscopic live donor nephrectomy. Urol Clin North Am 1999; 26: 247-255. 12. Kavoussi LR, Ratner LE. Laparoscopic nephrectomy. Kidney Int 2000; 57: 2175-2186.

donor

13. Lifson BJ, Teichman MH, Hulbert JC. Role and long-term results of laparoscopic decortication in solitary cystic and autosomal dominant polycystic kidney disease. J Urol 1998; 159: 702-706. 14. McDougall EM, Afane JS, Dunn MD, et al. Laparoscopic nephropexy: Long-term follow-up-Washington University Experience. J Endourol 2000;14: 247-250. 15. Chang TD, Dretler SP: Laparoscopic pyelolithotomy in an ectopic kidney. J Urol 1996;156:1753. 16. Hoenig DM, Shalhav AL, Elbahnasy AM, et al. Apollo Medicine, Vol. 6, No. 2, June 2009

27. Gill IS, Hodge EE, Munch LC, et al. Transperitoneal marsupialization of lymphoceles: A comparison of laparoscopic and open techniques. J Urol 1995b;153: 706-711. 28. Gill IS, Fergany A, Klein EA, et al. Laparoscopic radical cystoprostatectomy with ileal conduit performed completely intracorporeally: The initial 2 cases. Urology 2000a; 56: 26-30. 29. Iselin CE, Winfield HN, Rohner S, Graber P. Sequential laparoscopic bladder diverticulectomy and transurethral resection of the prostate. J Endourol 1996;10: 545-549. 30. Sanchez de Badajoz E, Hurtado AM, Garrido AJ, Gutierrez de la Cruz JM: Laparoscopy-assisted cystoplasty. J Endourol 1995b; 9: 269-272.

150

Review Article Retroperitoneoscopic surgery with extracorporeal uretero-ureteral anastomosis for treating retrocaval ureter.Int Braz J Urol. 2005;31(2):147-150.

31. Gill IS, Rackley RR, Meraney AM, et al. Laparoscopic enterocystoplasty. Urology 2000b; 55: 178-181. 32. Ansari MS, Mandhani A, Khurana N, Kumar A. Laparoscopic ureteral reimplantation with extracorporeal tailoring for megaureter: a simple technical nuance. J Urol. 2006; 176(6 Pt 1): 2640-2642.

36. Okumura A, Murakami K, Nozaki T, Fuse H. Laparoscopic ureterolysis for idiopathic retroperitoneal fibrosis. Int J Urol. 2005;12(12):1079-1081.

33. Castillo OA. Case report: laparoscopic repair of saccular renal-artery aneurysm. J Endourol. 2006; 20(4): 260261.

37. Mariano MB, Tefilli MV, Graziottin TM, Morales CM, Goldraich IH. Laparoscopic prostatectomy for benign prostatic hyperplasia- a six-year experience. Eur Urol. 2006; 49(1): 127-131.

34. Unno N, et al. Laparoscopic nephrectomy, ex vivo repair, and autotransplantation for a renal artery aneurysm: Report of a case.SurgToday 2007; 37(2):169-172. 35. Tobias-Machado M, Lasmar MT, Wroclawski ER.

38. Wadhwa P, Kolla SB, Hemal AK. Laparoscopic en bloc partial cystectomy with bilateral pelvic lymphadenectomy for urachal adenocarcinoma. Urology. 2006; 67(4): 837843.

151

Apollo Medicine, Vol. 6, No. 2, June 2009