LAPAROSCOPY IN UROLOGYCASE REPORT

Dr Allison MooreUrology Registrar

University of Cape Town

Use of Laparoscopy in Urology

■ Adrenal (adrenalectomy)■ Renal

– Simple nephrectomy– Radical nephrectomy– Partial Nephrectomy – Nephroureterectomy

■ Ureter– Pyeloplasty– Ureterolithotomy– Reimplant– Antireflux– Ureterolysis

■ Bladder– Radical/partial Cystectomy– Diverticulectomy

■ Prostate– Radical Prostatectomy

■ Lap Varicocoelectomy■ Lap orchidectomy/orchidopexy■ Urogynae

– VVF repair– Lap Sacrocolpopexy

■ Lymph nodes– Pelvic lymphadenectomy– Retroperitoneal lymphadenectomyEtc….

1st Lap Radical Nephrectomy = 1991

Lap Radical Prostatectomy:9 cases from 1991-1998

Lap Radical Cystectomy: 1992

Case Report:

■ Bladder diverticulum■ Case: 68 M

– Chronic BOO– Urethral stricture disease– Recurrent UTIs post successful DVIU– Large bladder diverticulum MCUG– No surgical hx– COPD, moderate BMI

Bladder diverticuli: overview■ Mucosal herniation ■ SCATTERED thin muscle fibres = POOR EMPTYING■ Male > Female■ Congenital vs acquired■ Acquired à most insignificant■ Complications:

– LUTS/Post void residual– UTI– Malignancy (incidence = 0.8-10%)– Stones

■ Indications correction

Surgical options Bladder diverticulectomy■ 1st 1992

■ Manage BOO

■ Gold standard: OPEN

■ Open, endoscopic, laparoscopic, robotic

■ Approach– Small: incise NECK (endoscopic)– Large: excise ■ extravesical■ intravesical■ or combination

■ Laparoscopic: – transperitoneal– extraperitoneal

Open Surgery: what the bosses say…

■ Difficult pelvic access

■ ID diverticulum

■ Stuck tissue

■ Bleeding

■ Wound sepsis

…

Why Laparoscopy??Be

nefit

s N

ephr

ecto

my

•Morbid subcostal

incision•Pain

•Bleeding•Atelectasis

Bene

fits

PELV

IC a

cces

s

•Radical Prostatectomy

•Radical cystectomy

•Difficult access

?? F

or B

ladd

er d

iver

ticul

um •Pelvis access•PATIENT:

•Moderate BMI

•Mild COPD•No previous

surgery•No

cardiovasculardisease

Laparoscopic BD technique■ TRANSPERITONEAL

■ Ureteric catheters

■ Identify diverticulum– Preop images/?obviously seen– Fill bladder– Flexible Cystoscope

■ Incise peritoneum

■ Circumferentially incise diverticulum à to neck

■ Neck of diverticulum = circumscribed + excised

■ NB ureter (?reimplant)

■ Close cystostomy

PORTS (as per Lap RP)

Robotic (RABD) (If you have lots of money)

Advantages

Less PAIN

COSMESIS

Faster RECOVERY

Shorter HOSPITAL STAY

?? Reduced COST

MAJOR PROBLEMS

Fatal gas embolism

Pneumothorax

Electrosurgical bowel injury

Post op crepitus

Patient selection

Prior surgeries + scars

LOCATION

COMORBIDITIES

Physiologic effects CO2pneumoperitoneum

Acidosis àmyocardium =

Cardiac arrhythmias

Contraindications to Laparoscopic Surgery

■ Uncorrectable coagulopathy

■ Intestinal obstruction

■ Significant abdominal wall infection

■ Massive haemoperitoneum or haemoretroperitoneum

■ Generalized peritonitis

■ Suspected malignant ascites

Potential DifficultiesPrior

Abdo or Pelvic

Surgery

MORBID OBESITY

Fibrosis e.g

peritonitis

Iliac or Aortic

aneurysm

Hernia: diaphragm

+ umbilical

Organomegaly

Pregnancy Ascites

Principles and Techniques■ PRE-OP:

– Bowel prep?

■ IN THE OPERATING ROOM:– Set up – Positioning + pressure points– Required instruments – U-cath

■ PERFORMING THE PROCEDURE:– Safe entry into abdomen – PLAN port placement– Watch intra-abdominal pressures (keep around 12mmHg)

Entry into peritoneal cavityHasson vs Veress

Adhesions? Palmers

Veress

Supine, 10-degrees TrendelenburgSigns of proper entry

TROCARS

• Non-cutting dilating trocars • Spreading abdominal wall musculature

Trocar placement■ Transperitoneal vs. Extraperitoneal

■ Consider: – Number– Size– Location/configuration– Skin incision

■ Surgeon preference à “Triangulation”?

■ Under vision (?optical trocars)

■ Twisting motion à towards site

■ Meticulous placement – ‘crossing swords’ + ‘rollover’

Insufflant: CARBON DIOXIDE

■ Most common

Favoured

•Colourless•Non-combustible•Very soluble in blood•Inexpensive

Potential problems

Absorbed CO2: COPDHypercapnia à cardiac arrhythmiasStimulates Sympathetic Nervous system

Alternative Gases

■ NOT in use: O2 + RA

■ Xenon, argon, krypton: (not widely adopted)

Less irritating Fewer acid-base changes + CVS effectsCO + increase MAP, HR and CVPSUPPORTS COMBUSTION

Inert, non-combustible Less irritating Useful pulmonary diseaseGAS EMBOLISM (blood solubility)EXPENSIVE

Blood loss + Transfusion rates■ Lap RN/Nephro-U: low rate transfusion (3% to 12%)

■ Lap/Robotic radical prostatectomy = low rate (experienced centres à2.5 %)

■ More extensive:– partial nephrectomy, RC, radical nephrectomy WITH ICV

thrombectomy– Experienced centres: Lap partial nephrectomy rates = 6-7%

■ ISSUES:– Vision– Converting to open…

TAKE HOME MESSAGES■ Bladder diverticulum

■ Place for Open vs Laparoscopic

■ LAPAROSCOPY in urology:– Nephrectomy– Pelvic surgery

■ Patient selection

■ SURGEON PREFERENCE

■ Knowledge

■ SKILL

References

■ Wein, A. Campbell-Walsh 11th Edition. ■ Clayman R et al. 1991. Laparoscopic Nephrectomy: initial case report. The journal of urology. 146;

278-82■ Parra R et al. 1992. Laparoscopic diverticulectomy: preliminary report of a new approach for the

treatment of bladder diverticulum. The journal of Urology. 1992; 148 (3) Part 1: 869-871■ Athanasiadis G, Bourdoumis A, Massod J. 2017. Is it the end for urologic pelvic laparoscopic

surgery? Sur Laparosc Endosc Percutan Tech. 2017 June; 27 (3), 139-■ Rassweiler J, Teber D. 2016. Advances in Laparoscopic surgery in urology, Nature review. Urology

2016 July; 13 (7): 387-99■ Zelhof B et al. 2016. Nephrectomy for benign disease in the UK: results from the British Association

of Urological Surgeons nephrectomy database. BJUI. 2016 Jan: 117(1): 138-44■ Atkinson T et al. 2017. Cardiovascular and ventilatory consequences of laparoscopic surgery.