Laparoscopy

What is Laparoscopy?
What are the primary treatments for tumors in urologic organs?

What new minimally invasive procedures are available for me?

What is Laparoscopy?
Laparoscopy is a minimally invasive surgical option for cancerous and non-cancerous urologic conditions involving various urologic organs such as the kidney, adrenal, bladder, testis and prostate.

Surgery can be performed via tiny dime-sized incisions rather than large cuts.  Postoperative patient recovery and pain can be dramatically reduced based on the laparoscopic surgical approach. Cosmesis, or appearance, can also be significantly improved in such surgical procedures.

In the past, most surgical procedures for structures within the abdomen had to be performed through an open incision. Though these procedures are necessary, the large incision is often associated with significant pain and discomfort, and a longer and slower recovery period. Surgeons have sought and developed less invasive means of performing the same procedure. The result of these developments is a surgical technique termed laparoscopy. Laparoscopy refers to the placement of a camera and narrow instruments into working ports positioned through small incisions (generally ½ to 1 cm) made in the skin. For procedures involving repair or removal of small structures, the incisions will remain this minimal size. One site may have to be slightly enlarged to accommodate removal of the diseased structure.

In the case of cancerous kidney masses, a slightly larger incision is made so that the kidney is removed intact. It is important that kidney masses be removed intact in order to avoid disruption. As laparoscopy has developed, variations on how the procedure is specifically performed now exist. These variations include:

  • dissecting out the kidney with laparoscopic instruments, placing the kidney in a bag, and then slightly enlarging one of the incisions at the end of the case;
  • making the slightly enlarged incision at the beginning of the case, placing one hand in the body to facilitate dissection, and then removing the kidney through this same incision that has already been created; and
  • performing laparoscopy through the side of the body (termed retroperitoneal laparoscopy), then removing the kidney in a bag through a slightly enlarged incision at the termination of the procedure.

All these laparoscopic procedures are performed by experienced laparoscopists and have been demonstrated to be very effective, while resulting in less postoperative pain, shorter hospital stay, and improved skin cosmesis when compared to open surgical procedures.

Laparoscopic Radical Nephrectomy
The primary treatment for kidney tumors is removal. The rationale for this is that medical studies demonstrate that surgical removal is the most effective treatment for tumors that, after a thorough medical evaluation, appear to be confined to the kidney. Small kidney tumors may only require partial kidney removal (see partial nephrectomy). Many kidney tumors may be removed with laparoscopic techniques. Only after consultation with an experienced laparoscopist can the determination be made whether a laparoscopic procedure is possible. Important factors in this determination include medical history, history of prior surgery, and specific factors related to the kidney tumor itself.

If the patient is a candidate for a laparoscopic procedure, the laparoscopic surgeon will be able to tell that individual what to expect. In the overwhelming majority of cases, the procedure will be completed laparoscopically. In rare instances, due to irregularities of the kidney or tumor anatomy and a heightened risk for bleeding, the procedure may be converted to an open procedure. Upon completion of the laparoscopic procedure the patient can expect to stay in the hospital on an average of two days. After discharge most patients undergoing laparoscopic surgery feel well and are able to move about in less than a week. However, all patients should keep in mind that even though the incisions are small, laparoscopic radical nephrectomy is a major procedure and that it takes the body time to recover after administration of a general anesthetic.

Laparoscopic partial nephrectomy
More recently, it has been demonstrated that small renal tumors can be effectively treated with partial kidney removal. This may be prudent in that some patients may have other medical illnesses, or may develop medical illnesses that will affect their kidney function. Thus, it is justified to preserve as much of a patient’s kidney function as possible while at the same time removing the entire tumor.

Partial nephrectomy (in this case also termed “heminephrectomy”) may also be performed for a small group of patients that have a duplication of their kidney. In simple terms, during their fetal development, their kidney and associated drainage tract developed in two distinct portions (an upper and lower part of the kidney) that are still intimately attached, but function separately. In certain cases this unusual development also results in obstruction of one of these segments, usually the upper segment, with loss of function. The nonfunctional segment itself may not necessarily be a problem, but it may cause pain, or develop infection, which may have serious or debilitating consequences for the patient. Thus, in certain situations, this nonfunctional segment is best removed.

Partial nephrectomy is a complex procedure whether performed in an open or laparoscopic fashion, necessitating surgical cutting through kidney tissue. The procedure requires meticulous surgical skill and has known risks of bleeding and urinary leakage. Laparoscopic partial nephrectomy is considered by most to be a highly complex procedure and is generally performed by experienced laparoscopists at large medical centers. Once again, only after consultation and thorough evaluation by an experienced laparoscopist can candidacy for this procedure be determined. At the University of Miami such cases are reviewed by a number of experienced radiologists and kidney surgeons to determine candidacy.

The specifics of how laparoscopic partial nephrectomy is performed are determined on a case-by-case basis. Some tumors can be removed through use of only laparoscopic instrumentation through a small port. The tumor, usually relatively small, is then placed in a bag and removed through one of the port sites. Larger tumors and tumors penetrating deeper into the kidney may be removed with use of hand assistance. This allows for greater control of renal bleeding and assessment of tumor extent.

Partial nephrectomy involves a risk of bleeding and the chance that a blood transfusion may be necessary. Partial nephrectomy may also involve a risk of urinary leakage, in which case a stent, or straw-like tube, may be placed in the involved kidney’s drainage system until the leakage stops. This stent may be easily removed in the doctor’s office. After the laparoscopic partial nephrectomy, the patient will have only a short stay in the hospital and will be discharged after there is no evidence of significant bleeding or urinary leakage from the operated kidney.

Laparoscopic treatment of renal obstruction
Blockages in the flow of urine from the kidney may be due to stones or disease of the muscular tube (ureter) that connects the kidney to the bladder. Some individuals are born with a narrowing at the point where the kidney (renal pelvis) and ureter join, a condition known as congenital ureteropelvic junction (UPJ) obstruction.

UPJ obstruction is defined as an obstruction of the flow of urine from the renal pelvis to the proximal ureter. The resultant back pressure within the renal pelvis may lead to progressive renal damage and deterioration. UPJ obstruction presents most frequently in childhood, but adults and elderly individuals also can present with such an obstruction. In adults, other etiologies for ureteral obstruction must be considered, including stones, ureteral compression from other disease processes, retroperitoneal fibrosis, and other inflammatory processes.

These all may cause impaired drainage of urine from the kidney into the ureter, resulting in elevated intrarenal back pressure, dilation of the collecting system, distention of the kidney, and loss of kidney function.

The surgical correction of this disorder has traditionally included removal of the narrowed segment of ureter with reshaping of the renal pelvis in an operation called a pyeloplasty. This operation can be successfully performed with minimal invasiveness laparoscopically. Laparoscopic pyeloplasty has been performed at the University of Miami for over 5 years. Success rates approaching 95% are witnessed with this delicate form of laparoscopic reconstructive surgery.

Laparoscopic robotic radical prostatectomy
Laparoscopic radical prostatectomy is a minimally invasive radical prostate cancer surgery that profoundly reduces bleeding, pain, and recovery time. The radical prostatectomy is the complete surgical excision of the prostate, seminal vesicles, tips of the vas deferens, and, depending on oncological considerations, surrounding fat, nerves, and blood vessels. The radical prostatectomy is a standard first-line treatment for prostate cancer. In contrast to open radical prostatectomy, the LRP does not require an abdominal incision and relies instead on tiny entry sites, most of which are no longer than five millimeters. In the cartoon, a typical operative field is represented, in which a surgeon, assistant, and voice-controlled robotic arm work through five entry sites for the introduction of surgical instruments. A laparoscope is introduced in the subumbilical site and is used to guide the operation. The surgeon and assistant each use the other four sites for the introduction of instruments. In contrast to open radical prostatectomy, the LRP makes no use of heavy retractors and does not require that the abdominal wall be parted and stretched for the duration of the operation.

Like cystoscopic, neurosurgical, and other operations, laparoscopic surgery takes advantage of modern optics. The LRP, a specific form of laparoscopic surgery, applies a scope that provides uniform lighting everywhere, including the far reaches of the narrow male pelvis. The scope used in LRP transmits dynamic, magnified images to a monitor that can be simultaneously viewed by everyone involved in the proceedings: surgeon, assistant, scrub nurse, circulating nurse, anesthesiologist, visitors, and students. As such, the LRP provides everyone present more precise and identical views of the a operative action, which promotes greater control of the anatomy and excellent coordination among team members. In the photo, one sees a typical image transmitted by a laparoscope, an image that would be visible to anyone in the operating room. In this example, the surgeon is placing a suture around the dorsal venous complex of Santorini, deep under the pubic bone. At this stage, the assistant is poised to retract the prostate.

In making use of good lighting, modern optics, magnification, single operative views, and finer instruments, LRP is a relatively bloodless, controlled, coordinated, and elegant operation.

Laparoscopic robotic radical prostatectomy
The prostate - a muscular gland somewhat bigger than a walnut that holds sperm and seminal fluid before it is expelled during orgasm - is the second leading site of cancer in men. Some 180,000 cases are diagnosed yearly, usually through a PSA blood test, and 37,000 men die, generally because the cancer has spread by the time it is found.

Once diagnosed, treatment options include watchful waiting, radiation therapy, hormonal manipulation/androgen deprivation, or complete surgical removal (radical retropubic prostatectomy). Most urologists feel that radical prostatectomy is the gold standard in treatments and is usually chosen by younger, healthy men because the long-term chances of a cure are highest. It carries the risks of impotence and incontinence, and there's a slight risk of death from the surgery. An estimated 2 to 4 percent of men have permanent trouble controlling their urine, and the rate of potency after the most careful operations ranges from about 40 to 70 percent, depending on the patient's age.

Laparoscopic prostate surgery, initially tried in the early 1990’s, and abandoned as having little benefit over traditional prostatectomy, has undergone a rebirth in the last four years. The surgery is performed with much the same instrumentation as is used for laparoscopic kidney surgery, but has the added advantage of 10 times the magnification for improved vision in hard to reach places within the body. International studies of several thousand patients show that laparoscopic surgery is as effective as standard prostatectomy in treating prostate cancer. In experienced hands laparoscopic prostatectomy is generally associated with minimal postoperative pain, low complications, short hospital stays and fast recovery.

Robotic technology enhances the advantages of laparoscopic surgery, taking it to the next level. The da Vinci™ Surgical System seamlessly and directly translates the natural hand, wrist, and finger movements into corresponding micro-movements of the instrument tips positioned inside the patient through small puncture incisions, or ports by use of instrument controls at a console outside the patient's body. For more information or for a simulated demonstration of the da Vinci™ please click here.

Advanced minimally invasive ablation of renal masses
Minimally invasive therapies for destroying tissue have been investigated for more than a decade in several clinical fields including urology. More recently, an increased interest has emerged in small probe or needle ablative techniques to kill tissue, both healthy and malignant. Needle ablative techniques are currently being utilized to treat the prostate glands of those who have lower urinary tract symptoms related to benign prostate enlargement. Different energy sources, freezing (liquid nitrogen or argon gas) or heating (radiofrequency, interstitial laser, contact laser, high intensity focused ultrasound, and microwave), have been studied that work by inducing temperature mediated thermal damage to cell membranes

How does increased temperature destroy cells?
Most heating therapies achieve their effects via radiant energy that is converted into thermal energy in the tissue. This thermal energy is conducted cell to cell in order to achieve the endpoint: cell death. Cell death or ablation is a result of heat that causes death by disruption of cellular architecture or by damaging essential cellular components. Eventual cell death from these therapies is time-temperature dependent. At low heat levels e.g. 45°C, it may take hours to promote irreversible damage and at 100°C it may only require a fraction of a second.

Radiofrequency ablation
Currently, many kidney tumors that are discovered are smaller in size than those found in previous years. They often cause no symptoms and are occasionally referred to as “accidental-omas”. They are commonly found while imaging for other ailments. The majority of solid kidney masses are malignant and are treated with surgical removal of the kidney (radical nephrectomy) or kidney sparing (partial nephrectomy). For selected individuals, a metal probe can be inserted into the center of the tumor and Radiofrequency (RF) energy can be applied to “cook” the tumor and destroy it. The tumor itself is not removed but rendered dead by the heat application. These needle probes are placed either during laparoscopic surgery or under CT (computerized tomographic) scan guidance depending on their location in the kidney. Generally tumors up to 3 centimeters can be effectively treated with this technique. Surgeons at the University of Miami ensure adequacy of treatment by placing thermometers at the outside of the tumor to make sure they are certain when it is “done”.