Hammad Ather ( Sindh Institute of Urology and Transplantation, Civil Hospital, Karachi. )
The last decade of the present century has seen tremendous progress in the development of minimally invasive surgery. These alternate surgical methods clearly provide two advantages; i) decreased post-operative complications resulting from less mechanical disruption of tissue planes and ii) decreascd hospital stay, helping to ease the pressure on in-patient beds and early return to work there by contributing to the overall national economy. Two disadvantages, however, are i) increased operative time and ii) delay or absence in appearance of methodologically sound, prospective controlled trials to independently assess the new technology. Tremendous enthusiasm attached with this innovative surgical tool resulted in this type of surgery. Laparoscopy arrived in Urology about six years back. Two factors that influenced the rapid growth of this procedure was the need to decrease post-operative hospital stay and minimize post-operative complications by preventing physiological changes associated with conventional open surgical methods. Since its humble beginning as a diagnostic tool, laparoscopy in Urology, has made great strides. It is now used for almost all ablative and reconstructive urologic procedures.
Clinically established laparoscopic urologic procedures include pelvic lymphadenectomy, varicoelectomy simple nephrectomy and adrenelectomy in the ablative category, whereas bladder neck suspension in the reconstructive field. Other ablative procedures which are now increasingly performed but, as yet, are not a first choice laparoscopic ally include renal cyst excision, orchiectomy, radical nephrectomy, nephroureterectomy, partial nephrectomy, retroperitoneal iyrnphadenectomy, vesical diverticulectomy, cystectomy and radical prostatectomy.
The reconstructive category include orchiopexy, nephropexv, pyeloplasty, ureterolysis, ureterouretcrostomy, ureterolithotomy and construction of iical conduit. Live donor nephrectomy. urethral sling and continent urinary diversion are still considered to be in the laboratory phase.
Pelvic lymphadenectomy is the most frequently performed laparoscopic surgery in the adult urologic practice1. Presently, it is indicated in patients with prostate cancer planned for retropubic prostatectomy with a high risk of nodal metastasis. PSA (greater than 40 ng/ml), TRTJS, histological type (Gleason grading of 8 or more) and a negative CT guided biopsy are few pre-operative parameters indicating laparoscopic pelvic lymphadenectomy. Rarely, it is also performed in the staging of bladder, penile, urethral2 and cervical cancers3. Pelvic lymphadenectomy is performed either as a limited transperitoneal or extraperitoneal procedure or by extended transperitoneal approach using 4-5 ports.
Varicocelectomy is most commonly performed for male factor infertility3 and rarely for .orchalgia and decreased testicular size in adolescents. It gained popularity due to the easy technique. First laparoscopic varicolectomy was reported by Sanchcz-de-Badojoz et al4 in 1990. It is performed via 3 or 4 port transperitoneal route. Unilateral or bilateral varlx ligation can be done taking 105 and 167 minutes respectively, complications are rare and results are comparable with embolization or open surgery.
The first laparoscopic nephrectomy was performed on 25th June, 1990 at Washington University, Barnes Hospital5. Since then, about 300 cases have been reported in literature5. This followed development in the technique of tissue entrapment and rapid marceilation. Although, most clinical conditions necessitating simple nephrectomy are amenable to laparoscopic nephrectomy, those, that render kidney hypotrophic are most easily performed. Although, most are carried out by a 5-post-transperitoneal approach, but anentirely retropentoneal approach has also been used. The latter technique is improved by the development of lagaroscopic recroperitoneal balloon dilatation by Gaur in6. The long operating time for laparoscopic nephrectomy (355 min versus 165 for open nephrectomy) is compensated by short hospital stay and consequent early return to full usual activities (3.7 days versus 1 month respectively).
Laparoscopic adrenalectomy is indicated in non-mali gnant small adrenal lesions (less than 6 cm) like pheochroniocytoma, Cushing\\\'s primary aldosteronism, non-active adenomaand other unspecified benign lesions7. Guazzani et al8 in 1994, compared 15 patients in each group of laparoscopic and open adrenalectomy. They concluded that though laparoscopically performed adrenalectomy has longer operative time (170 min. versus 100 min. respectively )but there is lesser blood loss (100 ml versus 450 nil), earlier resumption of work (9.7 days versus 16 days) and amelioration of hypertension in all patients.
Bladder neck suspension is the only clinically established laparoscopic reconstructive umlogic procedure performed presently. It is indicated in low grade (1-2) uncomplicated stress urinary incontinence and is performed using either a transperitoneal or an extraperitoneal approach.
McDougall et al8 in a randomised, prospective study compared laparoscopic bladder neck suspension with Rays vaginal needle suspension. He concluded that the results of the two procedures are comparable in the laparoscopy providing the advantage of short hospital stay, decreased post-operative analgesic requirements and shorter convalescence. In this tumultuous time, surgeons are sailing from a "tried and tested” World to an unchartered Sea. This on one hand is fraught with “dangers of new techniques” if used unscrupulously and on the other, promises the dream world of non-invasive surgery with no patient morbidity. Laparoscopy in Urology has come to stay with each passing day more and more procedures are included in the clinically established category and are compared to open surgical counterparts in prospective randomised trials.
1. Partin, A.W., Yoo, J., Carter, H.B. al. The use of prostate specific antigen, clinical stage and Glesson score to predict pathologic stage in men with localised prostate cancer. J. Urol., 1993;150:110-114.
2. Winfield, H.N., Donovan, J.F, See, WA. et al. Laparoscopic pelvic lymph node dissection for genitourinary malignancies: Indications, techniques and results. 3. Endourol., 1992;6:103.
3. Querleu, D., Leblanc, & and Cestelain, B. Laparoscopic pelvic lymphadenectomy in the staging of early carcinoma of the cervix. Am, J. Obst. Gynocol., 1991;164:579.
4. San chez-de-Badajoz E., Diaz-Ramirez, F Endoscopic varicocelectomy: Preliminary report ofa new technique J. UroL, 1992;147:73-75.
5. Clayman. RV., Kavourssi, L.R., Leng, SR. et al. Laparoscopic nephrectomy, initial report of pelviscopic ocgan ablation in the pig. 3. Endourol., 1990;4:24749.
6. Gaur, DD. Laparoscopic retropentoneoscopy: Use of a new device. J. Urol., 1992;148:1137.
7. Suaiki, K., lhara, H., Ka ama, S. et al. Laparoscopic adrenalectomy clinical analysis of25 cases. J. Urol., 1994;151:498-99.
8. McDougall, EM., Klutke, CO., Cleyman, R.V. et al. Comparative analysis of vaginal (Raz) and laparoscopic needle co!posuspaision for type land II stress urinazy incontinence J. Urol., 1994;155(F 2):499A,1085.