Future of Laparoscopy in Urologic Surgery

Nicholas Stroumbckis

Laparoscopy was first described by Kelling (1) nearly 90 years ago as a way to inspect the peritoneal cavity. Over the ensuing years, laparoscopy has been widely used in gynecology(2-3) and general surgery.(4-5) In part because of its overwhelming success in these specialties, and in part because of the technological advancement of the instrumentation involved, this revolutionary form of surgery is becoming increasingly popular within other specialties. Urologists have reacted with the most enthusiasm, which is only natural because laparoscopic techniques are essentially an extension of endourology. Laparoscopy, like endourology, has a number of beneficial characteristics, including being minimally invasive, thus providing for a shorter hospital stay and quicker patient recovery and possibly accounting for a lower morbidity rate, and having lower costs than standard open surgical procedures. However, unlike endourology, where newly developed procedures were introduced slowly over a period of nearly 10 years, the application of laparoscopic techniques in urology has spread widely within essentially the past 2 years.

This report reviews the status of urologic laparoscopy. In it, we stress the need for urologists to compare the effectiveness of these appealing procedures with that of a standard method. Minimally invasive procedures with low complication rates are not desirable if these procedures are less effective than the open ones they are supposed to replace. Specifically, we must ask (1) whether any laparoscopic procedure is as accurate diagnostically (or as effective therapeutically) as the open surgical procedures; (2) in which patients laparoscopy is truly a significant alternative to open surgery; and (3) whether the perceived patient benefits and reduction in the complication rate are actually achieved.

The number of both diagnostic and therapeutic urologic procedures involving laparoscopy is many and is increasing at an unprecedented rate. In the diagnostic area, the more common procedures are localization of undescended testicles and transperitoneal or retroperitoneal lymphadenectomy for staging cancer. In the therapeutic area, some of the developing procedures are varicocele ligation, drainage of lymphoceles and renal cysts, nephrectomy, endocavitary bladder surgery, bladder suspension procedures, and, most recently, radical prostatectomy.

Diagnostic Laparoscopy
For many years, laparoscopy has been used to localize undescended, nonpalpable testes, (6-9) and to diagnose intersex disorders (10-11) with very high success rates and minimal morbidity. However, the most widely publicized and commonly performed diagnostic procedure is transperitoneal lymphadenectomy, currently being used to stage prostate and bladder malignancy and thus help in the choice of therapy. Laparoscopic lymphadenectomy is currently being used to stage prostate and bladder malignancy. At present, neither radical prostatectomy (12) nor radiation (13) has improved the survival rate in patients with stage D1 disease (lymph node metastases). Therefore, patients with D1 disease may be spared the cost and morbidity of these two therapies if the stage of their disease is known. Traditional non-invasive staging modalities such as computed tomography, magnetic resonance imaging, pedal lymphangiography, transrectal ultrasound, and serum assays for prostate-specific antigen are not 100 percent accurate and show many false-positive results in cases of D1 disease. As a result, patients with clinically localized prostate or, less often, bladder cancer are subjected to staging lymphadenectomy, with radical surgery being performed if nodal disease is not detected. In the case of radical prostatectomy, lymphadenectomy adds little to the overall morbidity of patients with localized disease. However, patients found to have D1 disease are subjected to prolonged hospitalization as a result of nodal sampling, with an overall complication rate of 20 percent.(14-15)

Initial studies of the accuracy of transperitoneal laparoscopic lymphadenectomy indicate that the quantity of nodes removed with laparoscopy is almost identical to that removed with standard open lymphadenectomy. Schuessler et al (16) performed 12 laparoscopic lymphadenectomies for prostate cancer in a mean surgery time of 147 minutes, with nearly seven nodes removed from each pelvic fossa; no significant complications occurred. Parra et al (17) examined 24 patients undergoing pelvic node dissection, half of whom underwent open surgery and the other half of whom underwent laparoscopy. The number of nodes sampled with laparoscopy was 10.7 +/- 5.7, similar to the number retrieved by open surgery, which was reported to be 11.0 +/- 7.4. Importantly, no additional tumor-containing tissue was recovered at open dissection of the patient who had laparoscopy followed by open exploration. Griffith et al (l8) also compared open and laparoscopic lymphadenectomy. The average number of nodes removed by open surgery was 13.2, while the average number for laparoscopy was approximately 11.3. The operating time for open surgery was 165 minutes and that for laparoscopy was 186 minutes. The number of days of hospitalization averaged 5.9 for open surgery and 1.2 for laparoscopy, with the attendant costs of hospitalization being $4,300 for laparoscopy and $7,200 for open surgery. These studies, along with others, (19-20) indicate that the efficacy of laparoscopy is at least similar to that of open surgery, and underscore the benefits of laparoscopic surgery to the health care system.

Studies also indicate that in experienced hands the complication rates of laparoscopic lymphadenectomy are comparable to those of standard open techniques. In a 2-year, multicenter study, Kavoussi et al (21) reviewed the largest number of patients undergoing transperitoneal lymphadenectomy. In the 329 patients studied, 48 complications were presented, with 13 of those being intraoperative and consisting of injuries to the bowel, ureter, or vascular and nerve structures. The remaining 35 were postoperative complications and included urinary retention, lymphocele formation, ileus, deep vein thrombosis, and wound infections; there were also two small bowel obstructions. Certain limitations of the procedure were reported; in 16 of the patients studied, complete node dissection could not be performed because of body habitus, adhesions, or technical difficulties. Collectively, these studies (19-21) show a preliminary complication rate for laparoscopic lymphadenectomy of 15 to 21 precent, a rate similar to that of open standard lymphadenectomy.

Given the demonstrated comparability of results between open surgery and laparoscopy, there are a number of benefits that make laparoscopy a desirable surgical alternative. Most experiences to date have demonstrated two significant benefits, which are a shorter hospital stay and a more rapid recovery with possibly lower morbidity rates. For example, most patients are discharged within 24 to 48 hours, require minimal postoperative analgesics, and quickly return to their preoperative activities. This is particularly impressive in view of the age of patients with prostate cancer.

Based on results from Winfield et al (20) and others, (22-23) it appears that patients with pretreatment prostate-specific antigen levels of 30 or greater, tumor grade greater than 7, seminal vesicle involvement, or stage C disease all have a significant risk of positive nodes, and laparoscopy is a viable alternative. In addition, patients considered for radiation therapy, brachytherapy, or perineal prostatectomy may also be considered for laparoscopic lymphadenectomy to adequately diagnose Dl disease.

A number of issues need to be further investigated. For example, late complications such as peritoneal seeding of tumor, bowel hernias, and intestinal obstruction need to be reported and analyzed. Interestingly, malignant seeding of a trocar site, although remote, has been reported in a surgical patient undergoing laparoscopy.(24) The overall costs of laparoscopic lymphadenectomy to patients and hospitals may not be amenable to full assessment until such long-term studies are completed.

In view of the success of transperitoneal laparoscopic lymphadenectomy, it is not surprising that laparoscopic nodal sampling has been tried in cancers of the kidney and testis. (25) Each of these cancers, like those of the prostate and bladder, has its own unique features that will dictate individual assessment of the efficacy and safety of laparoscopic staging.

Therapeutic Laparoscopy
Although laparoscopy as a therapeutic procedure is less commonly used than its diagnostic applications, it is quickly apparent from a review of the reports to date that it offers the same benefits as the diagnostic applications. Perhaps the most common therapeutic role of laparoscopy is for varicocele ligation.

The classic approach in treating a varicocele is spermatic vein ligation. This procedure may be performed via a high-retroperitoneal (Palomo) or inguinal (Ivanissevich) approach, depending on body habitus, previous surgery, and physician and patient preference. Although the procedure carries minimal morbidity, postoperative discomfort can be considerable and complete recovery may require several weeks. In addition, the repair of bilateral varicocele requires two incisions and the patient has an even longer recovery time. Interventional radiology methods such as placement of coils or sclerosis with hot contrast medium are less invasive, but catheterization of the spermatic vein is not always possible.

Sanchez-de-Badajoz et al (26) were the first to use laparoscopy to treat left-sided varicocele, applying it in a series of 12 patients. Since then, Donovan and Winfield (27) have performed numerous laparoscopic varicocelectomies without significant complications. These investigators initially performed 14 laparoscopic varicocelectomies, including five cases with bilateral varicocele. The spermatic artery was identified and preserved in all but one varix ligation. All of their 14 patients had disappearance of their clinical varicocele. The number of veins isolated was between two and three, with the average operating time being approximately 118 minutes. Most patients (one patient required postoperative hospitalization because of prolonged recovery from anesthesia) were discharged on the day of surgery and returned to regular activity in 3 days with minimal need for analgesia. Among the 50 percent of patients who completed 6 months of follow-up, there was a significant increase in sperm density and motility. Recently, Donovan and Winfield performed 47 laparoscopic varix ligations with neodymium: yttrium-aluminum-garnet laser with only one recurrent varicocele, and five of 12 patients treated for infertility have reported pregnancies.(28) Similarly, Hagood et al (29) performed laparoscopic varix ligation in 10 patients. The operation time was between 90 and 120 minutes for the first three cases, with the remaining cases taking an average of 60 minutes. Again, all patients were discharged on the day of the procedure and returned to regular activities in 2 days.

Although the initial results of laparoscopic varix ligation are encouraging in terms of edicacy, long-term data need to be collected about the risks of laparoscopy for this application. The risk of vascular and internal organ injuries from trocar placement needs to be assessed, since standard spermatic vein ligation rarely involves those potential complications. We also need more data about the effects on semen quality and pregnancy rate in relation to the results of classic surgery and transvenous methods. Laparoscopic varicocelectomy, although feasible, remains to be proven as an alternative to standard vein ligation.

There is less experience with other therapeutic laparoscopic modalities, especially as the list of possibilities seems to increase with each week. Clayman et al (30) reported their initial clinical series of laparoscopic nephrectomies; One of these patients had an oncocytoma and the remaining nine nephrectomies were for benign disease. The average operating time was less than 6 hours, with an estimated blood loss of less than 250 mL. The average hospital stay was approximately 5 days, with a return to regular activity in 12 days. Coptcoat et al (31) similarly performed laparoscopic nephrectomy; among their seven patients, four had a malignancy. Those investigators concluded that laparoscopy may be more feasible for small renal tumors, and noted that more technical difficulty was encountered in procedures for benign disease. The indications for laparoscopic nephrectomy are not clear, and more data need to be collected nationally about the feasibility of this procedure. Other organ removal procedures such as radical prostatectomy, cystectomy, and adrenalectomy are currently under investigation.

A less drastic use of laparoscopy has been for marsupialization of lymphoceles and renal cystic disease, with good results. Parra et al (32) reviewed three cases of laparoscopic marsupialization of a pelvic lymphocele. All three procedures were successful, with the patients’ hospitalization lasting for only 24 hours and no complications occurring. Compared with traditional methods of sclerosis and drainage, there were fewer infections and a shorter duration of treatment. Hulbert et al (33) successfully used laparoscopy in three patients with renal cystic disease who were being considered for open surgical decortication. The list of therapeutic applications will undoubtedly increase as urologists become more familiar in laparoscopic techniques.

It is clear that laparoscopy will become a major tool for the present and future urologist in diagnosing and treating venous problems. With the demonstrated benefts over open surgery, laparoscopy will gain much acceptance in the urological field. However, laparoscopy is still an evolving area and needs to be carefully analyzed and compared with open procedures.

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