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Laparoscopy and Robotic Surgery in Urology

• Laparoscopy in Urology
• Laparoscopy in Urology: surgical technique
• Laparoscopy in Urology: complications

History of Laparoscopy

Diagnostic laparoscopy:

After the invention of the cystoscope by Nitsche in 1879, Kelling used this cystoscope in 1901 for the first diagnostic laparoscopy in animals. Jacobaeus performed in 1910 the first diagnostic laparoscopy in humans. The diagnostic laparoscopy remained until the mid-20th century in the hands of specialists of internal medicine, who further improved the technique. Important steps of progress were the invention of the Veress needle , CO₂-insufflation, trocars, powerful light sources and improved optics.

Laparoscopy: liver cirrhosis and splenomegaly.

Operative Laparoscopy:

The gynecologist Semm is acknowledged as the founder of laparoscopic surgery. The development of insufflators , the loop ligation, and various instruments are attributed to him. Many laparoscopic procedures were introduced by Semm: e.g., first uterine fibroids (1972 ), ovariectomy (1977 ) and laparoscopic appendectomy (1980). After the establishment of laparoscopy in the surgical community (first laparoscopic cholecystectomy by Mouret 1987), urologists slowly began to use laparoscopy. Table laparoscopic history informs about the time line of laparoscopic urologic surgery.

Robotic Laparoscopy:

Another milestone in the development of laparoscopic surgical technique is the development of robotic-assisted laparoscopy. The first provider in the market is the company Intuitive Surgical with the da Vinci Surgical console. The console consists of two components: a control console for the surgeon and a patient-side robotic unit. The da Vinci Surgical console has 3–4 arms depending on the modell which carry the surgical instruments and the camera unit. The camera unit provides a true stereoscopic view with magnification of the surgical field. In addition, the surgical unit enhances dexterity, greater precision and ergonomic comfort. The articulated instruments allow movements that are not possible with rigid standard instruments of laparoscopy. In sum, the da Vinci Surgical System enables more complex minimally invasive procedures involving complex dissection or reconstruction (partial nephrectomy, prostatectomy, cystectomy with urinary diversion).

Advantages:

Due to the mechanics described above, complex reconstructive procedures become feasible with a laparoscopic approach. Laparoscopic prostatectomy, previously practiced only by skilled laparoscopic surgeons, became a new surgical standard in several countries with the help of the robotic-assisted technique. The robotic-assisted technique allows in addition complex partial kidney resections and radical cystectomy with various forms of urinary diversion with the laparoscopic approach.

Disadvantages:

The main disadvantage are the huge costs consisting of the investment, the maintenance contract with the manufacturer and the need for expensive disposable instruments. If 300 cases per year are performed with the da Vinci Surgical console, additional costs of 2500 Euros will have to be calculated per operation. So far, randomized trials are lacking which justify the high costs for the health system.

Indications for Laparoscopy in Urology

Diagnostic laparoscopy:

A diagnostic laparoscopy is rarely indicated in urology: e.g., diagnosis of testicular location in cryptorchidism.

Operative laparoscopy:

The spectrum of laparoscopic surgery in urology is continuously growing. Vital for the success is, however, the level of training of the individual surgeon. Frequently performed laparoscopic operations are pelvic or retroperitoneal lymph node dissection, nephrectomy, partial nephrectomy, adrenalectomy, prostatectomy and surgery for UPJ obstruction. With the help of robotic-assisted laparoscopy, complicated reconstructive procedures in urology are becoming possible, such as complicated partial nephrectomy of hilar tumors or cystectomy with intracorporal urinary diversion.

Contraindications of Laparoscopy

Underlying Diseases:

• severe COPD
• severe heart failure
• peritonitis
• ileus
• active bleeding
• large aortic aneurysm

Previous Surgery:

After uncomplicated appendectomy, cholecystectomy or hysterectomy, laparoscopy is often possible and sucessful. If severe adhesions are present, laparoscopy should not be forced and a secure open approach is advisable.

References

  Deutsche Version: Laparoskopie in der Urologie