laparoscopy in urology case report€¦ · lap radical cystectomy: 1992. case report: bladder...
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LAPAROSCOPY IN UROLOGYCASE REPORT
Dr Allison MooreUrology Registrar
University of Cape Town
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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
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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
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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
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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
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Open Surgery: what the bosses say…
■ Difficult pelvic access
■ ID diverticulum
■ Stuck tissue
■ Bleeding
■ Wound sepsis
…
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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
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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
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PORTS (as per Lap RP)
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Robotic (RABD) (If you have lots of money)
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Advantages
Less PAIN
COSMESIS
Faster RECOVERY
Shorter HOSPITAL STAY
?? Reduced COST
MAJOR PROBLEMS
Fatal gas embolism
Pneumothorax
Electrosurgical bowel injury
Post op crepitus
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Patient selection
Prior surgeries + scars
LOCATION
COMORBIDITIES
Physiologic effects CO2pneumoperitoneum
Acidosis àmyocardium =
Cardiac arrhythmias
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Contraindications to Laparoscopic Surgery
■ Uncorrectable coagulopathy
■ Intestinal obstruction
■ Significant abdominal wall infection
■ Massive haemoperitoneum or haemoretroperitoneum
■ Generalized peritonitis
■ Suspected malignant ascites
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Potential DifficultiesPrior
Abdo or Pelvic
Surgery
MORBID OBESITY
Fibrosis e.g
peritonitis
Iliac or Aortic
aneurysm
Hernia: diaphragm
+ umbilical
Organomegaly
Pregnancy Ascites
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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)
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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
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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’
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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
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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
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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…
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TAKE HOME MESSAGES■ Bladder diverticulum
■ Place for Open vs Laparoscopic
■ LAPAROSCOPY in urology:– Nephrectomy– Pelvic surgery
■ Patient selection
■ SURGEON PREFERENCE
■ Knowledge
■ SKILL
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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.