Pelvic Lymph Node Dissection
Laparoscopic pelvic lymph node dissection (LPLND) in the setting of prostate cancer was the first adult laparoscopic urologic procedure to gain widespread acceptance. The technique was initially described prior to widespread prostate-specific antigen testing, and LPLND had positive results in up to one-third of prostate cancer patients. Due to lower positive node rates associated with stage migration, interest in stand-alone LPLND has waned. With the rise of laparoscopic/robotic radical prostatectomies and cystectomies, however, the utility of LPLND (as part of these procedures) remains.
There are no contraindications specific to LPLND other than those general to laparoscopy, although intraperitoneal laparoscopic hernia repair, other pelvic surgery, or radiotherapy can result in adhesions.
The patient is positioned supine with Trendelenburg tilt. LPLND can be performed transperitoneal or extraperitoneal (Figure 9–12). Initial access is typically through an umbilical port followed by two to three additional ports in a diamond- or fan-shaped pattern (Figure 9–13). Key landmarks are the obliterated umbilical ligament, gonadal vessels, and internal inguinal ring (Figure 9–14), with the limits of the nodal dissection for prostate cancer usually being the iliac bifurcation, the pubis, the obturator nerve, the pelvic side wall, and the medial umbilical ligament. Dissection for bladder, penile, or urethral cancer usually involves a more extended field, bounded by the common iliac artery, the genitofemoral nerve, and the bladder.
Balloon device inflated in the preperitoneal space for extraperitoneal laparoscopic pelvic lymph node dissection.
Port placements for laparoscopic pelvic lymph node dissection. A: Diamond configuration typically used. B: Fan configuration for use in obese patients.
Key landmarks for laparoscopic pelvic lymph node dissection are the obliterated umbilical ligament, gonadal vessels, and internal inguinal ring.
Complications of LPLND are similar to those of open PLND. Specifically, injuries to the obturator nerve, iliac and epigastric vessels, and ureter have been reported but are uncommon. Other potential complications include lymphocele, bowel or bladder injury, subcutaneous emphysema, thromboembolic events, and scrotal swelling. Open surgical pelvic lymphadenectomy and LPLND provide similar nodal yield.
Laparoscopic varicocelectomy is rarely performed today due to refinements in the subinguinal microsurgical technique (Ahmed et al, 2007).
Laparoscopy has been judged by many pediatric urologists to be the gold-standard diagnostic tool for nonpalpable testes. Although not as firmly established, laparoscopic orchidopexy appears to be comparable with, if not better than, open orchidopexy (Baker et al, 2001). Laparoscopy may be used for intersex evaluation as well.
Positioning is usually supine with the legs frog legged. A small laparoscope is inserted through a periumbilical site. One to three port sites have been utilized. The first step involves identifying the inguinal ring with the corresponding gonadal vessels and vas deferens. If the vas deferens and vessels are seen entering the inguinal ring, the laparoscope is removed and an open inguinal exploration is performed as would be for a palpable cryptorchid testis. If the gonadal vessels are blind ending, the procedure is terminated. If an unsalvageable testis is identified, laparoscopic orchiectomy can be performed. If a salvageable testis is identified intra-abdominally, working ports are placed and the testis is freed from its nonvital attachments (Figure 9–15). If sufficient cord length can be gained, a scrotal incision is made and the testis is fixed in a scrotal location. If there is insufficient cord length, a one- or two-stage Fowler–Stephens procedure may be performed. A multi-institutional review found decreased testicular atrophy and a higher rate of postoperative scrotal testicular positioning after the two-stage procedure. Fifteen complications were noted in 310 procedures, with an overall success rate of 93%.
Dashed lines indicate incisions into posterior peritoneum for orchidopexy of a left intra-abdominal testis.
Although simple renal cysts are common, they rarely require intervention. Occasionally, pain, infection, early satiety, or secondary obstruction can develop that prompts active treatment, although in many cases, percutaneous aspiration and sclerosis of the cyst will suffice. Even less frequently, a cystic mass may need to be explored for diagnostic purposes. Cyst decortication also can be performed for pain relief in patients with polycystic kidney disease who still have adequate renal function.
Via a three- or four-port approach (usually transperitoneal), the colon is reflected medially to expose the kidney, and Gerota's fascia is incised to expose the cyst(s). Laparoscopic ultrasound may be useful. If there is suspicion of a connection to the collecting system, or if the collecting system is in close proximity and at risk for injury, instillation of dyed saline through a previously placed retrograde ureteral catheter may be useful. The roof of the cyst is excised, without incising into surrounding renal parenchyma. A biopsy of any suspicious areas should be obtained. Perirenal fat may be fixed to the cyst base to help prevent cyst reaccumulation. Long-term success is high (Yoder and Wolf, 2004). Complications specific to renal cyst decortication include cyst regrowth and injury of renal parenchyma or collecting system.
Simple and Radical Nephrectomy
Laparoscopy has become a well-accepted technique for a number of benign and malignant renal conditions, including nonfunctioning kidneys, chronic infections, symptomatic polycystic kidney disease, and tumors. Initially, large tumor size was considered a contraindication for laparoscopic nephrectomy, but with experience, tumor size has become less of an issue. The only limitation is the expertise of the urologist. Laparoscopic radical nephrectomy including renal vein thrombus is feasible. Relative contraindications include profound perirenal inflammation, bulky lymphadenopathy that limits hilar access, large venous thrombus, and adjacent organ involvement.
The patient is placed in a lateral decubitus position, padded, and secured. Table flexion and variation in decubitus position from 45° to 90° varies with the specific approach and surgeon preference. The surgeon and assistant both stand toward the patient's anterior body wall for the transperitoneal approach.
The techniques for a laparoscopic nephrectomy will be discussed in detail as a template for other common laparoscopic upper retroperitoneal procedures. There are many variations on port placement. For transperitoneal laparoscopic nephrectomy, a three- to four-port “L”-shaped configuration for left nephrectomy and a reversed “L”-shaped pattern for right nephrectomy are commonly used. The initial port is placed two fingerbreadths below the costal margin at the lateral edge of the rectus muscle and the abdomen is insufflated initially to 15–18 mm Hg. Intra-abdominal organs are inspected for inadvertent injury. Another port is placed in the midaxillary line two fingerbreadths above the iliac crest. One to two additional ports are placed along the lateral edge of the rectus muscle including one able to accept the endoscopic stapler if use is anticipated. Depending on the patient's body habitus and relative position of the kidney and spleen/liver, other configurations may be chosen (Figure 9–16).
One of the possible port configurations for right transperitoneal laparoscopic nephrectomy.
For left-sided lesions, the left colon is mobilized from the splenic flexure toward the iliac vessels, leaving the anterior fascicle of Gerota's fascia intact. The lienophrenic ligament is incised, allowing medial rotation of the spleen. Further medial rotation is achieved by mobilizing the lateral edge of the pancreas, thus revealing the renal hilum. The ureter is identified and transected. Following the gonadal vein superiorly will help identify the renal vein. The renal vein is dissected over the aorta to help avoid damage to the adrenal or lumbar veins. One should be careful using clips on vascular branches near the renal hilum because these can interfere with subsequent utilization of the endoscopic stapler. The renal artery is typically found posterior to the renal vein and is transected after securing it with clips or an endoscopic stapler. Once the artery is transected, the renal vein is secured and transected in a similar fashion. If the hilar dissection is difficult and the vein and artery cannot be separated, the endoscopic stapler can be used to transect the artery and vein en bloc. The superior border of the kidney is dissected, either incorporating the adrenal gland or more medially if adrenal sparing is intended. The lateral renal attachments are the last to be transected, because they help suspend the kidney and ease hilar dissection.
The kidney can be removed intact or morcellated after being placed into a specimen retrieval bag. If intact extraction is desired, a premarked incision is utilized, or a port site may be extended for extraction. For morcellation, the neck of the bag is brought through the port site. Appropriate drapings should be used to prevent potential tumor seeding. Blunt forceps are used to remove the specimen piecemeal, and laparoscopic monitoring is used to help prevent injuries. These instruments are then considered contaminated and are removed from the field. As with all laparoscopic procedures, insufflation pressures should be reduced to 5 mm Hg for final evaluation of hemostasis. Port sites >5 mm that utilized cutting trocars require fascial closure.
For right-sided transperitoneal nephrectomy, the ascending colon is mobilized from the hepatic flexure toward the iliac bifurcation. The triangular ligament is incised, with care not to injure the diaphragm. The liver is retracted with a blunt-tipped instrument. The duodenum is mobilized medially to help expose the inferior vena cava (IVC). Entering the plane of Leriche directly anterior to the IVC will guide dissection to the renal vein. Dissection lateral to the lower edge of the IVC will reveal the psoas muscle and ureter. Although the right renal vein is shorter, it rarely has veins draining into it as on the left side. The remainder of the technique is similar to that previously described.
Retroperitoneal nephrectomy begins with the patient in a full lateral decubitus position with similar padding and bed adjustments. In contrast to the transperitoneal approach, the surgeon and the assistant stand on the dorsal side of the patient. After an incision is made over Petit's triangle, blunt dissection through the lumbodorsal fascia is performed and a plane is developed over the psoas muscle. A dissecting balloon trocar is placed into this space. There are commercially available dissecting balloon trocars for this purpose, or a “homemade” version can be constructed by attaching a glove to a catheter. The commercially available dissecting trocar has the advantage of allowing direct visual monitoring of the dissection. Pneumoretroperitoneum is created and two to three additional port sites are placed according to surgeon preference (Figure 9–17). The kidney is retracted anteriorly to allow direct access to the hilum. Blunt dissection easily exposes the artery, which is clipped and transected. Anterior to the arterial stump, the vein is dissected and controlled. After hilar control, the ureter is identified and transected. Further dissection is similar to that of transperitoneal techniques. Many laparoscopists remove the specimen intact when performing retroperitoneoscopic nephrectomy due to the limited working space. If morcellation is preferred, specimen-bag entrapment may require incising the peritoneum if the specimen is large. The final steps of ensuring hemostasis under low-pressure insufflation and inspecting the port sites remain the same.
One of the possible port configurations for left retroperitoneal laparoscopic nephrectomy.
The technique for hand-assisted laparoscopic nephrectomy is similar to that for transperitoneal laparoscopic nephrectomy. If hand assistance is chosen, port placement is altered to allow room for the hand-assistance device. For left-sided lesions, the hand-assistance device is typically placed in the midline and may incorporate the umbilicus. For obese patients, the device may be placed paramedian, closer to the pathology. For right-sided lesions, the device may be placed in the midline or alternatively in the right lower quadrant using a muscle-splitting diagonal incision (Gibson). Placement of the hand-assistance device is dependent on the surgeon's arm length, desired position of the nondominant hand, and the patient's body habitus. Two or three ports are placed according to surgeon preference. Dissection is similar to the transperitoneal description mentioned earlier. Lateral renal attachments can be transected earlier because the hand can provide counter traction, facilitating hilar dissection. Specimen extraction is rapidly performed through the hand-assist incision.
The major and minor complication rates from laparoscopic nephrectomy are approximately 5% and 10%, respectively, and approximately 3% of cases are converted to open surgery (Permpongkosol et al, 2007). Minor complications include ileus, mild hemorrhage, urinary tract infection, hernia, and wound infection. Major complications include pulmonary embolus, pneumothorax, injury to various viscera, and hemorrhage from the aorta, IVC, or iliac, gonadal, lumbar, or renal vessels. Technical complications are more common during the first 30–50 cases of a surgeon's experience.
Comparisons of laparoscopic and open surgical nephrectomy reveal shorter and less intense convalescence with laparoscopy and similar complication and cancer-control rates (Columbo et al, 2008). Operative times are longer for laparoscopy initially, but with experience, operative times may even be shorter than with open surgery. Studies comparing different laparoscopic techniques show similar outcomes, suggesting that no approach is uniformly superior (Gabr et al, 2009). The surgeon should be familiar with the various techniques so that the optimal procedure can be performed.
Nephroureterectomy is the gold-standard treatment for upper tract urothelial carcinoma. The open surgical procedure is performed through a long curved flank incision or two separate incisions, leading to significant postoperative morbidity. Laparoscopic nephroureterectomy incorporates the benefits of cancer control with less postoperative pain and earlier return to normal activity. Transperitoneal, retroperitoneal, hand-assisted, and robotic-assisted techniques have been described. The kidney dissection is similar to a laparoscopic radical nephrectomy except that the ureter is left intact prior to the distal transection.
Optimal management of the distal ureter remains controversial. The technique of transurethral resection of the intramural ureter, leaving the distal ureter free in the retroperitoneum, has been largely abandoned owing to risk of local recurrence. A number of alternative minimally invasive approaches have been described, including one- or two-port transvesical dissection of the distal ureter (Figure 9–18) with (two-port) or without (one-port) transvesical closure of the ureteral orifice, endoscopic stapling or energy ablation of the tented up ureter from an extravesical approach, and others. Some simply perform the nephrectomy laparoscopically and excise the bladder cuff and remove the specimen through a lower abdominal incision. Even in cases without open surgical bladder cuff, the nephroureterectomy specimen should always be removed intact. Cancer-control rates appear adequate, and complication rates are similar to those for laparoscopic radical nephrectomy (Manabe et al, 2007).
Transvesical dissection of the distal ureter performed with a Colling's knife on a resectoscope placed through a 10-mm port inserted suprapubically into the bladder. After the nephrectomy portion of the procedure and clipping of the ureter, incision (dotted black line) is gradually made around the ureteral orifice (white arrowhead) until the distal ureter can be pulled free of the bladder.
Partial Nephrectomy and Renal Mass Ablation
Partial nephrectomy is performed for imperative, relative, and elective indications. Some patients who are candidates for open surgical partial nephrectomy have been treated inappropriately with laparoscopic radical nephrectomy because of the more favorable postoperative convalescence. The laparoscopic approach to partial nephrectomy, however, provides both nephron-sparing and improved convalescence. Widespread adoption of the procedure has been limited by its technical difficulty.
Transperitoneal, retroperitoneal, hand-assisted, and robotic-assisted techniques have been described. Although the overall technique is similar to that for laparoscopic radical nephrectomy, a few modifications are required. Some physicians perform preoperative ureteral catheterization to assess collecting system closure. Laparoscopic ultrasound may be useful to delineate tumor margins and multifocality. The kidney is dissected from perirenal fat as needed to expose the lesion (leaving a cap of fatty tissue over the tumor) and bring it into the operative field. The renal artery may be occluded with a laparoscopic bulldog or Satinsky clamp, or direct manual compression using hand assistance can be used. Superficial lesions can be excised without hilar clamping, and methods for “clampless” partial nephrectomy for deeper lesions have been reported. Parenchymal cooling using a variety of methods has been described, but it is not standard, although other maneuvers to minimize reperfusion injury (intravenous fluids, mannitol, etc) are frequently used. Tumors are resected with “cold” scissors or energy devices (Figure 9–19). The use of biopsies and frozen section is variable. Vessels and collecting system entry sites are closed using intracorporeal suturing techniques and/or tissue glues. The overlying parenchyma is frequently coagulated using the laparoscopic argon beam coagulator. Tissue glues and bulking agents (collagen, gelatin, etc) may be placed on the resection bed to help optimize hemostasis. Bolstering sutures can be placed to compress and reconstruct the remaining renal tissue.
Partial nephrectomy. Tumor (black asterisk) is being elevated by a grasper (entering from top of figure), as it is excised with scissors. An irrigator–aspirator depresses the tumor bed and helps maintain visualization. The peripheral resection margin is indicated with the white line.
Complications of laparoscopic partial nephrectomy include hemorrhage and urinary leak, generally at a rate somewhat greater than for open surgical partial nephrectomy (Gill et al, 2007). Cancer-control rates appear to be equivalent to those of open partial nephrectomy.
An alternative to tumor resection is cryoablation or radiofrequency ablation of small peripheral renal lesions. The dissection techniques are similar to that for laparoscopic partial nephrectomy. A biopsy should be taken to confirm malignancy. For cryoablation, the probe is passed into the tumor and the lesion is frozen to less than −20°C, thawed, and then refrozen. This process can be monitored by laparoscopic ultrasound. For radiofrequency ablation, the probe is introduced into the lesion after adequate mobilization and biopsy and is used to deliver a preset amount of energy based on tumor volume. Temperature at the tip of the probe is 100°C. After treatment, the lesion may be resected, or the coagulated mass can be left in situ. Cryoablation and radiofrequency coagulation techniques may decrease blood loss and operative times compared with partial nephrectomy. Renal arterial clamping is unnecessary, thus avoiding the risk of ischemia and reperfusion injury. The spectrum of complications is similar to that of laparoscopic partial nephrectomy. Long-term data are scant, and close follow-up is required (Kunkle and Uzzo, 2008).
Laparoscopy has become the standard for donor nephrectomy in the United States. Most laparoscopic procedures are left-sided, single-artery kidneys for technical reasons, but multiple arteries and right-sided donation can be addressed with excellent outcomes. The positioning and dissection technique is similar to that of laparoscopic nephrectomy, except that the ligation of the vasculature is the last step before intact extraction. For the pure laparoscopic technique, a premarked low transverse incision is carried down to the peritoneum. The renal artery and vein are then ligated and transected. To optimize renal vein length, especially on the right side, an endoscopic stapler that lays down three rows of staples without cutting can be used, in place of the more commonly used stapler that lays down six rows of staples and cuts in between rows 3 and 4. A peritoneotomy is made and the kidney is passed to the recipient team.
Many centers use hand-assisted laparoscopic techniques for live renal donation. Proponents of hand-assisted approaches argue that the incision should be made at the beginning of the procedure and utilized for assistance in dissection. Others use the retroperitoneal approach for laparoscopic donor nephrectomy, claiming decreased operative times. Surgeon experience and comfort level will dictate the laparoscopic technique. Laparoscopic donor nephrectomy produces renal units that function as well as those from open surgical procedures, with similar complication rates (Nanidis et al, 2008).
Laparoscopic pyeloplasty is increasingly utilized to address ureteropelvic junction obstruction. Transperitoneal, retroperitoneal, and hand-assisted techniques have been described. Common to all approaches is the need to be well skilled in laparoscopic suturing, and as such robotic assistance has become popular. Port placement is similar to that for laparoscopic transperitoneal or retroperitoneal nephrectomy. Dissection and reconfiguration of the ureteropelvic junction is similar to that of open surgery and is dependent on intraoperative findings. The Anderson-Hynes dismembered pyeloplasty, Y-V plasty, Heineke-Mikulicz reconstruction, Davis intubated ureterotomy, Hellstrom vascular relocation, and tubularized flap pyeloplasty have all been described laparoscopically. The procedure has been performed in infants, children, adults, and the elderly. If there is an anterior crossing vessel, it is optimal to transect and anastomose the ureter anterior to the crossing vessel (Figure 9–20). A large redundant renal pelvis may be reduced and tapered. A ureteral stent may be placed before or during the repair.
Ureteropelvic junction obstruction of left kidney associated with crossing vessel (white line) before laparoscopic pyeloplasty. Renal pelvis is marked with white asterisk and ureter is indicated by a black asterisk.
Open surgical and laparoscopic pyeloplasty appear to offer equivalent pain relief, activity level improvement, and relief of obstruction. The outcomes are better than with other minimally invasive approaches such as endopyelotomy or balloon dilation (Dimarco et al, 2006). Complications are similar to that for laparoscopic nephrectomy, with the addition of urinary leak and failure of the procedure to correct the obstruction.
On the basis of shorter operative time, reduced complications and convalescence, and equivalent surgical outcome compared with open surgery, laparoscopic adrenalectomy is the standard approach for most surgical adrenal lesions, including aldosteronomas, pheochromocytomas, Cushing's adenomas, incidentalomas, metastatic lesions, symptomatic myelolipomas, and feminizing/virilizing tumors (Lee et al, 2008). Large (>6 cm), invasive carcinomas are considered by most to be the only contraindication to laparoscopic adrenalectomy. Experienced laparoscopists have reported successful laparoscopic adrenalectomy for up to 15-cm lesions. Transperitoneal (anterior or lateral), retroperitoneal (posterior or lateral), hand-assisted, and transthoracic laparoscopic approaches have been reported. Bilateral synchronous adrenalectomy and partial adrenalectomy have been performed.
The laparoscopic approach to the adrenal gland is similar to that previously described for transperitoneal laparoscopic nephrectomy, although the ports are placed in a subcostal location (Figure 9–21). The dissection can be compared to opening a book. For left-sided lesions, the spleen is mobilized medially while the characteristic yellow adrenal tissue is mobilized to the right. Dissection continues in a counterclockwise direction. The main adrenal vein enters the renal vein. Proceed cautiously at the superomedial aspect because the superior adrenal vein (from the inferior phrenic vein) can be substantial. After controlling the adrenal vein, blunt and sharp dissection is used to mobilize the adrenal gland from the psoas muscle and superior aspect of the kidney. On the right side, the surgical approach is again analogous to opening a book, and dissection proceeds in a clockwise direction. The triangular ligament is incised with the posterior peritoneum, allowing medial retraction of the liver and colon. This exposes the IVC, and the adrenal gland is gently mobilized laterally. The adrenal vein emptying into the IVC is ligated and transected.
One of the possible port configurations for right transperitoneal laparoscopic adrenalectomy.
Complication and conversion rate of laparoscopic adrenalectomy are lower than for nephrectomy (Permpongkosol et al, 2007). Vascular and visceral injuries, cardiovascular complications related to pheochromocytoma, pneumothorax, and other typical complications have been reported. Suppression of contralateral adrenal function by a cortisol-producing tumor (Cushing's syndrome) may result in an Addisonian crisis, typically within the first 10 postoperative days.
Retroperitoneal Lymph Node Dissection
Open surgical retroperitoneal lymph node dissection (RPLND) involves a xiphoid-to-pubis midline incision and significant morbidity related to ileus, blood loss, and postoperative pain. Laparoscopic RPLND offer a considerably less intense experience for the patient. The dissection template is the same as with the open approach. For left-sided lesions, the para-aortic, preaortic, and retroaortic nodes are removed (Figure 9–22). The boundaries are the renal vessels, the medial edge of the aorta, and the ureter inferiorly down to the iliac vessels. For right-sided lesions, the interaortocaval, precaval, retrocaval, and preaortic nodes are removed. The boundaries are the renal vessels, the aorta, and the ureter inferiorly down to the iliac vessels. Additionally, the para-aortic nodes between the renal hilum and the inferior mesenteric artery are removed. Laparoscopic RPLND should be approached with caution in patients with bulky nodal disease.
Left-sided laparoscopic retroperitoneal lymph node dissection. Black line indicates aorta and white lines indicate renal and gonadal veins.
The patient is positioned in a modified lateral decubitus fashion. The initial port is placed near the umbilicus. Additional ports are placed to optimize dissection and retraction. The dissection is similar to the previously described transperitoneal laparoscopic nephrectomy except that on the left side, the spleen and pancreas are rotated further medially and the descending colon is mobilized lower into the pelvis. On the right side, the posterior peritoneum is incised under the liver to reveal the superior margin of the IVC, and the colon and duodenum are mobilized further medially to expose the retroperitoneal area of interest. A methodical approach, using the same split-and-roll technique as in open RPLND, is performed. Nerve-sparing techniques are similar to the open approach in hopes of preserving ejaculatory function.
Complications of laparoscopic RPLND include hemorrhage, lymphocele, chylous ascites, injury to renal and lumbar veins, and bowel injury. Postchemotherapy dissections are more difficult, with higher morbidity and conversion rates. Follow-up studies suggest oncologic efficacy comparable with that of open techniques (Rassweiler et al, 2008).
Interest in laparoscopic urologic surgery intensified with successful laparoscopic techniques for radical prostatectomy. Laparoscopic prostatectomy has become routine in most centers with the availability of robotic assistance, with operative times similar to those for open prostatectomy. The indications for laparoscopic radical prostatectomy are similar to the open approach, and contraindications are the same as those for general laparoscopy.
A transperitoneal approach is most popular. The patient is positioned in a modified lithotomy fashion with the thighs abducted for access to the perineum and the table in steep Trendelenburg position. A periumbilical insufflation port is placed with four to five additional ports in a fan-shaped pattern. Laparoscopic dissection begins by incising the peritoneum posterior to the bladder to expose the seminal vesicles and vas deferentia, or by incising the peritoneum anterior to the bladder to open the space of Retzius. One major difference from the open procedure is that dissection of the prostate is often performed from the bladder neck distally to the prostatic apex. The lateral pedicles can be controlled with electrocautery or coagulating shears, or if nerve sparing is desired, then clips are used. The laparoscopic approach has the advantage of performing the anastomosis under magnified vision (and in three dimensions with the robot).
Once adequate experience has been gained, oncologic results (as measured by margins and prostate-specific antigen recurrence) are comparable with those with open radical prostatectomy (Ficarra et al, 2009). Similarly, incontinence and sexual dysfunction rates are comparable. Blood loss is less than with open techniques because the pneumoperitoneum helps reduce venous hemorrhage. Conversion to open surgery is rare after the initial learning curve.
Radical Cystectomy with Urinary Diversion
The laparoscopic approach to radical cystectomy with urinary diversion, although growing in popularity, has not achieved the dominance as in prostatectomy. The cystectomy portion of the procedure is often considered less technically demanding than prostatectomy; it is the urinary diversion with bowel that makes the procedure so difficult.
The cystectomy/cystoprostatectomy portion of the procedure is similar to that of laparoscopic radical prostatectomy. The urinary diversion with bowel can be performed through a “mini-laparotomy” after first harvesting the bowel laparoscopically, or it can be performed totally intracorporeally. Data on oncologic efficacy and complications are still sparse (Nix et al, 2010). Certainly, though, these techniques will continue to evolve.
Miscellaneous Laparoscopic Procedures
Numerous other laparoscopic procedures have been described. Interesting examples include laparoscopic ureteroneocystostomy for vesicoureteral reflux, psoas hitch with or without a Boari flap, augmentation enterocystoplasty, parapelvic cyst resection, lumbar sympathectomy, ileal ureter, anatrophic nephrolithotomy, pyelolithotomy, ureterolithotomy, flank herniorrhaphy, and catheterizable cecal tubes (ACE Malone). Continued improvement in technology, surgical skills, and patient demand will likely further expand laparoscopic urologic surgery.