Thomas Frede

COMPLICATIONS OF LAPAROSCOPIC PROCEDURES IN UROLOGY: EXPERIENCE WITH 2,407 PROCEDURES AT 4 GERMAN CENTERS

PURPOSEnThe 4 most active centers of the laparoscopy working group of the German Urologic Association collected data about the complications associated with laparoscopic surgery in urology.nnnMATERIALS AND METHODSnAt 4 centers 2,407 laparoscopies or retroperitoneoscopies were performed as of May 1998, including 776 for varicocelectomy, 259 for cryptorchidism, 481 for pelvic lymph node dissection, 351 for nephrectomy/heminephrectomy renal pathology, 139 for renal cyst resection, 58 for ureteral procedures, 44 for adrenalectomy, 41 for nephropexy, 41 for lymphocele fenestration, 40 for retroperitoneal para-aortic lymphadenectomy and 187 for other operations. The complications were evaluated, listed according to the anatomical specificity and grouped with respect to the surgical step during laparoscopy.nnnRESULTSnA total of 107 complications (4.4%) occurred. The re-intervention rate was 0.8% and the mortality rate was 0.08%. The complication rate depended on the difficulty of the procedure and averaged 1.0, 3.9 and 9.2%, respectively, for easy, difficult and very difficult operations. The majority were vascular injuries (1.7%) and visceral lesions (1.1%) followed by complications of healing and infection (0.8%). Only 0.2% of complications was associated with the access technique (trocar insertion), whereas most occurred during dissection (2.9%). The complication rate was 13.3% for the first 100 procedures and subsequently averaged 3.6%.nnnCONCLUSIONSnCritical documentation of experience from several institutions, especially for an analysis of complications of urological laparoscopy, is important for the development of this surgical technique. The overall complication rate is comparable to other specialties. Future technical developments in trocar insertion, tissue dissection and control of bleeding with our improved training program will further reduce the complication rate.

RETROPERITONEOSCOPY: EXPERIENCE WITH 200 CASES

PURPOSEnA retroperitoneal access is commonly used for open urological procedures. Since the introduction of the balloon dissecting technique by Gaur this anatomical route has also been used for laparoscopic surgery. We present our experience with retroperitoneoscopy in 200 cases.nnnMATERIALS AND METHODSnFrom December 1992 to October 1997 a total of 200 retroperitoneoscopic procedures were performed in 197 patients 4 to 82 years old, comprising 78 nephrectomies, 50 renal cyst resections, 14 nephropexies, 11 ureterolyses, 8 retroperitoneal lymph node dissections, 8 renal biopsies, 6 adrenalectomies, 6 heminephrectomies, 6 pyeloplasties, 5 ureterolithotomies, 6 ureterocutaneostomies and 2 others. Of the patients 38 (19%) and 22 (11%) had undergone previous abdominal surgery, and kidney and ureter operations, respectively. Dissection of the retroperitoneal space was enabled by the use of a balloon catheter in 14, balloon trocar system in 93 and finger dissection technique in 93 cases.nnnRESULTSnWe classified 76 procedures (38%) as simple (renal biopsy, renal cyst resections, ureterocutaneostomy), 102 (51%) as difficult (adrenalectomy, nephrectomy, nephropexy) and 22 (11%) as very difficult (pyeloplasty, heminephrectomy, lymphadenectomy). There was a significant learning curve during the first 50 cases reflected by longer operating time, and higher complication, conversion to open surgery and open reintervention rates (14, 10 and 6%, respectively). In addition to the learning curve, mean operating time depended on the difficulty of the procedure, averaging 45 to 100 minutes for a simple, 95 to 185 for a difficult and 185 to 240 for a very difficult retroperitoneoscopy. In the last 50 cases the complication, conversion and reintervention rates (2, 4 and 2%, respectively) were acceptable for routine clinical application.nnnCONCLUSIONSnAfter experience with more than 200 cases of retroperitoneoscopy the access technique has been significantly simplified. The procedure is standardized, safe and reproducible.

Heilbronn Laparoscopic Radical Prostatectomy

Introduction: In 1999, Guillonneau and Vallancien presented a refined approach of a descending laparoscopic radical prostatectomy which based mainly on the primary access to the seminal vesicles and an improved suturing and knotting technique. Based on our own experience reconstructive laparoscopy as well as with open retropubic radical prostatectomy we have used a combined ascending/descending technique similar to open surgery. In this paper we want to describe our approach and to present the initial results with the Heilbronn technique. Materials and Methods: A transperitoneal approach is used with a W–shaped arrangement of the trocars (13–mm umbilical port, 2×10 mm medial, 2×5 mm lateral ports). After the exposure of the Retzius’ space and control of the dorsal vein complex the urethra is incised and the distal pedicles of the prostate (± the neurovascular bundle) are transsected. We now pull the apex ventrally and start with the incision at the bladder neck followed by a transvesical access to both vasa deferentia and seminal vesicles. The gland is entrapped in the Extraction Bag®. After accomplishing the posterior wall of the urethrovesical anastomosis with five interrupted sutures, the foley catheter is placed into the bladder and the bladder neck is closed. Now the prostate is extracted via the umbilical incision. From March 1999 to June 2000, we have performed 100 cases (48 pT2–, 47 pT3– and 5 pT4 tumors). The mean preoperative PSA was 26.8 (1.4–75.5) ng/ml. Two tumors were grade 1, 72 grade 2 and 26 grade 3. Median Gleason score was 6 (3–9). All specimen were inked and examined according to the Stanford protocol. Postoperative continence was evaluated using a questionnaire monitored by a colleague who was involved in surgery. Results: We had 5 conversions (rectal injury, difficult dissection, adhesion, 2× bleeding at the dorsal vein complex). The mean operating time was 278 (180–500) min., the transfusion rate 31%. One patient required reintervention due to bleeding from the right obturator fossa. 95% of the patients did not require any analgesia on the second postoperative day. Positive margins were found in 17% of the patients, of which 12 had a PSA nadir to a value of less than 0.1 ng/ml within 3 weeks after surgery. In 82 patients, the anastomosis was tight after removal of the catheter, median catheter time was 8 (6–30) days. 4% developed a stricture at the anastomotic site which could be treated by laserincision. On discharge 33% were continent, after 6 months 81%, whereas only 2 patients still suffer from grade II stress incontinence at 9 months. Conclusions: Laparoscopic radical prostatectomy is feasable but requires laparoscopic expertise. Its learning curve is still ongoing. Morbidity is low, oncological control is similar to results of open surgery, functional results are promising.

Laparoscopic Retroperitoneal Lymph Node Dissection for Nonseminomatous Germ Cell Tumors: Indications and Limitations

PURPOSEnWe describe our experience with laparoscopic retroperitoneal lymph node dissection in 26 patients with nonseminomatous germ cell tumors: 17 had stage I disease with no clinical (computerized tomography, ultrasound or tumor markers) evidence of metastases and 9 (2 with stage IIb and 7 with stage IIc disease) had residual tumor after chemotherapy but with negative tumor markers. Laparoscopic dissection was performed to assess more fully pathological status of the relevant retroperitoneal lymph nodes in both groups.nnnMATERIALS AND METHODSnThe patient was positioned and trocars were introduced at sites similar to that used for transperitoneal laparoscopic nephrectomy (flank position with 3, 10 mm. and 2, 5 mm. ports). After the white line of Toldt was incised and the colon was reflected anteromedially, the retroperitoneal space was exposed. The landmarks of lymph node dissection were then isolated, including the ureter, aorta, inferior vena cava and both renal veins. Lymph node dissection was performed identical to that for open surgery, with a modified template including the paracaval, interaortocaval, upper preaortic and right common iliac nodes for right tumors, and para-aortic and upper preaortic nodes for left tumors. Lymph node chains were retrieved with a small organ bag.nnnRESULTSnThe procedure was completed successfully in 16 of 17 patients with stage I disease (mean duration 268 minutes for the left and 312 minutes for the right sides). No intraoperative complications were encountered. One patient had delayed ureteral stenosis requiring operative repair, 1 had a pulmonary embolism with an uneventful outcome and 1 who underwent laparoscopic retroperitoneal lymph node dissection on the right side later had retrograde ejaculation. Embryonal carcinoma was found in 1 of the 17 patients. Average postoperative hospital stay was 4.5 days for patients without complications or conversion to an open procedure. After a median followup of 27 months no patient had regional relapse but 2 had pulmonary metastases that were treated successfully with 3 cycles of platinum based chemotherapy. Laparoscopic dissection was significantly more difficult in patients with stage II tumors after chemotherapy. Only in 2 patients with stage IIb disease was laparoscopic lymphadenectomy successful. In 5 of the 7 patients with stage IIc cancer portions of the dissection had to be done after conversion to an open (conventional) operation via a small incision (suprainguinal or pararectal). In 1 patient the laparoscopic approach was completely abandoned and converted to an open operation via a standard midline incision. In all 9 cases histopathological examination revealed complete necrosis. No patient has evidence of disease.nnnCONCLUSIONSnOur preliminary experience suggests that a modified laparoscopic retroperitoneal lymph node dissection is feasible for stage I tumors. However, it cannot be recommended after previous chemotherapy (stages IIb and IIc disease).

Long–Term Experience with Laparoscopic Retroperitoneal Lymph Node Dissection in the Management of Low–Stage Testis Cancer

Objectives: We describe our experience with laparoscopic retroperitoneal lymphadenectomy (LRLA) in 34 patients with low–stage germ cell tumors treated from 1992 to 1998. All patients had clinical stage–I disease with no clinical evidence (CT scan, ultrasound, tumor markers) of metastases. A laparoscopic dissection was used to assess the pathologic status of the relevant retroperitoneal lymph nodes. Material and Methods: 17 patients were treated by a transperitoneal laparoscopic approach, whereas in the last 17 patients retroperitoneoscopic retroperitoneal lymph node dissection was performed. The lymph node dissection was performed identically to open surgery with the modified template according to Weissbach including the paracaval, interaortocaval, upper pre–aortic, and right common iliac zonal nodes for right–sided tumors, and para–aortic, upper pre–aortic zones for left–sided tumors. Retrieval of the lymph node chains was accomplished using a small organ bag. Results: The procedure could be completed successfully in 30 of 34 patients with stage–I disease. In these cases the mean duration of the procedure was 248 min. In 3 patients the lymphadenectomy was abandoned, because frozen section showed metastasis. In 1 case conversion to open surgery was necessary because of bleeding from the aorta. One patient developed a delayed ureteral stenosis which required operative repair. Three patients required temporary insertion of an indwelling ureteral stent, and another patient had a pulmonary embolism with an uneventful outcome. One patient with a LRLA on the right side later developed retrograde ejaculation. In 6 of the 33 patients (18%) embryonal carcinoma or mixed carcinoma was found. The postoperative hospital stay averaged 5.3 (3–9) days for the patients without complications or conversion to open surgery. After a median follow–up of 40 months no regional relapse occurred, but 2 patients developed pulmonary metastases which were treated successfully by three cycles of platinum–based chemotherapy. All patients have no evidence of disease. Conclusions: Our experience suggests that LRLA is a safe and accurate method for low–stage germ cell tumors with minimal invasiveness, but because of its technical difficulty it should be restricted to experienced centers.

Robotics and telesurgery – an update on their position in laparoscopic radical prostatectomy

Laparoscopy is handicapped by the reduction of the range of motion from six to only four degrees of freedom. In complicated cases (i.e. radical prostatectomy), there is often a crossing of the hands of surgeon and assistant. Finally, standard laparoscopes allow only 2D‐vision. This has a major impact on technically difficult reconstructive procedures such as laparoscopic radical prostatectomy. Solutions include the understanding of the geometry of laparoscopy, but also newly developed surgical robots. During the last five years, there has been an increasing development and experience with robotics in urology. This article reviews the actual results focussing on the benefits and problems of robotics in laparoscopic radical prostatectomy. Own experiences with robot‐assisted surgery include more than 1200 laparoscopic radical prostatectomies using a voice‐controlled camera‐arm (AESOP) as well as six telesurgical interventions with the da Vinci‐system. Substantial experimental studies have been performed focussing on the geometry of laparoscopy and new training concepts such as perfused pelvitrainers and models for simulation of urethrovesical anastomosis. The recent literature on robotics in urology has been reviewed based on a MEDLINE/PUBMED research. The geometry of laparoscopy includes the angles between the instruments which have to be in a range of 25° to 45°; the angles between the instrument and the working plane that should not exceed 55°; and the bi‐planar angle between the shaft of the needle holder and the needle which has to be adapted according to the anatomical situation in range of 90° to 110°. 3‐D‐systems have not yet proved to be effective due to handling problems such as shutter glasses, video helmets or reduced brightness. At the moment, there are only two robotic surgical systems (AESOP, da Vinci) in clinical use, of which only the da Vinci provides stereovision and all six degrees of freedom (DOF).To date, more than 3000 laparoscopic radical prostatectomies have been performed worldwide at 92 centres with this system. The main advantage of the system represents the translation of open surgical skills to laparoscopy. Despite recent development of basic tools (e.g. bipolar forceps) for the da Vinci robot, investment and maintenance costs still represent the major problem of the device. Additionally, the device does not provide any haptic sense (i.e. tactile feedback). Robotic surgery represents a turning point of surgical research. However, broad use of robotic systems is limited mainly because of the high investment and running costs. Interestingly, more than in the field of cardiac surgery, there seems to be a need for telemanipulators in urology, mainly to reduce the learning curve of standard laparoscopy. However, new training concepts used in combination with mono‐tasking computerized robots (AESOP) have proved their efficacy associated with a significant cost reduction.

Retroperitoneoscopic surgery — technique, indications and first experience

SummaryAlthough retroperitoneoscopic procedures were already being performed in the late seventies, it was the balloon-dissecting technique introduced by Gaur, together with the progressive experience in trans-peritoneal laparoscopic procedures in the upper retroperitoneum, that initiated the clinical breakthrough of retroperitoneoscopy. We modified the balloon-dissecting technique into a hydraulic, video-optically controlled balloon dissection of the retroperitoneal space. This technique permitted successful, extensive laparoscopic surgery on the kidney and ureter. We summarize the history of retroperitoneoscopy, the different methods of gaining access to the retroperitoneum and the types of surgery made possible by this new approach, along with our experience in our first 41 cases.

The Impact of Neoadjuvant Hormonal Therapy on the Outcome of Laparoscopic Radical Prostatectomy: A Matched Pair Analysis

PURPOSEnWe evaluated the effect of androgen ablation treatment on laparoscopic radical prostatectomy operative and postoperative parameters.nnnMATERIALS AND METHODSnA total of 50 patients (group 1) on neoadjuvant androgen deprivation, followed by laparoscopic radical prostatectomy, were compared to 50 (group 2) without any treatment who were matched for prostate volume, laparoscopic pelvic lymphadenectomy, nerve sparing procedure, surgical access type and pathological stage. We analyzed operative time, blood loss, intraoperative and postoperative complications, catheter time, procedure difficulty as scored by the surgeon and surgical margin status.nnnRESULTSnThere was no significant difference between the neoadjuvant and nonneoadjuvant groups with respect to mean operative time +/- SD (228.6 +/- 62.9 vs 219.4 +/- 65.1 minutes), mean blood loss (667.6.1 +/- 217.1 vs 729.8 +/- 285.1 ml) and median catheter time (7 vs 7.5 days). We also found no difference related to the complication rate. Ten of 50 prostate dissections (20%) in group 1 were classified as difficult, whereas in group 2 only 4 of 50 (8%) were scored as difficult (p = 0.084). The positive surgical margin rates did not differ.nnnCONCLUSIONSnThere was no significant difference with respect to operative or postoperative parameters in patients undergoing neoadjuvant androgen ablation therapy compared to controls. At centers where there is experience laparoscopic radical prostatectomy can be safely performed in patients who have undergone neoadjuvant hormonal therapy.

Retroperitoneal laparoscopic nephropexy

Laparoscopic nephropexy is a suitable and clinically established procedure for the treatment of symptomatic nephroptosis. The availability of a minimally invasive therapy can facilitate decisions regarding the indication after careful selection of patients.

Telepresence surgery: first experiences with laparoscopic radical prostatectomy

The concept of an intelligent steerable surgical instrument system has been described by various authors. Since 1998, telesurgical minimally invasive procedures have been performed with the da Vinci system, mainly for cardiac bypass surgery. We present our initial experience using the device for robot-assisted laparoscopic radical prostatectomy. The intuitive surgical system consists of two main components: the surgeon‘s viewing and control console with 3D-imaging, and the surgical arm unit that positions and manoeuvres detachable surgical instruments. These instruments are introduced via two 8 mm trocars and allow movements in all six degrees of freedom (DoF). The surgeon performs the procedure while seated at the console holding specially designed instruments. Highly specialised computer software and mechanics transmit the surgeon‘s hand movements exactly to the microsurgical movements of the manipulators at the operative site. The system used is a W-shaped five trocar arrangement, with the robot‘s arms at the lateral trocars (8 mm) and two assistant trocars medially (10 mm). A sixth trocar was used in the right suprapubic area for retraction of the gland (Foley catheter). The left assistant used different instruments, such as bipolar forceps, Ultracision, and Endoclip, wheras the right assistant mainly used the suction–irrigation device. The Intuitive System was attached after trocar placement and exposure of Retzius‘ space. We treated six patients (two pT2, four pT3, median Gleason score 6). The operating room time averaged 315 (range 242–480) min, including pelvic lymph-node dissection. No intra-operative complications occured, one patient required transfusions. There were no positive margins, median catheter time was 5 days. Three patients were completely continent after 1 month. Telerobotic laparoscopic radical prostatectomy is feasible. There is a learning curve with the device, mainly due to the magnification, 3D image and lack of tactile feedback. However, the experienced surgeon can become familiar with the device after a short time. There is still a need for further development of instruments for urological procedures.The concept of an intelligent steerable surgical instrument system has been described by various authors. Since 1998, telesurgical minimally invasive procedures have been performed with the da Vinci system, mainly for cardiac bypass surgery. We present our initial experience using the device for robot-assisted laparoscopic radical prostatectomy. The intuitive surgical system consists of two main components: the surgeons viewing and control console with 3D-imaging, and the surgical arm unit that positions and manoeuvres detachable surgical instruments. These instruments are introduced via two 8 mm trocars and allow movements in all six degrees of freedom (DoF). The surgeon performs the procedure while seated at the console holding specially designed instruments. Highly specialised computer software and mechanics transmit the surgeons hand movements exactly to the microsurgical movements of the manipulators at the operative site. The system used is a W-shaped five trocar arrangement, with the robots arms at the lateral trocars (8 mm) and two assistant trocars medially (10 mm). A sixth trocar was used in the right suprapubic area for retraction of the gland (Foley catheter). The left assistant used different instruments, such as bipolar forceps, Ultracision, and Endoclip, wheras the right assistant mainly used the suction–irrigation device. The Intuitive System was attached after trocar placement and exposure of Retzius space. We treated six patients (two pT2, four pT3, median Gleason score 6). The operating room time averaged 315 (range 242–480) min, including pelvic lymph-node dissection. No intra-operative complications occured, one patient required transfusions. There were no positive margins, median catheter time was 5 days. Three patients were completely continent after 1 month. Telerobotic laparoscopic radical prostatectomy is feasible. There is a learning curve with the device, mainly due to the magnification, 3D image and lack of tactile feedback. However, the experienced surgeon can become familiar with the device after a short time. There is still a need for further development of instruments for urological procedures.