Laparoscopic and endourological techniques have had a profound effect on urological practise. Implementation of “key-hole” surgery has allowed surgeons to accomplish operative tasks, using a special telescope inside the body and very long instruments, that previously required large incisions often resulting in considerable pain and suffering.
Minimally invasive surgery reduces the pain and morbidity of surgery, allowing a shorter convalescence and return to normal activities. An operation, which previously required a large flank or abdominal incision and a one-week stay in hospital, is now performed through 3-4 small (1 cm) incisions, with the patient being discharged within a few days. Patients achieve the same therapeutic benefits of open surgery, but with significantly less postoperative pain, shorter hospital stay, more rapid recovery and less scarring.
Minimally invasive surgery has wide applications in urology. This website will outline a few of the more common procedures we perform. Minimally invasive surgery in urology may be broadly classified in three groups:
1. Laparoscopic procedures as applied to the management of diseases of the kidneys, adrenal glands and prostate.
2. Endoscopic procedures as applied to the treatment of stones and obstruction of the kidneys and ureter.
3. Minimally invasive surgery of the prostate.
Each group lists the specific procedures offered at Urology Sydney and their indications. The website is intended as a guide for patients considering these procedures and outlines technical aspects of the procedure as well as what to expect after surgery. Please note that not all patients are suitable for minimally invasive surgery, however your urologist should discuss this option with you at the time of your consultation.
The list of urological procedures being attempted via a “key-hole” approach continues to grow. Laparoscopic nephrectomy, adrenalectomy and pyeloplasty may now be considered as routine procedures. The burgeoning worldwide experience with laparoscopic radical prostatectomy may eventually challenge the place of conventional open surgery for this indication as well, pending the long-term results that prove its oncological safety.
These techniques utilise instruments to get “inside” the kidney and ureter via a small cut in the skin (percutaneous) or per urethra (the channel through which urine flows out of the bladder). Energy sources such as Holmium LASER are used to disintegrate stones or relieve blockages.
This is a minimally invasive method of removing the kidney.
Most patients undergoing laparoscopic nephrectomy will have a kidney cancer or a poorly functioning kidney due to chronic obstruction, infection, reflux, stones or a vascular abnormality.Laparoscopic nephrectomy may be performed by a transperitoneal or retroperitoneal route. The transperitoneal approach is the most popular as it affords greater operating space, however the retroperitoneal route is more similar to the conventional open approach and enables early vascular ligation. There is no objective advantage for one technique over the other.
Hand-assisted laparoscopic nephrectomy, utilising specially designed “hand-ports”, are also favoured by some to facilitate tactile sensation, improved blunt dissection, organ retraction, haemostasis and specimen retrieval, however this occurs at the expense of slower convalescence and adds to the procedural cost. The transperitoneal route is our favoured technique.
Although a prospective randomised controlled trial comparing laparoscopic and open nephrectomy has not been forthcoming, experience with hundreds of patients and in a number of centres has shown a clear benefit for laparoscopic nephrectomy, for benign or malignant conditions. These advantages are reduced blood loss, lower postoperative analgesic requirement, earlier return to diet, improved cosmesis, shorter length of stay, reduced convalescence and an earlier return to normal activity.
Patients require catheter drainage of the bladder for the first 24 – 36 hours after surgery. Pain relief is administered via a drip on demand (patient-controlled analgesia). Diet is gradually re-introduced as bowel function returns to normal, which is usually within 2-3 days. Patients are usually allowed home within 3-5 days and are able to return to work in 4-6 weeks.
This operation is usually performed for transitional cell cancer (TCC) of the kidney or ureter. The approach to the kidney is identical to laparoscopic nephrectomy. Depending on the location of the tumour, the ureter may be removed entirely laparoscopically or in combination with endoscopic (via the urethra) or open surgery. A bladder catheter is left inside for 5-7 days until the bladder has healed, with patients well enough for discharge by this time.
This operation is rarely required these days as modern equipment allows endoscopic management of most stones by ureteroscopy. Using a key-hole technique the surgeon locates the stone in the ureter (a duct leading from the kidney to the bladder) and makes a longitudinal cut to remove the stone. The ureter is sutured closed and a stent left inside for 3-4 weeks until it has healed. A catheter is left to drain the bladder for the first 24-48 hours and the patient is discharged home usually within 2-3 days.
This is an operation to relieve an obstruction at the junction of the pelvis of the kidney and the ureter, which may manifest with pain, impaired function of the kidney, recurrent infections or stones.
The obstructed segment is excised and the outlet of the kidney reconstructed to permit free flow of urine down the ureter. A stent is left inside for 3-4 weeks until healed. A catheter and drain are left in at the end of the operation and removed within 2-3 days, after which the patient is usually ready to go home.
Laparoscopic partial nephrectomy
This is a key-hole operation to remove a diseased segment from the kidney. It is only suitable for tumours in specific segments of the kidney. Special glues are uses to prevent blood loss from the cut surface of the kidney.
The adrenal gland is a small organ situated slightly above the kidney, which can be affected by cancer and other disorders. Laparoscopic surgery has revolutionised the treatment of adrenal disease. While difficult by conventional open surgery, laparoscopic removal is quite straightforward, although identification of the gland can sometimes be difficult in patients with excessive retroperitoneal fat. The specific advantages of laparoscopic adrenalectomy, above the usual benefits of earlier recovery, are reduced blood loss and lower complication rate. Patients are normally well enough for discharge home within 2-3 days of the procedure.
Laparoscopic radical prostatectomy
The same procedure as a radical prostectomy is performed in a minimally invasive fashion utilising tiny instruments inserted through tiny incisions above and beside the belly button. The urinary tract is reconstructed and the prostate removed through the belly button incision leading to less pain, faster recovery and faster return to normal activities.
This is an operation to remove stones from the kidney. The stones are broken up and removed using a telescope introduced through a small skin puncture in the flank. A thin tube is left to drain the kidney and removed after 24-36 hours. An X Ray is performed prior to removing the tube to ensure all the stone has been removed. Antibiotics are administered to prevent infection, and patients are normally discharged in 2-3 days.
This operation is performed to treat stones, tumours or obstruction in the ureter (a 20 cm long duct which runs from the kidney to the bladder).
The ureteroscope is a long narrow telescope which is inserted through the urethra (the tube which exits the bladder) that permits direct visualisation of the ureter and application of various energy sources, such as laser, to destroy stones or tumours. Strictures or narrowings of the ureter can also be incised using laser. Ureteroscopic endopyelotomy refers to laser incision of one of these narrowings at the junction of the kidney and ureter.