13.06.2018 · 👁 4,235
For which operations has laparoscopy replaced the traditional open method in urology?
For the following surgical procedures, laparoscopy has replaced open surgery in urology as the method of choice in healthy patients without anatomical abnormalities and intra-abdominal adhesions
1. Laparoscopic plastic surgery for hydronephrosis with obstruction of the ureteropelvic segment.
The connection between the renal pelvis (where urine produced by the kidney is stored) and the ureter (the tube that connects the kidney to the bladder) may be blocked. This condition is called ureteropelvic segment obstruction. In most cases, ureteropelvic segment obstruction is a congenital narrowing, meaning people are born with this anomaly. Also, the cause of obstruction of the ureteropelvic segment is an additional vessel of the lower pole of the kidney, which can compress the ureter, leading to obstruction of the ureteropelvic segment. Although obstruction of the ureteropelvic segment is most often diagnosed in young children, it may not cause concern for a long time and is detected at an older age. Pain in the affected kidney is usually bothersome from time to time, especially after drinking large amounts of fluid due to stretching of the collecting system of the kidney above the site of obstruction.
Traditionally, ureteropelvic junction obstruction has been treated by open surgery. The results of this operation were very good, but on the other hand there remains the problem of a large incision, which can cause severe pain, slow recovery and is not cosmetically attractive. In recent years, attempts have been made to restore the ureteropelvic segment using endoscopic techniques (the operation was performed through the bladder without skin incisions). The advantage of these operations is the absence of skin incisions, but according to the literature, the positive result is approximately 10–20% less compared to the results of laparoscopic surgery to restore the ureteropelvic segment.
Laparoscopic plastic surgery for hydronephrosis makes it possible to restore the ureteropelvic segment without a large incision and complications associated with it. Laparoscopic pyeloplasty is performed under general anesthesia (the patient is asleep). Four small skin incisions are made through which trocars are inserted. In order to restore the patency of the ureteropelvic segment, special instruments and telescopic cameras are used.
At the end of the operation, a stent (a small plastic tube) is left inside the repaired segment to prevent scar tissue that forms during healing from causing obstruction again. Subsequently, the stent is removed.
2. Laparoscopic nephrectomy
Laparoscopic nephrectomy is a laparoscopic operation to completely remove the kidney.
The kidney is removed if its function is completely impaired or due to the development of a tumor. The purpose of the operation is to remove the kidney and surrounding fatty tissue (if kidney cancer is suspected).
A traditional nephrectomy is performed through a large incision in the abdominal wall. The disadvantages of this method are significant pain, which leads to the need for additional days in the hospital, and a long recovery period.
Laparoscopic nephrectomy, on the other hand, is performed through small incisions through which trocars are inserted to allow access to the kidney. Special instruments are used, including a telescopic camera, to enhance visualization, which increases accuracy and improves the results of laparoscopic surgery.
There are certain contraindications to the laparoscopic approach when removing a kidney, which include a large kidney tumor or if there is a danger of the tumor spreading beyond the kidney.
Laparoscopic nephrectomy is performed under general anesthesia (which means the patient is asleep). Laparoscopic nephrectomy lasts approximately 2 hours. Patients undergoing laparoscopic nephrectomy spend an average of 2-3 days in the hospital. The advantages of laparoscopic nephrectomy include a reduction in postoperative wound-related complications, less pain, and a shorter recovery period after surgery compared to open nephrectomy.
The results of laparoscopic kidney removal for a malignant tumor are comparable to the results of open nephrectomy.
3. Laparoscopic radical prostatectomy
Traditionally, a radical prostatectomy is performed through a single incision that starts at the pubic bone and ends just below the navel. In laparoscopic radical prostatectomy, five small incisions are made through which trocars and a laparoscope are inserted.
For some men, the nerve-sparing technique of laparoscopic radical prostatectomy may be used. They preserve the nerves that are responsible for the presence of erectile function in a man. The purpose of this surgical method is: firstly, to treat the patient’s prostate cancer, as well as to maximize the preservation of erectile function after surgery. According to the surgical literature, it can be concluded that when nerves are preserved, the frequency of spontaneous erections increases, and normal urination is restored more quickly.
Whether a patient can undergo nerve-sparing laparoscopic prostatectomy depends on several factors. The most important factor is the type of prostate cancer. This is determined by three main characteristics:
• Entry level PSA
• Gleason score (based on biopsy data, determines the degree of differentiation of prostate cancer)
• Data from digital rectal examination of the prostate gland
Nerve-sparing surgery is not indicated for men with a PSA level >10 ng/mL or with a primary Gleason score greater than 4. For these patients, the treatment of choice is conventional laparoscopic prostatectomy without nerve sparing.
Laparoscopic prostatectomy is performed under general anesthesia. Laparoscopic prostatectomy lasts approximately three hours. Patients undergoing laparoscopic prostatectomy spend an average of 2–3 days in the hospital, which is significantly less than those undergoing open radical prostatectomy. A urinary catheter is inserted into the bladder through the urethra (urethra) of the patient after laparoscopic prostatectomy, which remains in the bladder for a week. After a week, patients consult a doctor to examine the urination process. This involves removing the catheter, then waiting until normal urination has returned. Only after this the patient returns home. If you live very far from the hospital, then alternative scenarios are possible.
The advantages of laparoscopic prostatectomy are as follows:
• improved visualization
• reduction of postoperative pain syndrome
• shorter hospital stay
• quick return to normal lifestyle.
4. Renal cysts
Renal cysts are very common and occur in up to 50% of adults. The prevalence of kidney cysts increases with age. In 2/3 of the population over 80 years of age, kidney cysts are found when examined using radiological diagnostic methods. The causes of cysts in the kidneys are unknown.
Kidney cysts are divided into simple cysts and complex ones. Complex cysts are suspicious for the development of renal cell carcinoma in the cyst wall. Benign cysts almost never degenerate into a more suspicious cyst.
Computed tomography (CT) or ultrasound (US) is usually sufficient to diagnose a benign kidney cyst. If any questions arise during ultrasound, then CT provides all the necessary information (and vice versa).
Cysts can reach large sizes and cause discomfort for patients.
Cysts can cause pain due to:
• growth and stretching of the cyst wall
• pressure on the kidney
• pressure on the kidney's drainage system, causing obstruction
• pressure on other organs (stomach, intestines)
We have had good results with laparoscopic treatment of all types of cysts, including:
• very large cysts
• multiple cysts in the kidney (polycystic disease)
• cysts located deep in the kidney tissue.
Can laparoscopy in urology really be used in the treatment of malignant tumors (cancer)?
Concerns that have delayed the use of laparoscopic surgery for cancer treatment have been that patient survival and recovery rates will be reduced. Questions have arisen about the adequacy of tumor removal, the possibility of cancer metastasis and inadequate removal of affected lymph nodes during laparoscopic operations, and in connection with this the development of early relapses of a malignant tumor. In addition, some early research findings have suggested an increase in the rate of tumor cell implantation at trocar sites, which is associated with direct tumor contact with the trocar site or biological factors (eg, pneumoperitoneum) that stimulate cancer development. However, with careful laparoscopic removal of cancer, without insemination by tumor cells, results equivalent to those of open surgery have been reported.
What complications are associated with laparoscopy in urology?
With every laparoscopic procedure, traditional, well-described complications are possible, as with open surgery. However, laparoscopic surgeries may have unique, rare complications that can be life-threatening. Treatment of some of these complications requires conversion from laparoscopic surgery to open surgery.
1. Hernia or bleeding from the site of trocar insertion. Bleeding occurs when a blood vessel is punctured (for example, dilated umbilical veins in patients with liver disease). Hernias can occur in the 12 mm incision at the trocar insertion site and can lead to small intestinal obstruction.
2. Accidental injury from laparoscopic instruments and retractors, especially thermal burns or missed injury to the small bowel. One of the most dangerous complications is a missed wound of the small intestine during the insertion of a laparoscope or trocars.
3. Complications associated with pneumoperitoneum (carbon dioxide), especially the entry of carbon dioxide into a large blood vessel (CO2 embolism).
4. Injury to the bladder or stomach when inserting a Veress needle (the incidence of this complication can be minimized if the following rules are followed: the patient must empty the bladder before surgery, a catheter is inserted into the bladder to drain urine, a nasogastric tube is inserted into the stomach to drain its contents).
5. Intestinal obstruction due to displacement of clamps and surgical staples. Intestinal obstruction can also complicate open surgery, but more often occurs after laparoscopic surgery.
What specific complications of laparoscopic surgery should I be aware of?
Some complications associated with laparoscopic operations accompany surgical intervention, regardless of the approach technique.
Are there any complications associated with anesthesia?
There are several important anesthetic factors to consider when choosing laparoscopic surgery:
1. To adequately relax the abdominal wall, laparoscopic surgery requires general anesthesia, while some traditional open surgeries can be performed under epidural or even local anesthesia.
2. Creation of pneumoperitoneum, introduction of carbon dioxide, can lead to disruption of the cardiovascular and respiratory systems. The first method of dealing with these complications is to reduce the pressure while introducing carbon dioxide. But sometimes the surgeon converts laparoscopic surgery to open surgery due to these side effects alone.
a. Disturbances of the cardiovascular system include: decreased filling of the heart with blood and decreased cardiac output due to increased intra-abdominal pressure and the effect of carbon dioxide on respiratory parameters. If carbon dioxide enters a blood vessel when forced into the abdominal cavity, an air embolism can occur, which can lead to cardiovascular failure or a heart attack.
b. Respiratory problems: Increased intra-abdominal pressure can displace the diaphragm, leading to decreased lung capacity or lung collapse. Absorption of carbon dioxide by the peritoneum can cause increased concentrations of carbon dioxide in the blood and acidosis, and in 17% of patients lead to cardiac arrhythmias. Carbon dioxide pumped into the abdominal cavity can penetrate the subcutaneous tissues and cause pneumomediastinum (air in the mediastinum, the area between the two lungs) or subcutaneous emphysema (air in the subcutaneous tissues).
When will I be discharged home after laparoscopic urological surgery?
After major laparoscopic operations, patients can return home the next day or 2-3 days later.
Criteria for discharge of a patient after laparoscopic surgery include:
1. absence of nausea and vomiting (which are typical for laparoscopic operations due to pneumoperitoneum)
2. normalization of urination
3. adequate control of postoperative pain with painkillers.
Patients should avoid heavy lifting for two weeks after laparoscopic surgery, as this can lead to the development of postoperative hernias at the trocar insertion sites.
Conclusion:
The introduction of laparoscopy in urology has changed surgical practice, and this technique is now a fundamental component of modern medicine.
For some urological procedures, the benefits of laparoscopy are obvious, but patients should understand that in some cases laparoscopic surgery is contraindicated. Some patients do not trust laparoscopic surgeries and require open surgery. The key point is the patient’s quality of life, since laparoscopic surgery is an alternative method of surgical intervention. The main task is to ensure the development of new technologies as safe methods of treatment.
Ultimately, the benefits of laparoscopy in urology in any given case depend on a number of factors, including the skill and experience of the surgeon, patient preference, economic costs, the patient's health status, and the availability of specialized technology and equipment.
The Urologic Complex clinic performs all types of laparoscopic operations for pathologies of the kidneys, urinary tract and prostate formations.
For questions, you can contact us by phone +(998 71) 140-03-03, +(998 71) 140-01-60 and at Chilanzar, 12th block, st. M. Shaykhzoda, no. 7.
#urologiccomplex #urologicuz