Laparoscopy

Urologic Laparosopy

The past ten years has seen the growth of minimally invasive, or laparoscopic, surgery. The procedures are performed through "keyhole" incisions which reduces blood loss, pain, and scarring for the patient afterwards. The surgeons are able to accomplish this by looking inside of the body using a small telescope (laparoscope) attached to a camera and using long, miniaturized instruments inserted through the small incisions (Figure 1). In the past, the procedures were limited to relatively simple procedures such as removal of the gall bladder or ovaries. With increasing experience, however, the laparoscopic approach is being used in a variety of urologic procedures. In addition, urologists have been performing operations using endoscopes and small instruments within the urinary tract for decades, such as removal of kidney stones and resection of the prostate. At the University of California San Francisco, we have significant experience in the application of minimally invasive techniques to all areas of urology. On this web site you will find a discussion of the various urologic procedures which we routinely perform using laparoscopy. We anticipate that in ten to fifteen years, the vast majority of urologic surgery can be performed using laparoscopic techniques

Nephrectomy ( Removal of the Kidney)

The first laparoscopic nephrectomy was performed in 1990. Currently, laparoscopic nephrectomy is an accepted method to remove the kidney in many cases of benign (i.e., no cancer) renal disease. Common conditions in which simple nephrectomy has been successfully performed by the laparoscopic method include: renovascular hypertension, chronic kidney infection (chronic pyelonephritis), non-functioning hydronephrotic kidneys, non-functioning kidney with staghorn stone, symptomatic kidney with cysts.

No special preparation is needed prior to simple laparoscopic nephrectomy. In these operations, we typically use a transperitoneal approach (through the abdominal cavity) using 4 keyholes, or ports (Figure 2). After the kidney has been completely detached, it is placed into a plastic bag and removed from the body. Each port measures about 1 cm and leaves little scarring (Figure 3). Most patients resume a regular diet the night of surgery and are able to go home the next day. Advantages of removing the kidney by this method include reduced blood loss, minimal pain after the operation, improved cosmetic results, and earlier return to regular activity. These findings have been documented in multiple studies and have been confirmed by our experience. Potential complications include those that may be encountered in traditional open nephrectomy, such as bleeding, wound infection, and injury to adjacent organs. In rare occassions (<5%), the procedure is unable to be completed laparoscopically and a larger incision is made to remove the kidney.

With increasing experience performing laparoscopic nephrectomy for benign kidney disease, we have used this technique to remove kidneys (radical nephrectomy) for cases of suspected kidney cancer (renal cell carcinoma). The procedure is similar to that described above, with careful attention to removing the entire kidney and cancer with a wide margin of nearby fat as one would do in an open operation. The world-wide data show that the procedure is equally as effective as the open procedure in curing patients of the cancer while reducing discomfort and recovery time. More recently we have used laparoscopy to remove only the portion of the kidney containing the cancer (partial nephrectomy).

Nephroureterectomy (Removal of the Kidney and Ureter)

Other cancers of the urinary tract (transitional cell carcinoma) can also affect the kidney and the ureter (tube connecting the kidney and bladder). In these cases, the kidney and ureter are removed together (nephroureterectomy) at the same time because of a significant chance of cancer recurrence if only a portion of the urinary tract is removed. Historically, nephroureterectomy had to be done through either two separate incision (one flank/side and one abdominal) or a single long incision (Figure 4). We now are able to remove the kidney and ureter together using laparoscopy. The kidney and ureter are freed using the technique as described for nephrectomy, using 4 port sites. In some cases, a small incision is made so that a hand can be placed into the body to assist during the surgery, the so-called "hand-assisted" approach. The specimen is then removed whole through a small incision in the lower abdomen. This is done to allow accurate pathologic evaluation of the tissue, important for subsequent treatment decisions in transitional cell carcinoma. The distal end of the ureter, connected to the bladder, is then removed using cystoscopy. Similar to laparoscopic nephrectomy for renal cell carcinoma, laparoscopic nephroureterectomy for cancer has been shown to be highly effective while simultaneously reducing morbidity. Patients are typically hospitalized for 3 days and recover rapidly to normal activity. Disadvantages of performing laparoscopic nephroureterectomy include longer operative time and lack of long term follow up.

Figure 4.
Nephroureterectomy incision

Ablation of Kidney Lesions (Destruction of Kidney Lesions)

There has been increasing interest in treating kidney tumors without having to remove all, or even part, of the kidney. This is desirable for several reasons. First, many of the kidney tumors found today are detected incidentally and therefore are quite small. Excising all or part of the kidney may not be necessary in selected patients. In addition, some kidney tumors are associated with diseases (e.g. von Hippel Lindeau) where both kidneys can be affected with numerous tumors. Again, in these patients, we try to preserve as much normal kidney as possible. Finally, destruction or ablation of kidney tumors may be desirable in patients who cannot endure a longer, more complicated operation.

Ablation of cancerous tissue has been performed in urology for some time. The technique has been used to treat prostate cancers as well as benign prostatic growths and tumors in the liver. What is the best way to kill cancer cells? Several methods are effective, including freezing the tissue (cryoablation) and heating the tissue (radiofrequency ablation). We have applied our extensive experience with tissue ablation to treat kidney cancers in select situations. Laparoscopy is used to expose the kidney and the portion with the tumor. Under direct vision as well as ultrasound visualization, probes are placed into the tumor and the area of the tumor is ablated (Figure 5). Data suggest that cryoablation of kidney tumors is highly effective and well-tolerated by the patients. Preliminary information regarding radiofrequency ablation of renal tumors appears promising.

Adrenalectomy (Removal of the Adrenal Gland)

In collaboration with colleague Q.Y. Duh, MD in the Department of Surgery, we routinely perform laparoscopic adrenalectomy for a variety of adrenal diseases. These include pheochromocytoma, functioning adrenal adenoma, metastatic cancer to the adrenal, large adrenal adenoma, and adrenal cysts. Laparoscopic adenalectomy has rapidly become the gold standard in surgical excision of the adrenal gland.

Our preferred approach is through the abdomen, a lateral transabdominal technique, using 4 ports. Patients have significantly reduced pain and hospitalization when compared to open removal of the adrenal gland.

Robotic Radical Prostatectomy (Removal of the Prostate)

In many cases of prostate cancer, surgical removal of the entire prostate gland (radical prostatectomy) is the preferred treatment. Traditionally, prostatectomy has been accomplished by making an incision in the lower abdomen. Evolution in the surgical technique over the past twenty years has improved the ability to cure the cancer while reducing potential complications such as blood loss, incontinence, and erectile dysfunction. At UCSF we have extensive experience with radical prostatectomy and have achieved excellent results in all aspects.

Improvements in technology and surgeon experience have led to the development of minimally invasive (laparoscopic) operations, where the procedure is visualized with a small telescope and performed through several small incisions. Operations which are routinely performed in this manner at UCSF include removal of the adrenal and kidney. More recently, we have used this approach to perform radical prostatectomy. The operation has been greatly facilitated with the use of the state-of-the-art robotic system (daVinci Surgical System, Intuitive Surgical). It provides a magnified, three-dimensional view during the operation and maintains surgeon dexterity through its robotic arms. We are currently using the robotic system to perform radical prostatectomy, applying a technique similar to our open operation and thus drawing on our prior experience and achieving similar results. A comparison of the two procedures is summarized in the table below.

Physicians performing a procedure using the daVinci Surgical System.

Pyeloplasty (Repair of Ureteropelvic Junction Obstruction)

Blockage is often found in the urinary tract at the level of the kidney and ureter. These are termed ureteropelvic junction obstruction (UPJO). Most of these are congenital, due to altered development of the ureter, while others may develop due to a crossing blood vessel. The gold standard in the treatment of UPJO has been open surgery (pyeloplasty) with excision of the area of obstruction and reconstruction of the connection between the renal pelvis and ureter (Figure 6). This typically required a large incision in the side and several days of hospitalization. Recent attempts to correct UPJO through minimally invasive methods have been successful. Through a laparoscopic approach, we are now able to repair UPJO in exactly the same method as the traditional open pyeloplasty with shorter hospitalization (3 days) and reduced patient discomfort. Studies have indicated that results of laparoscopic pyeloplasty equal those of open surgery.

Donor Nephrectomy (Kidney Transplantation)

Availability of organs for transplantation continues to be a significant problem. While the use of kidneys from living donors for patients with end stage renal disease has increased, cadaveric kidneys constitute the majority of renal transplantations performed in this country. Several advantages are associated with live donor transplants: decreased waiting time; lower incidence of delayed graft function; improved patient and graft survival; and increased cost effectiveness. However, live donor nephrectomy is unique in that it places a healthy individual at risk from a major operation solely for the benefit of another person. Traditionally the kidney was removed through an incision in the side which was associated with a large incision, significant pain and substantial time to recuperation. Over the past year we have initiated a program of laparoscopic live donor nephrectomy in conjunction with Chris Freise, MD of the Department of Transplantation.

The kidney is freed using 4 ports and removed through an incision in the lower abdomen (Figure 7). The transplant surgeon is waiting and immediately prepares the kidney and places the kidney in the recipient. Results (graft survival) have been comparable to kidneys removed via traditional open surgery. In addition, patients are hospitalized approximately 3 days shorter and return to normal activity almost 3 weeks earlier.

Complex Reconstructive Operations

In recent years, we have applied our skills in laparoscopy to more complex operations. In some patients with extensive injury to the ureter, reconstruction is not possible. Traditional methods to manage these cases include permanent removal of the entire kidney (nephrectomy), removal of the kidney and placement in the pelvis near the bladder (autotransplantation), and use of a segment of bowel to create continuity between the kidney and bladder. Autotransplantation has the advantage of preserving kidney function but required two large incisions and prolonged time to recovery. We currently have one of the largest experiences in performing laparoscopic nephrectomy and subsequent autotransplantation. Patients have experienced more rapid recovery and excellent preservation of kidney function.

Other complex laparoscopic procedures in which we have experience include the use of a segment of intestine increase bladder capacity (augmentation cystoplasty) and excision of an abnormal out-pouching of the urinary tract (calyceal diverticulum).