Laparoscopic techniques were first applied to urology by Cortessi in 1976 with the first laparoscopic exploration of bilateral cryptorchidism, but the development of urological laparoscopy remained stagnant for more than a decade because the organs of the urinary system and male internal genital organs were mostly located in the retroperitoneum and deep pelvis, making laparoscopic urological surgery more difficult. It was not until 1990, when Clayman performed the first laparoscopic nephrectomy via the abdominal route, that this technique developed significantly. More and more urologists are using laparoscopy to perform surgery. With the development and maturity of the technology, laparoscopy is now widely used in various urological organ resections and reconstructive surgeries, and it has become an inevitable trend in the development of urological surgery because of its advantages such as less trauma and faster postoperative recovery of patients. This paper presents a review of various urological laparoscopic surgeries, especially their indications.
I. Laparoscopic renal surgery
1, laparoscopic simple nephrectomy
With the maturation of technology and accumulation of experience, the scope of indications for laparoscopic simple nephrectomy has been expanding, and it is suitable for almost all benign renal lesions that require surgical resection, such as renal atrophy due to various reasons, hydronephrosis, tuberculous kidney, polycystic kidney or renal stone, renal dysplasia, chronic pyelonephritis, etc. Rasswelier et al [1] concluded that renal lesions with significant adhesions can also be resected laparoscopically, but the possibility of conversion to open must be considered in severe cases of perinephritis, and tuberculosis and infectious lesions can be performed retroperitoneally to avoid contamination of the peritoneal cavity. In addition, laparoscopic subperitoneal nephrectomy is also feasible for those with significant adhesions or a history of previous renal surgery, as reported in one case by Moore et al.
2.Laparoscopic radical nephrectomy
Laparoscopic radical nephrectomy is suitable for renal tumors that are confined to the renal peritoneum, without surrounding tissue invasion and vascular and lymphatic metastases, and several reports have shown that three of them were distant metastases and one was a recurrence of ureteral stump, and no local recurrence of tumor or tumor implantation in the abdominal wall puncture port was seen. There was no significant difference in the annual survival rate. Laparoscopy is a safe and effective method for early renal tumors (T1-T2N0M0). It is now generally considered particularly suitable for tumors ≤5 cm in diameter, but Gill et al [4] reported that laparoscopic surgery at tumor diameters up to 12 cm was equally satisfactory, which was related to the proficiency of the procedure. The resected kidney specimen can be removed in whole or after crushing. The complete removal facilitates the accurate pathological staging of the tumor, thus providing a basis for judging the prognosis and next treatment.
3.Laparoscopic partial nephrectomy
Laparoscopic partial nephrectomy is mainly suitable for benign lesions located at the first pole of the kidney, including benign tumors, loss of function at the first pole of the kidney due to malformation, stones, chronic inflammation; non-functional or isolated renal parenchymal occupancy on the opposite side; bilateral renal tumors; small renal carcinoma limited to the first pole of the kidney with a diameter of ≤3 cm. The pathology was confirmed as renal cancer in 34 cases. With a mean follow-up of 7.2 months, no recurrence or metastasis was seen in situ or at the puncture site.
4.Laparoscopic renal cyst debulking
Laparoscopic renal cyst debulking is relatively simple compared with other urological laparoscopic surgery, so it is now one of the most performed urological laparoscopic surgeries in China, and the surgical effect is comparable to that of open surgery, but with less trauma and complications, so it can basically replace open surgery.
5, laparoscopic living donor kidney excision
In 1994, Gill et al [6] studied laparoscopic living donor nephrectomy using pigs as a model, and one year later, Ratner et al [7] reported the first laparoscopic human living donor nephrectomy in the world, which marked a great progress in renal transplantation. The use of laparoscopy for living donor kidney retrieval has likewise shown its minimally invasive advantages and is more acceptable to the donor.
Fabrizio et al [8] compared data on laparoscopic kidney extraction with open surgery and concluded that the surgical results were similar, but the laparoscopic group had less blood loss, less pain, shorter hospital stay, and faster recovery. methods and found a hand-assisted laparoscopic technique with the shortest operative time and a significant reduction in thermal ischemia time, but no significant difference in serum creatinine levels in the three groups of transplanted kidneys at long-term follow-up. Surgical routes can also be classified as transabdominal or extraperitoneal routes.
6.Laparoscopic total renal ureterotomy and cuffed ureteral orifice cystectomy
The classic surgical approach for migratory cell carcinoma of the upper urinary tract is through lumbar and lower abdominal incisions, which is tedious and traumatic. Laparoscopic total ureterotomy and cuffed ureteral cystectomy is performed firstly in the lithotomy position and then in the cystoscopic cuffed ureteral cystectomy, followed by laparoscopic total ureterotomy in the healthy side position.
The indications are: metastatic cell carcinoma of the renal pelvis and upper ureter, and symptomatic ureteral reflux. Shalhav et al [10] reported that there was no difference in the effect of laparoscopic treatment compared with open surgery for early-stage metastatic cell carcinoma of the upper urinary tract, and there was no significant difference in tumor recurrence, metastasis and survival rate between the two.
7.Laparoscopic pyeloplasty
Open dissection pyeloplasty is the standard procedure for the treatment of pelvic ureteral junction stenosis, but it is a very traumatic procedure; percutaneous paralleling or retrograde transureteral pelvic ureteral junction stenosis incision or expansion is an alternative minimally invasive treatment, but the success rate is low, postoperative bleeding may be large, and external pressure factors cannot be solved, so it is not widely carried out, while laparoscopic pyeloplasty combines the advantages of both, so it is expected to Janetschek et al [25] reported 65 cases of laparoscopic pyel ureteroplasty with an average operative time of 123 minutes and no surgical complications, with a success rate of 98% and one case of failure due to infected edema; Pardalidis et al [26] reported 22 cases of laparoscopic pyel ureteroplasty with an average operative time of 3.5 hours and an average blood loss of 150 ml. hours, with an average blood loss of 150 ml and a success rate of 100%.
8. Laparoscopic renal tubular lymphadenectomy
In the process of separating the renal vessels, it is necessary to widely separate the retroperitoneal tissues and repeatedly pull the kidney, which affects the blood supply to the kidney and causes great damage, and it is easy to miss small lymphatic vessels due to visual reasons. Hemal et al. performed posterior laparoscopic renal lymphatic vessel ligation in two patients with recurrent celiac disease, and the surgical results were good at 18-30 months of follow-up. We have used posterior laparoscopy to perform ligation of renal tubular lymphatics in more than 20 cases, and our experience is that, in addition to minimally invasive, less bleeding and faster recovery, the application of posterior laparoscopic technique for celiac disease has the characteristics of clearer observation and treatment of fine lymphatics around renal vessels and upper ureter due to the magnification of laparoscopy, which is more delicate and comprehensive than traditional open surgical ligation, with good recent results.
Second, laparoscopic adrenalectomy
Laparoscopic adrenalectomy was first reported by Ganner in 1992. Initially, its operation time was longer than that of open surgery, but as the operation was carried out, the technique gradually matured, and the time of laparoscopic adrenalectomy could be significantly shorter than that of open surgery, with the advantages of less bleeding, less tissue damage, less postoperative pain, shorter hospital stay and fewer complications, which is regarded as the gold standard of adrenal surgery. However, it is still controversial whether laparoscopic resection is suitable for adrenal malignant tumors and large adrenal tumors (>6 cm in diameter).
Laparoscopic ureterotomy for stone extraction
For ureteral stones, unlike adrenal, laparoscopy is not the first choice, because there are less damaging treatment options for stones, such as ESWL, PCNL or ureteroscopy. Its main indications are.
① Ureteral stones that have failed ESWL or ureteroscopy or percutaneous nephrolithoscopy;
(2) Those who are not suitable for ESWL or ureteroscopy, such as large, hard stones, or those with inflammatory polyps wrapped around them for too long;
③Ureteral stones with pelvic ureteral lesions requiring simultaneous surgical treatment.
Laparoscopic lymph node dissection and lymph node biopsy
The surgical indications for laparoscopic retroperitoneal lymph node dissection are the same as those for open surgery, but because the surgical site is near the midline of the retroperitoneum, there are some difficulties in revealing it, and there are large blood vessels in the surgical field, so the surgical technique is more demanding, but there are many reports in the literature. 34 cases were reported by Rassweiler [14] and 125 cases were reported by Janetschek [15], both of which concluded that laparoscopic retroperitoneal lymph node dissection is less invasive and has a lower complication rate with similar efficacy compared to open surgery.
The indications for laparoscopic prostate cancer pelvic lymph node dissection are mainly for prostate cancer with high risk of lymph node metastasis, such as patients with serum PSA > 40 μg/L, Gleason score ≥ 8, clinical stage B2, C or D0, or patients with CT scan finding enlarged pelvic lymph nodes and negative CT-guided puncture biopsy for radical retropubic prostate cancer. The surgical route can also be divided into a transabdominal or a transperitoneal route, both of which have similar operative time, number of detected lymph nodes and hospital stay, but the latter has significantly fewer complications of intestinal obstruction than the former.
In addition, laparoscopic technique can be applied to perform pelvic lymph node biopsy to facilitate prostate cancer staging.
V. Laparoscopic radical prostate cancer surgery
Radical prostatectomy includes the whole prostate, bilateral seminal vesicles and lymph nodes around the iliac vessels, which is more traumatic in open surgery. They concluded that laparoscopic radical prostatectomy can be performed laparoscopically, but it has no significant advantage over open surgery, and with the maturation of technology and improvement of equipment, the operating time of laparoscopic radical prostatectomy is significantly shorter than before, and the advantages of this procedure have been widely recognized. 2 cases (0.3%) had deep vein thrombosis, and they concluded that laparoscopic radical prostatectomy is significantly superior to traditional open surgery. They concluded that laparoscopic radical prostate cancer surgery is significantly superior to traditional open surgery, and that laparoscopic surgery is preferred for patients with prostate cancer who have indications for surgery.
Laparoscopic radical cystectomy
Laparoscopic radical cystectomy is suitable for bladder tumors that have not yet broken through the muscular layer. In 2001, Turk et al [19] first reported 5 cases of laparoscopic radical cystectomy with controlled urinary diversion, with an average operative time of 7.4 h, average blood loss of 245 ml, and no transfusion, and no intraoperative or postoperative complications. In 2002, Turk et al [20] reported 11 more cases with an average operative time of 6.7 h. Carvalhal et al [21] reported 11 cases with an average operative time of 7.3 h.
VII. Laparoscopic cryptorchidism surgery
Seventy percent of cryptorchidism cannot be palpated clinically and cannot be detected by ultrasound and other imaging examinations, so surgical exploration is needed. For intra-abdominal cryptorchidism, laparoscopic surgery can locate it on the one hand, and at the same time, surgical treatment is feasible. A large number of reports on laparoscopic exploration and descending fixation of cryptorchidism showed that the success rate of surgery was high, no testicular atrophy was observed after surgery, and the majority of testes were fixed in a satisfactory position in the scrotum. Lindgren et al [27] reported that laparoscopic treatment of 36 cases with 44 cryptorchidism resulted in no testicular atrophy at 6-month follow-up, 93% were in the ideal position in the scrotum, and 7% were localized in a high scrotal position. In addition, laparoscopy is also used for resection of intra-abdominal malignant cryptorchidism and gonadal biopsy, gender identification, etc.
VIII. Laparoscopic varicocele surgery
It is suitable for patients with severe bilateral or postoperative recurrence of primary varicocele. For patients with unilateral varicocele, this technique has no significant advantage compared with traditional surgery.
In addition to the above mentioned laparoscopic procedures, there are other procedures such as laparoscopic renal biopsy, renal prolapse fixation, bladder neck suspension for female stress urinary incontinence, and biopsy of retroperitoneal masses, etc., which cannot be described in detail due to space limitation. Laparoscopic surgery in urology has been carried out for just over 10 years and has been used in most urological procedures. Although the indications for some of the procedures are still controversial, it is believed that their scope of application will be further expanded as the technology matures, experience is accumulated and equipment is improved.
There is no doubt that laparoscopic technology represents the development direction of urological surgery.