Laparoscopic techniques, as the main part of minimally invasive surgical techniques, have had an extremely profound impact on the field of urology. Since the first application of laparoscopic nephrectomy by Clayman et al. in 1991, the application of laparoscopic techniques in urology has been expanding and the level of technology has improved rapidly. From upper urinary tract surgery to lower urinary tract surgery located deep in the pelvis, from simple organ destruction and resection to complex and delicate organ preservation and functional reconstruction surgery, all can be accomplished by laparoscopic techniques, and basically replace traditional open surgery, becoming the standard of modern minimally invasive urological surgery. This paper reviews the progress of laparoscopic techniques in functional reconstructive urological surgery.
I. Status of laparoscopic technology application.
1, standard laparoscopic surgery.
Standard laparoscopic surgery has become a standard treatment modality for many urological diseases, and its operation techniques have become very mature. In 1992, Gaur first applied a homemade balloon into the retroperitoneal space to inflate and open the space, thus forming an artificial “retroperitoneal cavity”, creating a retroperitoneal and pelvic extraperitoneal laparoscopic surgical approach. Since the main organs of the urinary tract and the adrenal glands are located outside the peritoneum, laparoscopic surgery via the external peritoneal approach is more in line with the anatomical features of urology, with the lumbar access to the retroperitoneal cavity, retroperitoneum and loose tissues around the kidney, without important vascular and neural tissues, direct access to the surgical area, easy identification of the renal artery, easy treatment of dorsal renal lesions, more direct access, less interference with the abdominal organs, and very little abdominal organ damage, intestinal paralysis and intestinal adhesions. Intestinal paralysis, intestinal adhesions, abdominal infection and other complications can help shorten the operation time, so it is widely used in kidney, adrenal and ureteral surgery.
2. Hand assisted laparoscopic surgery (HALS):
HALS is a cuff device that preserves the pneumoperitoneum on the basis of ordinary laparoscopic equipment, through which the operator can enter the abdominal cavity with one hand to cooperate with the surgery, which has certain advantages over standard laparoscopic surgery in terms of surgical safety and intraoperative exposure, but HALS also has the shortcomings of air leakage from the cuff device, greater damage, and slightly slower recovery. For complex urological procedures such as retroperitoneal lymph node dissection, partial nephrectomy, total ureterectomy and living donor kidney removal, especially for procedures requiring complete removal of the specimen, it is more suitable.
3. Endoscopic surgery via natural cavity and single-hole laparoscopic surgery.
With the development of minimally invasive surgery technology, scarless surgery of the abdominal wall (scarless surgery) has become a new hot spot for research. The basic approaches are natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). (gastric, colorectal or vaginal) incision and placement of a flexible endoscope into the abdominal cavity, resulting in a scar-free abdominal wall, less postoperative pain and a more minimally invasive, aesthetic result. However, because of the difficulty of operation via NOTES, abdominal infection and safety issues, it is still mainly limited to the animal experimental stage. In 2007, Rane et al. first reported transumbilical single-port laparoscopic ureterotomy for lithotripsy; in the same year, Raman et al. first reported transumbilical single-port laparoscopic nephrectomy. In 2008, Desai et al. firstly reported transumbilical single-port laparoscopic pyeloplasty, and LESS also began to be more widely used in urological reconstructive surgery.
4. Robot-assisted laparoscopic surgery.
In foreign countries, robot-assisted laparoscopic surgery has entered an explosive phase of development, involving almost all urological procedures, including radical prostate cancer, nephrectomy, partial nephrectomy, adrenalectomy, pyeloureteroplasty, radical total cystectomy, etc. The Da Vinci system is the first robotic system approved by the FDA for clinical use in the operating room, and It is the most mature and widely used robotic surgical system in the world. The system provides a high-definition, three-dimensional surgical field of view and utilizes a 720° freely movable internal wrist system to provide multiple degrees of freedom and flexibility beyond that of a human hand in a narrow surgical field, extending the surgeon’s ability to perform stable operations with improved surgical precision and safety, and with less bleeding and intraoperative blood transfusion and shorter hospital stays, making it a minimally invasive technique that surpasses ordinary laparoscopy. In the United States, robotic laparoscopic radical prostate cancer treatment has surpassed radical prostate cancer treatment by 60%. It is believed that robot-assisted laparoscopic surgery has great potential, and the Da Vinci system makes complex laparoscopic surgery simpler and more manageable, and may even change the future of surgical urology.
Second, the application of laparoscopic techniques in functional reconstructive urological surgery.
1, adrenal reconstruction surgery.
Laparoscopic partial adrenalectomy.
Since Gagner et al. performed laparoscopic adrenalectomy in 1992, laparoscopic adrenalectomy has become a common procedure for adrenal surgery. This surgical approach, especially in patients with bilateral adrenal lesions, often requires long-term drug replacement therapy after surgery. In contrast, laparoscopic partial adrenalectomy only removes the adrenal tumor and part of the adrenal gland around the tumor on the diseased side, which can preserve the normal function of the remaining adrenal tissue on the affected side and reduce intraoperative and postoperative complications. In recent years, many scholars advocate that even if the contralateral adrenal gland is normal, partial adrenalectomy on the affected side is recommended to prevent cortical insufficiency when the contralateral adrenalectomy is needed for other reasons in the future.
2. Reconstructive surgery of kidney and ureter.
(1) Laparoscopic nephrectomy with preservation of renal unit.
The main difficulty of laparoscopic renal tumor resection with preserved renal unit lies in the control of intraoperative renal bleeding and hemostasis of the trauma. Initially, in cases of exophytic renal tumors, laparoscopic resection could be performed without control of the renal hilum vasculature. Later, due to the application of a flexible ultrasound probe, which can outline the precise border of the tumor and temporarily block the hilum with a non-invasive vascular clip via laparoscopy, resection of tumors in the renal parenchyma became possible. In 2003, Gill et al. performed laparoscopic resection of 100 cases of single renal tumors up to 175 px in diameter. In 2003, Gill et al. performed laparoscopic nephrectomy with preservation of renal units in 100 cases of single renal tumor with diameter not more than 175 px. Compared with open nephrectomy, laparoscopic surgery was superior to open surgery in terms of operative time, blood loss, hospitalization time and recovery period, and there was a statistically significant difference between them.
(2), laparoscopic renal fixation.
Since Urban et al [13] first reported laparoscopic renal fixation via the abdominal route for the treatment of renal prolapse in 1993, the number of related reports has increased, and laparoscopic renal fixation requires adequate renal release and complete separation of the perirenal fat to enhance the degree of adhesion between the kidney and the surrounding tissues after surgery and to achieve the purpose of strengthening the kidney; the kidney can be fixed by suturing it to the lumbaris major fascia or by selecting mesh wrapping followed by suturing The kidney can be sutured to the lumbaris major fascia or sutured with mesh wrapping. The longest follow-up reported for laparoscopic minimally invasive treatment of renal prolapse was 9 years, with an average of 5.9 years. Laparoscopic renal fixation can achieve the same efficacy as open surgery, but the effect of laparoscopic surgery for renal prolapse still needs further follow-up.
(3) Laparoscopic pelvic and ureteroplasty.
The treatment of uretero pelvic junction obstruction (UPJO) includes various open pyeloplasty and intraluminal stenosis segment dissection and dilation and laparoscopic pyeloplasty. The success rate of open dissection pyeloplasty is over 90%, and it is regarded as the “gold standard” for the treatment of UPJO because of its wide indications and good long-term results. With the continuous improvement of laparoscopic equipment and the increasing maturity of operating techniques, scholars at home and abroad have performed various pyeloplasties using laparoscopy, and their success rates and long-term results are comparable to or even exceed those of open surgery, while the surgical trauma is significantly less than that of open surgery and the patients recover quickly. Patients were clinically pain-free or had significant symptom relief, identical to the open pyeloplasty group. At a mean radiological follow-up of 15 months, 98% of patients in the laparoscopic group had patency of the pelvic ureteral junction, with only one case of recurrent obstruction.
(4), Laparoscopic pelvic and ureteral lithotomy.
There are many modern methods for treating renal pelvis and ureteral stones, but open surgery for ureteral stones only accounts for 0.2% to 11.0% in developed countries. Retroperitoneal laparoscopic pelvic ureterotomy for stone retrieval is less traumatic, less bleeding, less painful, faster recovery, higher success rate, and has advantages in treating middle and upper pelvic ureteral stones. In recent years, it has been gradually promoted and the technology has developed faster, enriching the minimally invasive treatment methods for urinary stones. Laparoscopic pyelotomy for stone extraction is mainly suitable for large stones, cast stones or ectopic kidney stones, especially for those who have failed to be treated by extracorporeal shock wave lithotripsy. The operation consists of incision of the renal pelvis, removal of the stone, laparoscopic placement of a double “J” tube, and suturing of the pelvic incision if necessary. The postoperative stone free rate is comparable to that of incisional surgery.
3.Bladder and urethra reconstruction surgery.
(1) Laparoscopic radical prostatectomy followed by urethral bladder anastomosis.
Laparoscopic radical prostate cancer resection has been a difficult procedure to perform in the field of urology, and the anastomosis between the bladder neck and the urethra is its key step. laparoscopic radical prostate cancer resection was first reported by Schuessler et al. in 1997, but its main technical improvement was done by Guillonneau et al. and gradually formed a standardized procedure. they reported a group of 260 cases of transabdominal The procedure and goals of laparoscopic radical prostatectomy are basically the same as those of open radical prostatectomy, including pelvic lymph node dissection, prostate and seminal vesicle resection, and reconstruction of the bladder and urethra. Laparoscopy can magnify the visual object 12 times, providing the operator with an unprecedented field of vision, resulting in clearer visualization of anatomical structures, more delicate and accurate surgical procedures, significantly less intraoperative bleeding, as well as less additional injuries, more accurate protection of the neurovascular bundle, and preservation of the external urethral sphincter, thus reducing the incidence of postoperative urinary incontinence and impotence.
(2), Laparoscopic total cystectomy and urinary diversion.
Parra et al. were the first to report the first laparoscopic simple cystectomy in 1992. Later, radical cystectomy with laparoscopic assistance and removal of the bladder through a small incision in the lower abdominal wall or through an enlarged Trocar incision with urinary diversion has been increasingly reported. Laparoscopic removal of the bladder prostatic urethral sphincter has less chance of injury and also helps to preserve the neurovascular bundle. Laparoscopic surgery is also more protective of the body’s immune function than open surgery and may reduce postoperative infection complications. The magnification of the laparoscope results in a clearer operative field and more detailed observation.
In 2000, Gill et al. first reported 2 cases of bladder metastatic cell carcinoma in which radical cystoprostatectomy was performed laparoscopically with ileal conduit reconstruction done by an intraperitoneal non-handed suture technique. Subsequently, more reports of complete laparoscopic radical cystectomy and urinary diversion (including controlled urinary diversion) began to appear. Scholars believe that complete laparoscopic radical cystectomy and urinary diversion can further reduce surgical trauma, reveal the anatomy more satisfactorily, and facilitate the patient’s postoperative recovery; however, due to the difficulty of the procedure, the operator must be proficient in various laparoscopic techniques before performing it.
III. Summary.
Laparoscopic technique is an important part of modern urological surgery, and with the progress of various techniques, proficiency in surgical operation and accumulation of surgical experience, laparoscopic urological system reconstruction technique will be developed better and faster, and the application of laparoscopic technique in functional urological reconstruction surgery will certainly be further deepened and developed.