| Laparoscopic Urology
Please click on the following questions for further information 1. What is urology? |
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Kidney b. Adrenal c. Bladder d. Testis e. Prostate f. Varicocoele |
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Mr PD Rimington M.B.Ch.B., M.Med., F.C.S. (S.A. Urol)
Consultant Urologic Surgeon,
21 Lushington Road, Eastbourne BN21 4LG, UK.
Tel: +44 (0)1323 410441
District General Hospital, Kings Drive, Eastbourne BN21 2UD, UK.
NHS Direct Line +44 (0)1323 413700
What is urology?
Urology is the study of diseases of the urinary tract and the genital organs
of the male. It includes the medical and surgical care of patients of all ages
and both sexes.
What is
laparoscopy?
Laparoscopy is the ability to use an instrument called a laparoscope, a
sophisticated rod lens often connected to a camera system, to inspect the
inner areas of the body cavities. Using recent innovations, surgeons are able
to create working spaces where there are no natural ones.
What is laparoscopic
surgery?
Laparoscopic surgery describes a technique of surgery which has been and
continues to be developed, using a laparoscope for vision and small
instruments inserted into the body using “ports” to perform the operation.
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| Modern trocars no longer use sharp blades to penetrate the skin and muscle, but a dilating tip, as shown here |
What are the
advantages of laparoscopic surgery?
Advantages of laparoscopic surgery are both general and specific to each
individual operation. Here are the general advantages and individual
advantages will be described for each operation separately.
Better cosmetics
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| Laparoscopic scars, 10 days after surgery |
Conventional nephrectomy,
7 days after surgery |
Quicker recovery
Less blood loss
Faster return to full function
Less analgesic use
Are there any dangers?
Like any surgical technique, it takes time, training and experience to become
fully competent in laparoscopic surgery. In the early 90s there was an
over-enthusiastic embracement of certain laparoscopic surgical procedures and
as a result of inadequate training there were less than satisfactory results.
However the situation in urology has been carefully controlled and every
effort has been made to ensure the surgery has been safe and efficient from
the start.
Any laparoscopic procedure is a highly technical undertaking and no-one can
guarantee that conversion to the older style open operation will not be
necessary.
There is no reason why a patient cannot enquire about the surgeon’s experience
in laparoscopy before embarking on surgery. There is evidence to show that
surgeons who have done more cases have fewer conversions to open surgery and
complete the surgery more swiftly.
Which operations can
be done laparoscopically?
Kidney
The operation for removal of a kidney is called a Nephrectomy. This can be
Simple, to remove normal tissue that is no longer working properly, or Radical
to remove a tumour.
The operation can be done from the front, called a transperitoneal approach,
or from under the last rib on the affected side and this is called a
retroperitoneal approach.
Occasionally, the kidney needs to be removed along with the entire tube from
the kidney all the way to the bladder (called a nephro-ureterectomy) and this
operation often involves a small incision on the lower abdomen.
The recovery from a laparoscopic nephrectomy is remarkably swift with many
patients back to full activities within 3 weeks. They also suffer a lot less
from the smaller scars than the conventional surgical scar.
For a full patient information leaflet on this operation, please click here.
The adrenal gland is a small organ situated
just above the kidney on either side and it’s function is to provide various
hormones needed for the equilibrium of the body. Commonly it is removed due to
overproduction of these hormones or for tumours.
Many surgeons agree that removal of the adrenal gland (adrenalectomy) is THE
operation that demonstrates the advantages of laparoscopic surgery. Lying
above the kidney, it is high up in the abdomen and difficult to access by open
surgery, thus requiring a large incision. The laparoscopic operation can be
done from the retroperitoneal approach often using only 3 small ports for
access.
World wide, the laparoscopic approach to adrenalectomy is the offered as the
best standard of care.
Testis
The vast majority of baby boys are born with the testis already in the
scrotum. Interestingly, the testis is formed inside the abdomen at the same
height as the kidney. It migrates down to the scrotum of the foetus before
birth. Occasionally the testis stop descending along the usual path and it is
called “undescended.” Rarely the testis may migrate to an unusual place and is
called “ectopic.”
Between 1 and 2 years of age, the testis needs to be in the scrotum for normal
sperm production. If the testis can be felt in the canal from the abdomen to
the scrotum (called the “inguinal” canal) it is a minor procedure to bring it
into the scrotum.
However of the testis is in the abdomen, it is at risk of developing cancer
and must either be removed or brought into the scrotum. As ultrasound and
computer scans were unreliable to show the location of the testis, this was
done by making an incision on the abdomen called a laparotomy.
Laparoscopy reduces the size of the incisions and thus minimises discomfort
and scarring, speeding recovery. It offers the choice of removal or
repositioning where that is possible.
Varicocoele
The safest treatment for a varicose vein of the testis is embolisation done by
an experienced radiologist. However, this procedure can prove very difficult
if not impossible and it may fail from time to time. In this instance
laparoscopy provides an ideal alternative form of therapy with excellent
success rates and minimal side effects.
There are currently 2 types of “robot” in
common use in surgical procedures.
One type simply holds the lens and camera for laparoscopic procedures which
frees the assistant to help with the procedure. This type of “robot” does not
facilitate in the actual surgery itself.
The “da Vinci” operating robot made by Intuitive has enjoyed a rapid rise in
popularity as it facilitates the performance of the surgical procedure.
Laparoscopy, while providing a magnified and crystal clear picture of the
operating field, suffers in that the picture is only in 2 Dimensions and lacks
depth perception. The da Vinci system compensates for that by using a computer
system to provide 3 Dimensional vision. It also allows the use of instruments
which have a “wristed” tip providing easier access to awkward areas of the
body and making some aspects of surgery easier, especially in the earlier
stages of learning laparoscopy.
da vinci surgical robot during training
Early data shows some advantages to the use
of the da Vinci system
Mr Rimington is currently involved with Mr P Dasgupta and Mr S Khan in
developing the technique of robotic cystectomy at Guy’s and St Thomas Hospital
in London.