Every upcoming surgeon practising minimal access surgery should know the basics of urology , so that he or she can put his or her,s capabilities as a surgeon

1. Dr. Sreejoy Patnaik
Shanti Omni Super Speciality
Hospital
Cuttack
LAPAROSCOPY IN UROLOGY

2. LAP- ENDO

3. History of Lap. Urology
• The first laparoscopic Nephrectomy was performed in 1990 by
Clayman
• The procedure had an operative time of seven hours and
required a 1-unit transfusion and a six-day inpatient hospital
stay.

4. Challenges of Uro –lap. surgery
•Technically, more demanding
•Specialized team
•Slightly more expensive, use of consumables
•Advantages outweigh the challenges

5. Laparoscopic Surgery
•Key hole surgery
•Latest development of Urology
•Obvious advantages over conventional open surgery
•Smaller wound
•Less pain
•Quicker recovery, discharge, early return to work

6. Laparoscopic Urological Surgery
•Revolutionary development in last 2 decades.
•Experienced centres
•Improves Patient’s peri-operative quality of life
•Provides excellent view due to magnification – less tissue
trauma & minimal blood loss.

7. Approaches
The 3 three commonly used approaches are
1. Transperitoneal approach
2. Retroperitoneal approach
3. Hand assisted approach
4. Endoscopic Procedures

8. Transperitoneal approach
•Wider availability
•Working space
•Better identification of important landmarks
•Intestinal Injury ?
Retroperitoneal approach
•Restricted rapid access
•Renal pedicle identification.
•Reduce the incidence of ileus
•Injury to the intraperitoneal contents
Hand assisted approach
•Improved tactile feedback
•Bridge between open surgery
•Lap Gelport TM
•Lap Disc TM

9. ENDOSCOPIC APPROACHES
• CYSTOSCOPY- TURP/BNI/TURBT/OIU
• URETEROSCOPY-
• RIGID URETETROSCOPY URS
• FLEXIBLE URETEROSCOPY- RIRS
• PCNL- BY RIGID NEPHROSCPE
• MINI PERC - RENAL STONES

10. Laparoscopic Urological Procedures
Commonest procedures performed :-
Ablative Procedures: Urolithiases:
a) Simple nephrectomy Pyelolithotomy
b) Partial nephrectomy Ureterolithomy
c) Renal cyst marsupilisation Cystolithotomy
d) Radical nephrectomy Urachal Cyst excision
e) Radical cystectomy
f) Radical prostatectomy
Reconstructive Procedures:
a) Pyeloplasty
b) Lower ureteric reconstructions
c) Boari flap reconstruction
d) Ureteric reimplanation/Psoas hitch
e) Ileal ureter implantation
f) Orchipexy
g) Donor nephrectomy

11. Simple Nephrectomy
•Non functioning Kidney
•Pre renal transplant nephrectomy
(A) – Transperitoneal approach
Pneumoperitoneum - open technique or closed technique.
Ports are inserted in a strategic manner.
Preoperative CT Scan)” if done helps in determining the location of the kidney
and deciding the location of port placement.
Other parameters which determine the site of port placement are extent of
truncal obesity and body mass index (BMI).

12. Positioning
• Lateral decubitus position
• Near the edge of the table
• Lower limb is flexed
Technique
• Left side colon is reflected
• Iliac bifurcation
• Superiorly the splenorenal
• Renocolic ligaments
• Identify the ureter
• Gonadal vessels
• Ureter is lifted
• Psoas landmark

13. (B) – Retroperitoneal approach
Gaur etal
15mm incision petit triangle
Lumbodorsal fascia
Balloon dilator
(C) – Hand assist approach
Insert a non dominant
Hand assist device is inserted
Right lower quadrant midway between umbilicus and anterior
superior iliac

14. Laparoscopic Radical Nephrectomy
•T2 & T3a tumors.
•T1 tumors contraindicated with IVC thrombus
Technique
•Transperitoneal
•Lumbar & adrenal veins are doubly clipped & cut.
Results
•Advantage short hospital
•Low analgesia
•Comparable
•Open laparoscopic approach is a standard of care in T1 & T2.
• Renal thrombus is feasible

15. Laparoscopic partial nephrectomy
•Small renal masses
• Lesions in a solitary kidney
•Bilateral renal lesions
Technique
- Pneumoperitoneum
- Ports similar to simple nephrectomy
- Ureteric catheter placed per-urethrally - to instill methylene blue
- Identify the pelvicalyceal system prior to suturing
- Colon reflected and the ureter is lifted off the psoas muscle
- Dissection proceeds to the renal hilum
- Renal hilum dissected & satinsky applied
- Renal tumor is cut with cautery or harmonic
- Preferred scissors for excising the tumor should be with wide jaws.
- Pelvicalyceal system is closed followed by the cortical defect
- An indwelling ureteric catheter or alternatively a double J stent is placed for 48hours.

16. Pyeloplasty
•PUJ Obstruction
•RGP prior to positioning the patient
•5Fr pigtail catheter is inserted into the pelvicalyceal system
Technique
•30 degree Scope - pelvis is identified bulges out
•Dismembered Anderson hynes Pyeloplasty is preferred crossing vessel is
suspected
•Y-V plasty is preferred
The important steps of this procedure are
•Pyelotomy
•Spatulation of the ureter
•Pyelotomy is closed a 3-0/4-0 vicryl
•‘V’ stitch as anterior layer easier step to start , followed by posterior layer.

17. Donor Nephrectomy
Do no harm to the donor is the dictum
Technique
•Port placement mirrors that of simple nephrectomy
•CT angiography plays a pivotal role for strategic port placement.
•Ureter should be lifted of the psoas “in toto” as an ureterogonadal
packet.
•Dissection of the artery should be a thermal and should be kept to
the minimum.
•Topical papvarine instillation on the vessel helps in relieving spasm
•Upper pole should be separated from the spleen securing the adrenal
vein
•Graft should be adequately perfused by intravenous infusion of
mannitiol and furosemide prior to retrieval
•Retrive the graft through a pfannesteil incision

18. Laparoscopic ureteral reimplanation
Supine position a 11mm trocar for camera insertion umbilicus
Ureter is lifted transected as distally as possible
The bladder is filled with 200ml saline
Lateral and anterior peritoneum incised a boari flap is preferred
Spatulated ureter and the bladder flap are anastomosed in a tension free
manner with 4-0 polygalactin sutures
A stent is kept indwelling for 6weeks after the surgery
Laparoscopic stone removal
Procedure performed transperitoneal or a retroperitoneal approach
Placement of a stent ureteric catheter
Ureter lifted of the psoas
The ureter is slinged
Using a cold knife the ureter is incised
Spoon may be used for retrieving the stone
Stone may be entrapped in a bag for removal
Ureterotomy is closed with a 3-0 absorbable suture and a drain is placed.

19. Advanced Laparoscopic Procedures
•Laparoscopic ileal interposition
•Laparoscopic retroperitoneal lymph node dissections
•Laparoscopic radical cystectomy (LRC)
Laproendoscopic single site surgery
(LESS)
•Simple nephrectomy
•Pyeloplasty
•Reconstructive procedures
•Ureteroneocystostomy
•LESS donor nephrectomy
•Technically feasible procedure
•Steep learning curve

20. Robot Assisted Laparoscopic Urology
•Prostatectomy ,Pyeloplasty, Nephrectomy & Ureter reconstructions
•Donor nephrectomy
•Adrenalectomy
•Advantages:
•Robotic platform Da Vinci Si
•High definition visual magnification
•Better range of motion
•Additional arm for retraction
•A unprecedented range of accuracy and dexterity
•Its increased range of freedom
•Property of “motion scaling”
•Procedures requiring intracorporeal suturing
•Small spaces pelvis
•The cost benefit ratio is likely to be a driving force in further development and
application of this technology

21. Laparoscopic Nephrectomy
•Benign, non functioning kidney
•Renal cell carcinoma
Almost all tumours can be
removed laparoscopically

22. Laparoscopic Nephrectomy

23. LAP - URETEROLITOTOMY

24. LAP. PYELOLITHOTOMY
• VIDEO

25. LAP PARTIAL NEPHRECTOMY
• VIDEO

26. LAP RADICAL NEPHRO-
URETECTOMY
• VIDEO

27. LAP URACHAL CYSTECTOMY
• VIDEO

28. Laparoscopic Prostatectomy
5 small incisions
•Completely mimick all the principles
of open surgery
•Extraperitoneal approach, avoiding
contact with intestine

29. Laparoscopic Prostatectomy
•4-5 hours surgery
•Less blood loss, minimal blood transfusion
requirement
•Magnification allowing more accurate
dissection and preservation of continence and
erection
•Hospital stay of 2nights, early removal of
urinary catheter.

30. Laparoscopic radical prostatectomy
• Inverted fan shaped manner
• Endopelvic fascia incised
• Dorsal vein secured
• Vas deferens &
• Dissected secured hem-o-lok
• The lateral detrussor pillars are secured with
clips
• The urethra is dissected be to gain maximum length
• Posterior reconstruction stich “Rocco”
• The van velthowen technique (bidirectinal running suture) technique
with 3-0 monocryl
• Satisfactory oncologic outcome

31. Radical Prostatectomy

32. ROBOTIC PROSTATECTOMY

33. Laparoscopic Prostatectomy v/s
Robotic prostatectomy
•Assistance from robot in suturing
•3d view
•High capital and recurring cost

34. What is new in laparoscopy in urology?
• Almost all urological procedures can be done laparoscopically
• Reproducible, similar if not better results than open surgery
• What is the standard of care?

35. Laparoscopic urological surgeries
Procedure Standard of Care Current Opinion
Laparoscopic Radical
Nephrectomy
Yes Proven long term results for
tumour upto 7cm
Laparoscopic radical
nephroureterectomy
Yes Replaces open
Laparoscopic
marsupilazation of kidney
cyst
Yes Replaces open
Laparoscopic adrenalectomy Yes Replaces open
Laparoscopic pyeloplasty Not yet Very promising, awaiting
long term results

36. Laparoscopic urological surgeries
Procedure Standard of care Current opinion
Laparoscopic radical
prostatectomy
No Divided (laparoscopic, robotic
assisted laparoscopic, open)
Laparoscopic varicocelectomy No Divided (open microscope)
Laparoscopic extra peritoneal
herniorraphy
No Promising, awaiting long term
results
Laparoscopic ureterolithotomy No Advantage over open, but other
options available
Laparoscopic partial nephrectomy No At best, similar to open
Laparoscopic radical cystectomy No At best, similar to open
Laparoscopic retroperitoneal lymp
node dissection
No Promising, Development stage
Laparoscopic reimplatation of
ureter
No Early development stage
Laparoscopic augmentation cysto
plasty
No Early development stage

37. Summary
•Surgery is moving towards minimally invasive surgery.
•Urology - ESWL, Endoscopy, Percutaneous & Laparoscopy.
•More than one or a combination of MIS modalities may be used.
•Endoscopic and Per cutaneous procedures almost treat all the
urolithiases, prostatic and bladder diseases.
•Robotic Surgery is the future for dealing with Prostate and
Bladder.

38. THANK U FOR YOUR PATIENT HEARING