Minimally invasive surgery in urology represents the replacement of traditional open surgery by endoscopic surgery: either ureteroscopic, percutaneous, or laparoscopic surgery. The major advantage of endoscopic surgery is that by using small or no incisions to treat a urologic disorder, the convalescence period from surgery is reduced and the patient is able to resume regular activities sooner than if open surgery was performed. Examples of procedures that are performed in the Division of Urology that would be classified as minimally invasive are: percutaneous kidney surgery, laparoscopic nephrectomy, laparoscopic cryoablation of the kidney, laparoscopic partial nephrectomy, laparoscopic radical prostatectomy, laparoscopic pelvic lymph node dissection, laparoscopic pyeloplasty, laparoscopic pelvic lymph node dissection,and Acucize balloon incision for uretero-pelvic junction obstruction, etc.
Percutaneous Renal Surgery
Percutaneous renal surgery involves the development of a track (usually 1 cm in width) from the skin directly into the kidney. The endourologist then looks directly into the kidney through this track and is able to treat certain kidney disorders. The most common indication for percutaneous surgery is to remove large kidney stones (> 2.5 cm), which cannot be effectively treated with extracorporeal shockwave lithotripsy (SWL) or in patients in whom SWL has failed. Any form of anatomical obstruction of the kidney associated with a kidney stone is also best treated primarily with percutaneous surgery. In such cases, such as uretero-pelvic junction (UPJ) obstruction and calyceal diverticuli, percutaneous surgery can not only remove the stone completely from the kidney but also simultaneously treat the underlying anatomical abnormality that has resulted in the formation of the stone itself. Treating the stones with SWL in kidneys with anatomical abnormalities is inappropriate because if the stones do fragment with SWL, they will continue to reside in the kidney because of its abnormal drainage.
The advantages of percutaneous surgery are its minimally invasive characteristic compared to open surgery and its more definitive outcome compared to SWL. Patients typically remain in the hospital for a day or two after percutaneous surgery and are able to return to their regular activities in a week or two instead of the one to two months recuperative period required for open surgery. Indeed, the role of open surgery for many renal obstructive disorders is currently extremely limited.
Laparoscopic Urologic Surgery
Over the last decade, major strides have been made in the application of laparoscopic surgery to the treatment of urologic disorders. Almost all traditional open urologic surgery has been performed using the laparoscope. Despite this accomplishment, the use of laparoscopy continues to be defined in urology as several controversial issues remain. Without question, laparoscopic surgery is less morbid than open surgery and patients return to their regular activities much sooner than if open surgery was performed. The common application of laparoscopy in urology today is for pelvic lymph node dissection for the staging of prostate cancer, nephrectomy for benign and certain malignant diseases of the kidney, and living related nephrectomy for renal transplantation.
Laparoscopic pelvic lymph node dissection is performed for the staging of prostate cancer if it impacts on the choice of subsequent therapy. Based on whether prostate cancer has spread to the pelvic lymph nodes, the patient and his urologist may choose surgery, radiation, or hormonal therapy. Laparoscopic radical prostatectomy has not been universally accepted because alternative procedures such as open radical perineal prostatectomy may be less morbid and less costly than laparoscopy radical prostatectomy.
Laparoscopic kidney removal is becoming more widely accepted in the urological community. In situations where subsequent knowledge of precise kidney pathology is not a relevant clinical issue, laparoscopic kidney removal can be done with incisions that are only about one cm in size. In patients who have kidney cancer, the surgeon may chose to perform a hand-assisted laparoscopic (HALS) nephrectomy. The major advantage of HALS is that the entire kidney cancer is removed as in open surgery so that a precise pathological examination of the kidney can be performed for prognostic purposes. The morbidity of HALS is similar to that of a completely laparoscopic procedure, and much superior to that of traditional open renal surgery. With a completely laparoscopic nephrectomy for kidney cancer, there is a small risk of tumor spillage because the kidney has to be morcellated and removed in pieces through the small incisions. For living related kidney donor nephrectomy, HALS provides an organ for transplantation similar to that with open surgery with less morbidity to the donor.
In choosing between the various options for renal surgery, it is important to remember that percutaneous surgery (if appropriate) has the least morbidity, followed by laparoscopic surgery, followed by open surgery. Ultimately, the choice of procedure for a particular kidney disorder is made by the patient and his/her urologist after thorough discussion of the pros and cons of the various surgical options.
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