BBI Contributing Writer
ANAHEIM, California – Urologists were the first surgical specialty to adopt endoscopes. They started with light bulb illuminated cystoscopes in the 1800s and eventually invented ureteroscopy and intracorporeal stone management. Today, they are adopting the laparoscope for a wide variety of procedures. This year's American Urological Association (AUA; Baltimore, Maryland) annual meeting, held at the Anaheim Convention Center in June, featured numerous reports of laparoscopic approaches for pyeloplasty, repair of ureteropelvic junction obstruction, live donor kidney transplants and radical nephrectomy. Some of these surgical procedures are also being done using very sophisticated robots.
Radical prostatectomy has long been the best choice for patients with invasive cancer of the prostate. In the last few years, techniques have been fine tuned to spare the nerves necessary for continence and potency. "Since radical prostatectomy is such a large part of the urological practice, many urologists have elected to rediscover laparoscopy and to learn the techniques for prostatic surgery," Ralph Clayman, MD, of the Washington University School of Medicine (St. Louis, Missouri), said. "The interest in laparoscopic prostatectomy opens a door for these doctors and provides an opportunity for all urologists to explore the other possibilities that exist in laparoscopy," he said. "Specifically, with regard to the kidney, there is now broad consensus that laparoscopy is the better tool at hand for both simple and total/radical nephrectomy as well as for adrenalectomy. Pioneering work by Gill has also brought cystectomy into the laparoscopic realm."
In the rapidly evolving field of urological laparoscopic surgery, gaining expertise requires the incorporation of different modes of application as well as the wisdom to discern which confers the greatest benefit to the patient. Courses of this nature have been specifically designed to fill this need.
Laparoscopic radical prostatectomy
Prostate cancer affects nearly 200,000 men annually and is the second leading cause of death in men over the age of 55. For men who have been newly diagnosed with operable prostate cancer, there is now a new option – the laparoscopic radical prostatectomy. First, however, the urologic surgeon must be ready to speak to patients about rates of incontinence, impotence and cure of disease associated with this new technique – compared to the standard open surgical approach.
"If we do demonstrate that the incontinence, impotence and cure of disease rates are the same or lower with laparoscopic prostatectomy – and that's what patients worry about – they are going to flock to laparoscopic surgery," said Jack McAninch, MD, of the University of California (Berkeley, California), moderator of the panel that compared benefits of laparoscopic and open prostatectomies.
McAninch acknowledged that data on outcomes after laparoscopic prostatectomy are still scarce, and it is too new for a fix on five-year PSA failure rates. He assumes, however, that laparoscopic prostatectomy will enter into the mix of patient/surgeon choices.
Guy Vallancien, MD (Paris), and co-authors from five other European centers reported their 1,228 case experience with laparoscopic radical prostatectomy. Operative time was 108 to 750 minutes and blood loss was 50 cc to 3,500 cc. Only 2% of the procedures were converted to open surgery. Twenty-three patients need reoperations. There were thromboembolic complications in only two patients and no deaths. Histological examination revealed positive surgical margins in 17.8% of the cases presented.
Nerve sparing radical prostatectomy is also possible via the laparoscopic approach, according to Claude Abbou, MD, of Institut Mutalaiste Monstsouris. These authors presented a film demonstrating their technique. Abbou notes that laparoscopy offers improved visualization of the operative field over conventional retropubic or perineal approaches and may improve the quality of life for patients undergoing radical prostatectomy. In their experience with 150 patients, complete urinary control was achieved in 50% of the patients at one month. Potency rates at one month for unilateral and bilateral neurovascular bundle preservation were 27.5% and 54.3%, respectively. They believe improved visualization offered by the laparoscopes aids in identification of structures vital for preserving potency.
McAninch noted that until more cases are followed for surgical margins for cancer cure, it will not be known if adequate margins can be obtained for laparoscopic radical prostatectomy. Also, only longer follow-up will show whether rates of incontinence and impotence are better or similar to open approaches.
"Training for laparoscopic prostatectomy is a practical consideration that needs to be addressed," McAninch said, "especially given the very steep learning curve. Although Dr. Vallancien routinely completes the procedure in under three hours, those surgeons new to laparoscopic prostatectomy are taking as long as 12 hours," McAninch said.
"If patient desire drives the demand for laparoscopic prostatectomy – which I think is likely – how are we going to train residents, not to mention surgeons in their 40s and 50s who have only minimal experience with the laparoscope?" And, he added, "Who's going to pay for 12 hours of operating room time?"
Minimally invasive surgery should be considered a first-line treatment for patients with blockages occurring at the junction of the kidney and ureter, according to work done by David Chanl, MD, and others from Johns Hopkins School of Medicine (Baltimore, Maryland). Laparoscopic pyeloplasty is used to treat ureteropelvic junction obstructions – that condition where the ureter is blocked as it joins with the kidney.
The authors studied records of 100 laparoscopic pyeloplasty cases in 99 patients. "Results of the laparoscopic pyeloplasty are similar to those of traditional open abdominal surgery, but LP patients have reduced hospital stays and a more rapid recovery," Chanl said. The average operating room time was 4.2 hours but decreased with surgeon experience. Average blood loss was 181 cc and hospital stay 3.3 days. Of the patients who underwent concomitant pyelolithotomy, 90% were stone-free at last follow-up. There were 11 complications in this series.
Laparoscopic nephrectomy for cancer
Clayman and others compiled a long-term follow-up after laparoscopic radical nephrectomy for cancerous kidney. Reviewing 64 patients from January 1996 to now, open to laparoscopic approaches, they looked at the oncologic effectiveness of laparoscopic radical nephrectomy (LRN) and open radical nephrectomy (ORN). The five-year recurrence-free survival rate was of 92% for LRN and 91% for ORN. They concluded that LRN confers long-term oncologic effectiveness equivalent to traditional ORN.
According to Clayman, "There's more to it than that the patients who underwent laparoscopic nephrectomy lost less blood, left the hospital sooner and went back to work earlier than those who had open surgery. They also took 80% less pain medication." Clayman said he believes it is too soon to recommend laparoscopy for all patients who must part with a cancerous kidney. On the other hand, he noted, "If I or someone in my family developed renal cell cancer and needed a radical nephrectomy, there is no doubt that, barring a very unusual circumstance, it would be removed laparoscopically."
J. Stuart Wolf, MD, and others from the Michigan Center for Minimally Invasive Urology in the University of Michigan Health System (Ann Arbor, Michigan) has completed the first-ever randomized clinical trial comparing open surgery to laparoscopic surgery for kidney donors. He and his colleagues found that patients with the less-invasive operation used 47% less painkillers, that their hospital stays were 35% shorter and that they had 73% less pain at six weeks post-op. The donors also returned to strenuous activity and work much sooner. But, the operation for laparoscopic patients donating a kidney was longer and hospital costs were higher.
Robotic system for laparoscopic urology
During the AUA meeting, Intuitive Surgical (Mountain View, California) reported that it had received market clearance from the FDA to promote use of the da Vinci Surgical System and endoscopic instruments for performance of laparoscopic radical prostatectomy. The system consists of a surgeon's viewing and control console having an integrated, high-performance InSite 3-D vision system, a patient-side cart consisting of three robotic arms that position and precisely maneuver endoscopic instruments and an endoscope, and a variety of articulating EndoWrist instruments. The da Vinci system seamlessly and directly translates the surgeon's natural hand, wrist and finger movements on instrument controls at the surgeon's console outside the patient's body into corresponding micro-movements of the instrument tips positioned inside the patient through small puncture incisions (ports).
According to Richard Graham, MD, of Henrico Doctors' Hospital (Richmond, Virginia), "The new wrist mechanisms allow the surgical instruments – your miniature hands – to get into places you couldn't get into before and do things you previously couldn't do." They make it "much easier to suture" during minimally invasive surgery, he said. The surgeon's ability to see the surgical site is improved because the video monitor is now viewed through a port in the top of the console, allowing the surgeon to look down toward his hands, as in open surgery. Magnification is 10X and there is force feedback and motion scaling. Because of its precise motor mechanism, the system eliminates the motion artifact, or hand tremor, that can occur.
New therapies for SUI
Every day, women worldwide leave their homes fearing stress urinary incontinence (SUI), or unintentional loss of urine when they cough, sneeze, laugh or simply walk. This under-reported and under-diagnosed condition affects more than 18 million women worldwide, including 6.5 million in the U.S. Up to 30% of all women between the ages of 15 and 64 will suffer from incontinence.
Surgical procedures to treat SUI are costly and invasive. The most common approach involves surgically positioning cadaver or artificial slings to elevate the bladder and urethra to their normal position. Only about 200,000 women in the U.S. opt for this invasive, irreversible surgery each year. Many of these patients are dissatisfied with the results.
During the AUA gathering, a few new products and one exciting experimental approach were reported as possible ways to treat SUI. The SURx (Pleasanton, California) solution uses low power, bipolar radio frequency energy to treat the pelvic floor and surrounding tissue in a minimally invasive outpatient procedure. Heated tissue shrinks due to heat's effect on collagen. The resulting shrinkage tightens the previously lax tissue in the pelvic floor lifting the bladder neck to a more anatomically correct position. Studies also indicate that as the surgical wound heals, the body continues to weave a stronger framework of collagen, helping to restore normal continence. This investigational procedure can be performed laparoscopically or transvaginally. According to the company, investigational clinical results show a success rate comparable to more traditional procedures with a much lower complication rate.
Carbon Medical Technologies (St. Paul, Minnesota) showed its Durasphere Injectable Bulking Agent for SUI. Durasphere is composed of pyrolytic carbon coated beads suspended in a water-based gel. The objective of the Durasphere procedure is to obtain closure of the urethra from the bladder neck to mid-urethra by injecting the product into the submucosa until the tissue surrounding the bladder neck coapts. The product is introduced cystoscopically using a proprietary needle injection system. The company says a mean follow-up of 2.2 years shows 83% of patients were improved or dry at one year. The Durasphere procedure is covered by CPT code 51715 and is therefore reimbursed. If a physician chooses to remove Durasphere, that can be done by making a small incision or puncture in the bulked mucosa.
Longer term, women suffering with incontinence, may be able to grow their SUI cure. Embryonic stem cells are being used as an experimental source for urologic tissue reconstruction. University of Pittsburgh (Pittsburgh, Pennsylvania) researchers have successfully used stem cell tissue engineering to restore deficient urethral sphincter muscles in animal modes. "These findings are exciting on many levels," said Michael Chancellor, MD, of the University of Pittsburgh School of Medicine. In the study, researchers isolated muscle derived stem cells (MDSC) from normal rats, transduced them with a reporter gene and injected the stem cells into allogenic denervated proximal urethral sphincters. Improvement in physical measurements such as amplitude of fast twitch muscle contractions improved by approximately 88%.
According to Chancellor, "It's plausible that within the next year, urologists could do a small biopsy in a woman's arm, isolate 100 stem cells and expand that number to more than 100 million stem cells within a month." The woman could then return to the clinic to have her urinary sphincter rebuilt. "The process would be a simple outpatient procedure that could take as little as 10 minutes," Chancellor said.
New urologic devices
Intracorporeal stones are a major factor in the practice of most urologists. EMS Corporation USA (Dallas, Texas), a unit of EMS Electro Medical Systems SA (Nyon, Switzerland), has developed a unique combination device – the Swiss LithoClast Master. Intracorporeal stone disintegration is accomplished using either or both ultrasound and pneumatically generated shock waves. While not yet available in the U.S., the device has been used successfully in Europe. Rainer Hofmann, MD, Philipps University Medical School (Marburg, Germany), reported on work done with the unit comparing it to ultrasound or the original Swiss LithoClast alone. According to Hofman, all stones could be disintegrated and the device was highly efficient. He noted the new lithotriptor was easy to use and showed almost double the efficacy of either lithotriptor alone.
All surgeons are concerned about "turnover time," the time it takes the OR staff to move from the close of one surgery to the opening of another. A new sterilizer from SciCan (Pittsburgh, Pennsylvania), the StatIM 5000, may make a difference. Originally developed for the dental market, this device is fast, compact and reliable. The unit takes just nine minutes for a complete sterilization cycle for either hollow or solid instruments – including endoscopes. The unit is fully automatic and self-diagnosing. If a problem occurs, it will be indicated on an electronic display.