Laparoscopic
Urologic Procedures
What Procedures
do we perform laparoscopically?
Laparoscopic
Orchidopexy
Laparoscopic
Reimplantation of the ureters
Laparoscopic
Pyeloplasty
Laparoscopic
Mitrofanoff catherizable stoma
Laparoscopic
Catherizable cecostomy/MACE
Laparoscopic
Lymphatic sparing Varicocelectomy
Laparoscopic
Nephrectomy
Laparoscopic
Heminephrectomy
Laparoscopic
Ureteral stump removal
Laparoscopic
Orchiectomy
Laparoscopic
Gonadectomy
Laparoscopic
Ureteroureterostomy
Laparoscopic
Ureterocalicostomy
What is laparoscopy?
Laparoscopy is utilized to look in the abdomen and perform procedures if indicated without having to make large incisions in the patients. It greatly reduces the pain and discomfort post operatively in some cases and in others it makes the procedure more successful.
We have been involved in pediatric laparoscopic surgery since its inception. We have been pioneers in the field of laparoscopic surgery with numerous publications describing superior surgical results and in other instances we have been the first to describe a particular technique. We have been one of the earliest users of robotic assisted laparoscopy in the field of pediatric urology.
Members of the group are recognized as national experts in the field of laparoscopy and commonly are asked to review articles in the field for peer reviewed journals and to give presentations at national meetings. Members of the group are actively involved in teaching laparoscopy at advanced laparoscopy courses for other urologists.
Laparoscopic Orchidopexy
Surgical intervention for the intra-abdominal testis is considered essential for the preservation of testicular function and for monitoring of testicular cancer later in adulthood. Laparoscopy for the evaluation of the nonpalpable testis has been long recognized as the ideal means of evaluating such testis. Management of the intraabdominal testis has evolved over the years from large incisions with retroperitoneal and abdominal exploration to staged Fowler Stephens with laparoscopic clipping of the vessels to today’s one stage laparoscopic orchidopexy. In the 90’s laparoscopic orchidopexy became a well-established technique for the management of the intra-abdominal testis. Once the testis is noted to be intra-abdominal on diagnostic laparoscopy or, in some cases, sitting at the level of the internal ring, (peeping testis), and these testes are perfect candidates to be brought down laparoscopically. In some cases a first-stage clipping of the vessels may have been performed, and a secondary mobilization and descent of the testis is then performed. The clear advantage of laparoscopic orchidopexy in these cases has been demonstrated in multiple studies in the literature in which success rates of 95% have been achieved (author’s series); this technique will be described in this chapter.
INDICATIONS FOR
LAPAROSCOPIC ORCHIDOPEXIES
• Intra-abdominal testis
• The peeping testis (testis that move freely in and out of the internal ring)
• Inguinal testis in older patients in which vessel length is in adequate to reach the scrotum adequately
• 2 nd stage of a staged Fowler Stephens orchidopexy
CONTRAINDICATIONS
• There are no real contraindications to laparoscopic orchidopexies other than extremely numerous and dense bowel adhesions that would make laparoscopy difficult, or impossible to reach the testis. The experience of the surgeon in complex cases is the only other limiting factor.
PRE-OPERATIVE PREPARATION
• No pre-operative preparation is necessary for laparoscopic orchidopexy other than that which would be performed for routine surgery. Bilateral non-palpable testes should be evaluated with FSH, LH and testosterone levels if there is evidence of micropenis, or other manifestations of hypogonadism. In most cases, definitive exploration with laparoscopy would be called for, regardless of the blood tests, unless the FSH and LH levels are extremely elevated (in excess of three times normal
• Radiologic studies including CT scans and ultrasounds invariably are inaccurate, with false positive and false negative rates as high as 20%. A definitive procedure such as laparoscopy is called for positive identification of the presence or absence of the testis. Contrast augmented MRI studies have had a high success rates with no false negatives in only one reported series to date. In cases of pseudohermaphroditism a complete workup should have been done prior to laparoscopy.
• Prior to surgery informed consent should be obtained. The fact that some form of testis will be found in 80% of patients who are designated initially as having impalpable testis is something we have found in our experience. Of these 80%, some will be found in the groin and a simple inguinal orchidopexy can be performed. Others will have peeping testis or true intraabdominal testis. The other 20% of the patients will have had either an in utero torsion (15%) or true absence of the testis (5%). Parents should be informed that the success rate of the procedure varies from 70% to 95%. There exists a risk of atrophy even in cases where Fowler-Stephens vessel transections are not preformed (< 1%). In cases where Fowler-Stephens vessel transections are performed the rate of success can vary from 50% to 94%. The possibility of bowel injury, bowel obstruction and vascular injuries needs to be expressed in the preoperative discussion.
TECHNIOUE
• General anesthesia is provided, and in many cases a caudal anesthetic will be of extreme benefit to the child intraoperatively and post-operatively. Muscle relaxation is essential, and nitrous oxide gas should be off during the case.
• The laparoscopy cart is positioned at the foot of the table to facilitate viewing for both surgeons (only one monitor is necessary)
• The patient is brought down to the end of the table with his feet at the very distal end of the table.
• The penis is catheterized with an 8 French feeding tube and the bladder drained. (essential to avoid injury to the bladder, and should be left in till the end of the case, inadvertent injury to the bladder can occur if the bladder refills prior to extracting the testis.
• An infra-umbilical incision is made and one dissects down to the fascia. A box stitch using a 2-0 polyglycolic suture is placed.
• A small Ramel is created using a red rubber catheter and placed over the box stitch to facilitate clamping the trocar in position and preventing air leak, also this will be used to close the wound.
• Once the abdomen is opened, the blunt trocar is placed into the abdomen and the abdomen insufflated at a pressure of 12 mm.
• The child is placed in the Trendelenburg position and inspection of the intraabdominal contents is then performed.
• If the view of the pelvis is obscured by bowel or adhesions additional ports should be placed for mobilization of the bowel to allow full inspection of the pelvis.
• The internal ring should be inspected immediately upon entering the abdomen. It’s appearance and the presence of vessels and a vas will lead to a quick determination of whether any additional maneuvers are required. Absence of a vas deferens entering the ring will mean one of the following; intraabdominal testis or agenesis. The presence of a vas deferens will mean that there is a testis present. Whether it is viable or atrophic and its exact location is to be determined.
• The absence of a vas deferens should alert the surgeon that the possibility of renal agenesis may exist or that this patient may be a heterozygous carrier of cystic fibrosis. If there is a high intra abdominal testis, absence of the vas deferens will almost invariably make it impossible to bring this testis down utilizing a Fowler-Stephens technique (vessel transections) and Orchiectomy will need to be done or micro transplantation of the testis should be attempted if this is the sole testis.
• After inspection of the abdomen has been performed and both internal rings have been inspected one then starts to look for the testis. If the internal ring is closed, then the testis should either be down the canal or in scrotum, or this maybe a case of in utero torsion or in the rare instance a true case of agenesis. The presence of a vas deferens will help make the differential diagnosis. If there is a patent processus vaginalis then a testis should be present in the inguinal canal.
• The next critical step is to evaluate the vessels entering into the internal ring. Atrophic or small vessels entering into the internal ring will generally indicate a probable case of in utero torsion (fig 1). Inspection of the contralateral side will generally confirm that there is asymmetry of the vessels. Also, inspection of the vessels that run with the vas will indicate they are enlarged which is generally seen in torsion cases.
• If there are no vessels seen going into the ring, then there is a testis that is present somewhere in the abdomen or no testis at all (fig. 2). When a vas is seen entering the ring with no vessels entering the ring from the posterior abdominal wall, an easy mistake to make is to assume that this is a case of in utero torsion. In reality this could be a case of a looping vas with a testis sitting on the medial side of the iliac vessels. It is critical to see vessels entering the internal rings, regardless of whether there is a vas present or not. The descending and sigmoid colon should be reflected since the left testis can be obscured by either. The right testis is rarely obscured by the cecum, but it can be by the sigmoid at times.
• Once the testis has been identified and the distance from the ring is felt to be sufficient to bring the testis down into the scrotum without requiring a vessel transection, we then place our two additional ports. The ports are placed in the mid-clavicular line at the height of the umbilicus. The younger the patient, the closer to the level of the umbilicus the lateral ports should be. The older the patient, the lower they can be.
orchidopexy
• The first step is to transect the gubernaculum. This is done by grabbing the gubernaculum and gently tugging on it and working it out of the inguinal canal (fig 4). Always be sure that you grab the gubernaculum and stay away from the vas deferens and epididymal structures at all costs. Grasping the vas deferens or the epididymis will damage the blood flow to these organs and will eventually limit your ability to perform a one-stage Fowler Stephens procedure if need be (fig. 5).
• The gubernaculum is generally transected using a significant amount of tension and minimal amount of cautery. The gubernaculum is avascular and if significant bleeding is encountered during transection you may have cut into other structures.
• The dissection of the peritoneum is started by going along the lateral pelvic wall, staying about a centimeter away from the testicular vessels. The dissection is taken as cephalad as possible, up to where the vessels start to dip under the colon
• The dissection of the peritoneum then is taken medially over the median umbilical ligament, then over the bladder, going at least ¾ across the bladder wall in unilateral cases In bilateral cases the dissection can be taken completely across the bladder. Again, one must be very careful, staying as far away from the vas deferens as possible with this dissection. As little cautery should be used during the dissection as possible.
• Once the two legs of the dissection have been done, we then go back to the lateral dissection and then come over the testicular vessels, dissecting the peritoneum off of the testicular vessels. This peritoneum is then incised in a direction down toward the root of the mesentery. This dissection is critical to allow adequate length to be achieved ‘when bringing the testis down into the scrotum. Not performing this dissection will deter the testis from being able to drop completely into the scrotum in some cases. Attempting to do this dissection while the testis is on traction will generally lead to an inadvertent transection of the vessels since it is impossible to tell peritoneum from vessels when the vessels are on stretch.
• At this point a space is created between the bladder and the medial umbilical ligament to allow for egress of the testis via the abdominal wall. The bladder is dissected away from the medial umbilical ligament and the pubic bone is visualized. This dissection is done with a blunt dissector or an endopeanut mobilizing the bladder medially. The pubic bone can be seen as the space is created (fig 10). This maneuver is critical in preventing inadvertent bladder perforation utilizing this technique. It is also critical that the bladder catheter was left to gravity drainage throughout the case to prevent urine from accumulating in the bladder and thereby making the bladder more susceptible to injury.
• Care must be taken not to work on an angle that would take one laterally towards the femoral vessels. This can easily occur before one knows it and the femoral vein can easily be injured inadvertently.
• Once this dissection has
been completed, a dissector,
is pushed against the anterior abdominal wall muscles at the area of the external inguinal ring. This is pushed over the superior edge of the pubic bone. This will be the site of the neo ring that will be created.
• An index finger is then used to invaginate the scrotum and push up to the level of the external inguinal ring. The dissector should be palpated at this point. When there is as little tissue as possible between the dissector and the finger, this is the weakest point and this corresponds to the external ring. We then push through the anterior abdominal wall with a blunt dissector. The dissector is always put in on the ipsilateral side of the body, thereby always pushing from lateral to medial. This maneuver is critical to prevent inadvertent injury to the femoral and epigastric vessels. The push through the anterior abdominal wall is generally one that requires a fair amount of force, especially if one is an endopeanut or blunt probe.
• Once the dissector pushes through the anterior abdominal wall, a fairly prominent pop is heard and the dissector will push through and dissect down into the scrotum (fig 11). Once the dissector is in the scrotum then a sub dartos pouch is created in a standard fashion (fig 12). Once the pouch is created the dissector is pushed through the fat in the scrotum (fig 13) and a 5 mm trocar is placed over the dissector (fig 14). If radially dilating trocars are being used, the radially dilating sheath is then placed over the dissector, pulled into the abdomen, and then the dilating trocar is then placed into the abdominal cavity (n.b.: the instrument and the trocar must be the same size)
• Once the trocar is in
position, we then go ahead and place our endoscopic
• The testis is then pulled out through the anterior abdominal wall and into the scrotum. If there is no tension on the testis then a 4-0 polyglycolic stitch is placed through the capsule of the testis and this will be used to fix the testis in the scrotum. The testis will be fixed using two Keith needles that are brought down through the apex of the scrotum. These will generally be placed over a small cotton pledget to prevent the suture from cutting through the scrotum, if there is no tension at all, and then a cotton pledget is not necessary.
• If there appears to be tension on the testis, the abdomen is deflated and the tension on the testis is rechecked. This is a critical maneuver to evaluate for tension on the testis. This can mean the difference between one going in feeling that more dissection is necessary, or having a testis that is adequately placed. Once the testis is felt to be in adequate in position, the scrotum is closed and the suture is tied down.
• If there is excess tension and the testis is to high a Fowler-Stephens orchidopexy can be performed. The vessels are then clipped with endoscopic clips and the vessels transected. The testis is brought down into the scrotum and anchored in a similar fashion as previously mentioned.
• Inspection of the abdomen is then performed. The internal ring does not need to be closed in the overwhelming number of cases. The rings will sclerose down and require no further suturing. Only in cases where large hernias are present, then one can go ahead and perform suture ligation of the internal ring using a needle driver.
TWO-STAGE FOWLER-STEPHENS
ORCHIDOPEXY
In cases where the laparoscopy revealed that the testis was too high and descent of this testis down into the scrotum without performing vessel transection would be impossible, or the surgeon does not feel comfortable performing a one-stage Fowler-Stephens orchidopexy, a two-stage Fowler-Stephens orchidopexy is then the procedure of choice.
• Most failed Fowler-Stephens orchidopexies in the authors hands have come when the testes had been previously manipulated either with open surgery or laparoscopically. Dense adhesions around the epididymis are generally the primary cause of demise of the testis. Freeing up these adhesions generally will lead to damage to the fragile blood vessels going to the epididymis, and in most cases this will lead to atrophy of the testis. It is best not to dissect the testis out at all if one thinks that a two-stage procedure will need to be done. Manipulation of the testicle by dissecting it free and then leaving it will generally lead to adhesions that will be need to be taken down during the secondary procedure,. These adhesions can be difficult at times to free up, and can mean the difference between a viable testicle and an atrophic testicle six months later.
• After access into the abdomen has been obtained as previously described, one then will proceed to dissect out the testicular vessels by making a small incision in the lateral pelvic wall as close to the colon as possible.
• These vessels are then clipped using a clip-applier, and then transected.
• After six months have passed, in some cases the surgeon feels that he would like to give him an additional edge by utilizing human chronic gonadotropin injections to increase the vascularity of the testis.
• The testis is approached in a similar fashion as previously described, placing trocars in the same positions. The gubernaculum is then identified and transected. The lateral pelvic wall is then dissected, freeing up the testicular vessels. At the point where the vessel transection occurred, one can come across the peritoneum at this point, and then dissect down towards the root of the mesentery. The peritoneum is then incised over the medial umbilical ligament and then dissected off the bladder. Once the peritoneum has been dissected medially, we then should have a pedical of peritoneum that will feed the testicle along with the vessels going from the vas. The bladder is mobilized medially and the neo ring is created as previously described.
• The testis is then extricated in the same fashion as previously described, with significant care to make sure not to touch the epididymis or the vas. Once the testis is brought out, it is anchored in the same fashion as previously mentioned.
• The scrotum is closed and the abdomen is then inspected. The procedure is then terminated.
• On exiting the abdomen, regardless of the age of the child, each trocar site should be closed with a 3-0 polyglycolic suture. The box stitch is placed infraumbilically and is cinched up to close the midline incision. Each wound is then closed with a subcuticular closure. Steri-Strips are placed over the wound and the patients are extubated and returned to the recovery room.
Further reading
I Franco (2007) Surgical management of the
Undescended testis: The Kelalis-King-Belman Textbook of Clinical Pediatric
Urology 5 th (ed Docimo, Canning and
Khoury) Informa healthcare UK ltd
I Franco (2001) Evaluation and management of impalpable testis: Clinical
Pediatric Urology, 4 th (ed. Belman, King and Kramer) Martin Dunitz Ltd.,
B Lindgren, E Darby,L Faiella,
W Brock,
BW. Lindgren I Franco,
L Baker, S Docimo, I Surer, C Peters, L
Cisek, D Diamond, A Caldamone, M Koyle, W Strand, R Moore, R Mevorach, J Brady,
G Jordan, M Erhard, And I Franco( 2001), A Mutil institutional analysis of Laparoscopic
orchidopexy. British Journal of
Urology international; 87, 484-489
B Chang, L Palmer and I Franco. (2001)Laparoscopic
Orchidopexy: A review of a large Clinical series. British Journal of
Urology international; 87, 490-493
I Franco
(2001) Use of HCG stimulation for the evaluation and treatment of the
impalpable testis Hormonal evaluation and treatment in cryptorchidism In Dialogues in Pediatric Urology; 24(8)
Peeping Testis (a form of intraabdominal testis)
normal testis side with in utero torsion
Laparoscopic Pyeloplasty:
Pyeloplasty is an operation utilized to repair
an obstruction at the ureteropelvic junction. It typically requires
a large and painful incision below the rib cage on the affected side.
Laparoscopic pyeloplasty allows the surgeon to perform the procedure without a
large incision. The use of a robot to
perform this procedure allows the surgeon greater dexterity and vision to
perform the procedure in a timely fashion.
We have performed numerous laparoscopic pyeloplasties
with success rates that rival the open technique. We have been able to perform the procedure in
children as you as 2 years of age utilizing the Da Vinci robot.
Surgical Technique:
After adequate general
endotracheal anesthesia is provided, the patient is placed in lithotomy in
order for a ureteral catheter to be placed after retrograde pyelography. A Foley catheter is then placed. The patient is then taken out of lithotomy
and placed in a modified flank position (45 degrees). A beanbag is used to support the patient and
adequate padding is provided to the axilla and the knees. After the patient is prepped and draped, we
place an infraumbilical trocar. Two additional robotic trocars are then placed:
one in the mid-clavicular line; and one subcostally, even with the anterior
superior iliac spine. A fourth trocar is
then placed just above the umbilicus. The
dissection then ensues using straight laparoscopic dissection. The colon is taken down utilizing the
scissors and harmonic scalpel. After the
colon is mobilized the ureter is isolated and followed up to the renal
pelvis. The area of stenosis is then
evaluated for crossing vessels. Once the
area of stenosis is identified and the ureter has been freed from its
surroundings, two stay sutures are placed, one on the ureter inferiorly and one
on the renal pelvis. The ureter is then
transected across the area of stenosis.
If need be, this area is fully excised. In the robotic procedure the
robot is then positioned. After the
robot connections have been established, Pott’s scissors are used to
transect the pelvis on the lateral side.
The ureter is then spatulated on the medial side. The proper length for the anastomosis is then
measured. The first 4.0 polyglycolic
suture is then placed and tied at the apex.
A running stitch along the posterior wall is placed. The stent is then re-positioned into the renal
pelvis before running a 4.0 vicryl across the anterior wall. This anastomosis is completed using the
robotic needle holder and instruments.
In the hand sewn technique the anastomosis is completed by hand
utilizing 4- 0 polyglycolic sutures in a manner similar to that mentioned
above. The colon is then replaced into
its normal position. A 3.0 chromic
suture is used to anchor the colon to the abdominal wall in order to retroperitonealize
it. A Jackson-Pratt drain is then placed
behind the colon and sewn in place with 3.0 nylon. The drain is brought out through the most
superior trocar site to prevent evisceration of omentum when the drain is
removed.
UPJ obstruction due to a crossing vessel
UPJ obstruction with severe hydronephrosis
Laparoscopic Varicocelectomy
The management of varicoceles
in the adolescent male is controversial.
While the indications for intervention can be debated, effective
treatment options are available when intervention is deemed appropriate. These options include open surgery (palomo or
Ivanisivich), laparoscopy or percutaneous transvenous procedures. The Palomo technique first described in 1949
involves en masse transection of the testicular vessels in the retroperitoneum
above the internal inguinal ring.1 The varicocele recurrence rate
for the Palomo procedure has been reported to range from 0-16% with post-operative
hydrocele rates ranging from 7-24%.2-4 Comparatively, varicocele
recurrence rates and hydrocele rates utilizing microscopic assistance with an
inguinal approach range from 0-2% and
1-4%, respectively. 5-7 Universal utilization of the inguinal
approach for varicocelectomy has not occurred because of the technical
challenge of dissecting the investing veins that surround the testicular artery
at this level.
Minimally invasive surgical technique using
laparoscopy for the treatment of varicoceles in an adolescent was first
described in 1992 by Donovan and Winfield. 8 The site of varix ligation
technique is similar to that of the open Palomo approach and postoperative
hydroceles utilizing a laparoscopic approach have been observed in up to 28% of
cases. We
have been able to perform lymphatic sparing varicocelectomy and obtain minimal
recurrence rates and hydrocele rates that rival those of microscopic
varicocelectomy.
Dilated preserved lymphatics
