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Laparoscopic Surgery


What Is Laparoscopic Surgery?
What Procedures Do We Perform Laparoscopically?
Preoperative Preparation
Laparoscopic Orchidopexy
Inaccuracy of Other Tests to Locate a Testis
Two-Stage Orchidopexy (Fowler-Stephens)
Contraindications to Laparoscopy
Laparoscopic Pyeloplasty
Laparoscopic Varicocelectomy
Further Reading

Laparoscopic Surgery

What Is Laparoscopic Surgery?

Laparoscopy is utilized to look in the abdomen and perform any procedures that may be indicated without having to make large incisions. It greatly reduces the pain and discomfort postoperatively in some cases, and in others it makes the procedure more successful. PUA has been involved in pediatric laparoscopic surgery for urologic disorders since its inception. Dr. Brock and his associates published one of the earliest papers in the English language literature on laparoscopy for nonpalpable undescended testes in 1984 and the first paper on the technique of transinguinal laparoscopy in 1994. They were the first to perform diagnostic laparoscopy for the non-palpable testis in the New York area in 1985 and taught the first courses for this form of laparoscopy in children in New York State. Since 1984 the physicians of PUA have built upon these earlier innovations and have become pioneers in the field of laparoscopic surgery,publishing numerous medical-journal articles describing our superior surgical results. Laparoscopic surgery is now widely applied to the treatment of urologic disorders in children. We have been the first to develop and describe additional laparoscopic procedures or techniques and among the first in the field of pediatric urology to perform robotic-assisted laparoscopic surgery. Dr. Franco has a special interest and expertise in this area, and he and the other members of the group are now recognized as pioneers and national experts in the field of laparoscopy. They are frequently asked by the editors of major peer-reviewed medical journals to review articles about pediatric urologic laparoscopy, and they are frequently invited to give presentations at national meetings. Members of the group are also actively involved in teaching laparoscopy at advanced national and international laparoscopy training courses for other urologists.

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What Procedures do we perform laparoscopically?

Diagnostic laparoscopy
Laparoscopic orchidopexy
Laparoscopic pyeloplasty
Laparoscopic lymphatic sparing Varicocelectomy
Laparoscopic reimplantation of the Ureters
Laparoscopic mitrofanoff catheterizable stoma
Laparoscopic creation of catheterizable cecostomy/MACE
Laparoscopic nephrectomy (removal of a kidney)
Laparoscopic heminephrectomy (removal of half of a kidney)
Laparoscopic ureterectomy (removal of ureteral stump)
Laparoscopic orchiectomy (removal of an abdominal testis)
Laparoscopic gonadectomy (removal of abnormal sex organs)
Laparoscopic ureteroureterostomy (connect two ureters)
Laparoscopic ureterocalicostomy

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Preoperative Preparation

No preoperative preparation is necessary for laparoscopic orchidopexy other than that which would be performed for routine surgery.

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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 intra-abdominal 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 1990s 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 (the “peeping” testis), it is a perfect candidate to undergo laparoscopic treatment. 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 (PUA authors’ series).

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Inaccuracy of Other Tests to Locate a Testis

Radiologic studies including CT scans and ultrasounds used to locate the nonpalpable testis are unreliable, with false positive and false negative rates as high as 20%. A definitive procedure such as laparoscopy is needed for positive identification of the presence or absence of the testis. Contrast augmented MRI studies have had a high success rate with false negatives in only one reported series to date.

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. (Brock et al, 1983). Of these 80%, some will be found in the groin and a simple inguinal orchidopexy can be performed. Others will have a peeping testis or a true intra-abdominal testis. The other 20% of the patients will not have a testis, and no further treatment or intervention is needed.

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Two-Stage Orchidopexy (Fowler-Stephens Orchidopexy)

There are cases where diagnostic laparoscopy shows that the blood vessels to the intra-abdominal testis are too short to allow the testis to be brought all the way to the scrotum without harm. It is possible to divide these vessels by laparoscopic surgery without injury to the testis. In this situation nearby blood vessels will then grow toward the testis, allowing it to be moved to the scrotum at a later date. It usually takes about six months for these blood vessels to get to the point that they provide enough blood flow to the high testis that allows it to be moved to the scrotum by a second laparoscopic procedure. This is called a two-stage Fowler-Stephens orchidopexy, and it is the procedure of choice in this situation.

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Contraindications to Laparoscopy

There are no real contraindications to laparoscopic orchidopexy other than extremely numerous and dense bowel adhesions that would make laparoscopy difficult. The experience of the surgeon in complex cases is the only other limiting factor.

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Laparoscopic Pyeloplasty

Pyeloplasty is an operation utilized to repair an obstruction at the ureteropelvic junction (UPJ). The UPJ is the point where the urine from the kidney starts to empty into the tube that will carry the urine to the bladder (the ureters). Open (non-laparoscopic) pyeloplasty 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 shorter time.

We have performed numerous laparoscopic pyeloplasties with success rates that rival the open surgical technique. We have been able to perform the procedure in children as young as two years of age, utilizing the DaVinci robot.

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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. The goal of the operation, regardless of which method is used, is to interrupt or obstruct the abnormal veins that are allowing blood to run backward to the testis. Once the blood vessel has been blocked or divided, the blood will stop at the point where the vein has been divided and will no longer back up into the scrotum. The veins can be divided just above the testis near the scrotum, higher up in the inguinal area (the groin) or in the lower abdomen. Minimally invasive laparoscopic techniques for the treatment of varicoceles in an adolescent were first described in 1992. The other available treatment options include open surgery (Palomo or Ivanisivich techniques) or percutaneous trans-venous embolization procedures.

We have been able to perform lymphatic sparing varicocelectomy and obtain minimal recurrence rates and hydrocele rates that rival those of microscopic varicocele repair. Pain and recovery time have also been reduced using laparoscopic techniques.

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Further Reading

Brock,W.A., M.J. Smolko and G.W. Kaplan. "Location and Fate of the Nonpalpable Testis in Children," Journal of Urology, 129 (6):1204-1206, 1983.

Brock, W.A., D.H. Lowe and G.W. Kaplan. "Laparoscopy for Localization of Nonpalpable Testes," Journal of Urology, 131:728-29, 1984.

Brock, W.A., and J. Horgan. "Transinguinal Laparoscopy," Journal of Urology, 157:473-474, 1994.

Franco, I., B. Lindgren, E. Darby, L. Faiella, W. Brock, E. Reda and S. Levitt. "Laparoscopic Orchiopexy: Procedure of Choice for the Nonpalpable Testis." Journal of Urology, 159:2132-2135, 1998.

Reda, E.F., B.W. Lindgren, I. Franco, S. Blick, S.B.Levitt, W.A. Brock, L.S. Palmer and S.C. Friedman. "Laparoscopic Fowler-Stevens Orchidopexy for the High Abdominal Testis," Journal of Urology, 162:990-994, 1999.

Franco, I., L. Baker, S. Docimo, I. Surer, C. Peters, L. Cisek, D. Diamond, A. Caldomone, M. Koyle, W. Strand, R. Moore, R. Mevorach, J. Brady, G jordan and M. Erhard. "A Multi-Institutional Analysis of Laparoscopic Orchidopexy," British Journal of Urology International, 87:484-489, 2001.

Franco, I., B. Chang and L. Palmer. "Laparoscopic Orchidopexy: A Review of a Large Clinical Series," British Journal of Urology International, 87:490-493, 2001.


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