Editorial Overview from Seminars in Urology
Jose M. Hernandez-Graulau, M.D.
Department of Urology, Lincoln Hospital, New York Medical College, Valhalla, N.Y.
THIS ISSUE of Seminars in Urology is the second and last in a series that is devoted to minimally invasive surgery. It is quite clear that the continuing development of minimally invasive surgical techniques are rapidly becoming an intricate part of the urologst's everyday practice.
Part II of this monograph begins with an outstanding review of diagnostic and therapeutic applications of minimally invasive technology written by Dr Manyak from the George Washington University Medical Center. This article is intended to pique the curiosity of the reader to keep an open mind about the potential applications of certain aspects of minimally invasive technology.
The second article, written by Parra and Boullier from St. Louis University School of Medicine, deals with two interesting applications of laparoscopic surgery in the treatment of bladder diverticula and simple cystectomy. There are, obviously, specific indications for this approach. However, the fact that this can be done via the laparoscope is fascinating. Dr Albala et al present an interesting description of laparoscopic bladder suspension for the treatment of stress incontinence. Although this procedure may be more time-consuming because of a steep learning curve to master the procedure, the patient's hospital stay and presumably the convalescence time are greatly reduced.
In Part I of this series, Albala et al described their expenence with laparoscopic transabdominal nephrectomy. Dr. Hulbert, from the University of Minnesota, has expanded the role of laparoscopic techniques in the retropentoneum. In Part II of this series, Dr. Hulbert presents the feasibility of treating patients with cystic disease in selected patients. The advantage of this approach over the percutaneous technique is that the cyst wall can be excised to decorticate the cyst, greatly reducing the possibility of recurrence. He points out, however, that all measures must be taken to assure that there is no evidence of malignancy in the wall of the cyst. Dr. Hulbert is one of the first to report the use of laparoscopic techniques for retroperitoneal lymphadenectomy. This approach is actually an extended lymph node sampling in patients who would otherwise have undergone surveillance only for clinical stage A testis cancer. Surveillance alone will not differentiate between patients with clinical stage A disease who in fact have pathological stage B-I or early stage B-II disease. Therefore, laparoscopy will enable the urologist to access and remove the targeted nodes from optimal staging of this particular subgroup of patients. The application of this technique, however, is highly controversial at the present time.
The next article written by Boullier and Parra reviews the current status of laparoscopic pelvic lymphadenectomy in the staging of prostate cancer. This new approach is inspiring a revival of the radical perineal prostatectomy. As this technique becomes popular and refined, it may become the procedure of choice before radical retropubic prostatectomy in men with preoperative prostate-specific antigen levels over 20, advanced clinical stage, and/or poorly differentiated tumors.
The sixth article, by Dr. Hulbert, from University of Minnesota, is a detailed description of the laparoscopic management of renal cysts. Schlegel and Goldstein, from the New York Hospital-Cornell Medical Center, then present their experience in treating clinical palpable varicoceles with a new anatomical approach by delivering the testis to identify and ligate the external and gubernacular veins and by using optical magnification (8X) to see and preserve lymphatics and testicular arteries. The article offers a very detailed description of the procedure, as well as a review of other techniques such as radiographic balloon occlusion or embolization of the internal spermatic veins, and the retroperitoneal musclesplitting approach as described by Palomo. The use of the laparoscope for the treatment of varicocele has been described in Part I of this series by Dr. Winfield.
Today, the treatment of primary ureteropelvic junction obstruction (UPJ obstruction) by endourological techniques, properly named "endopyelotomy" by Badlani et al, is well accepted by endourological surgeons. We review our experience with endopyelotomy using the Hulbert endoelectrosurgical knife (Cook Urological, Spencer, IN). Endopyelotomy, already a minimally invasive technique, is greatly "technically" facilitated by the use of the Hulbert endoelectrosurgical knife because of its precise endoscopic control.
Not many urologic surgeons realize that vasectomy, a minimally invasive procedure used by 7 percent of all couples in the United States for contraception, can be modified to make it even less invasive. The "no-scalpel vasectomy," a technique developed in China to improve acceptance of vasectomy as a choice of permanent contraception for men, involves two new surgical instruments for a single, atraumatic method for delivery of the vas deferens out of the scrotum. The procedure is very well described, step by step, by Schlegel and Goldstein, from the New York Hospital-Cornell Medical Center.
Transurethral resection of the prostate (TURP) is the current gold standard for managing benign prostatic hypertrophy (BPH). This operation is the second most common surgical procedure performed in the United States. With cost for this surgical treatment on the order of more than $4.5 billion per year, it is not surprising to see the urologic and medical communities making an effort to come up with nonsurgical and minimally invasive alternatives for managing BPH. The last four articles of this series deal with current minimally invasive surgical techniques for the treatment of this ancient ailment.
Transurethral balloon dilatation (TUBD) of the prostate, a nonsurgical option for the treatment of symptomatic BPH, has been under some criticism because of its variable efficacy. TUBD of the prostate, however, has been shown to be a safe and simple procedure with minimal morbidity. Dr. Reddy et al, from the University of Minnesota, present their experience with TUBD of the prostate using a 120 F balloon dilator. Previous balloon dilators size varies from 75 Fr to 90 Fr. The initial results using the 120 Fr balloon dilator are promising. Prostate stenting, a procedure first used by Fabian in 1980, has undergone improvements, gaining interest and currently being investigated for the treatment of BPH. Kletscher and Oesterling, from the Mayo Clinic, present an outstanding review of the technique of transurethral incision of the prostate (TUIP) as a viable alternative to transurethral resection. TUIP has been shown to be an effective method for relieving urinary outflow obstruction caused by BPH when prostatic size is 30 g or less. The article reviews the indications, complications, and an extensive review of the literature.
The last article, written by Dixon and Lepor, from the Medical College of Wisconsin, reviews the current laser delivery systems being evaluated for prostate surgery, including Transurethral Ultrasound Guided, Laser-lnduced Prostatectomy (TULIP procedure) and the most recent Visual Laser Ablation of the Prostate (V-LAP procedure).
Although laser prostatectomy is very well tolerated and in general has a very satisfactory outcome, Drs. Dixon and Lepor are right to caution urologists not to present this treatment as a safe and effective treatment option without supportive data and without giving the consumer proper counseling regarding the expectations of treatment.
This concludes Part II of this series of Minimally Invasive Urology in Seminars in Urology. I am very fortunate indeed to have assembled what can only be termed an all-star cast of contributors, each an acknowledged expert in his or her own sphere of interest, and each an experienced teacher, lecturer, and author. Once again, I want to convey my sincere appreciation to all the authors for their outstanding contributions. I want to reiterate that, because of space limitations, it is impossible to include all minimally invasive surgical procedures available or in development today. However, I think the material presented in both of these issues of Seminars in Urology captures the rapidly changing pace of urologic technology as we enter the decade of the 1990s.