ENDOUROLOGY UPDATE - Laparoscopic Surgery -

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					ENDOUROLOGY UPDATE
 - Laparoscopic Surgery -
    가톨릭의대 강남성모병원
        서성일
• Laparoscopy in urologic field
     1976    Diagnosis of UDT
     1989    Lapa. PLND
     1990    Lapa. Nephrectomy
     1993    Lapa. Pyeloplasty
     1994    Hand assisted lapa. nephrectomy
     1995    Lapa. Donor nephrectomy
LAPAROSCOPIC RADICAL
 PROSTATECTOMY (LRP)
LRP : Oncological evaluation after 1,000 cases at
montsouris institute. (Guillonneau et al) (J Urol 2003: 1261-6)

• Jan 1998 – Mar 2002, 1000 LRP, F/U=12mon (1-48)
• Age 636.2 yrs, PSA 106.1 ng/ml
• Clinical stage:                 Pathologic stage:
                                       75
   75
                    66
                                                    57.2

   50                                  50

                          30.4

   25                                  25    20.3
                                                           14.2
                                                                  7.7
        0.6   0.3                2.7
                                                                          0.6
    0                                   0
        T1a   T1b   T1c   T2a    T2b        pT2aN0 pT2bN0 pT3aN0 pT3bN0   pT1-
• Surgical margin (+)                                                     3N1

  pT2a=6.9%, pT2b=18.6%, pT3a=30%, pT3b=34%
• Predictor of margin(+)
  PSA, clinical stage, pathologic stage, gleason score
• Overall biochemical progression-free survival rate
  : 90.5% at 3yrs
                                                         89%
                          91.8%, 88%




                                77%
                                                         74%



             50%
                              44%
                                    91%
                                                                              93%



                                                                             79%

                                   65%
                                                                             56%




• After RRP, progression free survial rate : 93% at 3yrs
     88% microscopic extracapsular extension and surgical margin(-)
     75% extracapsular extension and surgical margin(+)
     47% seminal vesicel invasion(+) (Catalona et al, J Urol 160, 2428-34)
                                    91%
                                                                              93%



                                                                             79%

                                   65%
                                                                             56%




• After RRP, progression free survial rate : 93% at 3yrs
     88% microscopic extracapsular extension and surgical margin(-)
     75% extracapsular extension and surgical margin(+)
     47% seminal vesicel invasion(+) (Catalona et al, J Urol 160, 2428-34)
Peri-operative complications of LRP:
The Montsouris 3-year experience
(Guillonneau et al) (J Urol 2002: 51-6)

• Jan 1998 – Feb 2001, 567 pts, age=42-77 (63.5) yrs
                        Complications       Number (%) No. of revision
• PLND in 19.4%
                        Anastomotic fistula   57 (10)         1
• Overall complication rate=17.1% (97/567)
                        Bladder injury        9 (1.6)
  Surgical revision =3.5% (20/567)
                                   Ureter injury          3 (0.5)        2

                                   Obstructive anuria     1 (0.17)       1

                                   Bowel injury          17 (2.92)       6

                                   Neurological injury    3 (0.5)

                                   Hemoperitoneum         5 (0.88)       5

                                   etc                    10 (1.8)       5

                                   Total                 105 (18.5)   20 (3.5)
*   Evolution of the complication rate with experience
                    1-50    51-100
BMI                 24.7     25.7
PSA                 10.98    10.82
% PLND               34       28
Op time             268      245
EBL                 514      435
% transfusion        18       8
% conversion         12       2
Catheter duration    7.6      7.3
Hosp. stay           7.1      6.4
No. rectal injury    1        0
% revision           2        2
*   Evolution of the complication rate with experience
                    1-50    51-100   101-200    201-300
BMI                 24.7     25.7      26.1       26
PSA                 10.98    10.82    10.50      11.24
% PLND               34       28       18         18
Op time             268      245       213       196
EBL                 514      435       270       374
% transfusion        18       8         2         5
% conversion         12       2         0         0
Catheter duration    7.6      7.3      4.2        5.8
Hosp. Stay           7.1      6.4      4.9        6.9
No. rectal injury    1        0         2         0
% revision           2        2         2         3
*   Evolution of the complication rate with experience
                    1-50    51-100   101-200    201-300   301-400   401-500   501-567
BMI                 24.7     25.7      26.1       26        26       25.6      25.8
PSA                 10.98    10.82    10.50      11.24     10.72     10.03     9.58
% PLND               34       28       18         18        20        13        15
Op time             268      245       213       196       184       186       174
EBL                 514      435       270       374       429       420       292
% transfusion        18       8         2         5         5         3         4.7
% conversion         12       2         0         0         0         0         0
Catheter duration    7.6      7.3      4.2        5.8       5.8       5.5       6.8
Hosp. Stay           7.1      6.4      4.9        6.9       6.5       6.0       6.4
No. rectal injury    1        0         2         0         1         2         2
% revision           2        2         2         3         4         4         7.5

    • 82.9% 의 환자에서 No Complication !!
       comparable with RRP.
       앞으로 경험이 더 축적되고 테크닉이 발전하면 더 긍정적인
          결과가 나올 것으로 기대된다.
*   Evolution of the complication rate with experience
                    1-50    51-100   101-200    201-300   301-400   401-500   501-567
BMI                 24.7     25.7      26.1       26        26       25.6      25.8
PSA                 10.98    10.82    10.50      11.24     10.72     10.03     9.58
% PLND               34       28       18         18        20        13        15
Op time             268      245       213       196       184       186       174
EBL                 514      435       270       374       429       420       292
% transfusion        18       8         2         5         5         3         4.7
% conversion         12       2         0         0         0         0         0
Catheter duration    7.6      7.3      4.2        5.8       5.8       5.5       6.8
Hosp. Stay           7.1      6.4      4.9        6.9       6.5       6.0       6.4
No. rectal injury    1        0         2         0         1         2         2
% revision           2        2         2         3         4         4         7.5

    • 82.9% 의 환자에서 No Complication !!
       comparable with RRP.
       앞으로 경험이 더 축적되고 테크닉이 발전하면 더 긍정적인
          결과가 나올 것으로 기대된다.
LRP vs open radical prostatectomy:
a comparative study at single institution
(Rassweiler et al) (J Urol 2003: 1689-93)

• RRP – 219 pts (group 1)
  RPP – 219 pts (early, group 2), 219 pts (late, group 3)
Post operative course
References            No. pts.   OP time   Early reintervention   Early Cx.   Transfusion
Open radical Px.
  Hautmann et al          418      168             9.0               23.0          NA
  Hammerer et al          320       NA             7.3               21.9          27.8
  Gheiler et al          1,129      NA             4.0               7.9           NA
  Catalona et al         1,870      NA             NA                4.2           9.0
  Lepor et al            1,000      NA             1.0               3.3           9.7
  Present series          219      196             6.8               19.2          26.9
LRP
  Guillonneau et al       350      217             4.0               16.7          5.7
  Rassweiller et al       180      271             4.5               15.0          17.0
  Turk et al              125      235             2.1               10.5          3.0
  Hoznek et al            217      281             NA                NA            2.0
  Present series
      Early               219      288             4.2               13.9          14.2
      Late                219      218             2.0               6.1           5.5
Follow up results
References            No. pts.   (+) margin    PSA      Continence   Anastomotic
                                  (all/pT2)   relapse     (12M)        stricture
Open radical Px.
  Hautmann et al        418         NA         NA          81            8.9
  Hammerer et al        320         NA        16.6         91            7.6
  Gaylis et al          116       37/17.2      NA          92            NA
  Catalona et al       1,870        na         7.0         92            3.8
  Lepor et al          1,000        20/        1.0         NA            1.0
  Present series        219      28.7/15.7    15.1         89.9         15.9
LRP
  Guillonneau et al     350      15.1/10.7     8.0         85.5          0
  Rassweiller et al     180        16/2.3      5.0         97            3.3
  Turk et al            125      44.1/29.4     2.1         92            1.4
  Hoznek et al          217      24.6/16.8    10.0         86.2          NA
  Present series
      Early             219        21/6.8     13.4         90.3          6.4
      Late              219      23.7/11.9     NA          91.7          4.1
Laparoscopic management of rectal injury during LRP
(Guillonneau et al) (J Urol 2003: 1694-6)



• Incidence = 13/1,000 (1.3%)
• 11 cases – intra-operatively detected
   laparoscopically meticulous primary repair without colostomy
      (9 cases = cure without problem,
       2 cases = peritonitis developed  re-intervention)
• 2 cases – post-operatively detected
   open repair
      (1 cases = rectourethral fistula)
Laparoscopic management of rectal injury during LRP
(Guillonneau et al) (J Urol 169, 1694-1696)



• Incidence = 13/1,000 (1.3%)
• 11 cases – intra-operatively detected
   laparoscopically meticulous primary repair without colostomy
      (9 cases = cure without problem,
       2 cases = peritonitis developed  re-intervention)
• 2 cases – post-operatively detected
   open repair
      (1 cases = rectourethral fistula)
Assessment of surgical tech. and peri-operative morbidity
associated with extra vs trans-peritoneal LRP
(Hoznek A et al) (Urology 2003: 617-22)

• TP-LRP (n=20), EP-LRP (n=20), retrospective study,
   2 groups are well matched for age, PSA, BMI…..
Assessment of surgical tech. and peri-operative morbidity
associated with extra vs trans-peritoneal LRP
(Hoznek A et al) (Urology 2003: 617-22)

• TP-LRP (n=20), EP-LRP (n=20), retrospective study,
   2 groups are well matched for age, PSA, BMI…..
Location of margins (+) after retropubic, perineal, and
laparoscopic radical prostatectomy for organ confined
Pca (Salomon et al) (Urology 2003: 386-90)
• 1988-2001, 538 radical prostatectomy, 371 organ confined Pca

             RRP (n=116),       RPP (n=86),        LRP (n=169)
Margin (+)   22 (18.9%)         12 (13.9%)         32 (18.9%)
Location of margins (+) after retropubic, perineal, and
laparoscopic radical prostatectomy for organ confined
Pca (Salomon et al) (Urology 2003: 386-90)
• 1988-2001, 538 radical prostatectomy, 371 organ confined Pca

             RRP (n=116),         RPP (n=86),           LRP (n=169)
Margin (+)   22 (18.9%)           12 (13.9%)            32 (18.9%)
                    50%

                                                44.4%
                                     41.7%              41.6%

                                  33.3%

                      29.1%               25%
                          20.8%
                                                   13.9%
LAPAROSCOPIC RENAL
     SURGERY
• Laparoscopic donor nephrectomy as standard option.
  pure or hand assisted, trans or retroperitoneal
• Recent issue
  Laparoscopic nephron-sparing procedure !!
  - imaging technique improve, incidental tumor ↑
  - often small tumor (<4cm), slow growth (0.35cm/yr),
       low metastatic potential
  - metachronous contralateral tumor 4-15%
  - some degree of renal insufficiency at 10 yrs F/U in Rad. Nx
  - 4cm이하의 종양에 대한 cancer free survival 의 차이가
       nephron-sparing 과 radical surgery간에 별로 없다.
• Goal of nephron-sparing surgery
  - oncologically-complete local excision
  - optimal functional preservation
   이러한 원칙 하에 몇몇 센터에서 minimally invasive nephron
  sparing surgery가 시행되고 있고 긍정적인 결과들이 보고되고
  있다.
Laparoscopic partial Nx.: a new horizon
(Gill IS and Kaouk JH) (Current opinion in urology 2003: 215-9)



• Pre-op 3D CT
• A flexible laparoscopic USG
  (tumor size, depth, distance from collecting system,
   satellite mass)
• transperitoneal – ant., anterolateral, upper pole mass
  retroperitoneal – posterior mass
• Hilar control ?
   transperitoneal – a. v. 을 동시에 clamp
   retroperitoneal – a. v. 을 각각 clamp
• Hypothermia
  renal ischemic injury directly related
   to warm ischemic time (30min)
• Ureteral catheter
  indigocarmin액 주입하여 collecting
  system확인하고 water tight 봉합
• Hemostasis
  surgical bolster

• Results
• < 4cm , renal tumor
   partial Nx. (treatment of choice)
• Laparoscopic radical Nx.의 등장으로 partial Nx.가 약간 주춤.
• Laparoscopic technique의 발전과 경험의 축적으로 laparoscopic
  partial Nx.가 치료법으로 자리잡아가고 있는 추세입니다.
Hand-assisted urological laparoscopy
(Pietrow PK and Ablara DM) (Current opinion in urology 2003: 233-7)



• Many authors have proved the safety and efficacy of this
  technique.

• Radical/simple Nx.
    – Nakada et al (Urology, 2001:517-20)
      : HAL Nx offers considerable benefits with regard to pt recovery at the
      expense of increased OR time.

    – Batler et al (J Endourol 2001: 513-6)
      HAL Nx performed by residents with minimal experience.
• Partial Nx.
   – Wolf et al (2000)
     open partial Nx 와 비교.
     peripheral, exophytic, small tumor
     OR time was longer, but recovery was more favorable
   ………………..

• Radical/simple NUx
   – Shalhav et al (2000)
   – Stifelman et al (2001)
   ………………..

• Live donor Nx
   – Wolf et al (2001)
   – Ruiz-deya et al (2001)
   – 강남성모병원 , more than 100 HALDN
     ; HALDN appears to be a safe, technically feasible and effective alternative to
     conventional ODN. And HALDN may offer several advantages over the conventional
     ODN in terms of less postoperative pain, shorter convalescence, and minimal cosmetic
     disfigurement. The recipient graft function is similar in HALDN and ODN groups.
• Partial Nx.
   – Wolf et al (2000)
     open partial Nx 와 비교.
     peripheral, exophytic, small tumor
     OR time was longer, but recovery was more favorable
   ………………..

• Radical/simple NUx
   – Shalhav et al (2000)
   – Stifelman et al (2001)
   ………………..

• Live donor Nx
   – Wolf et al (2001)
   – Ruiz-deya et al (2001)
   – 강남성모병원 , more than 100 HALDN
     ; HALDN appears to be a safe, technically feasible and effective alternative to
     conventional ODN. And HALDN may offer several advantages over the conventional
     ODN in terms of less postoperative pain, shorter convalescence, and minimal cosmetic
     disfigurement. The recipient graft function is similar in HALDN and ODN groups.
Hand assisted retroperitoneoscopic nephroureterectomy:
comparison with the open procedure
(Kawauchi A et al) (J Urol 2003: 890-4)




                    B: camera
Hand assisted retroperitoneoscopic nephroureterectomy:
comparison with the open procedure
(Kawauchi A et al) (J Urol 2003: 890-4)

• 34 cases of hand assisted retroperitoneoscopic NUx. vs
  34 cases open NUx.
LAPAROSCOPIC RADICAL
    CYSTECTOMY
Laparoscopic radical cystectomy and continent orthotopic
ileal neobladder performed completely intracorporeally:
the initial experience. (Gill IS et al) (J Urol 168, 13-8)
•   1 man & 1 woman
•   Orthotopic substitution- Studer method
•   수술시간 : 8.5, 10.5 시간, no transfusion, surgical margin (-)
•   Post op: incontinence (-), IVP – 정상 upper tract.
Laparoscopic radical cystectomy and continent orthotopic
ileal neobladder performed completely intracorporeally:
the initial experience. (Gill IS et al) (J Urol 168, 13-8)
•   1 man & 1 woman
•   Orthotopic substitution- Studer method
•   수술시간 : 8.5, 10.5 시간, no transfusion, surgical margin (-)
•   Post op: incontinence (-), IVP – 정상 upper tract.
• Laparoscopic radical cystectomy and ileal conduit
   (강남성모병원 )
   – Laparoscopic PLND
   – Laparoscopic radical cystectomy
   – Ileal conduit (open)
  수술시간 = 9 시간,
  수혈 = 2 unit.
  술후 재원기간 =8일
  pathology = margin (-)
  specific Cx (-)
기   타
The effect of previous abdominal surgery on urological
laparoscopy (Parsons JK et al) (J Urol 168, 2387-90)

• radical nephrectomy (n=131), simple nephrectomy (n=64)
  pyeloplasty (n=131), renal biopsy (n=88)

• 이전의 수술 병력 (복강내 수술 또는 복강내 유착을 유발시킬 수
  있는 수술) 이 transperitoneal laparoscopic 수술에 미치는 영향 ?

• 수술 병력(+) = 전체 환자의 48%
  수술 병력(-) 군과 비교 하였을 때
  합병증의 발생, 수술시간, 재원기간, 개복수술로의 전환 등의 측
  면에서는 유의한 차이를 보이지 않았다. 다만 첫번째 trocar 삽
  입시 복강내 손상의 발생 가능성이 높다는 보고가 일부 있다.
Port site metastasis in urological laparoscopic surgery
(Tsivian A and Sidi AA) (J Urol 169, 1213-8)


• Port site metastasis rate = 0.8% - 21% ?
  정확한 발생율은 아직 알 수 없다.
   (open radical nephrectomy의 수술부위 전이율은 약 0.4%)
• Urologic laparoscopic 수술 시행 후 9건의 port 부위의 전이가 보고.
• Port site 전이에 미치는 요인
     – 술자의 경험
     – 그 외 예방할 수 있는 방법들
        - 복수가 있는 경우 수술을 피할 것,
        - trocar를 단단히 고정하여 빠지지 않도록 하며 주위로 가스가 새지 않게 한다
        - 수술 중 종양부위에 손상을 가하지 않는다.
        - 장기를 체외로 빼낼 때 laparoscopic bag을 이용
        - 복강 내 가스를 빼내기 전에 배액관을 먼저 삽입
        - 10mm 이상의 trocar 삽입 부위는 복막을 봉합
• Rassweiller et al
  1,098례의 laparoscopic urologic oncologic surgery 분석
  (F/U = 58 months)
  local recurrence = 8/1098 (0.73%)
  port site metastasis = 2/1098 (0.18%)

• laparoscopic urologic oncologic surgery 시행 후 국소재발이나
  port 부위의 전이율은 매우 낮으며, 이는 수술 테크닉 측면보다는
  종양자체의 특성에 더욱 의존적이라고 하였다.
경청해주셔서 감사합니다.