LAPAROSCOPIC UROLOGICAL SURGERY - PERIOPERATIVE EXPERIENCES OF INITIAL 100 CASES

1. Assistant Professor, Department of Urology, Dhaka Medical College Hospital. 2. Assistant Professor, BSMMU, Dhaka. 3. Medical Officer, Department of Urology, Dhaka Medical College Hospital. 4. Resident, Department of Urology, Dhaka Medical College Hospital. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 23 November 2019 Final Accepted: 25 December 2019 Published: January 2020


Methods:-
From January 2016 to July 2019, all the medical records of 100 patients who underwent laparoscopic urological surgery in Department of urology, Dhaka Medical College Hospital and other hospitals in Dhaka, Bangladesh were assessed and evaluated retrospectively. All the procedures were done by a single surgeon through transperitoneal approach. Evaluation of the patients was done with demographic variables, diagnosis, surgical procedure, approach of laparoscopy, operation time, hospital stay, requirement of analgesia, blood transfusion, complications during and after surgery and conversion to open surgery. All patients were optimized preoperatively as our routine clinical practice. Mechanical bowel preparation was given from the day before surgery. Written informed consent was taken from every patient with permission of open conversion during the surgical procedure. All the procedures were done under general anesthesia. Upper abdominal procedures were done in 45 0 lateral decubitus position without flexion of the table and pelvic procedures were done in semi lithotomy with steep Trendelenburg position. Operation time was defined as the time interval between starting point of pneumoperitoneum creation and skin closure. All the patients were monitored closely during hospital stay then follow up schedules were made at 7 th post-operative day, 1 month and 6 months.
For creation of pneumoperitoneum, Veress needle was used in every cases. During trocar placement pneumoperitoneal pressure was achieved 15 mmHg in upper abdominal cases and 20 mmHg in pelvic cases that were reduced to 12 mmHg and 15 mmHg respectively during the rest of the period. The employed energy sources were monopolar and bipolar diathermy with sometimes thermal (LigaSure-Covidien) for dissection. For upper abdominal cases dissection started with incision along the line of Toldt for colonic mobilization. Large size locking polymeric clips (Hem-O-Lok) were applied on renal vessels during nephrectomy and to achieve control of other pedicles. Dorsal venous complex was controlled either by knotting or LigaSure. Customized laparoscopic bag was used for organ retrieval through mini-laparotomy without morcellation.
In case of cyst decortication, retrograde pyelography was done routinely. After aspiration of cyst fluid, excised cyst wall was sent for histopathology. In case of ureterolithotomy, longitudinal ureteral incision was made by laparoscopic scissors. Incision site was closed with 5-0 vicryl suture after antegrade placement of a double J stent in every patient. In case of pyeloplasty, 5-0 vicryl suture was applied for running closure and antegrade double J stent was placed in every case.
Radical cystectomy specimen was retrieved through supra-umbilical mini-laparotomy incision. Every patient underwent ileal conduit urinary diversion extra-corporeally.

Results: -
The demographic characteristics of 100 patients are shown in Table 1. All the patients underwent transperitoneal approach. The 100 cases included 11 renal cyst decortication, 2 adrenalectomy, 4 simple nephrectomies, 8 radical nephrectomy, 3 radical nephroureterectomy, 26 pyeloplasty, 2 anterior transposition of ureter, 19 ureterolithotomy, 16 radical cystectomies, 3 VVF repair, 3 varicocelectomy, 1 orchidopexy and 2 radical prostatectomy ( Table 2). Per and post-operative data are shown in Table 3 and Table 4 respectively. There was no mortality. Total 5 patients required open conversion, among them 3 cases per-operatively and 2 cases post-operatively. Per-operative 1 case was radical cystectomy procedure due to excessive bleeding from inadvertent injury of superior vesical artery that was managed with immediate open conversion uneventfully, and another 2 cases were radical prostatectomy procedure that were converted to open due to lack of skill. Post-operatively 1 case of pyeloplasty required exploration due to excessive drain output and after exploration it was found that drain is within the PC system through suture line. After withdrawing the drain, the defect was repaired and patient recovered with uneventful post-operative period.
Another post-operative case that required laparotomy was post-radical cystectomy due to urinary leakage and operative findings was avascular necrosis of distal few cm of left ureter. Patient was managed with cutaneous ureterostomy with good post-operative outcome.

Discussion:-
In the field of urology, minimal invasive surgery is replacing the open surgical procedure. Laparoscopic surgery has many advantages in comparison to open surgical procedure 2 . Transperitoneal approach is mainly preferred by most of the surgeons that is cited in literature 3,4 . It has several advantages such as familiar anatomy, wide range of movements of the instruments etc. We performed all of our cases transperitoneally.
Our first laparoscopic case was simple renal cyst decortication. We performed total 11 cases uneventfully with excellent perioperative outcomes. In case of stone surgery, first laparoscopy was applied by Wickkam 5 . We performed total of 19 cases of upper ureteric stone. Our observation is that large stone and stone impacted in the mucosa is better managed by laparoscopy than push back and PCNL, however further study is needed.
Laparoscopic simple and radical nephrectomy is comparatively safe and has low complication rate than open surgery 6 . Most common complications in laparoscopic nephrectomy are hemorrhage and adjacent organ injury. We encountered no such complication in our series.
In early 90s pyeloplasty was first done by laparoscopy and now considered the most preferred method for correction of ureteropelvic junction obstruction 7 . Outcome is similar to the open surgery with better cosmetic and quality of life. It may be done by transperitoneal or retroperitoneal approach. We performed all of our cases through transperitoneal approach. Our observation is that transperitoneal approach is much comfortable due to familiar anatomy, normal position of the kidney during surgery, crossing vessel manipulation and wide range of instrumental movement.
We performed total 16 cases of radical cystectomy. Laparoscopic approach is advantageous in the view of better magnification and optimal vision deep to the perineum. The challenges are control of dorsal venous complex, avoidance of rectal injury and preservation of blood supply of the distal ureter. We faced one case of avascular necrosis of the distal few cm of left ureter and our observation is that during dissection adequate amount of periureteric tissue should be preserved and avoidance of crushing the ureter with instruments. Ileal conduit urinary diversion was done extracorporeally in every case.
Laparoscopic radical prostatectomy has been increasingly popular day by day. With robotic assistance it is now the standard practice in many centers 8 . It has several advantages such as magnified picture and relatively easier access deep into pelvis in comparison to open procedure, small incision, less pain and faster recovery. But it is difficult procedure, and long learning curve and surgical skill is needed to perform the procedure safely.
So far as our knowledge our complications rate is comparable to other studies 9 .
experiences of number of cases and surgical skill is needed to overcome the learning curve. We believe that in the field of laparoscopy our experiences will help the patients to prefer this technique and we will provide more patient satisfaction.