Laparoscopic urologic surgery in malignancies - part 9 docx

Minimally Invasive Radical Prostatectomy After Previous Abdominal Surgery 246 Minimally Invasive Radical Prostatectomy After Previous Inguinal Hernia Repair 247 Recurrent Hernias 249 Tot

anterior, but getting disoriented in the fat anterior to

Gerota's fascia risks duodenal injury

The key to a smooth radical nephrectomy is neatlydeveloping the plane between the colon mesenteryand the anterior surface of Gerota's fascia There is aqualitative difference in the character of the fat; thisshould be learned on normal patients before taking

on the obese While it is easier to get lost in the obesepatient's mesentery, it is more difficult to actuallycause through-and-through mesenteric rents Theserents can be dangerous as internal herniation ofbowelcan occur through them

The total size ofthe contents ofGerota's fascia canvary enormously, as shown in Fig 6 In general, wom-

en have less perinephric fat than men and that fatseems less dense and adherent However, the patient'sBMI does not yield a good prediction as to theamount ofperinephric fat

The radical nephrectomy or nephroureterectomy isperformed in the standard fashion Retraction of bow-

el or fat can be done with paddles or effective tion can be done with an assistant' hand through theextraction site incision We prefer an entrapment bagfor specimen extraction On occasion, the kidney andits perinephric fat are too large for entrapment andthe specimen must be retrieved manually via the ex-traction site Because the total surgical specimen islarge, the extraction sites need to be slightly larger.Attempts to pull a very large specimen through toosmall an extraction site risks specimen rupture andspillage

retrac-In obese patients, using a hand-assist port is ful The hand can provide retraction extremely effi-

use-Fig 5 Obese patient positionedfor left radical

nephrec-tomy Note well-demarcated line where abdominal fat falls

medially approximately at the lateral border of the rectus

abdominis The deep cleft suprapubically makes for an

over-hanging ledge of fat above the incision A longitudinal

ex-traction incision is preferable, for example through this

pa-tient's previous lower midline scar, but there is still a large

amount of subcutaneous fat to traverse

Fig 6a, b Two patients with same BMI show different amounts of perinephric fat

ciently and specimen extraction is easy However,

placement ofthe hand port is a problem An umbilical

site often requires going through a large amount of

ventral fat and the operator's arm can become quite

fatigued A site at the lateral border of the rectus is

more ideal, but the incision is more uncomfortable for

the patient

In nephroureterectomy in obese patients, the distal

ureteral resection should be done open via the

extrac-tion site

Retroperitoneal Lymphadenectomy

Laparoscopic retroperitoneal lymphadenectomy for

testis tumor staging is routinely performed by several

groups As imaging and chemotherapy regimens have

improved, the indications for the staging procedure

have decreased Janetschek [5] has shown that

laparo-scopic node dissection is safe and effective in stage I

disease, but he has not reported any experience with

the obese The series ofRassweiler et al [6] and

Nel-son et al [7] similarly do not describe the results in

obese males Positioning for the surgery ranges from

oblique to supine With significant obesity, it is likely

that the abdominal fat of truly large individuals would

interfere significantly Often, resection of residual

masses after chemotherapy is required Small residual

masses after chemotherapy have been resected

laparo-scopically [8], but none in obese patients have been

reported

Pelvic Lymphadenectomy

Pelvic lymphadenectomy alone is being done much

less frequently than a decade ago when it was the

most common urological cancer operation done

lap-aroscopically There will be very few cases now in

which the probable staging is unknown and nodal

sta-tus needs to be known in advance ofa planned

treat-ment modality Pelvic lymphadenectomy in the obese

patient is more difficult primarily due to the ventral

abdominal girth and the bowel pushing down into the

pelvis and obscuring the dissection The dissection

it-selfidentifies and preserves the vessels, vasa, pubic

bone, ureter, bladder, and prostate and removes all the

nodal tissue with a large amount ofadipose tissue In

obese subjects, a full preoperative bowel prep is useful

in reducing the sheer bulk ofthe bowel contents

Though there is little hard evidence that nitrous oxidecauses bowel distention, anesthesia is requested toavoid its use A steep Trendelenburg position helps alittle with opening up the vision in the pelvis For thisreason, securely taping the patient to the table preop-eratively is mandatory Unfortunately, the steep Tren-delenburg position makes ventilation ofthe obese pa-tient more difficult

Lower Urinary Tract MalignanciesLaparoscopy for lower urinary tract malignancies ismuch more difficult than for upper tract cancers due

to the lower ventral abdominal fat, as shown in Fig 7.Gynecological surgeons have a long-standing experi-ence in laparoscopic extirpative pelvic surgery inobese patients [9, 10], but little experience with recon-structive procedures

Radical cystectomy is performed by only a fewgroups [11], though many groups have adapted lap-aroscopic techniques to open cystectomy procedures.The benefit to the patient of a smaller incision is less

Fig 7 CT scan of an obese patient's pelvis at the level of the upper edge of the pubic symphysis The shortest direct distance from skin to anterior rectus fascia is 12 cm and to the bladder is 20 cm The longest available laparoscopic tro- cars are 15 cm

apparent in cystectomy, because a larger extraction

in-cision is required for specimen removal

The most difficult, time-consuming part of the

cys-tectomy is the urinary diversion In obese patients,

isolating the bowel segment can be quite tedious with

open surgery due to the thickness and decreased

mo-bility ofthe mesentery But what almost prohibits use

ofthe laparoscopic approach is creating the stoma A

good stoma is everted well above the skin and the

skin is left flat and smooth for faceplate adherence A

thick bowel mesentery is difficult to bring through the

fascial opening and thick subcutaneous fat requires

the bowel to be mobilized more [12] The creation of

a Turnbull-type stoma may be required to obtain a

satisfactory ostomy even in open surgery in the obese

It seems likely that new ideas and/or material will be

required before conduits can be done safely and

effi-ciently in the obese

Laparoscopic radical prostatectomy is not done on

obese patients frequently for the following three

rea-sons

1 Obese males in the prostate cancer age group often

do not have life expectancies long enough to

war-rant the potential morbidity ofthe procedure

2 Fewer surgeons have the broad experience required

for laparoscopic prostatectomy than is the case for

laparoscopic upper tract surgery

3 Obesity makes identification of anatomical

struc-tures more difficult in the pelvis

Patients in the American series reported by Menon

et al had an average BMI ofonly 27.7+2.8 SD [13]

European patients are even thinner The largest

Euro-pean series oflaparoscopic radical prostatectomy

re-ports an average BMI of25.8Ô2.8 SD [14] An

Ameri-can patient with a BMI of38 is the most obese yet

re-ported [13]

No particular points have yet been reported in

how to handle the obese prostatectomy patient

Those surgeons who perform a transperitoneal

approach first try to identify the vasa deferentia and

the seminal vesicles from behind the bladder in the

male cul-de-sac With obesity, these structures cannot

be seen through the overlying peritoneum; the

sur-geon relies upon experience and an innate sense of

orientation The entirely preperitoneal approach is

employed by other surgeons Obesity places a large

amount oflateral stress on the trocars in attempting

to get the correct angle to operate deep under the

pubic bone

Morbidity

An increase in the complication rate for the obeseshould be expected Certainly the rate ofconversion toopen surgery is higher in the obese both for proce-dures done for benign disease and or for malignancies[15±21] Even inducing anesthesia is more difficultdue to short and thick neck, large tongue, and redun-dant pharyngeal and soft palate tissue Awake fiberop-tic intubation may be necessary for select patients.Cardiopulmonary problems will be increased due toboth the higher rate ofpreoperative cardiopulmonarydisease and the intraoperative increased pulmonarystress However, the laparoscopic approach should de-crease the pain ofpulmonary toilet as well as the nar-cotic requirements compared to open surgery

Anesthesia Effect on Pulmonary Function

Obesity has many effects on ventilation [22±26] There

is increased oxygen consumption and CO2production,decreased lung volumes and chest wall compliance, aswell as increased work for breathing Some of themorbidly obese will also show signs ofPickwickiansyndrome These signs include hypercarbia, hypox-emia, polycythemia, sleep apnea, pulmonary hyperten-sion, congestive heart failure and a predisposition toairway obstruction Obese patients may also have gas-troesophageal reflux disease, complicating inductionofanesthesia [27]

Oncological results should be equivalent in theobese and nonobese There may be a tendency to try

to squeeze specimens through a too small extractionsite in obese patients This may lead to a higher rup-ture rate ofspecimens and extraction bags From atheoretical perspective, this may increase local recur-rences and port site metastases

Current LimitationsVisualization and exposure as well as the loss oftac-tile sensation remain problems with laparoscopic sur-gery Unlike open surgery, laparoscopic surgery de-mands that the surgeon be as ambidextrous as possi-ble This is caused by constraints on the degrees offreedom necessary when operating through smallports In obese patients, it may be necessary to add

one or two more ports to aid in retraction and

expo-sure However, ifyou add too many ports, both costs

and overall incision size increase

Future Horizons

As our technology gets better, we will be able to see

better with less light Camera technology is improving

rapidly There are advances in chip technology that

place the imaging sensor on the tip ofthe scope rather

than at the end ofa lens rod system Camera

sensitiv-ity is also increasing Light sources are also being

im-proved to the point that they are self-contained and

are more efficient Ultrasound may be a necessary

ad-junct to laparoscopic surgery that will replace the

sense oftouch with much more sensitive, flexible and

expensive instrumentation Finally, computer-assisted

surgery through robotics, information displays at the

time ofsurgery, and robotic assistants may be helpful

in laparoscopic surgery, especially in challenging

pa-tients such as the obese

Conclusions

Obese patients benefit more from laparoscopic surgery

for genitourinary malignancies than thinner patients

However, the surgical procedure is distinctly harder

on the surgical team Because the number ofobese

pa-tients with genitourinary malignancy will be

increas-ing rapidly in the comincreas-ing decades, surgeons willincreas-ing to

undertake laparoscopic procedures will be in demand

While the most experienced laparoscopic surgeon

usually takes on the obese patients, training programs

teaching laparoscopy need to emphasize to trainees

the magnitude ofthis growing population ofthe obese

References

1 Clinical guidelines on the identification, evaluation, and

treatment ofoverweight and obesity in adults (1998)

NIH Publication 98±4083, June 1998, p vii.

2 McTigue KM, Garrett JM, Popkin BM (2002) The

natur-al history ofthe development ofobesity in a cohort of

young U.S adults between 1981 and 1998 Ann Intern

Med 136:857±864

3 Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ

(2003) Overweight, obesity, and mortality from cancer

in a prospectively studied cohort ofU.S adults N Engl

J Med 348:1625±1638

4 Ezri T, Hazin V, Warters D, Szmuk P, Weinbroum AA (1999) The endotracheal tube moves more often in obese patients undergoing laparoscopy compared with open abdominal surgery Anesth Analg 162:665±669

5 Janetschek G, Hobisch A, Peschel R, Hittmair A, Bartsch G (2000) Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous testicular carcinoma: long-term outcome J Urol 163: 1793±1796

6 Rassweiler JJ, Seemann O, Henkel TO, Stock C, Frede T, Alken P (1996) Laparoscopic retroperitoneal lymph node dissection for nonseminomatous germ cell tumors: indications and limitations J Urol 156:1108±1113

7 Nelson JB, Chen RN, Bishoff JT, Oh WK, Kantoff PW, Donehower RC, Kavoussi LR (1999) Laparoscopic retro- peritoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular tumors Urology 54:1064±1067

8 Palese MA, Su L, Kavoussi LR (2002) Laparoscopic roperitoneal lymph node dissection after chemotherapy Urology 60:130±134

ret-9 Eltabbakh GH, Piver MS, Hempling RE, Recio FO (1999) Laparoscopic surgery in obese women Obstet Gynecol 94:704±708

10 Ostrezenski A (1999) Laparoscopic total abdominal terectomy in morbidly obese women A pilot-phase re- port J Reprod Med 44:853±858

hys-11 Gill IS, Kaouk JH, Meraney AM, Desai MM, Ulchaker

JC, Klein EA, Savage SJ, Sung GT (2002) Laparoscopic radical cystectomy and continent orthotopic ileal neo- bladder performed completely intracorporeally: the ini- tial experience J Urol 168:13±18

12 Duchesne JC, Wang YZ, Weintraub SL, Boyle M, Hunt

JP (2002) Stoma complications: a multivariate analysis.

Am Surg 68:961±966

13 Menon M, Tewari A (2003) Robotic radical tomy and the Vattikuti Urology Institute Technique: an interim analysis ofresults and technical points Urology

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14 Guillonneau B, El-Fettouh H, Baumert H, Cathelineau X, Doublet JD, Fromont G, Vallancien G (2003) Laparo- scopic radical prostatectomy: oncological evaluation after 1000 cases at Montsouris Institute J Urol 169: 1261±1266

15 Mendoza D, Newman RC, Abala DM, Cohen MS, Tewari

R, Winfield H, Glascock JM, Das S, Munch L, Grasso M, Dickinson M, Clayman R, Nakada S, McDougall EM, WolfIS, Hulbert J, Leveille RJ, Houshair A, Carson C (1996) Laparoscopic complications in markedly obese urologic patients (a multi-institutional review) Urology 48:562±567

16 Fazelli-Matin S, Gill Hsu THS, Sung GT, Novick AC (1999) Laparoscopic renal and adrenal surgery in obese patients: comparison to open surgery J Urol 162:665±669

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af-18 Alponat A, Kum CK, Koh BC, Rajnakova A, Goh PM

(1997) Predictive factors for conversion of laparoscopic

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RD, Hammel J (2002) The impact ofmorbid obesity, pneumoperitoneum, and posture on respiratory system mechanics and oxygenation during laparoscopy Anesth Analg 94:1345±1350

25 Ogunnaike B, Jones SB, Jones DB, Provost D, Whitten

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gastroin-pp 1169±1183

Minimally Invasive Radical Prostatectomy After Previous

Abdominal Surgery 246

Minimally Invasive Radical Prostatectomy After Previous

Inguinal Hernia Repair 247

Recurrent Hernias 249

Total Extraperitoneal Preperitoneal Repair

Technique 249

References 251

Since the first laparoscopic nephrectomy was

per-formed by Clayman in 1990 [1], urological

laparo-scopy has undergone a rapid advancement Many of

the standard operations in urology can now be

per-formed laparoscopically or with minimally invasive

techniques, including simple and radical nephrectomy,

partial nephrectomy, nephroureterectomy, pyeloplasty,

primary and secondary pelvic and retroperitoneal

lymph node dissection, antireflux operations, radical

prostatectomy and even radical cystectomy plus

uri-nary diversion It is well accepted that laparoscopic

ur-ologic surgery is associated with a considerable

learn-ing curve, especially in technically difficult operations

such as partial nephrectomy or radical prostatectomy

Despite the growing experience with laparoscopic

op-erations, there is still some uncertainty about relative

or absolute contraindications to the laparoscopic

approach Historically, previous abdominal surgery

has been considered as a relative contraindication to

transperitoneal laparoscopy due adhesion formation,

making minimally invasive surgery even more

de-manding Furthermore, adhesion formation after

ab-dominal surgery remains a major cause

ofpostopera-tive morbidity, and adhesion formation after

transab-dominal procedures may be completely unpredictable,

making laparoscopic access and dissection difficult or

impossible

Adhesions from previous intra-abdominal surgery

can be divided into two groups The first group

in-cludes adhesions or scar tissue formations internally

at the surgical site Examples are scar tissue formationaround the ileocecum following appendectomy or ex-tensive bowel or colon adhesion after hemicolectomy.The second type ofadhesion originates from the ab-dominal wall where the peritoneum has been incised.The formation of adhesions is an adaptive response tolocalized peritoneal injury and the location ofthe ad-hesions corresponds to the site ofthe peritoneal in-jury Adhesions may extend through the entire lengthofthe peritoneal incision, so that the external scarmay not be indicative oftheir extent or location.Autopsy studies showed intra-abdominal adhesionsafter open abdominal surgery in up to 90% of patients[2] There are only few data available comparing adhe-sion formation in patients with previous open vs pre-vious laparoscopic procedures In contrast to historicaldata on open abdominal procedures, Pattaras and co-workers found adhesion formation in only 22.2% ofpatients with previous laparoscopic procedures [3, 4].These data suggest that transperitoneal laparoscopicprocedures may cause fewer and less severe adhesionscompared to open surgical procedures The reducedrate of adhesion formation corresponds with the find-ing ofFornara et al that laparoscopy reduces opera-tive trauma and the extent ofacute-phase reactions asmeasured by different serum parameters such as IL-6,IL-10 and C-reactive protein [5]

While there are a number ofreports on tion rates in various laparoscopic procedures in urol-ogy [6, 7], only little is known about the aspect ofprevious open or minimally invasive procedures in ur-ological laparoscopy There are few reports that pre-vious abdominal surgery does not significantly alterthe outcome ofsubsequent urological laparoscopy [8,9]

complica-Parsons and co-workers from John Hopkins viewed their experience about the effect of previousabdominal surgery on urological laparoscopy [9]: out

re-10.3 Prior Surgery

Jens-Uwe Stolzenburg,Kossen M.T Ho,Michael C Truss

of700 patients operated on between 1995 and 2001,

366 (52%) had never undergone surgery, 105 (15%)

had a history ofabdominal surgery in the same

ana-tomical region and 229 (33%) had a history

ofabdom-inal surgery in a different region The four most

com-mon laparoscopic procedures were radical

nephrecto-my, simple nephrectonephrecto-my, pyeloplasty and renal biopsy

The authors found that a history of surgery at the

same site was associated with increased operative time

and increased hospitalization Differences in operative

blood loss, complications and conversion rates in

pa-tients with and without a history ofsurgery did not

reach statistical significance Despite the differences in

operative time and hospitalization, the authors

con-cluded that previous abdominal surgery does not

ap-pear to affect adversely the performance of subsequent

urological laparoscopy

Seifman et al from Ann Arbor, Michigan, reviewed

their experience with renal and adrenal laparoscopic

procedures in patients with previous abdominal

opera-tions [10] In their population of76 patients, they

found no differences in operation time (median, 220

vs 210 min; p>0.05) However, the mean hospital stay

was longer in the group ofpatients with previous

ab-dominal surgery (3.8 vs 2.6 days; p=0.002) Also

op-erative and major complications rates were more

com-mon in patients who had undergone previous

opera-tions (16% vs 4%; p=0.009 and 16% vs 5%; p=0.022,

respectively) Access and total complication rates did

not significantly differ statistically Of note, an upper

midline scar or lateral upper quadrant scar was

asso-ciated with a greater access complication rate, but not

a higher operative complication rate They concluded

that previous open abdominal surgery increases the

risk ofoperative and major complications, which have

an impact on the length ofhospital stay The location

ofscars also has an impact on the access complication

rate

One report suggests a higher risk ofgas embolism

in patients with previous abdominal surgery [11];

however, this complication has not been noted by

others We were unable to identify a single case of gas

embolism in our patient population with or without

previous abdominal surgery

Minimally Invasive Radical Prostatectomy After Previous Abdominal Surgery

Because ofthe above-mentioned concerns, someauthors regard previous extensive transabdominal sur-gery or previous pelvic surgery as a contraindicationfor laparoscopic radical prostatectomy (LRPE) [12] Inother laparoscopic centers, previous major abdominalsurgery or pelvic surgery is not a contraindication fortransperitoneal LRPE [13, 14] Due to the formationofabdominal adhesions the transperitoneal procedure

is certainly more demanding, time-consuming andpossibly associated with more complications, althoughrandomized data are not available to date In contrast,the endoscopic extraperitoneal radical prostatectomytechnique (EERPE) avoids these problems in patientswith prior abdominal surgery because it is a totallyextraperitoneal approach [15, 16]

Many laparoscopic procedures on retroperitonealorgans have utilized a transperitoneal approach such

as transperitoneal nephrectomy or transperitonealpyeloplasty In these cases, the transperitoneal routeoffers the advantages of familiarity of the approachand increased working space However, in urologicalpelvic surgery, especially in prostatectomy, the limitinganatomical landmarks are the pubic arc and the pelvicfloor musculature and not the abdominal cavity Re-cently, it was demonstrated that the extraperitonealapproach to the prostate is equal or even superior tothe transperitoneal approach in radical prostatectomy[17, 18]

Our own experiences include 500 cases scopic extraperitoneal radical prostatectomy per-formed between December 2001 and April 2004 Thepatients were stratified into five groups: I no previousabdominal, inguinal or prostate surgery (322 patients,64.4%); II previous upper abdominal surgery (13 pa-tients, 2.6%); IIIa previous lower abdominal or pelvicsurgery or open inguinal hernioplasty (105 patients,21%); III b laparoscopic/endoscopic inguinal hernio-plasty (nine patients, 1.8%); IV previous prostatic sur-gery (22 patients, 4.4%); and V a combination ofgroups II, III and IV (29 patients, 5.4%) Groups I and

ofendo-II were analyzed together since the previous operativefields in group II were distant from the Retzius space.The mean patient age was 63.7 years (range, 42±

77 years) Mean preoperative values ofprostatic specificantigens (PSA) was 12.1 ng/ml (range, 1.4±67 ng/ml)

In 218 cases (43.6%), pelvic lymphadenectomy was

per-formed depending on the preoperative Partin

calcula-tion [19]

The overall mean operative time was 149 min

(140Ô36 min without lymphadenectomy, 161Ô41 min

with lymphadenectomy) In group I, the mean operative

time was 147Ô39 min, in group II 157Ô46 min, in

group IIIa 150Ô37 min, in group III b 170Ô48 min,

in group IV 162Ô49 min, and in group V 159Ô

37 min There was no statistically significant difference

with regard to operative time between patients with or

without previous abdominal or pelvic surgery

In all 500 cases, there were no intraoperative

com-plications that required conversion to open surgery

The transfusion rate was 0.8% (four patients; one

pa-tient in group I, and three papa-tients in group IIIa) We

had three early re-operations (0.6%) caused by

bleed-ing on the 1st postoperative day (one patient in group

I, two patients in group IIIa) and eight late

re-opera-tions (1.6%) These include four laparoscopic

fenestra-tions and one percutaneous drainage ofsymptomatic

lymphoceles (two patients in groups I/II and one

pa-tient each in groups IIIa, IV and V); one temporary

dysfunctioning colostomy in a patient with a rectal

fistula (group IV), one repair of a port site hernia

(group I) and one transurethral incision ofan

anasto-motic stricture (group V) There were no other major

complications No intra-abdominal complications

(prolonged ileus, bowel injury or peritonitis) occurred

that was attributable to the totally extraperitoneal

approach ofthe procedure

With regard to the pathological results, 161 patients

(32.2%) had cancer limited to the prostate (stage pT2a

in 67 patients, pT2b in 94 patients); 273 patients had

histological evidence oftumor extension beyond the

prostatic capsula (pT3a, 54.6%) and 62 patients had

tumor infiltration into the seminal vesicles (pT3b,

12.4%) Four patients had pT4-tumors (0.8%) In 12

out of218 patients who underwent concurrent pelvic

lymph node dissection, pelvic nodal involvement was

found The rates of positive surgical margins for pT2

tumors was 10.5% (17/161 patients) and for pT3

tu-mors 33.4% (112/335 patients)

Endoscopic extraperitoneal radical prostatectomy

can be performed regardless of patient urological

his-tory Prior prostate surgery such as transurethral

re-section ofthe prostate or bladder neck incision is not

a contraindication for EERPE Furthermore, there is

no statistically significant difference between patients

with and without prior abdominal and pelvic surgery

with regard to operative time and complication rates.Because ofthe totally extraperitoneal approach, pre-vious abdominal surgery does not interfere with endo-scopic extraperitoneal radical prostatectomy

Minimally Invasive Radical Prostatectomy After Previous Inguinal Hernia Repair

Inguinal hernia repair is one ofthe most commonsurgical procedures Therefore it is not surprising thatmany patients with prostate cancer already had pre-vious inguinal hernia surgery Hernia repair optionscan be broadly categorized into open and laparoscopictechniques The open technique was first described in

1884 by Bassini and involved reinforcement of the guinal floor combined with ligation of the hernia sac

in-In 1973, Stoppa et al introduced the application ofalarge polyester prosthesis during the open procedure,placed preperitoneally, for inguinal hernia repair [20].Laparoscopic hernia techniques can be performedtransperitoneally or totally extraperitoneally The keyelement in the development ofthe transabdominalpreperitoneal repair (TAPP) or the total extraperito-neal preperitoneal repair (TEP) has been the introduc-tion ofprosthetic materials for a tension-free hernior-rhaphy

The classical methods ofhernia repair only seldomlead to postoperative adhesion formation, which influ-ences a laparoscopic procedure in the small pelvis likeradical prostatectomy Simply during totally extraperi-toneal prostatectomy, the creation ofthe preperitonealspace can be aggravated by a fixation of the perito-neum to the abdominal wall In special cases, a partialintraperitonealization ofthe procedure can be helpful.The adherent peritoneum is incised on a length of2±

3 cm to make placement ofthe lateral trocars possibleunder visual control The resulting capnoperitoneumdoes not influence the further steps of the procedureand does not minimize the preperitoneal space ifthepatient is sufficiently muscle relaxed

In contrast, a preperitoneally placed mesh can lead

to extensive adhesions between the abdominal wall,the mesh and the peritoneum Different authors dis-cuss previous preperitoneal hernia repair with meshplacement as a contraindication for a laparoscopicradical prostatectomy [12] In these cases, a perinealapproach for prostatectomy is frequently recom-mended

Our own experiences with 70 laparoscopic radical

prostatectomies and of500 cases ofendoscopic

extra-peritoneal radical prostatectomies show that prior

mesh placement does not represent an absolute

con-traindication to this kind ofoperation In our patient

population, we had two patients with a unilateral

modified Stoppa operation, four patients with

unilat-eral TEP, one patient with bilatunilat-eral TEP and four

pa-tients with unilateral TAPP procedure in their history

The preperitoneal space could be developed and the

trocars could be placed as shown in Fig 1a without

problems and the operation finished successfully in

the first two patients The mesh placed into the

pre-peritoneal space during the open procedure did not

interfere with the EERPE procedure

In patients with prior laparoscopic preperitoneal

hernia repair, we use a modified trocar placement to

avoid complication during trocar placement associated

with mesh adhesions In patients with a mesh in theleft inguinal region, the first steps of the procedure toinsert the balloon trocar and the optical (Hasson-type) trocar are similar to the classical EERPE proce-dure [15] A 1.5-cm paraumbilical incision is made onthe right-hand side, and preparation is carried down

to the rectus abdominis aponeurosis The anterior tus fascia is incised, and the rectus muscle fibers arevertically separated by blunt dissection, exposing theposterior rectus fascia The balloon trocar is intro-duced along the posterior rectus sheath and the bal-loon is slowly insufflated under direct visual control.The balloon trocar is exchanged for the optical (Has-san-type) trocar and a 5-mm trocar is placed directly

rec-in the midlrec-ine halfbetween the umbilicus and thesymphysis, as shown in Fig 1b The preperitonealspace is carefully developed However, no extensiveadhesiolysis is performed in the left inguinal region

Fig 1a±c Trocar placement for endoscopic radical tectomy (EERPE) a Trocar placement for standard proce- dure b Trocar placement in patients with prior mesh place- ment to the left inguinal region c Trocar placement in patients with prior mesh placement to the right inguinal region

prosta-The preperitoneal space is only developed to the point

where safe trocar placement is possible in the

pararec-tal line In that way, the operator, standing on the left

side ofthe patient, is working through a trocar in the

left pararectal line and a trocar placed in the midline

(Fig 1b)

In patients with a mesh in the right inguinal

re-gion, the first 15-mm incision is made in the

infraum-bilical crease on the left side to the midline and the

balloon trocar and the optical trocar are inserted as

described above A 5-mm trocar is placed in the left

pararectal line (Fig 1c) and the creation ofthe

pre-peritoneal space is continued Once the peritoneum

has been completely dissected free from the left

poste-rior aspect ofthe rectus muscle, a 12-mm trocar is

placed approximately two fingers breadth medial to

the left anterior superior iliac spine No extensive

ad-hesiolysis is performed in the right inguinal region to

avoid injury ofthe peritoneum fixed to the mesh In

these patients, the right lateral trocar is renounced

and a 5-mm working trocar is placed into the

pararec-tal line 2±3 cm above the symphysis instead (Fig 1c)

The assistant, standing on the right side ofthe patient,

is working through this trocar and a trocar placed in

the pararectal line at the level ofthe umbilicus, as

shown in Fig 1b This system oftrocar placement

usually permits a prostatectomy without technical

dif-ficulties However, pelvic lymph node dissection may

not be feasible on the side where the mesh is placed

Recurrent Hernias

In the literature, relatively little attention is given the

concomitant appearance ofinguinal hernia in patients

with prostate cancer Although the coincidence of

prostate cancer and inguinal hernia has not been

de-scribed in clinical studies, we encounter patients with

both diseases in clinical practice Some authors

de-scribe a concomitant inguinal hernia in 13%±18% of

these patients, including 3% recurrent hernias [21±

23]

Total Extraperitoneal Preperitoneal

Repair Technique

The preperitoneal laparoscopic approach offers several

advantages, two important anatomical ones being

di-rect access to the posterior inguinal anatomy and clear

visibility ofall possible hernial defects In cases of

concomitant inguinal hernia (there is no differencebetween primary or recurrent hernias), we use a stan-dardized procedure for TEP hernia repair during pros-tatectomy After placement of all trocars in the pre-peritoneal space, EERPE starts with hernia sac prepa-ration In direct hernias (Fig 2d), the hernia sac isfound medial to the epigastric vessels In such cases,traction and countertraction are used to reduce thehernia sac In indirect hernias, cautious dissection ofthe spermatic cord enables the reduction ofthe herniasac The hernia sac is completely dissected out oftheinguinal canal and left in the preperitoneal space(Fig 2c) Reduction ofany hernias encountered allowscomplete exposure ofthe pelvic structures, which isnecessary for pelvic lymph node dissection and pros-tatectomy The actual hernia repair with mesh place-ment has to be performed at the very end of the pros-tatectomy, after finishing the urethrovesical anastomo-sis

In recurrent indirect inguinal hernias, the key to asafe dissection is the creation of a space posterior tothe epigastric vessels at a level halfway between theumbilicus and the anterosuperior iliac spine Fromthere, access can be gained to the transversus abdomi-nis muscle laterally The dissection is then continuedalong the lateral aspect, first in the cranial direction

to place the 5-mm working trocar in the lateral iliacfossa at the level of the anterosuperior iliac spine, andsecond toward the inguinal ring The hernia sac isnow situated between the Retzius space medially andthe space with the inserted trocar laterally The herniasac is then dissected away from the cord structures in

a perpendicular fashion Very seldom, mostly in casesofscrotal hernias, a sharp dissection or even cuttingofthe hernia sac is necessary In that case, care has to

be taken to close any defect of the peritoneum at theend ofthe hernia sac preparation to avoid contact be-tween the finally placed mesh and the bowel

At the very end ofthe prostatectomy, the spermaticcord is elevated and an opening is created behind thespermatic cord at the side ofthe inguinal hernia to al-low the comfortable passage of a synthetic mesh Weprefer a Prolene mesh (8±10´13±15 cm, depending onthe size ofthe inguinal defect), which is prepared ex-ternally (Fig 2a, b) The mesh is incised in the mid-dle, the length ofthe cut being 6 cm At the distal endofthe split, a small hole is cut into the mesh to pro-vide sufficient space for the spermatic cord The split

is then covered by a flap (Prolene mesh, 6´5 cm) andthe flap is fixed by Prolene ligature For placement in

Fig 2a±f Total extraperitoneal hernia repair with mesh

placement into the preperitoneal space (TEP technique, left

side) a Externally preparedProlene mesh (8±10´13±15 cm).

b The preparedmesh is rolledup for placement in the

pre-peritoneal space through the 12-mm trocar c Direct hernial

orifice d Indirect hernial orifice e Placement of the mesh roll beneath the spermatic cord f The mesh is systemati- cally unfolded around the spermatic cord and the hernial orifices are completely coveredby the mesh e epigastric vessels, sc spermatic cord, p pubic arc, hs hernial sac

the preperitoneal space through the 12-mm trocar, the

prepared mesh is rolled up (Fig 2b) It is then placed

beneath the spermatic cord (Fig 2e) Subsequently,

the mesh is unfolded upon the epigastric vessels and

the hernial orifice (Fig 2f) The direct and indirect

spaces are completely covered by the mesh The

pre-pared flap covers the split and the mesh is fixed by

the spermatic cord Figure 3 shows a schematic ofthe

mesh placed in the preperitoneal space No staples or

sutures are necessary to fix the mesh

In our series ofEERPE, a total of33 inguinal

her-nia defects were treated concomitantly during EERPE

Unilateral hernias were identified in 27 patients and

bilateral hernias were identified in three patients

Three were recurrent hernias and four hernia defects

were incidental

The mean additional time for the hernioplasty was

12 min in unilateral hernias and 20 min in bilateral

hernias Although our follow-up has been short, there

was no recurrence to date and most recurrences in

hernia surgery are early There were no specific

com-plications attributed to the TEP procedure These

re-sults demonstrate that the progress oflaparoscopic

and endoscopic techniques permits us to extend and

combine the indications for its use to include complex

oncological surgery such as radical prostatectomy and

reconstructive surgery such as hernia repair

(includ-ing recurrent hernias) ifthe totally extraperitoneal

ac-cess is used, providing a safe and minimally invasive

approach to radical prostatectomy and inguinal hernia

repair

In summary, there is little dispute that adhesion

formation after previous open surgery can be

exten-sive and in general makes subsequent open and

lapa-roscopic surgery more difficult While some authors

regard previous open abdominal surgery as a

contra-indication to subsequent laparoscopic surgery, there

are actually no supporting data in the urological

lit-erature Our own experience with endoscopic

extra-peritoneal radical prostatectomy in patients with

pre-vious open or minimally invasive hernia repair

sup-ports the view that this kind ofsurgery is certainly

more demanding, but technically feasible Especially

in patients with prior abdominal surgery, the benefits

ofa totally extraperitoneal approach in radical

prosta-tectomy is obvious [24]

Although patients with previous abdominal surgery

should be approached with caution, it would be

unfor-tunate to deny laparoscopic or endoscopic procedures

to these patients while risks can be successfully

mini-mized by thorough understanding ofthe surgicalanatomy and meticulous laparoscopic and endoscopicpreparation and technique In the hands ofthe experi-enced laparoscopic/endoscopic surgeon, previous ab-dominal or pelvic surgery is not a contraindication tolaparoscopy As in any surgical procedure, the experi-ence ofthe surgeon determines the quality ofthe pro-cedure and the complication rate

3 Pattaras JG, Moore RG, Landman J, Clayman RV, Janetschek G, McDougal EM et al (2002) Incidence of postoperative adhesion formation after transperitoneal genitourinary laparoscopic surgery Urology 59:37±41

Fig 3 Schematic drawing of mesh placement in the peritoneal space covering the direct and indirect hernial ori- fices aw abdominal wall, e epigastric vessels, p pubic bone,

pre-r pre-rectus muscle, sc spepre-rmatic copre-rd, vd vas defepre-rens

4 Fornara P, Doehn C, Seyfarth M, Jocham D (2000) Why

is urological laparoscopy minimally invasive? Eur Urol

37:241±250

5 Vallancien G, Cathelineau X, Baumert H, Doublet JD,

Guillonneau B (2002) Complications oftransperitoneal

laparoscopic surgery in urology: review of1311

proce-dures at a single center J Urol 168:23±26

6 Fahlenkamp D, Rassweiler J, Fornara P, Frede T,

Loen-ing S (1999) Complications oflaparoscopic procedures

in urology: experience with 2407 procedures at 4

Ger-man centers J Urol 162:765±771

7 Savage SJ, Schweitzer DK, Gill IS (2000) Reoperative

ur-ologic laparoscopy: a critical analysis Program

ab-stracts World Congress ofEndourology, Sao Paulo,

Bra-zil, A71

8 Parsons JK, Roberts WW, Jarrett TW, Kavoussi LR,

Chow GK (2001) Urological laparoscopy after previous

abdominal surgery J Urol [Suppl] 165:22, A94

9 Parsons JK, Jarrett TJ, Chow GK, Kavoussi LR (2002)

The effect of previous abdominal surgery on urological

laparoscopy J Urol 168:2387±2390

10 Seifman BD, Dunn RL, Wolf JS (2003) Transperitoneal

laparoscopy into the previously operated abdomen:

ef-fect on operative time, length of stay and complications.

J Urol 169:36±40

11 Cottin V, Delafosse B, Viale JP (1996) Gas embolism

during laparoscopy: a report ofseven cases in patients

with previous abdominal surgical history Surg Endosc

10:166±169

12 Rassweiler J, Sentker L, Seemann O, Hatzinger M,

Rum-pelt HJ (2001) Laparoscopic radical prostatectomy with

the Heilbronn technique: an analysis ofthe first 180

cases J Urol 166:2101±2108

13 Guillonneau B, Vallancien G (2000) Laparoscopic radical

prostatectomy: the Montsouris experience J Urol 163:

418±422

14 Guillonneau B, el-Fettouh H, Baumert H, Cathelineau X,

Doublet JD, Fromont G, Vallancien G (2003)

Laparo-scopic radical prostatectomy: oncological evaluation

after 1,000 cases a Montsouris Institute J Urol 169:

1261±1266

15 Stolzenburg J-U, Do M, Pfeiffer H, Kænig F, Aedtner B,

Dorschner W (2002) The endoscopic extraperitoneal

radical prostatectomy (EERPE): technique and initial perience World J Urol 20:48±55

ex-16 Stolzenburg J-U, Do M, Rabenalt R, Pfeiffer H, Horn L, Truss M, Jonas U, Dorschner W (2002) Endoscopic ex- traperitoneal radical prostatectomy (EERPE) ± initial experience after 70 procedures J Urol 169:2066±2071

17 Hoznek A, Antiphon P, Borkowski T, Gettman MT, Katz

R, Salomon L, Zaki S, de la Taille A, Abbou CC (2003) Assessment ofsurgical technique and perioperative morbidity associated with extraperitoneal versus trans- peritoneal laparoscopic radical prostatectomy Urology 61:617±622

18 Roumeguere T, Bollens R, Bossche MV, Rochet D, Bialek

D, Hoffman P, Quackels T, Damoun A, Wespes E, man CC, Zlotta AR (2003) Radical prostatectomy: a pro- spective comparison ofoncological and functional re- sults between open and laparoscopic approaches World

Schul-J Urol 20:360±366

19 Partin AW, Mangold LA, Lamm DM, Walsh PC, Epstein

JI, Pearson JD (2001) Contemporary update ofprostate cancer staging nomograms (Partin tables) for the new millennium Urology 58:843±848

20 Stoppa R, Petit J, Abourachid H, Henry X, Duclaye C, Monchaux G, Hillebrand JP (1973) Original procedure ofgroin hernia repair: interposition without fixation of Dacron tulle prosthesis by subperitoneal median approach Chirurgie 99:119±123

21 Stolzenburg JU, Pfeiffer H, Nehaus JM, Sommerfeld M, Dorschner W (2001) Repair ofinguinal hernias using the mesh technique during extraperitoneal pelvic lymph node dissection Urol Int 67:19±23

22 Stolzenburg JU, Rabenalt R, Dietel A, Do M, Pfeiffer H, Doschner W (2003) Hernia repair during endoscopic (laparoscopic) radical prostatectomy J Laparoendosc Adv Surg Tech 13:27±31

23 Schlegel PN, Walsh PC (1987) Simultaneous neal hernia repair during radical pelvic surgery J Urol 137:1180±1183

preperito-24 Stolzenburg JU, Truss MC, Bekos A, Do M, Rabenalt R, StiefCG, Hoznek A, Abbou CC, Neuhaus J, Dorschner

W (2004) Does the extraperitoneal laparoscopic approach improve the outcome ofradical prostatect- omy? Curr Urol Rep 2:115±122

Validation of Current Simulation 261

The Role of Robotics in Learning Laparoscopy 263

Laparoscopic Training Program: A Must 264

Hands on Training Courses 265

Fellowships 265

References 267

Introduction

Urology amongst other surgical specialties is not

going to escape the great changes medicine is facing

in the beginning ofthis century To acquire an

ade-quate surgical experience in a time-efficient manner is

becoming more difficult than it was in the past

Be-sides the very well known fact that an operation

per-formed by a trainee lasts longer and is more expensive

than the one performed by a staff surgeon [1, 2],

cur-rent economical constrictions and increasing demands

in health care (cost reduction pressure), fiscal

con-straints and medical and legal considerations

(increas-ing social demands and resident's lowered

responsibil-ity) limit the time available in the operating room and

the opportunities for the trainee to practice and learn

while operating on real patients [3] Also, operating

approaches are changing and in urology open surgery

is increasingly replaced by endoscopy and

laparo-scopy, the former being essentially a one-man

proce-dure, where teaching while assisting is more difficultthan in open surgery [3] and the later being recog-nized as a difficult and still novel technique

In contrast with the open technique, the scopic technique brings about several changes in theway the surgeon observes and manipulates (Table 1).Particularly the combination ofobservation and ma-nipulation, the eye-hand coordination, is disturbed.There are several causes for these changes; the images

laparo-on the mlaparo-onitor are not the same as observed with thenaked eye and the surgeon has to perform a 3D taskviewed on a 2D screen Furthermore, the images arepresented by the camera assistant and no longer fol-low the head and eye movements ofthe surgeon; inaddition, there is a disparity in the direction ofmove-ments ofthe surgeon's hands and the tip ofthe lapa-roscopic instrument, known as the fulcrum effect [4].Moreover, the laparoscopic instruments do not havethe same functionality as the human hand For exam-ple, the movement is reduced from six degrees of free-dom to four, due to the fixed entry point of the in-struments in the abdominal wall Since there is nocontact between hands and tissue, tactile informationabout tissue properties is lost to a large extent Be-cause the hands are outside the abdominal cavity, in-formation on the position of hand and fingers, calledproprioception, does not directly support the manipu-lation oftissue In addition to these disturbances, be-

laparoscopy Three-dimensional Absent 6 degrees

cause the laparoscope is usually managed by an

assis-tant, the images do not match the proprioceptive

infor-mation ofthe surgeon, the direction ofsight differing

from that of surgeon, and even the location of the

moni-tor may significantly influence performance [4, 5]

Time and experience are required until proficiency

is reached and the new technologies are incorporated

into the surgical armamentarium In this complex

sce-nario where traditional surgery coexists with

endo-scopy and laparoendo-scopy and where robotic surgery

ap-pears as an attractive possibility, a balanced approach

has yet to be reached Learning by try and error is no

longer possible and new learning approaches have to

be considered

Conversely, as the number ofminimally invasive

procedures rises, the urological teaching centres will

face the challenge of providing residents with the

sur-gical training that optimizes learning and provides

surgeons with the possibility ofmaintaining skills and

learning new approaches

Surgical Education

Surgical training has traditionally been a true

appren-ticeship where trainees were learning while

perform-ing under the guidance ofa more experienced surgeon

or mentor Progressive trainee involvement with

grad-ual devolving ofresponsibility has been the method

adopted for surgical training for centuries Surgeons

have learned at ªthe foot of the masterº [6]

The educational literature refers to three domains

ofcompetence: knowledge, skills and attitudes [7]

Knowledge is reached by processing the reliable

and accessible information This information

tradi-tionally provided by books is currently expanding to

multimedia and web environments

Skills require development ofa psychomotor

com-petencies sustained by regular practice, proper

moti-vation and a competent training program

Attitudes relate to how knowledge and skills are

combined in patient care, the professional attributes

including clinical judgement, decision-making and

be-havioural intangible qualities ofvalue in becoming a

competent clinician [8]

Skills development is a steadily progressive

acquisi-tion ofsurgical dexterity and spatial orientaacquisi-tion

Prac-tice is the basis ofsurgical skills but in the current

medical scenario manual and technical skills must be

acquired prior to performing invasive procedures in a

competent manner A surgeon should and must beable to practice new procedures repeatedly untiljudged to be proficient without endangering patients.Ultimately, during the training process it would be de-sirable to face cases of increasing complexity in order

to measure progress and improvement Complex gical psychomotor skills as needed for laparoscopy are

sur-in part sur-innate and sur-in part learned from extensive andrepetitive practice [9] The acquisition ofa new psy-chomotor skill includes three different phases [10] Inthe first phase known as the cognitive phase, the trai-nee learns the basic steps ofthe procedure After un-derstanding these steps, the novice progresses to thesecond phase or integration where a mental inventory

of the different steps is transferred into psychomotoraction Nevertheless, performance remains erratic un-til the trainee reaches the third or automatic phasewhen repetitive practice perfects motor skills so thatthey are automatically executed with little cognitiveinput The importance ofthe cognitive component hasbeen fully recognized in the learning process of a newsurgical skill It is clear by now that only after a di-dactic session do individuals significantly improveperformance Later, the retention of a motor skillseems to be more dependent on the degree to whichthe skill was mastered rather than the environment inwhich it was learned [11] Learning is optimized whenfeedback is incorporated [12]

In addition to the above-mentioned processes, theindividual neuropsychological attributes ofsurgeonsinclude complex visual-spatial organization, stress tol-erance and psychomotor abilities Visual spatial abilityseems to be related to competence and quality ofre-sults in complex surgery Individuals with higher vi-sual-spatial scores seem to do significantly better inthe surgical procedure than those with lower scores.However, after practice and feedback, the individualswith lower scores may achieve a comparable level ofcompetence [13]

The goals ofa surgical education programmeshould be: standardization ofthe acquisition ofsurgi-cal skills and assessment ofthe performance in a uni-form setting to ensure the maintenance of the acquisi-tion ofskills and to develop programs to teach newskills

However, in proposing a new way oftraining manyquestions remain unsolved, the most important beingthe assessment ofcompetence, i.e how can the medi-cal community ensure that the trainee has reachedsufficient proficiency? Current assessment of the trai-