Technology and increased skill advance laparoscopy

With increasing experience with laparoscopic partial nephrectomy, more centrally located tumors require a heminephrectomy and pelvicaliceal repair. These characteristics result in longer warm ischemic time, operative time, and hospital stay, but blood loss and complications have decreased.

Experts in laparoscopic urology are more skilled and more able to duplicate even the most complex open techniques, Dr. Nakada observed. As a result, fewer indications exist for open extirpative or reconstructive renal surgery. The key question is whether these techniques can be successfully transferred from centers of excellence to the general urology community.

"Hemostatic agents to control bleeding and leakage are making complex procedures simpler and safer," said Dr. Nakada. "We are able to progress laparoscopically in part due to technology, such as new commercial hemostatic agents and collecting system glues, which make the complex reconstructive procedures less arduous. The laparoscopic bar is being raised on the basis of technology and experience."

A videotape training system may help reduce complications from urologic laparoscopy procedures. The system uses two double-blinded expert referees to review the complete unedited tape of a surgeon performing laparoscopic nephrectomy or adrenalectomy.

Training in laparoscopic surgery is undergoing significant change, said Dr. Nakada. The ability to videotape a surgeon performing a procedure and then critique it or the opportunity to use a simulator to observe a surgeon perform a procedure will eventually change surgical training drastically.

Just as airline pilots practice in a simulator when they are training, surgeons should be practicing in a similar environment.

"The concept of the videotape training system, where experts review and critique surgery performed by a surgeon, is the beginning of an optimal way to proctor, monitor, and eventually train laparoscopic surgeons," said Dr. Nakada.

Indications for laparoscopic radical nephrectomy are expanding. Patients with locally advanced disease treated with laparoscopic technique have outcomes similar to those treated with nephrectomy at 33 months.

"What this means is that not only can we take out kidney tumors laparoscopically, but select centers are removing large tumors with locally advanced disease laparoscopically," Dr. Nakada said. "Locally advanced renal cell carcinoma remains an indication for open surgery. These procedures are being reported laparoscopically with good results by several centers."

With both cryosurgery and radiofrequency ablation, image-guided access is preferable to laparoscopic access. Short-term data are encouraging, but significant complications still occur, especially when treating tumors near the hilum.

Cryosurgery and radiofrequency ablation are among the most rapidly changing areas of urology, said Dr. Nakada. Image-guided treatment of small renal tumors could substantially change the approach to clinical management.

"By ablating a small tumor, you eliminate the need for even a laparoscopic operation," he said. "At our center, as well as in many others, we are doing this in conjunction with our radiologists. The short-term data are very encouraging. Urologists should be aware that small renal tumors may be managed in the future by an image-guided treatment, as opposed to even a laparoscopic partial nephrectomy."

A study examining the learning curve for laparoscopic radical prostatectomy showed that improvement in operative time did not reach a plateau until the 129th case. Techniques to achieve continence and nerve preservation reached steady state after 25 cases.

Laparoscopic radical prostatectomy is a complex operation that is simplified somewhat by the robot. Numerous groups are performing this procedure, and more data on long-term results are becoming available.

"In the near future, we should have a better sense as to the benefits of the laparoscopic and robotic approaches, as compared to the open approach," said Dr. Nakada. "This is a vitally important issue and trend for urologists, and we have to keep watching for reports from the busiest centers. Laparoscopic prostatectomy is here to stay."