High-Risk Laparoscopic Urologic Surgery

Abstract

Currently, the majority of operations in the urologic field can be performed laparoscopically. Even in experienced hands, some operations are considered of increased risk either because of increased surgical difficulty of the specific case or because the patient per se is at risk due to associated comorbidities. Scope of this review is to present the existent experience regarding difficult laparoscopic urologic cases, along with points of technique, the product of the experience collected by performing such difficult laparoscopic cases. Knowledge of anticipated difficulties allows both patients and their surgeons to be better prepared. Patients have their expectations from laparoscopy realistically set, whereas urologists, especially those new to laparoscopy, realize their abilities and properly set their indications to achieve the best for their patients.

Introduction

O ver the last decade laparoscopic surgery has been popularized and developed to such an extent that can be considered the gold standard for many types of procedures in many specialties.^1,2 This is because it is as effective as open surgery, but associated with less postoperative pain, shorter hospital stay, faster recovery, and a better cosmetic result. With advances in laparoscopic equipment and more experience, almost all urologic operations may be done with this technique, from the most simple such as varicocelectomy to the most complex such as partial nephrectomy and radical cystectomy.^3
–5

Laparoscopy as a technique presents several peculiarities. Although the image of the surgical field is excellent because of the high fidelity of existing optics and screens, laparoscopic equipment does not provide equivalent tactile feedback and the same degree of movement freedom the hand provides during open surgery. Thus, laparoscopic surgery requires special training and familiarity with the technique per se and its specialized instrumentation. Laparoscopy is a relatively new technique and thus a big part of urologists are at their initial level of experience, a fact that can be translated in long operative hours even for relatively simple cases. This is important once one considers the pathophysiology associated with the creation of pneumoperitoneum and the maintenance of increased intraabdominal pressures during the case (Table 1). It is essential that both the anesthesiologist and the surgeon are familiar with these changes and are prepared to tackle any kind of problems during laparoscopic surgery.

Table 1.

Pathophysiologic Changes During Pneumoperitoneum Formation

System	Pathophysiologic changes	Cause
Cardiovascular	• Decreased venous return • Arrhythmias • CVP falsely elevated	• Pressure on IVC • Hypercarbia from increased CO₂ absorption • Vagal response to distention of the peritoneum • Pressure on IVC
Respiratory	• Decreased functional residual capacity	• Elevation of the diaphragm from the pneumoperitoneum
Urinary	• Oliguria	• Pressure on renal parenchyma and renal vein from the pneumoperitoneum
Acid–base balance	• Metabolic acidosis	• Hypercarbia from absorbed CO₂

CVP = central venous pressure; IVC = inferior vena cava.

Case selection during initial experience and precise definition of indications and contraindications for laparoscopy are important to have a successful outcome. Even in experienced hands, some operations are considered of increased risk either because of increased surgical difficulty of the specific case or because the patient is at risk due to associated comorbidities. Knowledge of anticipated difficulties allows surgeons to realize their abilities and properly select their cases for laparoscopy, and enables them to properly inform their patients as well.

High-Risk Patients

High-risk patients may be divided into patients of high anesthetic risk and patients of high surgical risk.

High-risk anesthetic patients

American Society of Anesthesiology score

Patients with high risk of receiving anesthesia are patients scheduled to undergo surgery on an elective or emergent basis, while their general condition is not optimal because of their comorbidities or their underlying pathology. In addition, their current condition is unlikely to improve to make the procedure of ordinary risk.

Therefore, patients are assigned a score (American Society of Anesthesiology [ASA] score), which in essence describes the patient's physical status and comorbidities (Table 2). Physical status of patients is affected by organ-confined diseases such as cardiac insufficiency, prior myocardial infraction, cirrhosis of the liver, chronic obstructive pulmonary disease (COPD), severe asthma, renal failure, or other systemic diseases (diabetes mellitus or hypertension). The ASA score helps define the risk a patient has because of his or her medical problems. In general, patients with higher ASA scores have a higher risk for complications, often leading to longer hospitalization.^6
–8 This is true for both open and laparoscopic cases. However, laparoscopy as a surgical technique, because of the creation of the pneumoperitoneum and the use of CO₂ as gas insufflator, leads to pathophysiologic changes that may not be well tolerated by patients with medical comorbidities and thus high ASA scores.

Table 2.

American Society of Anesthesiology Score

American Society of Anesthesiology score	Patient description	Morbidity (%)
Category 1	Normal healthy individual	0.1
Category 2	Patients with mild systemic disease	0.2
Category 3	Patient with severe systemic illness that does not cause a handicap	1.8
Category 4	Patient with systemic illness that is a continuous threat to the patient's life	7.8
Category 5	Dying patient with life expectancy less than 24 hours with or without surgery	9.4
Category E	Is applied as a prefix in case of emergent surgery

Increased intraabdominal pressure during laparoscopy diminishes blood flow to the abdominal and retroperitoneal organs^9

–12 and increases systemic vascular resistance, leading to reduced cardiac output. Normovolemic patients with normal cardiac function may tolerate intraabdominal pressures around 15 mm Hg without a problem; however, even healthy individuals may experience a significant decrease of cardiac output return when, for example, the intraabdominal pressure reaches 40 mm Hg. Immediate release of the pneumoperitoneum is necessary to prevent acute drop of arterial blood pressure. In fact, patients with heart failure may not tolerate even modest increases of intraabdominal pressures. In addition, their myocardium cannot promptly adapt to abrupt changes of total circulating volume. Therefore, one should operate with the lowest possible intraabdominal pressures,¹³ and attentive fluid replacement from the anesthesiologist must take place to avoid fluid overload and not to deplete the cardiac patient.¹⁴ Standard fluid required during laparoscopy is less than that required during open surgery since insensible and third space losses are reduced as the body cavity is not opened, and thus the traumatic surface is less. Further, urine production during laparoscopy is decreased because of the pressure the pneumoperitoneum has on the renal parenchyma.^15,16 Patients with renal failure are at increased risk of fluid overload if cautious fluid replacement is neglected.

Absorption of CO₂ especially during long operating times can lead to acidosis, which can lead to tachycardia and ectopic ventricular systole. In addition, hypercapnia along with the peritoneal irritation from the pneumoperitoneum can lead to vagal irritation and bradycardia. Acidosis should be prevented especially in patients with diseased myocardium. Increased intraoperative ventilation with creation of compensatory respiratory alkalosis and bicarbonate infusion can restore a normal pH.^17
–19 Vagal reactions can be prevented by the use of atropine before insufflation or creation of pneumoperitoneum at a low flow rate.²⁰ A decrease in intraabdominal pressures when hypercapnia and acidosis occurs helps minimize hemodynamic and pulmonary compromise.²¹

High intraabdominal pressure also elevates the diaphragm, affecting negatively the pulmonary function by reducing the capacity and compliance of the lungs and worsening the ventilation–perfusion mismatch. Usually, hyperventilation compensates for excess CO₂ expulsion; however, this may not be enough in patients with COPD.^22
–24 Helium can be used as an alternative gas insufflator for patients with severe COPD, since it is only slowly absorbed and its use is not associated with additional cardiopulmonary adverse effects.^25,26 Gasless laparoscopy by using an abdominal lifting device to create the working space is another alternative to CO₂ pneumoperitoneum in patients with significant cardiac or pulmonary disease, but one should consider the absence of the pneumoperitoneum-induced tamponade effect on bleeding, as well as a comparatively smaller working space.^27,28

Nitrous oxide has less physiologic effects at the blood concentration as well, but it can be used only if a heat source will not be used. This anesthetic agent, however, results in bowel distention and should be replaced when troublesome bowel distention occurs.^29

–32

Despite the cardiorespiratory failure similar-status laparoscopy causes, this technique is not precluded for patients with high ASA scores if proper preoperative preparation and attentive intraoperative monitoring is followed.

Tips and tricks when operating patients with high ASA scores:

Lowering intraabdominal pressure when hypercapnia and acidosis occurs

Operating at minimal intraabdominal pressures necessary for adequate surgical field view

Limited fluid replacement to prevent overload

Increased ventilation with compensatory respiratory alkalosis

Initial creation of pneumoperitoneum at low flow rate volumes and potential use of atropine before insufflation to prevent vagal reactions caused by abrupt abdominal distention

Alternative use of helium insufflation when CO₂ use is forbidden

Age

Older patients frequently have associated medical conditions (e.g., diabetes, heart failure, and renal failure), which are not prone to further improvement. Such patients have diminished reserves and tolerance to complications³³ and encounter the risks described in the previous section since they are usually assigned a higher ASA score.

However, even in the absence of medical comorbidities, increased age on its own is a factor for an increased ASA score. The pneumoperitoneum may significantly deteriorate the patient's cardiac function since it creates during surgery a condition similar to cardiac failure. In addition, good respiratory function is required to compensate for the metabolic acidosis caused by CO₂ absorption. Usually, elderly have decreased cardiorespiratory reserves even if their cardiopulmonary function is not abnormal.³⁴ Therefore, like any high-ASA-score patient undergoing laparoscopy, elderly patients should be operated with the minimal intraabdominal pressure necessary, and proper ventilation and attentive fluid replacement are necessary. Elderly patients are also at increased risk because postoperative mobilization in this age group is slower and harder, a fact predisposing to deep venous thrombosis, pulmonary embolism, atelectasis, and pneumonia.

Advances in anesthesia and postoperative care have allowed serious operations to be performed in third aged patients when considered necessary. The feasibility of this group of patients to tolerate laparoscopic procedures and take advantage of the less postoperative pain and faster recovery this technique offers has been addressed by various studies.

In a study³⁵ comparing the two methods of open and laparoscopic nephrectomy in patients older than 80, the advantages of laparoscopy were confirmed. Patients undergoing laparoscopy were fed faster and had a quicker recovery compared with their open surgery patient counterparts. Avoiding a large flank incision causes less postoperative pain and allows for less analgesic requirements. As a result, postoperative pulmonary toilet is better performed, while postoperative delirium, as well as ileus, occurs less frequently. Complications, operative time, and estimated blood loss were similar between the two compared groups, confirming that with appropriate experience, laparoscopy may be performed with success in this group of elderly patients.

Also, when compared with their younger counterparts who undergo similar laparoscopic procedures,³⁶ older patients, despite having more comorbidities, with proper perioperative care may undergo laparoscopic procedures with equivalent results, fast recovery, short hospitalization, and similar intraoperative and postoperative complication rates.

Obesity (body mass index >30 kg/m²)

Obese patients are considered high-risk patients, and a high body mass index alone is enough to assign them an ASA score of 3. These patients frequently have diabetes, hypertension, various degrees of heart failure, and COPD. The above-mentioned comorbidities increase the risk for postoperative complications and make anesthesia riskier^37
–39 because of the reasons described in the high ASA section.

A rare complication, coined “rhabdomyolysis,” has been described in obese patients undergoing laparoscopic surgery.^40–41 Rhabdomyolysis is the rapid breakdown (lysis) of skeletal muscle (rhabdomyoma) caused by injury to muscle tissue. The muscle damage may be caused by physical (e.g., crush injury and muscle ischemia) or nonphysical factors (e.g., anesthetic neuromuscular blocking agents and electrolytic metabolic disorders). The destruction of the muscle leads to the release of the breakdown products (e.g., myoglobin) of damaged muscle cells into the bloodstream, leading potentially to acute renal failure.

When massively obese patients undergo laparoscopy, various parts of their body are under significant amount of pressure. If this pressure is for a prolonged amount of time and padding is not appropriate, traumatic compression of skeletal muscles and obstruction of their blood supply may occur, leading to rhabdomyolysis. Whenever this complication was described, it was usually caused by prolonged operating times (≥4 hours) with the patient placed during surgery in an extended lateral decubitus position. Male sex was also associated with an increased risk of this complication in this group of patients.^42
–44 During the procedure special care must be taken to properly pad points of pressure to avoid this rare but potentially serious condition.

Postoperatively, these patients are harder to mobilize, are more difficult to make breathe correctly, and have worse trauma healing. Such patients are also more challenging technically,⁴⁵ and because of this during initial laparoscopic urologic experience, obesity was once considered a relative contraindication.⁴⁶ These patients require increased intraperitoneal pressures and longer insufflation time⁴⁷ to maintain a proper pneumoperitoneum. Working pressure of 20 mm Hg may be needed during the entire case to achieve a larger working space, and this may have an effect on ventilation. Frequently peri-renal fat is abundant, making dissection and detection of structures quite challenging, facts that add to total operating time.

Initial experience with laparoscopic nephrectomy in obese patients presents with a higher rate of complications (57% vs. 16%)⁴⁸ and conversion rates (35% vs. 6%)⁴⁹ compared with their thinner counterparts. With time and increased experience, conversion rates and hospital stay between obese and nonobese patients became the same during laparoscopic nephrectomy; however, obesity was still associated with slightly greater operative times, estimated blood loss, and transfusion rates.^47,50,51 In other series of laparoscopic renal procedures, such patients are operated without increased morbidity and hospital stay.^52

–55 The use of longer laparoscopic instrumentation, as well as proper trocar placement with lateral shift, allows the execution of laparoscopic procedures in such patients who among others may benefit the most from the avoidance of a large flank incision.⁵⁶ Because of the abundancy of subcutaneous fat, the use of a purse string suture of the rectus sheath may make closure easier.

Obese patients may undergo radical prostatectomy taking advantage of the excellent view one may obtain with the laparoscopic camera. However, experience obviously has a role on operative time. Both pure laparoscopic and robotic radical prostatectomy have been performed with success. Blood loss, operative times, and hospital stay varied among series probably because of the operative experience involved.^57

–61

Obesity is reported to be associated with increased positive surgical margins in laparoscopic radical prostatectomy for patients with similar stages. This can be attributed to the increased surgical difficulty associated with such cases.⁶² Thus, some recommend that in early stages of the learning curve obese patients are not candidates for robot-assisted laparoscopic prostatectomy.⁵⁹ However, when evaluating oncologic outcomes one must consider that obesity could be associated with higher-grade and more aggressive tumors.⁶³

Tips and tricks when operating obese patients laparoscopically:

Extra foam padding at points of pressure

Working pressure of 20 mm Hg during the entire case may be needed.

Use of extra-long morbid obesity trocars and instruments

Trocar placement with lateral shift bringing organ target closer

Consider using a purse string suture of the rectus sheath to make easier closure

While waiting for elective surgery, patients should be advised to loose weight when possible.

High risk of patients because of increased surgical difficulty

Individual surgical experience plays a major role for the final outcome of a surgical procedure. However, there are certain cases predicted to be harder than others even before the procedure begins. This could not be truer for laparoscopy given its particularities as a technique.

Initial indications were limited at the beginning of laparoscopic urologic experience; however, with increasing experience, contraindications are constantly decreasing.

Laparoscopic procedures in patients with prior abdominal surgery or radiation

Adhesions are found in 75% to 90% of reoperations.⁶⁴ They may distort anatomic planes, change usual landmarks, and adhere the bowel to the anterior abdominal wall. Even in open surgery the existence of intraabdominal adhesions and the obliterans of normal anatomic surgical planes because of fibrosis located in the site of previous surgery makes dissection in the same region harder and injury of adjacent organs possible.⁶⁵

In addition to a difficult dissection, the creation of the pneumoperitoneum is more hazardous in patients previously operated. Creation of the pneumoperitoneum is safer with the open method (Hasson); however, it may be established with the Veress needle as well, provided the proper puncture site is selected. Usually, it is safer to insert the needle far away from the previous surgical scar, more preferably in the left or right upper abdominal quadrant. Alternatively, the procedure may be performed retroperitoneally and the peritoneal cavity may be then entered if needed.^66,67 This way one avoids existing bowel adhesions, minimizing the risk for complications.

Frequently because of adhesions between the bowel and the abdominal wall, placement of auxiliary trocars is not possible before the takedown of these adhesions. This is possible with proper instrumentation such as a teaching laparoscope. This is an off-set 0° telescope with a working channel similar to that of a nephroscope through which a laparoscopic instrument may be accommodated to dissect and free-up space for additional trocar placement. With this instrument it is possible to both see and work at the same time through only one port.

For the above-mentioned reasons, laparoscopy in patients with a previous surgical intraabdominal surgery was considered initially a relative contraindication.⁶⁸ However, for an experienced laparoscopist this is not considered a contraindication anymore.⁶⁹ Nevertheless, such a procedure may require a longer operating time and the risk for conversion to open surgery may be higher.^70,71

Tips and tricks during laparoscopy in patients with previous surgical history:

Initial port placement preferably with the open (Hasson) technique

If a Veress needle is used, a site away from previous scars and preferably over the liver, spleen, or left lower quadrant should be preferred.

The retroperitoneal approach can alternatively be used.

A teaching offset laparoscope can be very useful to lyse adhesions and create space for subsequent trocar placement.

Laparoscopic procedures in anticoagulated patients

Many patients necessitating elective surgery for malignancy may be chronically using oral anticoagulation due to atrial fibrillation, a mechanical heart valve or a history of deep venous thrombosis or pulmonary embolism. Continuation of oral anticoagulation during the operation increases the risk for bleeding, but stopping it increases the risk for thrombosis. Proper perioperative management with temporary discontinuation of oral anticoagulants and initiation of low molecular weight heparin or unfractionated heparin may decrease the risk for complications. Laparoscopic experience and the use of new hemostatic measures such as hemostatic glues, ultrasonic scissors, and other sources of energy allowed procedures for the upper urinary tract in such patients to be performed with success, without prolonged surgical times or conversion rates. The hemostatic effect of the pneumoperitoneum on small venous bleeding and meticulous intraoperative hemostasis allows laparoscopy to be performed safely, without increased intraoperative blood loss, which is particularly important in these patients with heart problems, who do not tolerate easily great variations of their blood count. Nevertheless, these patients must know that they have a higher risk for postoperative bleeding and transfusion.^72,73 Thus, intensive care of postoperative vitals is required to promptly identify postoperative bleeding that may require reexploration.

In collaboration with the hematology service, perioperative anticoagulation coverage and meticulous follow-up of coagulation parameters must be tailored each time to the patient's individual risk for thrombosis.

Medication that can impair normal clotting mechanisms, such as nonsteroidal antiinflammatory drugs, aspirin, coumadin (warfarin), antiplatelet aggregation compounds, and multivitamins like vitamin E should always be elicited during history taking. In addition, one must always take in consideration the synergy such medications may have with other medications, especially antibiotics.

Tips and tricks for laparoscopic surgery in anticoagulated patients:

Consultation with hematology and relevant specialties for proper temporary replacement of oral anticoagulants with low molecular weight heparin

Hemostatic glues (fibrin glue or thrombin glue) and all energy types (monopolar, bipolar, and ultrasonic scissors) for hemostasis should be readily available.

Laparoscopic surgery in patients with renal anatomic abnormalities

A large series of laparoscopic management of pathology in kidneys with congenital abnormalities do not exist because of the rarity of such cases and the difficult they may present. Aberrant position and vascularity of such kidneys makes extensive preoperative imaging necessary. Computed tomography (CT) angiography may provide excellent images of the aberrant renal vascular supply.⁷⁴ Precise knowledge of vascular anatomy helps the surgeon avoid inadvertent vessel injury. Trocar placement must be individualized according to the position of the abnormal kidney.

Ureteropelvic junction obstruction exists in 30% of horseshoe and ectopic kidneys. Laparoscopic pyeloplasty in such kidneys compared with an open or endoscopic approach presents with better results although valid comparisons are difficult due to the small number of existing cases in the literature. An anterior approach allows for easy and fast identification of aberrant vessels and the completion of the pyeloplasty.⁷⁵

Laparoscopic hemi-nephrectomy in a horseshoe kidney has been performed with success; however, only a handful of cases have been presented. This procedure is particular because of the existence of aberrant vessels and the existence of the renal isthmus between the two kidneys.⁷⁶ The isthmus may be transected with the assistance of a laparoscopic vascular gastrointestinal anastomosis (GIA) stapler or a harmonic scalpel if it is void of vessels and relatively thin. If the isthmus has feeding vessels, these may be dissected and ligated, allowing for subsequent sharp dissection of the bridge of tissue unifying the two kidneys.⁷⁷

Tips and tricks in patients with renal congenital abnormalities undergoing laparoscopic surgery:

Detailed imaging is crucial.

CT with three-dimensional reconstruction is helpful in identifying aberrant vasculature.

The anterior approach for pyeloplasty in horseshoe kidneys is preferred.

The GIA or the harmonic stapler for heminephrectomy in a horseshoe kidney can be very helpful.

Laparoscopic procedures in patients with a solitary kidney

Renal procedures in patients with solitary kidneys must be performed with extreme caution since any unnecessary damage to the remaining kidney may make the patient anephric and lead to dialysis. In case of renal malignancy partial nephrectomy is an absolute indication. Renal vascularization is temporarily interrupted until the tumor is excised, the calyceal system sutured, large bleeding vessels ligated, and the remaining renal parenchyma closed. As easily understood, ischemia time must be as short as possible. If warm ischemia is performed, this theoretically should not overcome 30 minutes, whereas in case of cold ischemia, this time may be prolonged to an hour. Every ischemia prolongation poses a threat to the kidney.

Partial nephrectomy has been performed with success laparoscopically for tumors <4 cm and almost always under warm ischemia. Although cold ischemia can be performed laparoscopically,⁷⁸ its application is cumbersome and is not used in everyday practice. It is easily understandable that laparoscopic partial nephrectomy in a solitary kidneys requires great laparoscopic experience in order for all steps of partial nephrectomy to be performed quickly and if possible in less than 30 minutes. Use of resorbable clips (Lapra-Ty II) instead of knot tying to secure the sutures, large-size cold Endo-scissors to achieve a perpendicular cut of the whole layer of parenchyma to excise the tumor within a healthy margin, and various hemostatic glues to assist hemostasis may expedite the procedure helping reduce ischemia time.⁷⁹ In addition measures such as mannitol and furosemide administration, used during any case of partial nephrectomy 15 to 20 minutes before the initiation of warm ischemia, to provide diuresis and antioxidant action should be used routinely.

Literature of such cases is limited with only a handful of patients and from centers with great laparoscopic expertise. Such procedures were successfully performed with similar results to elective laparoscopic partial nephrectomies.⁸⁰ Mean ischemia time was 29 minutes in the largest series reported, although warm ischemia time of 55 minutes was reported as well.⁸¹ Mean renal function was affected in most patients, nevertheless, without the need for hemodialysis in the majority of patients. Renal damage was more probable in patients with compromised renal function preoperatively (Cr ≥ 1.5 mg/dL), patients of advanced age (≥70 years), and obviously when warm ischemia time extended ≥30 minutes.^82
–84

Tips and tricks in patients undergoing laparoscopic surgery on a solitary kidney:

Use of mannitol and furosemide 15 to 20 minutes before warm ischemia initiation

Warm ischemia time may be reduced with the use of (1) large laparoscopic scissors, (2) Lapra-Ty II clips instead of knot tying, and (3) hemostatic glues to assist in hemostasis.

Laparoscopic procedures with particular technical difficulties

As a general rule particularly for difficult cases, patients must be informed about the related difficulties and the increased risk for conversion to open surgery.

Large renal tumors: Large renal tumors present technical difficulties during their surgical extirpation. Frequently, there is not much space for the dissection of the hilar vessels, while the existence of abundant collateral renal circulation may lead to increased blood loses during nephrectomy. The same technical challenges exist during laparoscopic management of such tumors as well. Removal of the specimen is also a problem since a larger incision is required for intact removal, and morcellation is tedious for such bulky kidneys. For the above-mentioned reasons laparoscopic hand-assisted nephrectomy seems a logical alternative. Small series of patients with renal tumors of mean diameter of 9 cm were treated with this approach. Estimated blood loss, operative times, analgesic requirements, time to oral feeding, and hospital stay were better with laparoscopy when compared with their open counterparts for tumors of the same size.⁸⁵ However, it is postulated that laparoscopy should not be used for tumors larger than 15 cm, which are better treated with open nephrectomy.

Laparoscopic partial nephrectomy in centrally located tumors: Centrally located tumors are near the renal hilum, and because of their technical difficulty there are usually treated with radical nephrectomy. However, when partial nephrectomy is indicated, tumor removal is particularly challenging even when tackled open. In centers of laparoscopic excellence, very experienced laparoscopic surgeons have performed such cases. From a technical point these tumors require excellent preoperative imaging and planning. Three-dimensional CT imaging is necessary to schedule the exact plane of dissection of the tumor and its relationship with the hilar vessels. Tumor dissection is usually performed from the lateral toward the medial edge of the tumor, and often meticulous and extensive dissection of the renal vessels is required. After removal of the tumor, closure of the collecting system is required and should be performed with care not to disrupt renal vascularization of the renal remnant. The risk for positive surgical margins is present but similar to any partial nephrectomy. Warm ischemia time, total operative time, and hospital stay are longer than those required for laparoscopic partial nephrectomy for peripherally located tumors. However, blood loss and complications are similar.^86,87

Laparoscopic nephrectomy for renal tumors with renal vein thrombus extending in the inferior vena cava: Renal tumors with thrombus extending in the renal vein or inferior vena cava (IVC) require nephrectomy along with removal of the thrombus, which may extend up to the right atrium. It is obvious that this procedure requires meticulous dissection of the IVC with control and transection of the latter to remove the thrombus. This procedure is performed in an open fashion and surgeons with transplant or vascular experience are often called to assist.

With the use of laparoscopic Satinsky's clamps or specialized laparoscopic Bulldog applicators, control of major vessels is possible during laparoscopic procedures. In addition, laparoscopic ultrasound allows precise identification of the tumor thrombus in the IVC. Laparoscopic nephrectomy for such tumors with thrombus extending minimally in the IVC has been performed with the help of a laparoscopic vascular GIA, which was placed at the entrance of the renal vein in the IVC after the thrombus was “milked” backward in the renal vein.⁸⁸

Alternatively, when the thrombus is extending more in the IVC (level 2) or “milking” back the thrombus is not possible due to inflammation or invasion of the vessel wall, then a 7-cm incision can be performed after complete laparoscopic dissection of the renal vein and IVC. Through this incision controlling and opening the IVC, removing the thrombus and closing the remaining venous gap is possible with safety.⁸⁹ The authors suggest that the size of this incision is the same with the one necessary for the removal of large renal specimens. However, the risk for pulmonary embolism during dissection is significant, and thus dissection of the renal vessels and IVC must be performed gently and before mobilization of the renal parenchyma.

It is obvious that this procedure is technically demanding. In addition, the advantages of this approach in terms of operating time, estimated blood loss, and hospital stay are still not evident to justify the risks of the laparoscopic approach.

Laparoscopic nephrectomy for benign inflammatory conditions: Frequently, a kidney after a serious inflammation such as xanthogranulomatous pyelonephritis (XGP) or pyonephrosis requires a nephrectomy. Intraoperative difficulties are caused by the extensive fibrosis, with inflammatory extension and involvement of the hilar and nearby organs. This makes injury of adjacent organs or vessels of the renal hilum during mobilization of the kidney highly possible. A procedure of this kind is considered among the most difficult open urologic procedures. As it is easily understood the laparoscopic approach is even harder. Ligation of the hilum is usually performed en bloc with the use of a laparoscopic EndoGIA since vessel ligation of each renal vessel separately is very difficult and dangerous in such cases.

Comparison of laparoscopic to open nephrectomies for such conditions showed an increased operative time and blood loss for laparoscopy, suggesting the technical difficulties encountered.^90,91 The increased conversion rates to a hand-assisted procedure (35%)^92,93 or an open procedure (17%)^90,91,94,95 reflect these difficulties as well. Complications are increased and range between 10% and 60%,^90

–96 but are similar to those encountered with open nephrectomies in these situations as well. On the other hand, laparoscopy was advantageous regarding time to oral feeding, analgesic requirements, and hospital stay. Use of a laparoscopic endobag for specimen retrieval may prevent infection of the port/wound site.

Currently, laparoscopic nephrectomy in kidneys with inflammatory disease remains a high-risk procedure. It is not indicated unless performed by a very experienced laparoscopist.

Laparoscopic radical prostatectomy in patients with history of previous operation in the preperitoneal space: A previous procedure involving the prevesical space of Retzius may cause scarring, thus leading to a harder radical retropubic prostatectomy. Especially, placement of meshes for hernia repairs causes an intense fibrotic reaction in the minor pelvis, making tissue dissection and consequently removal of the prostate or lymph nodes very challenging. This difficulty has been mentioned in laparoscopic series, but is not considered a contraindication in experienced hands. Port placement modification can facilitate the procedure.^97
–99

Laparoscopic radical prostatectomy in patients with a history of prostatic manipulation: As in open radical prostatectomy, it has been reported that laparoscopic radical prostatectomy is technically difficult in patients with a history of transurethral resection.¹⁰⁰ Such patients are reported to have worse surgical/functional and oncological outcomes compared with patients without previous transurethral prostate resection. These results may be explained by the laborious prostatic extirpation seen in such cases. Difficult dissection makes neurovascular bundle preservation difficult.^101,102 Obviously, reported potency and positive surgical margin rates were worse. Scarring could also explain the higher postoperative anastomotic stricture rate presented. Finally, operative times and hospital stay were also longer, reflecting the difficult dissection. At least, a 6-month period between the transurethral resection and the radical prostatectomy is advised in such cases.

Laparoscopic radical prostatectomy has been reported as salvage treatment in recurrent prostate cancer after failed high intensity focused ultrasound therapy, external beam radiotherapy, or brachytherapy.^103,104 All these interventions potentially could represent a barrier in the performance of laparoscopic radical prostatectomy due to the extensive postprocedural fibrosis and the associated risk of significant complications, such as rectal injury. In a small series of such patients with short-term oncologic and functional evaluation, the authors reported no additional morbidity and mortality, decreased incidence of rectal injuries and urethral strictures, and less estimated blood loss compared with the open salvage technique. However, the need for larger studies and longer follow-up to evaluate the usefulness of the laparoscopic technique in such circumstances was addressed.

Finally, although neo-adjuvant hormonal therapy causes some scarring around the prostate, operative and postoperative outcomes were not different when compared with a group of patients not treated with neo-adjuvant hormonal therapy.¹⁰⁵

Tips and tricks for laparoscopic urologic surgery of particular technical difficulties:

Inform patients about increased risk of conversion to open.

Consider hand-assisted laparoscopy for large tumor nephrectomy.

Exact vascular imaging is necessary for laparoscopic partial nephrectomy of centrally located tumors.

Gentle dissection of renal vessels and IVC is necessary to prevent dislocation or renal vein thrombus.

Laparoscopic Satinsky's clamps or specialized laparoscopic Bulldog applicators allow control of major vessels.

Laparoscopic ultrasound allows precise identification of the tumor thrombus in the IVC.

Laparoscopic vascular GIA helps perform laparoscopic tumor nephrectomy with thrombus extending minimally in the IVC.

Laparoscopic vascular GIA helps ligate the renal pedicle en-bloc when dissection of each vessel separately is very difficult as in XGP nephrectomy.

Removing of XGP specimen using a laparoscopic bag helps to avoid contamination of the trocar site and subsequent wound infection.

Modification of trocar site placement necessary.

Conclusion

Because of all the above-mentioned difficulties, case selection during initial experience and precise definition of indications and contraindications for laparoscopy must be properly set to have a successful outcome. With improved perioperative care, adequate experience, and knowledge of points of technique for difficult cases, a complex and challenging laparoscopic procedure in even sicker patients can be made easier and safer. Thus, high-risk patients may still be candidates for laparoscopic surgery, but definition of associated risks is necessary to properly assess and tackle perioperative problems and adequately inform preoperatively the patients involved.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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High-Risk Laparoscopic Urologic Surgery

Abstract

Introduction

High-Risk Patients

High-risk anesthetic patients

American Society of Anesthesiology score

Age

Obesity (body mass index >30 kg/m2)

High risk of patients because of increased surgical difficulty

Laparoscopic procedures in patients with prior abdominal surgery or radiation

Laparoscopic procedures in anticoagulated patients

Laparoscopic surgery in patients with renal anatomic abnormalities

Laparoscopic procedures in patients with a solitary kidney

Laparoscopic procedures with particular technical difficulties

Conclusion

Footnotes

Disclosure Statement

Abbreviations Used

References

Obesity (body mass index >30 kg/m²)