Minimally Invasive Surgery Within The Genitourinary System

Through advances in technology, it is possible to perform many diagnostic and therapeutic procedures using minimally invasive techniques. The patient enjoys the same benefits of open surgery, however, the need for pain medication is greatly reduced and the time to return to normal activities is significantly shorter.

In this portion of the website we will discuss the various procedures currently performed by minimally invasive surgery in the context of the genitourinary system. We will explain the indications for these procedures and report the outcome information that is currently available. Not all patients are candidates for all of the procedures listed here. Each patient merits individual evaluation and consideration. The patient and surgeon must candidly discuss the treatment strategies that may be applicable and select the one option most suitable for the patient.

A. What is Minimally Invasive Surgery?
Minimally Invasive Surgery (MIS) refers to group of techniques that permit access to the internal organs without use of a customary large incision. To access the internal organs, various techniques are useful. In the case of extracorporeal shock wave lithotripsy (ESWL), the targeted kidney or ureteral stone is imaged with fluoroscopy, a low radiation energy (i.e X-ray). The stone is fragmented by high-energy shock waves that are generated outside of the body. Shock waves travel through the body very much like sound waves. The energy of the shock waves is delivered to the stone in focus and not to the surrounding tissue. The stone is fragmented to particles of a size that can pass spontaneously. An incision to remove the stone is thus avoided.

Another technique for minimally invasive access into the upper urinary system is called ureteropyeloscopy. For this, small caliber semi-rigid or flexible fiberoptic telescopes are passed directly into the urethra and on to the urinary bladder, the ureters, advancing up to the kidneys if necessary. The small ureteropyeloscopes are connected to a high-resolution video system that produces a magnified image of the inside of the urinary tract. The surgeon can therefore see the inside of urethra, the urinary bladder, the ureters and the inside of the kidney. There are small ports in these small ureteropyeloscopes that permit passage of miniaturized instruments and lasers for surgery to be performed. Small biopsy forceps can sample suspicious tissues; laser fibers can deliver energy to fragment a stone (intra-corporeal lithotripsy), incise a stricture, or to destroy a small cancerous tumor.

The kidney and upper ureter can also be entered through a small incision in the back through which a telescope, called a nephroscope is introduced. This operation is called percutaneous nephroscopy. Again, lasers, and grasping instruments can be introduced through these video-nephroscopes to allow for the treatment of large kidney stones or the incision of scar tissue that obstructs the outflow of urine from the kidney.

Laparoscopy is the newest and most sophisticated technique of minimally invasive surgery. This technique uses small cylindrical tubes called trocars to enter the abdominal cavity. The trocars allow entry of a video-telescope, called a laparoscope, to view the entire abdominal cavity and its contents from inside the patient. Accessory small trocars allow the introduction of fine instruments necessary to perform surgery. In laparoscopy several small keyhole incisions (usually 1 to 2 centimeters in size) are used in place of a significantly larger and more painful incision. The patient undergoes a similar operation by laparoscopy as by open incision. The advantages of laparoscopy include less pain, a more rapid recovery, a decreased hospital stay, and a quicker return to normal activities. Laparoscopy has also allowed the introduction of minimally invasive cryoablation techniques to treat small kidney cancers. A list of minimally invasive techniques currently utilized in the genitourinary system and their specific indications can be found in the following table. A more detailed discussion of each procedure will follow.