• Conservative Treatment
• Surgical Treatment
• Minimally Invasive Surgical Treatment

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.

B. Removal of the Kidney (Laparoscopic Nephrectomy)

• Indications - Patients found to have kidney cancer need to have their kidney removed in order to treat the cancer. Patients with recurrent kidney infections, severe stone disease or long term obstruction of the kidney may develop intractable pain or lose function of the diseased kidney so that nephrectomy is warranted. Finally, over 4,000 people each year in the United States donate one of their two kidneys to a loved one for transplantation.

  Standard surgery to remove a kidney requires a flank or abdominal incision of 8 to 20 inches in length. Moreover, in many instances a rib has to be removed to allow adequate exposure. Most of these procedures may be performed by laparoscopy with similar success rates using small "key hole" incisions.

• Procedure - The patient must undergo general anesthesia for this procedure. Four to five small cylindrical tubes called trocars are placed into the abdominal cavity. The trocars allow entry of a video-telescope, called a laparoscope, to view the entire abdominal cavity and kidney. The video-telescope gives the surgeon a magnified view of the operating field and allows identification of vessels and structures with more clarity than is possible in open surgery. Accessory small trocars allow the introduction of fine instruments necessary to perform surgery. With all the trocars and instruments in place the vessels which bring blood to and from the kidney are clipped as well as the ureter. The kidney is then freed from all of its surrounding structures. The kidney is placed into a bag within the body and removed by enlarging one of the trocar incisions approximately 2 inches.

• Results Several investigators, including our group, have compared laparoscopic nephrectomies to standard open nephrectomies in terms of time of surgery, blood loss, pain medication requirements, length of hospital stay, time to return to normal activity and complications. The results show that operating time is slightly longer by laparoscopy. However, the amount of pain medication required, time in the hospital and time to return to work is significantly shorter for these patients. The cosmetic results are better for patients treated by laparoscopy. In addition, the complication rates and blood loss was similar in both groups.

C. Removal of Kidney and Ureter (Laparoscopic Nephroureterectomy)

• Indications - The kidney, ureter and bladder is lined by tissue called transitional epithelium. When cancer occurs within this lining it is referred to as transitional cell carcinoma. Symptoms may include pain, bleeding or bladder irritation. The diagnosis is confirmed by performing ureteroscopy and obtaining tissue biopsy. If cancer is diagnosed tests are performed to determine if the disease has spread. In patients with disease confined to the urinary tract, treatment includes removing both the kidney and ureter. In the past this operation required a two large incision, one in the flank and a second incision in the lower abdomen. Using laparoscopy this same procedure may be performed using 3 to 4 small keyhole incisions.

• Procedure - The patient must undergo general anesthesia for this procedure. First, the ureter where it enters the bladder is freed using a specially designed cystoscope. Next, four to five small cylindrical tubes called trocars are placed into the abdominal cavity. The trocars allow entry of a video-telescope, called a laparoscope, to view the entire abdominal cavity and kidney. The video-telescope gives the surgeon a magnified view of the operating field and allows identification of vessels and structures with more clarity than is possible in open surgery. Accessory small trocars allow the introduction of fine instruments necessary to perform surgery. With all the trocars and instruments are in place the vessels which bring blood to and from the kidney are clipped . The kidney and ureter are now freed from all their surrounding structures. The ureter is dissected all the way down to the bladder. The kidney and ureter are then removed as one by extending one of the trocar incisions 2 to 3 inches.

• Results - Several investigators including ourselves have compared laparoscopic nephroureterectomies to standard open nephroureterectomies in terms of operative time, estimated blood loss, pain medication requirement, length of hospital stay, time to return to normal activity and complications. We have concluded that though the operative time appears longer the amount of pain medication required, time in hospital and time to return to work is significantly shorter. In addition there was no increase in complications and blood loss was similar in both groups. After the operation the patient is required to have a tube draining the bladder (Foley catheter) for 7-10 days to insure proper healing of the bladder. This precaution is also required when performing the older open procedure.

D. Unroofing of Renal Cysts and Renal Biopsy

• Indications - Cysts can form in the kidney for many reasons and mostly are non-cancerous, benign and require no further intervention. However, in some instances a cyst may enlarge to the point that it causes pain, obstructs the kidney or leads to high blood pressure. Cysts may become infected or bleed. Sometimes a cyst, which at one time appeared benign, may change its shape or features to the extent that malignancy is suspected. For any of the above reasons cyst unroofing and subsequent biopsy may be required. In addition certain renal diseases require a biopsy for diagnosis.

  Laparoscopy has provided an ideal way to manage these problems. No large incisions are required, direct visualization of the cyst and/or kidney is provided and tissue for the pathologist is obtained for more detailed evaluation. In addition an ultrasound probe may be placed through one of the ports to examine the remainder of the kidney with the highest resolution possible.

• Procedure - The patient must undergo general anesthesia for this procedure. Two to three small cylindrical tubes called trocars are placed into the abdominal cavity. The trocars allow entry of a video-telescope, called a laparoscope, to view the entire abdominal cavity and kidney. Accessory small trocars allow the introduction of fine instruments necessary to perform surgery. With all the trocars and instruments in place the surface of the cyst is completely exposed and cyst fluid is drained. The cyst is then cut out and the base of the cyst biopsied. The cyst fluid and biopsy are sent to the pathologist for analysis. When only a kidney biopsy is required a portion of the kidney is exposed and a biopsy is taken. An advantage of this technique is that an ultrasound probe may be placed through the trocar directly onto the kidney to help guide where the biopsy should be performed and to image the kidney.

• Result -Investigators have demonstrated success rates in greater than 95% in patients undergoing cyst unroofing with low complication rates. Operative time averages 90 minutes. Hospital stay is less then 48 hours in most cases. Pain medication requirement is minimal and return to work is often within 2 to 3 weeks. Other options to treat this problem include an open incision. In cases requiring an open procedure pain medication, hospital stay and time to return to work are all longer. Another method to treat renal cysts and/or renal biopsy is placing a needle through the skin into the cyst and/or kidney using the help of x-rays. In theory this procedure is less invasive than laparoscopy however this technique does not allow direct visualization of the kidney or cyst, does not provide a large sampling of tissue, does not allow for high resolution ultrasound guidance and has a relatively high incidence of recurrence when performed for cyst management.

E. Repair of Kidney Obstruction (Laparoscopic Pyeloplasty)

• Indications - A kidney obstructed at the level where the kidney meets the ureter is referred to as a ureteral pelvic obstruction. (picture ) . Ureteral pelvic obstruction may be caused by several factors. The most common cause is congenital; the patient is born with the obstruction. In these patients the obstruction may not become evident until later in life. Other causes of ureteral pelvic obstruction include stone disease, infection and trauma. Once the diagnosis is made, testing must be performed to determine if the obstruction should be repaired (pyeloplasty) or the kidney should be removed (nephrectomy).

• Procedure - The patient must undergo general anesthesia for this procedure. Four to five small cylindrical tubes called trocars are placed into the patients side just below the ribs. The trocars allow entry of a video-telescope, called a laparoscope, to view the entire abdominal cavity and kidney. The video-telescope gives the surgeon a magnified view of the operating field and allows identification of vessels and structures with more clarity than is possible in open surgery. Accessory small trocars allow the introduction of fine instruments necessary to perform surgery. With all the trocars and instruments in place the obstructed portion of ureter is identified and cut out. The ureter is then reattached to the kidneys' pelvis in such a way to prevent further stricture formation

• Results - Long term results of laparoscopic pyeloplasty have confirmed that complications remain low, blood loss is minimal and outcomes are excellent paralleling those performed using the standard open technique.

F. Removal of the Adrenal Gland (Laparoscopic Adrenalectomy)

• Indications - The adrenal gland produces several hormones. Hormones are substances that circulate throughout the blood stream to help regulate blood pressure, sugar level and salt production. When these hormones are produced in excess they can cause imbalances in the body. An adrenal gland which produces too much of any one hormone often requires removal. Another reason to remove the adrenal gland is for suspicion of cancer. Like the kidney, humans have two adrenal glands and can survive normally with one.

• Procedure - Several laparoscopic techniques have been developed to remove the adrenal gland. The decision of which to use is based on size and location of the adrenal gland. Common to all procedures is the use of 4 laparoscopic ports, a camera and specialized instruments to dissect free the adrenal from it's surrounding structure and clipping of the adrenal artery and vein. Removing the adrenal can be particularly challenging secondary to its close proximity to vital structure such as the vena cava, pancreas, liver and spleen. Prior to advent of laparoscopic removal of the adrenal gland large incisions were required to gain adequate exposure to prevent injuring these vital structures while removing the gland.

• Results - The success rates of laparoscopic adrenalectomy have been excellent approaching 95%. The operation takes about 2 to 3 hours, hospital stay is only a few days and post-operative pain is significantly less when compared to the older open technique. Note however, significantly large glands and those producing volatile hormones may still be more safely removed using the open technique.

G. Pelvic Lymph Node Sampling

• Indications - Prostate cancer first spreads to the pelvic lymph nodes. Determining if the cancer has reached the pelvic lymph nodes is extremely important because the treatment options for those patients are different than those with cancer confined within the prostate gland. The individuals prostate blood test level (prostate specific antigen or PSA), appearance of the prostate biopsy as evaluated under a microscope, and their digital rectal exam can help predict if the cancer has spread to the lymph nodes but is not always accurate. In those patients with a high index of suspicion of lymph node seeding a lymph node sampling is required.

• Procedure - Three ports are placed to perform this procedure. Pelvic lymph nodes are sampled from both the right and left side. The camera provides magnification to help prevent injury to major arteries, veins and nerves that surround the pelvic lymph nodes. In addition lymphatic injury when unrecognized may cause significant fluid accumulation post-operatively. This complication may be minimized by the use of laparoscopic magnification.

• Results - The operation takes about one hour to perform with a hospital stay of 24 hours. The amount of narcotics required after the procedure and time to return to work is significantly less when compared to the open technique. The amount of tissue sampled using the laparoscopic technique is similar to that obtained using the open technique.

H. Hand Assisted Laparoscopy

• Indications - In an effort to simplify, improve safety, increase availability and decrease the learning curve of laparoscopy investigators have developed the DexterityӠPneumo Sleeve. This device allows the surgeon to place one hand in the abdomen while maintaining the pneumoperitoneum required to perform laparoscopy. Tactile sensation can be achieved as well as improved spatial orientation. In addition this device has the potential to decrease operating time. Hand assisted laparoscopy may be applied to any laparoscopic procedure in which a specimen measuring greater than 5cm. needs to be removed. The theory is that laparoscopic procedures requiring removal of a large specimen demand the creation of an incision to remove the specimen. Hand assisted laparoscopy allows the surgeon to make this incision at the beginning of the procedure and use it to the their benefit rather than at the end.

• Procedure - The set up, anesthesia and equipment are the same in a hand assisted laparoscopic case and a pure laparoscopic case. The difference involves the use of the pneumosleeve and the creation of a small incision just large enough to place the surgeon's hand. This addition allows the surgeon the best of both worlds. Laparoscopic magnification and instrumentation may be used in combination with a hand in the operating field. Note the incision created at the beginning of the procedure is no larger then the incision required at the end to remove the specimen. (pictures )

• Results - Operative time is similar if not shorter in the hand assisted laparoscopic procedures compared with total laparoscopic procedures. Estimated blood loss, analgesic requirement, length of hospital and return to normal activity is similar in both groups.

I. Ureteropyeloscopy

• Indications - There are many reasons why one may need to look inside the ureter but the major indications are for stones, strictures and tumor. Kidney stones typically are formed within the kidney and then pass down into the ureter. It is here, within the ureter, that the stone gets lodged. Once stuck within the ureter the kidney becomes obstructed and pain ensues. Not only is this extremely uncomfortable (likened to having a baby) but when associated with infection it is life threatening. Ureteroscopy allows the surgeon to access the stone, disintegrate it with a laser or remove it with a basket.

  Strictures are narrowings of the ureter associated with abnormal, unhealthy tissue. Strictures may form in the ureter from the passage of stones, previous surgery, radiation therapy for cancer or for reasons not yet completely understood. However, when a stricture does form and is associated with obstruction of the kidney it must be corrected. Ureteroscopy allows the surgeon to locate the stricture and repair the stricture using balloon expansion, electrical incisions or lasers. It is a minimally invasive technique and prevents a skin incision.

  Cancer, which forms from the lining of the urinary system, is known as transitional cell carcinoma and may arise anywhere along this tract. (Picture ) When transitional cell carcinoma occurs within the kidney or ureter it is a particularly difficult problem. It may be difficult to make the diagnosis since it may be mistaken for a stone, a blood clot or a non-cancerous lesion. When the diagnosis is made the treatment often involves removing the kidney and ureter on the side where the tumor is present (nephroureterectomy). Ureteroscopy has allowed the minimally invasive urologist to more accurately diagnose this disease and in certain situations treat the cancer through the ureteroscope.

• Procedure - Ureteroscopy and ureteroscopic surgery can be performed using a regional anesthesia or general anesthesia. All procedures are performed using video magnification. Diagnostic procedures typically last 30 minutes to an hour. Therapeutic procedures may last up to two hours. The vast majority of patients are sent home the same day or within 24 hours of the procedure. In some patients a temporary internal catheter is placed which spans the ureter. It is removed within 3 Ǡ10 days.

• Results - To diagnose transitional cell carcinoma ureteroscopy is the best test available. It allows the urologist to actually sample a piece of the tumor and send it for evaluation under the microscope. Here at New York Presbyterian Hospital we have a group of patients who underwent ureteroscopy with a high suspicion for cancer. After the ureteroscopy and biopsy specimen was taken it was found that in fact they did not have cancer but the mass was benign not warranting a more invasive procedure. From our vast experience in this field we believe that all patients with a suspicion of transitional carcinoma of the ureter and/or kidney should undergo ureteroscopy.

  Regarding stone disease ureteroscopy is excellent. Up to 95% of patients who undergo ureteroscopy for stones are made stone free. Very few complications have been noted in this group of patients with the majority of patients returning home the day of or 24 hours after the procedure.

  To treat strictures of the ureter the success of ureteroscopy is dependent on the length of the stricture, and the cause of the stricture. In favorable circumstances the success rate is 80% in less then favorable circumstances the success rate approaches 50%. In either case it is a minimally invasive procedure which does not require an incision and has little down side in experienced hands.

J. Cryosurgery

Cryosurgery involves freezing tissue to extremely cool temperatures (-190 Celsius) in order to kill the cells. The mechanism of this destruction includes disruption of the cell wall, organelles within the cell and prohibiting blood from circulating. With the advent of newer delivery systems and ultrasound guidance one can destroy a focal area of tissue/cancer with accuracy up to 2.5 mm.

• Indications - Dermatologists have the most experience with cryosurgery for treating cancers of the skin. Within the last decade urologists have chosen to use this technology for the treatment of prostate cancer. Most recently other applications have been explored including the use for treating liver cancer bone cancer and kidney cancer. Here at New York Presbyterian we are most interested in utilizing cryosurgery for the treatment and cure of small kidney cancers.

  About half of all patients with kidney cancer are diagnosed "incidentally". That is a test such as an ultrasound or CT scan was ordered for another issue and "incidentally" a kidney tumor was discovered. In small isolated tumors treatment options consist of removing part if not all the kidney. Another treatment option being investigated is cryosurgery of the kidney tumor. Patients with only one kidney or decreased renal function, where removal of a portion or the entire kidney would mean dialysis for life, cryosurgery holds great promise.

• Procedure - Cryosurgery of the kidney is performed laparoscopically. Three ports are placed to allow access to the kidney and site of tumor. Using ultrasound guidance the cryoprobe is placed in the center of the lesion. The probe then is cooled to DZ90 Celsius creating an ice ball. Using the ultrasound and specially designed temperature probes, the tumor and tissue surrounding it for 1cm. is cooled to Ǵ0 Celsius. The advantages of includes minimally invasive (no blood loss, no surgical incision, outpatient surgery), short recuperation period, procedure can be repeated if the first cryosurgery has failed, radical surgery is still an option if the first cryosurgery fails. Picture

• Results - Several investigators including ourselves have performed and followed patients over time undergoing cryosurgery of kidney cancer. Operative time is under 2 hours, hospital stay is 3 days or less, estimated blood loss is negligible and complications are extremely rare. Results in terms of cancer control are promising. Patients on follow-up CT scan have had no evidence of recurrence with follow-up out to 5 years. In patients who underwent biopsy of the cryosurgically-treated cancer no evidence of tumor was identified. This technique has great promise in the arsenal against kidney cancer.

K. Extracorporeal Shock Wave Lithotripsy (ESWL)

• Indications - Patients with kidney and/or ureteral stones may be candidates for shock wave lithotripsy. Contraindications to patients undergoing this procedure are pregnancy and unresolved infection. If the stone measures greater then 2centimeters, shock wave lithotripsy may not be the best initial treatment. In stones located in the lower part of the ureter shock wave lithotripsy may be a inadequate and is not a first choice for women of child bearing age.
• Procedure - The patient lies flat on the lithotripsy table or partially submerged in a water bath in older models. The lithotriptor is then targeted to the stone using fluoroscopy, a low radiation energy. 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. It certain cases an internal stent is required temporarily to enhance stone passage and prevent obstruction from impacted stone fragments.
• Results - The results of ESWL depend on the size of the stone, stone burden, type of stone, and location. In general ESWL is used for stones less than 1 to 2 centimeters in size. Most stones fracture well with ESWL treatment. Hard stones such as calcium oxalate monohydrate and cystine stones are more difficult to break with ESWL and therefore often require percutaneous nephrostolithotomy. Fragments from stones located higher within the collecting system are more likely to pass spontaneously than stones in the lower portion of the kidney, simply due to gravitational effect. Stones larger than 1 to 2 centimeters or hard stones will often require multiple ESWL treatments to entirely rid the kidney of all stone fragments.