In 1999, Jens Rassweiler developed a different laparoscopic technique similar to the classic open anatomic radical prostatectomy. Most importantly, this technique included an ascending part, with ...early division of the urethra, followed by a descending part, with incision of the bladder neck and dissection of the cranial pedicles, seminal vesicles, and vasa deferentia.
Since March 1999, more than 1200 laparoscopic radical prostatectomies (LRPs) were performed in our department using the Heilbronn technique.
Aim: Despite the extensive experience with minimal invasive stone therapy, there are still different views on the ideal management of renal stones. Materials and Methods: Analysis of the literature ...includes more than 14,000 patients. We have compared these data with long-term results of two major stone centers in Germany. The results have been compared concerning the anatomical kidney situation, stone size, stone localization and observation time. Results: According to the importance of residual fragments following extracorporeal shock wave lithotripsy (ESWL), we have to distinguish between clinically insignificant residual fragments and clinically significant residual fragments (CIRF). 24 months following ESWL stone passage occurs as a continous process, and if there are no clinical symptoms, any endoscopic procedure should be considered as overtreatment. According to these results, stone-free rates of patients increase in longer follow-up periods. Newer ESWL technology has increased the percentage of CIRF. Conclusion: We consider ESWL in most patients with renal calculi as first-line treatment, except in patients with renal calculi bigger than 30 mm in diameter. Copyright (C) 2001 S. Karger AG, Basel.
Open surgery is based on the access to the treated organ via one large 5- to 30-cm incision dividing the skin and abdominal muscles or fascias. This large skin incision provides the surgeon and ...assistant(s) with a direct view of the anatomy, enabling the introduction of their hands and instruments. They can look down at their work with their heads and necks in a neutral position, using both hands, with natural hand-eye coordination (Fig. 6.1a). For delicate surgical actions, it is even possible to support the wrists by leaning on the patient’s body or on a specially developed armrest 7, 21, 33. However, there are also some drawbacks, particularly in case of pelvic surgery:
- The light conditions might be suboptimal.
- The distance to the tissue/organ is relatively long (i.e., urethra).
- The view to the object might be hindered by bone (suprapubic spine).
- The view for the assistant might be suboptimal due to the narrow anatomical conditions.
- The position of the surgeon is ergonomically suboptimal (i.e., torsion of the body).
In 1991, laparoscopic nephroureterectomy was been introduced as a treatment option for upper tract transitional cell carcinoma. Based on personal long-term experience and the review of the current ...literature, we analyzed the actual results of this technique in comparison to open surgery. We reviewed the charts and followed up 23 patients who underwent laparoscopic nephroureterectomy at the Klinikum Heilbronn between December 1994 and December 2003, and 21 patients who underwent open nephroureterectomy during the same period. Demographic, perioperative, and follow-up data were compared. Additionally, we performed a MEDLINE/PUBMED search and reviewed the literature on laparoscopic and open nephroureterectomy between 1991 and 2004 (n = 1365 patients). The analysis of the literature including the Heilbronn experience revealed a slightly longer operating time (276.6 vs 220.1 min), and signifi- cantly lower blood loss (240.9 vs 462.9 ml) in the laparoscopic series. No differences of minor (12.9% vs 14.1%) or major complication rates (5.6% vs 8.3%) were observed. All nine comparative studies revealed a significant dose reduction of the morphine equivalents after laparoscopy. In all ten comparative series the hospital stay was shorter after laparoscopy, but only in six series was the difference statistically significant. The frequency of bladder recurrence (24.0% vs 24.7%), local recurrence (4.4% vs 6.3%), and distant metastases (15.5% vs 15.2%) did not differ significantly in both groups. The actual diseasefree 2-year survival rates (75.2% vs 76.2%) were similar. The 5-year survival rates averaged 81.2% in the three laparoscopic (n = 113 patients) and 61% in the ten open series (n = 681 patients). Six port site metastases were reported in 377 (1.6%) analyzed patients occurring 3-12 months following laparoscopy. Open radical nephroureterectomy still represents the gold standard for the management of upper tract transitional cell carcinoma; however, laparoscopic radical nephroureterectomy offers the advantages of minimally invasive surgery without deterioration in the oncological outcome. In cases of advanced tumors (pT3, N+), open surgery is still recommended.
Whilst the patient is supine, following induction of anaesthesia, a urinary catheter is inserted. The patient is now rotated to the lateral position and the urinary bag is placed either at the top or ...bottom end of the bed for access by the anaesthetist. The legs are separated and protected with either pillows or a specially designed foam or rubber device between them as seen in the inset, in order to relieve any weight on pressure points, while the legs are slightly flexed at the knees. All other bony points, including shoulders and hips, are protected by the rubber or foam mat that is positioned on the operating table. The head and neck are supported with either pillows or a rubber head ring in order to maintain them in a neutral position. Depending on the softness of the table mattress, an axillary rubber roll may be required (not illustrated in these images) to prevent brachial plexus injury.
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