Laparoscopic approaches in urology - Wiley Online Library

Blackwell Science, LtdOxford, UKBJUBJU International1464-410XBJU InternationalJanuary 2005 952 Update Article LAPAROSCOPIC APPROACHES IN UROLOGY ABDELMAKSOUD et al.

Laparoscopic approaches in urology ALAA ABDELMAKSOUD, CHANDRA SHEKHAR BIYANI, FARIBORZ BAGHERI and GÜNTER JANETSCHEK Urology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt, and Elisabethinen Hospital, Linz, Austria

The use of laparoscopy was one of the most important steps in the progress of medicine, and has developed through the 20th century. Gynaecologists took the initial lead in introducing this technology, followed by

general surgeons. Since the first laparoscopic nephrectomy in 1990, most ablative and reconstructive urological surgery has been attempted laparoscopically. Laparoscopic urological

surgical approaches include conventional transperitoneal and extraperitoneal; in this review the different approaches, with the relevant anatomical considerations, are discussed.

INTRODUCTION

PERITONEAL, PRE- AND RETROPERITONEAL SPACES

laparoscopic nephrectomy, after mobilizing the ipsilateral colon, the anterior surface of Gerota’s fascia covering the kidney is first visualized and the renal hilum is identified subsequently.

Although laparoscopy has been used for nearly 100 years (Table 1) [1–11] only recently, after the advent of laparoscopic cholecystectomy, have developments over the last 15 years led to a surge of interest in laparoscopic procedures. Clayman et al. [7] at Washington University reported the first laparoscopic nephrectomy in 1990; since then most ablative and reconstructive urological surgery has been attempted laparoscopically. Currently, with increasing surgical experience and the development of newer instruments, different approaches have been established for laparoscopic procedures. Naturally, for any laparoscopic urological procedure, access to the site of the lesion should be gained first. Approaching the area of the lesion depends on many factors, i.e. the diseased organ, site and size of the lesion, the procedure planned and the experience of the surgeon. The creation of an adequate space (pneumoperitoneum or pneumoretroperitoneum) is the most important step in the procedure. The aim is to develop a good protective exposure during the laparoscopic procedure that must be adequate to perform the operation and deal with any possible complications.

ANATOMICAL CONSIDERATIONS IN UROLOGICAL LAPAROSCOPY Without a sound knowledge of the relevant surgical anatomy the practising surgeon will repeatedly get into difficulties; thus we present the basic anatomical considerations in urological laparoscopy. 244

Several peritoneal ligaments are landmarks in the peritoneal cavity. The ligamentum teres passes from the superior margin of the umbilicus to the liver and contains the obliterated umbilical vein. The falciform ligament is a peritoneal reflection that covers the ligamentum teres and attaches it to the diaphragm. During transperitoneal laparoscopic surgery on the left side, the spleen, pancreas, left colon and stomach overlie the left kidney and adrenal. Laparoscopic exposure is usually obtained by mobilizing the splenic flexure of the colon medially and dividing the splenocolic ligament. Dividing the phrenocolic, splenorenal and renocolic ligaments achieves further exposure. Contrarily, on the right side, the right colonic flexure lies at a lower level. Mobilizing the right colonic flexure is necessary in renal surgery on the right side. This mobilization may not be necessary during transperitoneal right adrenalectomy as the right adrenal gland lies directly under the peritoneum. Incision of the peritoneum just lateral to the vena cava will give access to the renal hilum and to the adrenal vein. Exposing the upper pole of the right kidney and adrenal is achieved by retracting the right lobe of the liver and dissecting the peritoneal attachments to the upper pole of the kidney and adrenal (Fig. 1 and Fig. 2). The parietal peritoneum that lines the anterior abdominal wall reflects over the intraabdominal viscera and defines a space between the peritoneum and the anterior renal (Gerota’s) fascia. The laparoscopic surgeon should enter this space during initial exposure of the kidney. During transperitoneal

©

In contrast, during retroperitoneal laparoscopic nephrectomy, because of the anteromedial displacement of the kidney by the balloon dissector, the posterior surface of Gerota’s fascia is exposed and this allows early recognition of the main renal artery and vein close to their origin from the aorta and inferior vena cava, respectively. The psoas muscle is an important anatomical landmark in retroperitoneoscopic surgery. The renal artery pulsations, aortic pulsations, gonadal vessels and the inferior vena cava are important anatomical landmarks for locating the renal hilum during laparoscopic nephrectomy. Proper development of the retroperitoneal space and identification of adequate anatomical landmarks is important during retroperitoneoscopy. Sung and Gill [12], in a prospective study collected objective data with regards to anatomic landmarks during retroperitoneoscopic radical nephrectomy. They observed that the anatomical landmarks visible on initial inspection were: psoas muscle (100%), Gerota’s fascia (100%), peritoneal reflection (83%), ureter and/or gonadal vein (61%), renal artery pulsation (56%), aortic pulsation (90%), and the inferior vena cava in (25%). They also noted that when four or more anatomical landmarks were visualized on initial examination after balloon dilatation, the hilar dissection was significantly faster. In the lower abdomen five peritoneal folds converge on the underside of the umbilicus. The median umbilical fold (remnant of the obliterated urachus) ascends in the midline from the dome of the bladder to the

2 0 0 5 B J U I N T E R N A T I O N A L | 9 5 , 2 4 4 – 2 4 9 | doi:10.1111/j.1464-410X.2005.005277.x

LAPAROSCOPIC APPROACHES IN UROLOGY

Year 1901 1911 1933 1938 1960s 1989 1991 1991 1992 1992

Ref [1] [2] [3] [4] [5] [6] [7] [8] [9] [10]

1993

[11]

Event First attempt to inspect the abdominal cavity First large clinical experience Used carbon dioxide Pneumoneedle Controlled automatic insufflator Laparoscopic cholecystectomy Laparoscopic nephrectomy Laparoscopic pelvic node dissection Retroperitoneoscopy with balloon dilatation Laparoscopic adrenalectomy Laparoscopic prostatectomy Laparoscopic cystectomy Laparoscopic ureterolithotomy Gasless laparoscopy

FIG. 1. A longitudinal section of the abdomen; the dotted lines show the lines of peritoneal incisions on both right and left sides during transperitoneal adrenalectomy.

FIG. 2. A picture taken after establishing pneumoperitoneum during laparoscopic transperitoneal right adrenalectomy. G, gall bladder; HD, hepatic duct; D, duodenum; P, pancreas; L, liver; TC, transverse colon; RV, renal vein; K, kidney; A, adrenal gland; VC, vena cava.

TABLE 1 The history of laparoscopy

FIG. 3. A diagram showing the anatomical landmarks in the male pelvis. The dotted line indicates the incision of the peritoneum to expose the seminal vesicles in transperitoneal radical prostatectomy.

peritoneal side of the umbilicus. The next pair of folds comprises the two medial umbilical folds (obliterated umbilical arteries) and the bladder lies between these folds. Lateral to these folds the lateral umbilical folds mark the site of the inferior epigastric artery and vein. The vas deferens issues from the internal inguinal ring and runs medially, crossing the medial umbilical ligaments then runs posteriorly to the seminal vesicle. In transperitoneal laparoscopic radical prostatectomy, the seminal vesicles are exposed after incising the peritoneum reflection between the bladder and rectum, guided by the course of the vas deferens (Fig. 3). In laparoscopic transperitoneal pelvic surgery, medial and lateral umbilical ligaments are

©

2005 BJU INTERNATIONAL

important anatomical landmarks, together with the vas deferens in males. The preperitoneal space lies between the endo-abdominal fascia and the peritoneum. The only contents are remnants of the umbilical arteries and vein, the urachus and the inferior epigastric vessels; the space usually contains a variable amount of fat. Access to the preperitoneal space is gained by penetrating all the layers of the abdominal wall but stopping just short of peritoneal cavity. This dissection can be accomplished with a finger but many surgeons prefer to use a blunt-tipped Hasson cannula. Entering this space will give direct access to the extraperitoneal pelvic organs.

PATIENT POSITIONING DURING UROLOGICAL LAPAROSCOPY The position of the patient during laparoscopic surgery varies according to the procedure to be done and the type of approach used in this procedure. In upper tract surgery the patient is put in the flank position, giving a better space to work. When supine, the site of the lateral peritoneum reflection is located anterior to the posterior axillary line. Using autopsy and radiographic studies, Capelouto et al. [13] showed that the anteroposterior dimension of the retroperitoneal space is doubled if the patient is moved from the supine to the flank position. Chiu et al. [14] reported a significant shift of the colon anteriorly by changing the patient’s position from supine to lateral. This manoeuvre increased the distance between the quadratus lumborum and colon from 8.7 to 23.3 mm on the left side and 4.6 to 18.1 mm on the right. During transperitoneoscopy the patient is placed in a 45∞ flank position, and in retroperitoneoscopy in a complete 90∞ flank position. In laparoscopic pelvic surgery, patients are placed supine with different Trendelenburg adjustments to increase the working space and to retract the colon caudally.

APPROACHES IN UROLOGICAL LAPAROSCOPY Laparoscopic procedures in the abdomen or pelvis can be performed through a transperitoneal or extraperitoneal approach (Fig. 4). 245

A B D E L M A K S O U D ET AL.

(i) Abdomen: • Transperitoneal-lateral • Transperitoneal-anterior • Extraperitoneal-lateral • Extraperitoneal-posterior (ii) Pelvis: • Transperitoneal • Extraperitoneal (iii) Hand-assisted – a valuable approach for removing large organs [15]. TRANSPERITONEAL APPROACH (LATERAL/ANTERIOR) The transperitoneal approach has been used for a long time and is considered the most popular technique among urologists. The transperitoneal lateral route is commonly used for upper urinary tract surgery because it provides a large working space. Patient positioning helps to retract organs by gravity and many anatomical landmarks guide the surgeon when using this approach. However, if a procedure is required on both sides, e.g. bilateral adrenalectomy, it necessitates repositioning the patient. The principal disadvantage is the possible long-term complication of intra-abdominal adhesions leading to bowel obstruction. The anterior transperitoneal approach is used in pelvic surgery, e.g. laparoscopic radical prostatectomy. The choice between a lateral or anterior approach is determined by the patient’s anatomy and disease entity. In the transperitoneal approach a pneumoperitoneum must be established first, either by closed or open techniques. For the closed technique, pneumoperitoneum is achieved by blindly inserting the Veress needle into the peritoneal cavity and insufflating CO2 through the needle to the peritoneal cavity [4]. The Veress needle should be tested to confirm proper functioning of the spring mechanism, to avoid injury to abdominal viscera or vessels. The abdomen is inspected and palpated for scars, lumps or organomegaly, and any abnormal pulsations. An incision is made around the umbilicus for inserting the needle and first trocar later. This area is preferred because the parietal peritoneum is adherent to the anterior abdominal wall, no abdominal wall vessels can be injured, and it is a central area where the whole abdominal cavity can be scanned. 246

If adhesions are suspected between the bowel and anterior abdominal wall, the needle should be inserted above and lateral to the umbilicus, either on right or left side after abdominal ultrasonography to determine the size of the liver and spleen. The needle and first trocar should also be inserted away from the umbilicus in cases of umbilical hernia and portal hypertension. In most renal and adrenal surgery when the lateral transperitoneal approach is used the needle is usually inserted lateral to the rectus muscle above the level of the umbilicus on either side, according to the site of the lesion. For the open technique (Hasson) [16], a small (1.5–2 cm) incision is made over the umbilicus, incising the anterior rectus sheath, splitting the recti and incising the peritoneum. A finger is then introduced to ensure that there are no adhesions between the anterior abdominal wall and the bowel or omentum. A blunt-tip Hasson cannula is introduced inside the abdomen and sutures placed on each side to fix it and to ensure an airtight seal around the trocar. After gaining access to the peritoneal cavity, CO2 is insufflated and the secondary trocars inserted accordingly. This open technique is used if significant adhesions are suspected from previous abdominal surgery or inflammation, or in children, because of the relatively short distance between the anterior abdominal wall and the intra-abdominal organs. In the USA this technique has also been widely adopted for the unoperated abdomen because it is very safe. RETROPERITONEAL APPROACH (LATERAL/POSTERIOR) Most organs of interest to the urologist are extraperitoneal and most open urological procedures are extraperitoneal. However, in laparoscopy the main problem for the retroperitoneal approach was creating the retroperitoneal space, until Gaur [9] described his technique for creating it; since then, retroperitoneoscopy has become popular. To access the retroperitoneal space the open (Hasson) technique is used. While the patient is in the complete flank position (lateral approach), a horizontal 1.5 cm skin incision is made at the tip of the 12th rib. Using a pair of S-retractors the flank muscles are bluntly split up to the anterior thoracolumbar fascia, which is then incised to enter the retroperitoneal space. By gentle finger dissection, a retroperitoneal space for the

FIG. 4. A diagram showing the direction of the different laparoscopic approaches in a transverse section of the abdomen. Lateral transperitoneal (anterior), lateral retroperitoneoscopy (middle) and posterior retroperitoneoscopy (posterior).

FIG. 5. A diagram showing the direct access to the renal hilum (arrow) by retroperitoneal approach.

balloon dilator is created between the psoas muscle posteriorly and Gerota’s fascia anteriorly. The balloon dilator is inserted into the dissected space and inflated with 800 mL of air or saline for adults and 400–600 mL for children. The distended balloon displaces Gerota’s fascia and the kidney, anteromedially exposing the posterior aspect of the renal hilum and the adjacent vessels (Fig. 5). Secondary trocars are inserted under finger guidance, then the Hasson cannula is inserted through the 1.5 cm incision. The same technique is used in the posterior retroperitoneal approach while the patient is prone. The trocars are inserted under the 12th rib (Fig. 6). It can also give fast access to the adrenal gland and to the renal hilum. This approach is preferred in bilateral adrenal or renal surgery, as there is no need to change the patient’s position [17,18]. The total extraperitoneal approach addresses some of the perceived disadvantages of the transperitoneal approach. The retroperitoneal approach provides early control of the renal vessels and allows extraperitoneal dissection without bowel manipulation, resulting in minimal ileus and rapid recovery. The major

©



disadvantages of this approach are the relatively narrow space and scarce anatomical landmarks. The retroperitoneal approach is contraindicated if there is a history of retroperitoneal abscess or surgery. Large tumours or huge kidneys are relative contraindications for this approach, because of the marked reduction of the working space. In a prospective randomized study we compared the transperitoneal and retroperitoneal approaches for endoscopic radical nephrectomy to assess the possible differences in the outcome related to patients’ morbidity and technical difficulty for the surgeon. Forty patients with cT1, T2 RCC were randomized into two equal groups, i.e. laparoscopic radical nephrectomy (LRN) and retroperitoneoscopic radical nephrectomy (RRN). The patient demographics and tumour characteristics were comparable. Two surgeons with differing experience performed an equal number of procedures in either arm. The outcome was compared and technical difficulty for the surgeon and assistant assessed with the European scoring system. All procedures were completed with no need for conversion to open surgery. There was no statistically significant difference between the approaches in the number and size of the trocars used, the length of incision, specimen weight, pathological stage, operative time, additional procedures (e.g. adrenalectomy and/or lymph node sampling), estimated blood loss, blood transfusion, analgesic requirement, length of hospital stay and minor or major complications. All patients in LRN group resumed oral intake 1 day after surgery, while only three-quarters did so in the RRN group. The technical difficulty score, either for the surgeon or the assistant, did not differ significantly between the groups. Both approaches have equal oncological efficacy. Robotic assistance (AESOP) was more difficult with RRN than LRN (Günter Janetschek, personal communication). This first prospective randomized study comparing LRN and RRN showed no real difference between the approaches in relation to patient morbidity or the technical difficulty for the surgeon.

EXTRAPERITONEAL APPROACH FOR PELVIC SURGERY This approach can be used in laparoscopic pelvic surgery like bladder neck suspension, pelvic lymph node dissection, bladder

©


diverticulectomy and radical prostatectomy [19,20]. The extraperitoneal space is created as follows: • The patient is placed supine or in the lithotomy position. A Foley catheter is inserted in the bladder to empty it. • A 1.5–2 cm skin incision is made either just below the umbilicus or midway between the umbilicus and symphysis pubis. The subcutaneous fat is dissected until the anterior rectus sheath is reached. Another incision is made in the sheath after placing two stay sutures to assure air-tightness and to fix the trocar. • After blunt splitting of the recti muscle, the transversalis fascia is incised and the retropubic space created by the index finger. A balloon is inserted in this space and inflated with 1 L of air or saline. • A 12-mm blunt trocar is applied to this space and the two stay sutures of the anterior rectus sheath tied around it. CO2 insufflation is begun and the laparoscopy lens introduced through this port. Other ports are applied under vision. Although the working space in this approach is sometimes a little more restricted and orientation more difficult, the ultimate result is a procedure with no intraperitoneal manipulations and associated with much less postoperative pain and ileus. A recent study comparing the early oncological results of laparoscopic radical prostatectomy by the extraperitoneal or transperitoneal approach showed no significant difference between them in preoperative characteristics, except for the Gleason score, which was higher in the extraperitoneal group [21]. There were no differences in transfusion rate, hospital stay, medical and surgical complications and positive surgical margins. The operative duration was longer in the transperitoneal approach (248.5 vs 220.0 min, P < 0.001). Another study by the Heilbronn group [22] comparing the transperitoneal and extraperitoneal approaches for radical prostatectomy showed that there were no significant differences between the approaches in the important variables. In addition to the preference and experience of the surgeon, any previous abdominal surgery, gross obesity and requirement for simultaneous inguinal hernia repair may be considered selective indications for the extraperitoneal approach.

The approach, whether for abdominal or pelvic surgery, should be based on the surgeon’s experience and preference. Sometimes other factors may influence the choice of approach, e.g. obesity or previous surgery. We recommend the transperitoneal approach for beginners and then parallel training in both techniques. HAND-ASSISTED APPROACH The hand-assisted technique may be useful in dissection and to control blood loss, and the additional incision may facilitate specimen extraction. Typically, operating surgeons use their subordinate hand to retract, expose and compress the organ. This technique requires an incision length (in centimetres) equivalent to the glove size of the surgeon, to apply a pneumosleeve device through it for the surgeon’s hand. The surgeon’s hand in the abdomen makes the surgery easier and quicker because of the technical facility of the fingers, improved tactile sense and the overall versatility of the hand compared with current mechanical instruments. In addition, having a hand in the abdomen seems to add an extra margin of safety to the procedure [23–25]. However, the incision required to place the hand into the abdomen might increase postoperative pain and disability. The device adds extra cost to the procedure.

PORT SITES Since the array of ports determines the working range of the instruments, the port sites must be carefully planned to meet the particular requirements of the procedure. The following considerations may be helpful in planning. Generally, the camera is introduced via a port in the umbilicus in the transperitoneal approach, or a central port in retroperitoneoscopy. However, there are some exceptions to this rule. The sites of the working ports must be chosen so they are not too close to one another or to the camera port or operative site. A distance of ≥5 cm must be allowed in all cases. Ideally the two instruments handled by the laparoscopist should meet at the operative site at an angle of 45–90∞. However, in procedures in which the operative field is very large, such as nephroureterectomy, this angle is continually changing and cannot be ideal for all manoeuvres. In this setting the laparoscopist 247

A B D E L M A K S O U D ET AL.

must be constantly aware of the workable compromise, but whatever the situation, the laparoscope-bearing sheath must not run parallel to the instrument-bearing sheath. Most commonly the camera port and the two working ports for the surgeon are arranged so they form a triangle, with the tip pointing downward [26]. EXITING THE ABDOMEN The procedure for exiting the abdomen is as essential to the success of laparoscopic surgery as is the correct insertion of the Veress needle for insufflation. First, all port sites should be checked to ensure that there is no late bleeding from the peritoneum. Second, the use of fascial sutures to close the port sites prevents herniation, and such sutures are certainly required for all port sites of >10 mm in adults. These can be placed under direct endoscopic control, and a 5-mm laparoscope should be left in the field for this purpose. For 5-mm port sites the skin should be sutured, but it is not necessary to suture the fascia. However, in children fascial sutures are required for all port sites. Finally, it is good practice to close the skin with intracutaneous absorbable sutures, as there is no requirement for the patient to return to hospital for their removal [27]. Some surgeons prefer to use the gas-less mechanical retraction for retroperitoneoscopy and laparoscopic pelvic surgery. By this technique the working space is created by retracting the abdominal wall with automated body-wall retractors that attach to the sides of the operating table. Avoiding the complications of gas insufflation is the principal advantage of this approach but the operating space available is reduced. Moreover, the retraction is poor in obese patients and prolonged retraction can cause necrosis of the abdominal muscles [28]. There are special considerations during laparoscopic surgery in children: • The open technique (Hasson) is preferable as the distance between the abdominal wall and the viscera is short. • Because of the relatively narrow space, whether intra- or retroperitoneal, the rate of CO2 insufflation should be slow and 10 mmHg is enough. • The urinary bladder should be catheterized before surgery, to avoid bladder injury, as the bladder is intraperitoneal in children. 248

CONCLUSION Laparoscopy is like open surgery but with a more difficult approach, and therefore the basic techniques and the instruments do not differ as much as initially expected. Understanding and anticipating the various anatomical landmarks associated with the transperitoneal and extraperitoneal approaches are critical for safe and successful laparoscopic surgery. Retroperitoneoscopy, pelvic extraperitoneoscopy and hand-assisted laparoscopy are important adjuncts to the laparoscopic options in urological surgery.

FIG. 6. A diagram showing the trocar arrangement in posterior retroperitoneoscopy, with the patient prone.

REFERENCES 1

Kelling G. Über Ösophagoskopie, Gastroskopie und Colioskopie. Münchener medezinische. Wochenschrift 1901; 49: 21–4 2 Jacobeus HC. Über die Möglichkeiten; die Zystoskopie bei Untersuchung seroser Hohlungen anzuwenden. Münchener Medezinische Wochenschrift 1910; 57: 2090–2 3 Fervers C. Die Laparoskopie mit dem Cystoskope. Med Kilnik 1933; 29: 1042–5 4 Veress J. Neues Instrument zue Ausfuhrung von Brust-oder Bauchpunktionen und pneumothoraxbehandlung. Deutsche Med Wochenschr 1938; 41: 1480–1 5 Semm K. Tissue puncher and loop ligation. New aids for surgical therapeutic pelviscopy: Endoscopic intra-abdominal surgery. Endoscopy 1978; 10: 119–27 6 Dubois F, Berthelot G, Levard H. Cholecystectomie par coelioscopie. Nouvelle Presse Médicale 1989; 18: 980– 2 7 Clayman RV, Kavoussi L, Soper N et al. Laparoscopic nephrectomy: Initial case report. J Urol 1991; 146: 278–82 8 Schuessler WW, Vancaillie TG, Reich H et al. Transperitoneal endosurgical lymphadenectomy in patients with localized prostate cancer. J Urol 1991; 145: 899–903 9 Gaur DD. Laparoscopic operative retroperitoneoscopy. use of a new device. J Urol 1992; 148: 1137–9 10 Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing syndrome and pheochromocytoma. N Eng J Med 1992; 327: 1033 11 Nagai H, Kondo Y, Yasuda T, Kasahara K, Kanazawa K. An abdominal wall-lift

12

13

14

15

16

17

18

19

20

method of laparoscopic cholecystectomy without peritoneal insufflation. Surg Endosc 1993; 3: 175–9 Sung GT, Gill IS. Anatomic landmarks and time management during retroperitoneoscopic radical nephrectomy. J Endourol 2002; 16: 165–9 Capelouto CC, Moore RG, Silverman SG, Kavoussi LR. Retroperitoneoscopy: Anatomical rationales for direct retroperitoneal access. J Urol 1994; 152: 2008–10 Chiu AW, Chen K-K, Wang J-H et al. Direct needle insufflation for pneumoperitoneum. anatomic confirmation and clinical experience. Urology 1995; 46: 432–7 Wolf JS Jr, Moon TD, Nakada SY. Hand-assisted laparoscopic nephrectomy: technical considerations. Tech Urol 1997; 3: 123–8 Hasson HM. Open laparoscopy versus closed laparoscopy. a comparison of complication rates. Adv Plan Parent 1978; 13: 41–50 Fujisawa M, Kawabata G, Gotoh A et al. posterior approach for retroperitoneal laparoscopic bilateral nephrectomy in a child. Urology 2002; 59: 444–6 Walz MK, Peitgen K, Hoermann R et al. Posterior retroperitoneoscopy as a new minimally invasive approach for adrenalectomy. Results of 30 adrenalectomies in 27 patients. World J Surg 1996; 20: 769–74 Gill IS, Clayman RV, Alabala DM et al. Retroperitoneal and pelvic extraperitoneal laparoscopy: an international perspective. Urology 1998; 52: 566–71 Bollens R, Vanden Bossche M, Roumeguere F et al. Extraperitoneal

©



radical prostatectomy: results after 50 cases. Eur Urol 2001; 40: 65–9 21 Ruiz L, Salomon L, Hoznek A et al. Comparison of early oncologic results of laparoscopic radical prostatectomy by extraperitoneal vs transperitoneal approach. Eur Urol 2004; 46: 50–6 22 Erdogru T, Teber D, Frede T et al. Comparison of transperitoneal and extraperitoneal radical prostatectomy using match-pair analysis. Eur Urol 2004; 46: 312–20 23 Tschada RK, Rassweiler JJ, Schmeller N, Troedoarakis V. Laparoscopic tumor nephrectomy in the German experiences. J Urol 1995; 153: 479A, 1003

©


24 Keeley FX, Sharma NK, Tolley DA. Hand-assisted laparoscopic nephrouretrectomy. J Urol 1997; 157: 399A, 1565 25 Wolf JS Jr, Moon TD, Nakada SY. Hand assisted laparoscopic nephrectomy: technical considerations. Tech Urol 1997; 3: 123–8 26 See WA, Monk TG, Weldon BC. Complications of laparoscopy. In Clayman RV, McDougall EM eds, Laparoscopic Urology. St. Louis: Quality Medical, 1993: 183–206 27 Elashry OM, Wolf JS Jr, Nakada SY et al. Comparative clinical study of port closure techniques following laparoscopic

surgery. J Am Coll Surg 1996; 183: 335– 44 28 Flax S. Gasless laparoscopy for urologist. Can J Urol 1997; 4: 309–13 Correspondence: Alaa Abdelmaksoud, Urology Department, Faculty of Medicine, Ain Shams University, PO Box 9535, SOS, Nasr City, Cairo, Egypt. e-mail: [email protected] Abbreviations: L(R)RN, laparoscopic (retroperitoneoscopic) radical nephrectomy.

249