[Hand-assisted laparoscopy]. / Laparoscopia manualmente asistida.

OBJECTIVES: Laparoscopic surgery has not been extended enough among the urologists due to the inaccessibility of the retroperitoneal organs and consequently to the steep learning curve that is required. In this article we describe our experience in laparoscopic surgery assisted by the surgeon's hand introduced in the operating field. This is a technique that we have been using since 1994 and that has not been generally accepted until very recently. METHODS: Difficult nephrectomies and nephroureterectomies are considered to be the main indications for this technique. The approach to each kidney is described. RESULTS: The operating time is dramatically reduced. The surgeon's hand introduced intra-abdominally allows for a better control in difficult situations. The economic cost is lower. The use of analgesics and the recovery time in the postoperative period is similar to that of conventional laparoscopy. CONCLUSIONS: The optimal indication for this procedure are cases that require a very large and mutilating incision. The learning curve is significantly easier and it is an invaluable technique in cases considered until now to be unsuitable for an endoscopic procedure.

[Voice-directed robotic cystoscopy]. / Cistoscopia robotizada dirigida mediante la voz.

OBJECTIVE: In line with our previous studies in the field of robotics, a new application of our robotic arm is presented: voice-directed cystoscopy. METHODS: Cystoscopy was performed in a sow using a voice-directed robotic arm to which a cystoscope had been attached. The computer executes all the processes that enable interaction with the surgeon and communication with the robotic system. The surgeon directs the movements of the cystoscope by voice, using instructions easily recognizable by the voice identifier. RESULTS/CONCLUSIONS: This system is easy to operate and carries out the commands given by the surgeon with great precision and safety.

[A decade of laparoscopic varicocelectomy: costs and learning stages]. / Una década en la varicocelectomía laparoscópica: costes y fases de aprendizaje.

OBJECTIVE: To present the results of a retrospective study on laparoscopic varicocelectomy, with special reference to the changes in the operating time observed throughout the training period. METHODS: We have reviewed the laparoscopic varicocelectomy procedures performed from 1987 to 1997. The operating times were graphically represented and compared, and the modifications and complications observed over the ten-year period were analyzed. RESULTS/CONCLUSIONS: The operating times decreased as the number of procedures increased and its duration further decreased as the interval between operations became shorter. In our case, the average operating time after the training period has been completed is 44 minutes. The cost of laparoscopic varicocelectomy and laparoscopic surgery in general is comparable to that of open surgery if nondisposable material is utilized.

[Transurethral resection by remote control]. / Resección transuretral mediante control remoto.

OBJECTIVE: Telepresence allows working in distant environments by means of telemanipulators, which consist of two main modules: a master arm handled by the human operator and a slave arm that reproduces its movements. We have found in TUR unique conditions for telemanipulation and our aim is to perform this operation by remote control; in other words, to create a telepresence system for prostatectomy that would permit a surgeon to carry out an operation from a distant location for the first time. METHODS: We have developed a slave arm equipped with a resectoscope at its tip and which is able to perform the necessary movements for this type of surgery with ultramillimetric precision. This device is teloperated by the surgeon by means of a master arm that simulates a working element. RESULTS/CONCLUSION: This system will permit performing an operation from a remote site easily and for the first time, with all the advantages this may entail.

Laparoscopy-assisted cystoplasty.

A new clinical endoscopic cystoplasty technique is described. The patient presented with a microbladder and a markedly dilated left ureter. One month earlier, he had had a right-side nephrectomy for tuberculosis. Five trocars were introduced: one of 10 mm via the umbilicus, one of 5 mm in each iliac fossa, and one of 11 mm in each flank. We opened the peritoneum and freed the bladder walls to the pelvic floor, dissected free and sectioned the ureter as low as possible, and withdrew it with a loop of intestine through a minilaparotomy. We isolated a segment of intestine and restored continuity. The ureter was anastomosed to the isolated segment and reintroduced into the abdomen. The intestinal segment was taken around the bladder and fixed on each side. One jaw of the EndoGIA was introduced into a small incision in the bladder dome and the other into the intestinal segment, and the instrument was triggered. The operation was concluded by introducing an appropriately oriented conventional Roticulator stapler via the minilaparotomy to grip the bladder-intestinal breach and triggering. The patient's bladder capacity was effectively increased, and 20 months later, he is asymptomatic and the intervals of diurnal micturition are more than 3 hours.

[Endoscopic treatment of inguinal cryptorchism]. / Tratamiento endoscópico de la criptorquidia inguinal.

OBJECTIVE: A new endoscopic approach for the treatment of the testicle located in the inguinal canal is described. METHOD: Three trocars are inserted in the umbilicus and both flanks, then the spermatic vessels and vas deferens are dissected. A 2 cm skin incision is performed at the level of the internal inguinal ring and a finger is introduced. An incision is made endoscopically in the inguinal canal between the epigastric vessels and the conjoined tendon. With the finger the testicle is located and partially dissected. Pressure is applied on it until it is introduced into the peritoneal cavity through this incision, where it is released by dividing the sustentaculum testis. The cord is then pulled, the testicle is passed in front of the epigastric vessels and taken through the internal ring. Once the testicle is free in the peritoneum, it is brought into the scrotum. Finally, the inguinal canal is closed endoscopically. CONCLUSIONS: So far endoscopic orchiopexy has only been performed in intraabdominal testicles, and we believe that this procedure can extend the indications of endoscopic treatment for the undescended testis.

Laparoscopic cystectomy and ileal conduit: case report.

A completely new combined laparoscopic cystectomy and ileal conduit technique for removal of an infiltrating bladder cancer was carried out on a 64-year-old woman. The bladder was dissected free and extracted whole through the right flank. The right ureter and a loop of intestine were withdrawn through the same incision. An ileal segment was isolated and intestinal continuity restored. The right ureter was anastomosed to one extreme of the segment that was then reintroduced into the abdomen, taken across to the left side, withdrawn with the left ureter, anastomosed extracorporeally, and reintroduced. The stoma was constructed in the left flank at the patient's request. Recuperation was unusually fast and painless, and little postoperative analgesia was required. Further experience and a two-team approach could reduce the operation time to 3 or 4 hours. We are now convinced that combining the two procedures was better for the patient, even though it prolonged the time in the operating room.

[Endoscopy-assisted renovascular surgery]. / Cirugía vasculorrenal endoscópicamente asistida.

OBJECTIVES: Laparoscopic surgery still has many impediments which render it impracticable or very difficult in many cases. In this article we describe in the laboratory the possibilities of performing it helped with a hand that has previously been introduced in the abdomen through a minilaparotomy. METHODS: Once the animal is in the lateral decubitus position, a longitudinal suprapubic incision of some 5 cm is done, through which the surgeons left hand is introduced. Then, together with the instruments, the kidney, its vessels, the aorta and vena cava are dissected. In one case the left renal artery was temporally clamped, divided and then sutured. RESULTS: This minimally invasive technique allowed in all the cases to accurately perform the operation in a very short time and with minimal risk. CONCLUSIONS: The main indication of this technique are the cases in which a large incision is required, as in large renal tumors or testicular cancer surgery. It is particularly useful in previously operated patients, or if a complication arises during a laparoscopy, or if a minilaparotomy is required as, in ileal conduits. This procedure also opens the door to a new approach to renovascular surgery.

[Extraperitoneal laparoscopic urethropexy]. / Uretropexia laparoscópica extraperitoneal.

The present article describes a procedure for bladder neck suspension. The peritoneum is detached using a technique that we previously described. A 1.5 cm suprapubic incision is performed. The fascia is incised and a sound is introduced to dissect the retropubic space. A balloon tipped catheter is introduced into the Retzius space and inflated with saline to release the peritoneum. A blunt trocar is inserted, the optics is introduced and a Stamey needle is used to pass a no. 1 nylon suture to fix the vagina to the rectus fascia. The maneuver is repeated on the other side. The sutures are then tied independently on each side under visual control, without tension and ensuring adequate elevation of the bladder neck. This technique requires only one port, allows direct visualization of the bladder neck and avoids all the risks of an intraperitoneal approach. In conclusion, we believe this technique has all the advantages of an open procedure, but using a minimally invasive approach, and may well become the treatment of choice in urinary stress incontinence.

[Laparoscopic cystoplasty]. / Cistoplastia laparoscópica.

An endoscopic cystoplasty technique is described for the first time herein. The foregoing was performed in a patient with a previous right nephrectomy due to genitourinary tuberculosis and a microbladder with marked dilatation of the ureter. The procedure commences with the insertion of a 10 mm trocar through the umbilicus and a 12 mm trocar through each flank at the level of the umbilicus and a 5 mm trocar is placed in each iliac fossa. The peritoneum is divided and the bladder wall is dissected free up to the pelvic floor. The ureter is then dissected and cut as low down as possible. A minilaparotomy is performed and the ureter and a loop of intestine are brought out. A segment of the intestine is isolated and continuity is reestablished. The ureter is anastomosed to the isolated intestinal segment and reinserted. The isolated intestinal segment is placed around the bladder and fixed with one suture on each side. A small incision is made in the bladder dome and a similar incision is made very close to this one in the intestinal segment. An Endo-GIA device is inserted, with the narrow portion in the intestine and the larger one in the bladder, and fired twice for each side. Finally, a Roticulator-type stapling device is inserted through the small laparotomy incision and positioned in the precise angle. The stapling device is opened, the bladder and intestinal orifices are positioned and stapled, which completes the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Radical cystectomy and laparoscopic ileal conduit]. / Cistectomía radical y conducto ileal laparoscópico.

Herein we describe for the first time a laparoscopic cystectomy procedure and an ileal conduit that were performed in a single session in a patient with a tumor infiltrating the right wall. The procedure starts by releasing the ureters from the iliac junction up to a point close to the bladder. The peritoneum is incised superiorly at the level of the urachus and we proceed until the space of Retzius and the lateral walls are released. The vesicouterine plica is then incised and the bladder wings are dissected with the Endo-GIA. With a straight dissector, the urethra is released and cut until the bladder is completely free within the abdominal cavity. The trocar is removed from the right flank, the incision is extended up to about 4 cms and the bladder is removed. The right ureter and an ileal loop are then brought out through the incision on the right flank. A segment of intestine is isolated and intestinal continuity is reestablished using mechanical sutures. Then the ureter is implanted at one end of the isolated intestinal segment. The other end of the segment of intestine is taken to the left flank and anastomosed extracorporeally in a similar manner to the ureter of that side. The ileal conduit is positioned transversely so it is unnecessary to take the ureter to the opposite side. Finally, a stoma is created, which the patient desired done in the left side, and the procedure is completed. Although the operating time is long, the surgical insult is minimal because the McBurney type flank incisions cause little injury to the abdominal wall.

[Laparoscopic urethropexis]. / Uretropexia laparoscópica.

Herein we describe a new technique of urethropexy which is performed laparoscopically. The procedure starts with the insertion of a cystoscope and the bladder is filled to determine its limits precisely. The peritoneum is then incised at the level of the urachus until it is opened wide and we advance into the space of Retzius until the entire anterior aspect of the bladder and the urethra are released. A minimal suprapubic transverse skin incision is made up to the fascia. An atraumatic needle with 1-0 vicryl suture is introduced through the incision and grasped with the endoscopic needle holder. A suture is placed in the neck and the needle and suture are brought out at the other end of the incision. Similar sutures, up to a total of four, are placed higher up. They are tied over the fascia and the procedure is completed. This technique has the advantage over the so-called needle techniques in that it permits placing the sutures required in the exact position under visual control. Moreover, the sutures can be tied easily, safely and securely because it is done externally.