Clinical Services

Section of Endourology, Laparoscopy and Minimally Invasive Surgery

In all surgical disciplines, there is a trend toward less invasive techniques for operative procedures. Such minimally invasive procedures result in shorter hospital stays, improved patient convalescence, and improved cosmesis. For these reasons, patients, when confronted with the prospect of undergoing surgical intervention, often inquire about the availability of minimally invasive techniques. In urology, such techniques are available for the treatment of urinary tract stones, obstruction, and other genitourinary disorders.

The use of extracorporeal lithotripsy (SWL) and rigid and fiberoptic endoscopy is referred to as endourology.

For treatment of genitourinary cancers, anatomic abnormalities, and obstruction, surgery performed through small skin incisions (.5-1 cm), with the use of a camera and specialized instruments, is known as laparoscopy.

Carson Wong, MD, a fellowship trained endourologist and laparoscopist, is committed to offer such minimally invasive techniques to improve patient care. In addition, after definitive surgical treatment, specifically in stone disease, Dr. Wong specializes in the prevention of stone recurrence. Following are brief descriptions of common endourologic and laparoscopic techniques.

Extracorporeal Shock Wave Lithotripsy (SWL)

This minimally invasive modality allows for the disintegration of genitourinary stones without “physically touching” the patient. Under sedation with radiographic guidance, shock waves are generated by a machine (lithotriptor), passed through the patient’s body, and focused onto the stone. Repeated focusing of these waves on the stone results in stone fragmentation. These fragments, if small enough, can then spontaneously pass in the patient’s urine. Success of this treatment modality is dependent on the stone size, location, and composition, and the anatomy of the urinary system.

Ureteroscopy

Ureteroscopy refers to passage of a small telescope, equipped with a light at its tip, up through the urethra to access the urinary system. Through this instrument, lasers, stone breaking devices, and stone removal baskets can be introduced. In addition to stone breakage and removal, strictures (narrowing) causing obstruction of the ureter can also be treated in this manner. Performed under anesthesia, ureteroscopy allows for performance of these operations without skin incisions from a scalpel.

Percutaneous Renal Surgery

Percutaneous renal sugery refers to the placement of a tube (approximately 1 cm diameter), through the patient’s back, into the kidney drainage system. Through this tube, a telescope, lasers, stone breaking devices, and stone removal graspers and baskets can be inserted. As well, procedures to relieve kidney obstruction can also be performed using this technique. Though more invasive than SWL or ureteroscopy, as performance of a skin incision (approximately 1 cm) and general anesthesia are required, percutaneous renal surgery remains much less invasive than traditional open surgery.

Laparoscopy

Traditionally, patients requiring surgery for urological cancers (kidney, ureter, adrenal, prostate, and bladder) or urinary tract reconstruction have “gone under the knife” for an open skin incision. The push for minimally invasive surgery has led to the development and refinement of urologic laparoscopy. Keeping in mind that the principals and results of open surgery must not be compromised (i.e. cancer cure and correction of anatomic abnormality), laparoscopy is a technique that duplicates the results of open surgery. The benefits of the technique are that it:

1. decreases patient morbidity (i.e. postoperative pain, shorter hospital stay)
2. improves cosmesis (i.e. avoidance of the long skin incision scar of open surgery)
3. enables a faster recovery to baseline physical activity

Instead of a long skin incision, 3-5 day hospital stay, and 6-8 week recovery period that results from open surgery, laparoscopic surgery results in 3-4 small skin incisions (.5-1 cm, scars often unnoticed once healed), 24-48 hour hospital stays, and 2-3 week recovery periods for resumption of normal physical activity.

Procedures that can be performed using this technique include:

1. nephrectomy/partial nephrectomy (complete/partial kidney removal)
2. donor nephrectomy (donor kidney removal for kidney transplant)
3. nephroureterectomy (kidney and ureter removal)
4. pyeloplasty (repair of kidney obstruction)
5. prostatectomy (prostate removal)
6. vesicovaginal fistula repair (repair of abnormal communication between bladder and vagina)

Robot-Assisted Laparoscopic Prostatectomy

The emergence of radical prostatectomy as a preferred prostate cancer treatment has corresponded with wider availability of minimally invasive surgery. Studies show that for many patients, a minimally invasive approach can reduce complications and promote faster recovery times. In the United States today, surgeons use one of three approaches to radical prostatectomy: open surgery, laparoscopic surgery and robot-assisted laparoscopic surgery, of which the latter two are minimally invasive.

An open prostatectomy requires an 8-10 inch incision on the patient's abdomen for direct access to the operative site. Conventional laparoscopic and robot-assisted laparoscopic approaches require several dime-sized incisions, or operating “ports,” which are used to introduce narrow-shafted instruments. The surgeon and assistants maneuver the instruments from outside the body, under vision provided by a surgical camera.

The potential advantages of laparoscopic and robot-assisted laparoscopic prostatectomy over conventional open surgery include smaller incisions for less post-operative pain and improved cosmetics; reduced blood loss and less need for blood transfusions, as well as a faster return to normal activities.

The two major drawbacks of conventional laparoscopy are that it relies on the use of rigid, hand-held instruments and visualization provided by a standard 2D video monitor. While these technologies enable smaller incisions, they can limit the surgeon's sense of depth of field, his/her dexterity and precision. Standing at the patient's side, the surgeon must operate in a counterintuitive fashion, moving the long-shafted instrument handle in precisely the opposite direction as he or she intends to move the instrument tip. The surgeon maneuvers the instruments while looking up at the 2D view of the operating field projected on a tableside video monitor and while instructing an assistant on how to position the surgical camera.

In contrast, nerve sparing da Vinci Prostatectomy (dVP) incorporates state-of-the-art robotic technologies that provide natural depth of field and allow a surgeon's hand movements to be scaled, filtered and translated into precise micro-movements of tiny instruments at the operative site. The superior visualization, enhanced dexterity, precision and control enable the surgeon to perform complex procedures - like radical prostatectomy - through dime-sized operating “ports.”

For most patients, da Vinci Prostatectomy offers substantially less pain and a much shorter recovery than traditional prostate surgery. Other advantages may include reduced need for blood transfusions, less scarring and less risk of infection. In addition, recent studies suggest that dVP may offer improved cancer control and a lower incidence of impotence and urinary incontinence.

Cutting-Edge Technology

The Section of Endourology and Laparoscopy is committed to increasing its arsenal of minimally invasive techniques. Techniques that are currently being implemented include:

1. Cryosurgery - ablative techniques for renal masses
2. da Vinci - robot-assisted laparoscopic prostatectomy
3. GreenLight Laser - photoselective vaporization of prostate
4. Tissue engineering for organ regeneration
5. New screening blood test for prostate cancer

Patient Inquiries

To find out more about minimally invasive surgical techniques, please contact:

Carson Wong, MD, FRCSC, FACS
Adult Urology, University of Oklahoma Medical Center
Assistant Professor
Chief, Section of Endourology, Laparoscopy, and Minimally Invasive Surgery
University of Oklahoma Health Sciences Center
920 Stanton L. Young Boulevard, WP 3150
Oklahoma City, OK, 73104

405 271 6900
405 271 3118 - FAX
carson-wong@ouhsc.edu