Future Directions

Considerable progress has taken place in the short time since Parra's simple cystectomy in 1992 to the complex reconstructive laparoscopy of today. Advances in this arena are a true testimony to the logical and elegant progression from the porcine and cadaveric technical models to the initial clinical cases. Small series of laparoscopic urinary diversion have shown acceptable functional outcomes, which need to be substantiated by larger published series with long-term follow-up. We are no longer exploring the feasibility of these complex laparoscopic procedures, but rather refining the techniques in order to decrease operative time.

The debate between pure laparoscopy and open assistance continues. Those groups who have demonstrated the feasibility of pure laparoscopic techniques have truly pushed the frontiers further than previously imagined. As is often the case, giant leaps hasten the acceptance of small strides. Even if these "laparoscopic-only" approaches do not become common practice, these innovative groups have made the broader community receptive to laparoscopic-assisted approaches, which have become increasingly widespread.

Considering the innovation we have recently witnessed, it is easy to envision that in the near future, laparoscopic reconstructive techniques will catch up to open surgery. Will we then avert the entire debate? In the near future, further experience with freehand suturing and refined intracorporeal anastomotic and reconstructive suturing technology will allow complex reconstructions to be performed as quickly as with open surgery. Then the choice between open assistance and pure laparoscopy will become one of surgeon preference rather than an issue of technical complexity and decreased operative time. Existing reviews of this topic have recognized that continued refinement of laparoscopic dissolvable staples is one example of a device that would bring us a step further in that direction. Furthermore, robotic surgery has already enhanced the surgeon's performance by simplifying complex maneuvers. Robotic technology therefore holds great promise and potential to effortlessly facilitate the dexterity and flexibility of open surgery. This field will continue to narrow the time gap between open and laparoscopic surgery.

Currently, this technical debate exists within the walls of specialized academic centers. It is clear that the next challenge will be to extend experience into the broader urologic community. In the near future, open-assisted laparoscopic urinary diversion is likely to be the technique of choice to facilitate this transition.

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