Introduction

In an astonishingly short period of time, laparoscopic reconstructive urology has become a feasible option for the experienced laparoscopist. The evolution from purely extirpative laparoscopic procedures to the creation of complex urinary diversions completely intracorporeally has been rapid. As urologists' experience with laparo-scopic prostatectomy expanded, the additional control of the vesical pedicles with stapling devices brought laparoscopic radical cystectomy within reach. Subsequent construction of a urinary diversion remains a significant challenge. The past decade has witnessed profound strides in laparoscopic reconstructive urology since 1992 when Parra et al. performed the first laparoscopic cystectomy for recurrent pyocystis in a 27-year-old paraplegic woman who already had an ileocolonic reservoir with a continent stoma created five months earlier. That same year, the first laparoscopic-assisted ileal conduit was reported by Kozminski and Partamian, where a cystectomy was not performed.

Currently, many of the commonly employed urinary diversions have been demonstrated to be technically possible laparoscopically owing to a series of well-designed animal experimental models, followed by clinical experience, increasing facility with intracorporeal suturing techniques, and the continual refinement of laparoscopic instrumentation. The various types of urinary diversions that have been

TABLE 1 ■ Summary of Published Approaches to Selected Urinary Diversions

Pure

Assisted

Noncontinent diversions

Ileal conduit

Cutaneous ureterostomy

Ileovesicostomy

Continent diversions

Ileal neobladder

Rectosigmoid pouch

Cutaneous catheterizable reservoir

Mitrofanoff urinary stoma

Note: A check mark indicates the procedure has been performed either purely laparoscopically or laparoscopic-assisted.

performed laparoscopically can be subdivided into noncontinent urinary diversions (cutaneous ureterostomy, incontinent ileovesicostomy, ileal conduit) and continent urinary diversions (rectosigmoid pouch, catheterizable reservoir, and orthotopic neoblad-der). Because each of these techniques is in evolution, there is no universally agreed upon technique. Tables 1 and 2 summarize the published approaches to particular urinary diversions to date.

General guidelines for choosing the type of laparoscopic urinary diversion best suited to each patient do not differ from their open surgical indications.

At all times, sound oncologic principles and the creation of an appropriate urinary diversion suited to the individual patient take precedence. If the surgeon is unable to perform the desired diversion by laparoscopic techniques, open surgery should be employed.

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