Urs E Studer

Department of Urology, University of Bern, Bern, Switzerland

This is an impressive overview on how fast literally every form of urinary diversion has been performed by dedicated laparoscopic surgeons. While complete intracorporeal construction of urinary diversions have been successfully performed, the procedure may be facilitated either by doing the diversion hand assisted through a minilaparotomy or by exteriorization of the bowel segment used for construction of the reservoir. The use of robotic surgery is another evolving technique that should make the procedures easier for the surgeon and thus shorten the operative time.

In the reports on the feasibility of various forms of laparoscopic urinary diversions, much emphasis is placed on the surgical time. When compared to open surgery, it is generally longer, even in the hands of experienced surgeons. This, however, must not necessarily be a disadvantage. This initial shortcoming was the basis of many forms of innovative research to shorten and facilitate laparoscopic surgery. These techniques will ultimately also facilitate and be used in open surgery. Besides introducing new instruments that had been developed for laparoscopic surgery in open surgery, the advantages of laparo-scopic surgery, e.g., decreased tissue trauma, also stimulate the open surgeons to further refine their technique, which ultimately benefits the patient. The current status shows a rapidly evolving technique, with benefits for the patients undergoing laparoscopic urinary diversion, often hand assisted or with a mini-laparotomy, not being overwhelming for the moment and being somewhat compensated by a prolonged anesthesia time. These momentary shortcomings, however, are the motor for further improvements, from which, very likely, not only laparoscopic surgery but also robotic surgery and even classical open surgery will further benefit.

The future will be bright, provided the following points are kept in mind:

■ The authors' advice in the introduction—that the laparoscopic surgery must be governed by the laws of oncological surgery.

■ The patient must receive the type of urinary diversion that fits his/her condition best and not one that is more easily feasible by laparoscopic surgery.

■ Errors committed earlier with open surgery should not be repeated. Only spheroidal reservoirs have the best pressure characteristics and the optimal ratio between volume and the (reabsorbing) intestinal mucosa used for its construction. Funnel-shaped outlets for orthotopic bladder substitutes must be avoided to prevent kinking of the reservoir outlet. No antireflux mechanisms with a high probability of complications should be used. Ischemia and exposure of mesenchymal tissue to urine must be avoided to prevent strictures.

■ The use of laparoscopic techniques should not compromise the long-term results, e.g., by damaging neurovascular bundles or heat damage to sensitive tissues such as anastomotic areas by electrocautery. The best possible functional long-term result counts and not the hospital stay or the operative time.

■ All new developments should focus only on possible long-term patient benefit. Techniques that demand a long learning curve for the surgeon, for which many patients would have to pay with (increased) long-term morbidity, would be unethical.

■ The ultimate goal must be the development of techniques that can not only be performed by artists in the field, but that can also be used by the majority of surgically active urologists.

■ Not everything that is new is necessarily better.

If these points are kept in mind, the future developments in endoscopic surgery will be rapid and convincing. Refinements of robotic surgery should allow some replacement of laparoscopic surgery. While the costs for laparoscopic or robotic surgery are actually of some concern, a drop in costs can be expected as soon as the techniques are widely used. As soon as further developments show the advantages of minimal invasive surgery as convincingly as it had been shown for replacing open (partial) nephrectomy with laparoscopic surgery, this will also become standard procedure for urinary diversion.

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