Urology

Urological Surgery

Types of Surgery
Surgery Techniques: Laparoscopic, Robotic
Choosing Between Laparoscopic, Robotic or Open Surgery

Types of Surgery

There are a variety of surgeries that are routinely done laparoscopically or robotically in urology:

Nephrectomy:

  • Simple nephrectomy: The kidney is removed from the body because of disease like kidney stones, pain or chronic infection. Laparoscopic surgery allows much faster recovery than traditional surgery. Several small incisions are made for the camera and instruments in this surgery, and the kidney is cut into small pieces to take out of one of these small incisions. Traditional surgery involves an incision through the flank or side often through the ribcage to remove the kidney.
  • Radical nephrectomy: In this surgery a kidney is removed due to a large tumor or cancer. The kidney is largely removed with laparoscopic instruments and then an incision large enough to remove the kidney as an intact specimen is made (usually about four to six inches in size and much smaller than the incision needed for open, traditional surgery.

Repair of ureteral obstruction: Minor congenital problems with the development of the kidney can lead to obstruction of the urine coming out of the funnel of the kidney called the renal pelvis. This obstruction causes the kidney to swell and can lead to stones, urinary infections and periodic pain. This obstruction is called a UPJ (uretero-pelvic junction) obstruction. Laparoscopic or robotic surgery can be used to remove the area of obstruction and reconnect the ureter to the “pelvis” of the kidney allowing proper drainage. Recovery from laparoscopic or robotic surgery for these problems is much faster than for open surgery. In some cases, however, open surgery may still be needed.

Posterior urethroplasty after pelvic fracture:

Urethral injury (pelvic fracture urethral distraction defect): When a pelvic fracture link to pelvic fractures page tears the urethra and a large gap is left between the prostate and the urethra, patients need a reconstructive surgery called a posterior urethroplasty, which is usually performed three months after their pelvic fracture. During this time most patients rely on a catheter that goes through the abdominal wall into the bladder called a suprapubic tube.

What is involved in surgery? In posterior urethroplasty the scarred tissue that has filled in the gap between the urethra and the prostate is removed, and the urethra is reconnected to the bottom of the prostate, which reconstructs the channel and the flow of urine. Patients typically have an incision in the perineum measuring about four to five inches. (The perineum is the area between the bottom of the scrotum and the anus.) In some rare cases where there is more extensive damage, an incision needs to be made in the abdomen to make the connection.

Sometimes, in order to bridge the gap between the urethra and the prostate, patients need to have a groove of pubic bone removed from the underside of the pubic arch. Fortunately this does not destabilize the pelvis and does produce any long-term problems. The surgery takes between three to five hours and usually patients need to have both a suprapubic tube as well as a catheter in the urethra for about three to four weeks after surgery. X-rays are done in our clinic to make sure the connection has healed well between the urethra and the prostate. Then the catheter is removed and the suprapubic tube is plugged and left in for safety for one to two additional weeks. As long as patients are urinating well, then the suprapubic tubes is removed when they return. This follow up can also be done closer to home by patients’ referring urologist.

One problem that can arise in men that have had a urethral injury after a pelvic fracture is damage to the urinary sphincter muscle. One of the two sphincters in men is right in the area of the injury at the base of the prostate. Either the injury or surgery to fix the injury can destroy the function of this sphincter in many cases. Fortunately, there is another sphincter muscle at the top of the prostate where it meets the bladder and because of this most men do not leak urine after this injury. If there has been damage to the other sphincter from the original trauma or nerves going to the bladder, then, occasionally, men may need additional procedures to regain their sphincter function and treat incontinence (involuntary leakage of urine).

The success of this type of surgery is excellent and in our experience is greater than 90% in restoring the ability to urinate. This surgery is highly specialized and should be done only by surgeons with experience in treating urethral injuries after pelvic fracture. We do not recommend internal cutting procedures or daily catheterization to treat these injuries as this type of management will often make the area of stricture longer and worsen the ultimate success of surgery. These maneuvers almost never work in the long-term.

At University of Utah we treat many men with pelvic fractures and urethral injuries every year. Patients are commonly referred throughout the west to our institution. Salt Lake City is an easy city to fly into and to navigate, and for this reason it is an ideal location for patients to travel to for specialty care. We are happy to arrange for a pre-operative consultation and review data over the phone. This allows patients to come for a clinic visit early in the week and undergo surgery the same week. We seek to treat patients from around the nation at our center in this way when there is not a local urologist with expertise in this type of surgery.

Prostate surgery for cancer: Robotic surgery has become the leading surgical method prostate removal. There are a variety of reasons for this. Certain advantages include ease of the surgery compared to open surgery, decreased blood loss and a lower rate of scarring between the urethra and the bladder. There is no evidence that patients have better sexual or urinary function compared to traditional open surgery. There is also no evidence that curing prostate cancer is better with robotic surgery compared to open surgery.

Surgery Techniques: Laparoscopic, Robotic

Laparoscopic surgery: The first laparoscopic kidney surgery was done approximately two decades ago Since then the application of laparoscopy to urology has increased dramatically. In laparoscopic surgery very small incisions about a half inch are made to pass long instruments and a camera into the abdomen. The abdominal wall is expanded with a harmless gas to make space to see the abdominal organs internally with a camera placed through the abdominal wall. The laparoscopic instruments are controlled by the surgeon outside the abdomen. Under video guidance the surgery is performed internally by the surgeon controlling the instruments externally. The advantage of laparoscopic surgery is that patients recover more quickly than traditional surgery and also the surgery is more cosmetic. A number of urologic surgeries are now done laparoscopically including removal of the kidney, repair of congenital obstruction of the ureter and treatment of kidney cancer.

Robotic surgery: Robotic surgery is a misnomer because the robot does not perform the actual surgery. The robot is instead controlled by the surgeon who sits at a console and guides the robot’s movements within the abdomen. This type of surgery is very similar to laparoscopic surgery. There are very small incisions, and a camera is used inside the abdomen along with long instruments controlled from outside the abdomen. In robotic surgery, rather than the surgeon controlling the instruments, the robot translates movements made on the robotic console into movements of the instruments within the abdomen. The advantage of this over laparoscopic surgery is that the movements of the robotic instruments are much finer and more detailed, and delicate surgery can be performed within the abdomen. For this reason robotic surgery has become preferred for a lot of urologic surgery over laparoscopic surgery. The types of conditions that are commonly treated this way are prostate cancer surgery, removal of a tumor from the kidney and treatment of congenital ureteral obstruction.

Choosing Between Laparoscopic, Robotic or Open Surgery

Your surgeon should counsel you thoroughly about the options for these approaches. Often there are significant advantages and disadvantages for laparoscopic or open surgery, and your surgeon’s advice will depend a lot upon the nature of your problem and your health, among many other factors.