HISTORY OF LAPAROSCOPY IN UROLOGIC SURGERY

 

The foundation of modern laparoscopy was laid in 1805 when Bozzini developed the first self-contained endoscope ( Bozzini, 1806 ). Although his concept of direct visual inspection of the urethra was fiercely rejected by his peers, other investigators pursued his original concept; among them was Nitze (1877) , who was the first to introduce glass optics for magnification ( Nitze, 1879 ).

 

The shift toward laparoscopy was initiated by Kelling (1901) , a surgeon who was the first to apply Nitze's cystoscope, introduced through a trocar, in a closed-cavity endoscopic examination of a living dog. During the initial step of this procedure, Kelling insufflated the peritoneal cavity with air using a needle to observe changes to the intra-abdominal organs at pneumoperitoneum pressures sufficient to stop intra-abdominal hemorrhage (i.e., up to 50 to 60 mm Hg). Jacobaeus (1910) , an internist in Stockholm, is credited with transforming Kelling's concept into a clinical diagnostic technique, which he named koelioskopie. Jacobaeus used a trocar with a trapdoor as a single port of entry, thus allowing for simultaneous insufflation and endoscopy of the abdominal cavity. In the United States, Bernheim (1911) performed a visual inspection of the peritoneal cavity with a proctoscope, a procedure he termed organoscopy, at Johns Hopkins University.

 

In the early 1900s, a major problem for all endoscopic procedures was the attainment of a clear, bright image. The problem was twofold, in that the endoscopist needed both a high-power light source and high-quality optics. Improvements in the former area were made by French and English investigators in the early 1950s, resulting in an external high-power light source that was efficient and cold, thereby precluding potential intra-abdominal thermal damage. Major advances in endoscope resolution and contrast were subsequently achieved by Hopkins, who introduced large, rod-shaped quartz lenses to transmit light in the early 1960s ( Harrison, 1976 ).

 

Parallel to the development of light sources and improved optical instruments, inventions and changes in the areas of insufflation techniques and trocars occurred. After Kelling reported his use of air filtered through sterile cotton to insufflate the peritoneum with a needle, Zollikofer of Switzerland introduced the use of carbon dioxide (CO2) in 1924. The insufflating needle was modified in 1918 by Goetze, who developed a needle with an automatic spring for gas insufflation ( Gaskin et al, 1991 ). In 1938, Veress, a Hungarian internist, reported on his experience with a spring-loaded needle to insufflate the pleural space to create a pneumothorax; this needle subsequently became the standard for closed insufflation of the abdomen ( Veress, 1938 ). Subsequently, major contributions in the development of automatic insufflation and monitoring of intracavitary pressure were made ( Palmer, 1947 ; Eisenburg, 1966 ). In 1974, Hasson reported on his concept of gaining open access to the peritoneal cavity before introduction of the first trocar, thereby reducing the incidence of potential complications.

 

The early application of laparoscopy was largely limited to diagnostic purposes and became a technique generally practiced by internists and in particular by gastroenterologists. Indeed, one of the largest series in the United States of laparoscopic procedures for examining the liver was reported by Ruddock (1957) . In the surgical arena, it was gynecologists who pushed laparoscopy into the realm of therapeutic procedures (e.g., tubal ligation, therapeutic abortion). Semm, a German gynecologist, is recognized as the “father” of modern-day laparoscopy owing to his broad development of laparoscopic operative techniques and instruments ( Gunning, 1974 ; Semm, 1987 ). Indeed, he was the first to perform a laparoscopic appendectomy ( Semm, 1983 ). However, it was not until the mid 1980s that laparoscopy moved from gynecology into the realm of general surgery. With the advent of laparoscopic cholecystectomy, initiated by the French investigators Filipi and Mouret, the old world order of incisional surgery started to crumble. In 1985, Filipi performed the first laparoscopic cholecystectomy on an animal ( Davis and Filipi, 1995 ). In 1987, Mouret of Lyon, France, performed the first clinical laparoscopic cholecystectomy. He never published his case but did report it at a meeting. Subsequently, Dubois performed his first clinical cases in 1988 ( Dubois et al, 1989 ). Meanwhile, Reddick and Olsen (1989) served as early pioneers in popularizing laparoscopic cholecystectomy in the United States. By the mid 1990s, laparoscopic cholecystectomy was the procedure of choice for most indications for surgical removal of the gallbladder.

 

The development of laparoscopy in urology paralleled, to a large extent, the changes in general surgery. Up until the late 1980s, laparoscopy had limited applications in urology. Indeed, aside from Cortesi and colleagues' (1976) report of using the laparoscope in pediatric patients to explore for undescended testes ( Silber et al, 1980 ) and Smith's report in 1985 of using the laparoscope to aid in the percutaneous removal of a stone from a pelvic kidney, laparoscopy remained a technique in search of a broad application ( Eshghi et al, 1985 ). This situation drastically changed over 24 months, from 1989 through 1990. First, Schuessler and colleagues (1991) reported their initial experience with laparoscopic staging pelvic obturator lymphadenectomy for prostate cancer after having performed the first case in 1989. Then in 1990, after extensive laboratory trials, including the development of the basic concepts of organ entrapment and tissue morcellation, Clayman and coworkers (1991b) performed the first clinical laparoscopic nephrectomy. Also in 1990, Sanchez-de-Badajoz and colleagues (1990) reported the first laparoscopic varicocelectomy, a feat rapidly corroborated independently by Donovan and Winfield (1992) and Hagood and associates (1992) . As in general surgery, laparoscopy took urology by storm. Numerous courses, books, and articles soon appeared on the scene to guide urologists into the laparoscopic realm.

A new era in operative urology had begun. Soon, a steady stream of newly developed laparoscopic procedures started to challenge their conventional open surgical counterparts. Initial emphasis was on ablative procedures: lymphadenectomy, varicocelectomy, transperitoneal and retroperitoneal nephrectomy for benign and malignant disease, nephroureterectomy, partial nephrectomy, adrenalectomy, cyst decortication, lymphocele drainage, cystectomy for benign disease, bladder diverticulectomy, retroperitoneal lymphadenectomy, and orchiectomy ( Sanchez-de-Badajoz E, 1990 ; Clayman et al, 1991 ; McCullough et al, 1991 ; Schuessler et al, 1991 ; Das, 1992 ; Donovan and Winfield, 1992 ; Gagner et al, 1992 ; Hagood et al, 1992 ; Hulbert and Fraley, 1992 ; Morgan and Rader, 1992 ; Parra et al, 1992 ; Suzuki et al, 1992 ; Thomas et al, 1992 ; Winfield et al, 1992 ; Kerbl et al, 1993 ; McDougall et al, 1993 ; Nadler et al, 1995 ). In 1995, Kavoussi and associates performed the first clinical donor nephrectomy ( Ratner et al, 1995 ). Over the next 5 years, the technique became more refined, and it has since spread throughout the world. At many centers, laparoscopic donor nephrectomy is the standard of care. As urologists became more skilled, they expanded their laparoscopic procedures into the realm of more difficult ablative surgery.

 

Hand-assisted laparoscopy was originally developed as a supportive technique to laparoscopic splenectomy ( Kusminsky et al, 1995 ). Subsequently, hand-assisted laparoscopy was also embraced by urologic surgeons ( Saadeh et al, 1995 ; Tschada et al, 1995 ). Developments in commercially available devices: the Gelport (Applied Medical, Rancho Santa Margarita, CA), the Omniport (Advanced Surgical Concepts, Wicklow, Ireland), and the LapDisc (Ethicon Endosurgery, Cincinnati, OH) have further spurred this approach. The first report on the use of the PneumoSleeve in laparoscopic nephrectomy was published in 1997 by Nakada and coworkers. In the meantime, hand-assisted techniques have been successfully applied to a variety of other laparoscopic procedures, among them nephroureterectomy, colectomy, Roux-en-Y gastric bypass, complex hysterectomy, distal pancreatectomy, rectopexy, and fundoplication ( Bemelman et al, 1996 ; Gorey and Bonadio, 1997 ; Klingler et al, 1998 ; Pelosi and Pelosi, 1999 ; Schweitzer et al, 1999 ). The hand-assist approach opened the door for more urologists to enter the arena of laparoscopic ablative renal surgery.

 

The most challenging aspect of laparoscopy is reconstructive surgery. Urologists began to develop skills in this area and thus expanded the indications for laparoscopic surgery into other areas. By using laparoscopic techniques for suturing and intracorporeal knot tying, the following procedures were successfully completed laparoscopically: reimplantation of the ureter, ureteroureterostomy, pyeloplasty, bladder neck suspension, Fowler-Stephens orchidopexy, transperitoneal and extraperitoneal bladder autoaugmentation, and nephropexy ( Bloom, 1991 ; Nezhat et al, 1992 ; Ehrlich and Gershman, 1993 ; Schuessler et al, 1993 ; Urban et al, 1993 ; McDougall et al, 1995 ; Vallancien et al, 2002 ). In some new laparoscopic procedures, the technical steps and surgical feasibility were established at one academic institution, with subsequent clinical applications performed elsewhere ( Urban et al, 1992 ; Atala et al, 1993 ; Gill et al, 1994 ).

 

In the mid 1990s, interest in laparoscopy waned as the need for pelvic lymph node dissection dropped precipitously owing to advances in nonoperative staging of prostate cancer. Indeed, with the combination of Gleason grade, physical examination, and prostate-specific antigen level, the need for pelvic lymph node dissection was eliminated in upward of 95% of patients presenting with potentially surgically curable prostate cancer. Also, data revealed that laparoscopic varicocelectomy and bladder neck suspension, although feasible, were not as cost effective as, or better for the patient than, alternative, well-established surgical methods. These developments, combined with the complexity of renal and ureteral laparoscopic procedures, caused a major decrease in laparoscopic interest in the urologic community.

 

However, as more data were published on the beneficial aspects of laparoscopic renal and ureteral surgery, and as donor nephrectomy became accepted worldwide, more urologists grew to embrace laparoscopy as the technique of choice for these procedures. This was further spurred by the pioneering work of Vallancien and Guillonneau in the realm of radical prostatectomy; although the initial report by Schuessler was of interest, it was the development and dissemination of this procedure at L'Institut Mutualiste Montsouris that re-ignited interest among urologists in laparoscopy. Additional procedures soon followed, including cystectomy, gastrocystoplasty, enterocystoplasty, and ileal ureter ( Parra et al, 1992 ; Docimo et al, 1995 ; Raboy et al, 1997 ; Schuessler et al, 1997 ; Abbou et al, 2000 ; Gill, et al, 2000, 2000c [113] [115]; Guillonneau et al, 2000 ). Raising the bar even higher, Gill and associates (2000) reported on laparoscopic radical cystoprostatectomy, bilateral pelvic lymphadenectomy, and ileal conduit urinary diversion in patients with muscleinvasive bladder cancer, with the entire procedure being performed intracorporeally. In addition. laparoscopy is being used more and more in the area of retroperitoneal lymph node dissection (RPLND) for testicular cancer. Although still somewhat controversial, several centers offer laparoscopic RPLND and have shown that the outcomes can be equal to open surgery ( Allaf et al, 2005 ).

 

With an increasing number of multi-institutional studies emerging in which laparoscopic procedures are compared with their open surgical counterparts, it becomes clear that, owing to equivalent efficacy combined with distinct advantages in postoperative pain, cosmesis, recovery, and length of hospital stay, laparoscopy has moved into the mainstream of urologic surgery. Indeed, it is becoming increasingly clear that the objectives of almost all aspects of open retroperitoneal surgery, be it of the kidney, ureter, adrenal gland, or lymph nodes, can now be achieved laparoscopically with far less patient injury and suffering. Minimally invasive surgery is superseding open surgery at major medical centers throughout the world. In this new millennium, the old craft of open surgery has an ever-diminishing role in the treatment of urologic disease. The sage musings of Osler at the inception of the 20th century continue to stimulate surgeons to further refine their craft: “Diseases that harm require treatments that harm less.”