Minimally Invasive Urological Surgery

For hundreds of years surgeons have operated by making incisions large enough for a surgeon's hands to enter the patient's body and manipulate surgical instruments. Now, with the advent of 21st-century technology, surgeons instead use mini video cameras and tiny instruments that allow them to see and operate inside the body without making large incisions or putting their hands inside the body.

This approach, known as minimally invasive surgery (MIS), requires only very small incisions, often called "key hole incisions", which is why minimally invasive surgery is also known as key hole surgery. The great advantages of MIS over traditional surgery is faster recovery, less post-operative pain and smaller scars. 

Within the last decade, urological surgeons have performed thousands of minimally invasive surgeries using robotic equipment manufactured under the brand name da Vinci. Physicians at Pacific Urology have become some of the most experienced da Vinci urological surgeons in the nation – in fact, since 2002, when the first robotic radical prostatectomy was performed at John Muir Concord Campus, Pacific Urology physicians have performed more than 500 robotic procedures of various types. With a da Vinci system, a surgeon inserts miniaturized instruments and a high-definition 3D camera through a small incision in the patient. Seated comfortably at a special console adjacent to the operating table, the surgeon views a magnified, high-resolution 3D image of the surgical site.

The surgeon then uses hand movements to manipulate robotic arms into precise micro-movements within the surgical area. These arms permit far more control over very delicate procedures. Meanwhile, the surgeon retains total control over the surgery, as the robotic equipment is not programmable and does not make decisions on its own.

Urological Surgeries With the da Vinci Robot

Radical prostatectomy

This common robotic surgery is a treatment for prostate cancer. The da Vinci robotic radical prostatectomy has essentially replaced the open-surgery technique for 99 percent of Pacific Urology patients.  The advantages are:

• Faster recuperation
• Shorter catheterization times
• More rapid return of good bladder control
• More rapid return of normal sexual function
• More rapid return to normal activities
• Less scarring or minimal visible scars

Because robotic surgery is relatively new, long-term data on cancer control is lacking in comparison to the ten- and fifteen-year survival rates that already exist for traditional prostatectomies. However, most urologists performing robotic radical prostatectomies believe the long-term data will eventually show no difference between open and robotic techniques. To date, other measures of success, such as PSA recurrence and "positive surgical margins" show no difference between the two techniques.  

Partial nephrectomy for kidney cancer

If a patient had kidney cancer in years past, surgeons removed the whole kidney. But for the past 10 years, most kidney cancers are discovered when they are small, less than 5 cm.  If kidney cancer is discovered at this stage, a surgeon can often remove just the cancer with a small margin of normal kidney tissue, thus preserving the rest of the kidney. 

Not long ago, doctors developed a technique using a laparoscope (a tube for viewing and operating through a small surgical incision) to perform partial nephrectomies, but this kind of surgery is very difficult and requires unusual skill and training. A breakthrough came in 2008, when several physicians at Pacific Urology received special training in da Vinci robotic partial nephrectomies. The da Vinci Robot allows them to perform a better operation, due to the 3-D High Definition imaging, and the delicacy and precision of the robotic wrists.  Dr. Taylor and Dr. Hopkins are currently accepting patients for this remarkable procedure.

As a result, many Pacific Urology patients go home the next day after this minimally invasive procedure – a benefit that draws patients from around Northern California and even from out of state for this procedure.  

Robotic pyeloplasty for UPJ obstruction

A blockage between the renal pelvis (the urinary drainage system of the kidney) and the ureter (the tube connecting the renal pelvis to the bladder) is called a ureteropelvic junction obstruction (UPJ Obstruction).  The blockage is usually congenital, meaning a patient is born with it, but is occasionally acquired. 

The blockage causes urine to back up inside the kidney, and back pressure damages the kidney.  Symptoms of UPJ obstruction are flank pain, infection, fever, and blood in the urine.  Occasionally, an ultrasound exam or CT scan of the abdomen can reveal a "silent" UPJ obstruction, before symptoms develop.  

In the past,  the gold standard for surgical repair of UPJ obstruction was an open pyeloplasty, involving a large flank incision (and large scar), several days in the hospital, and a long recuperation.  The pyeloplasty required exposing and removing the blockage, and then performing a plastic repair or reconstruction, to allow urine to flow freely down to the bladder without any back pressure on the kidney. 

Although open pyeloplasty had an excellent success rate of from 95 to 98 percent, urologists have worked to develop less invasive methods.  One result is the endopyelotomy, in which a surgeon passes a scope through the urinary passages to the point of obstruction, where hot wires or lasers cut the narrow spot. An internal splint, called a stent, is left in place for six weeks for proper healing. 

The endopyelotomy is indeed minimally invasive surgery, but it has a high failure rate of as much as 50 percent in some cases. Endopyelotomy is now used selectively in cases where it has the highest success rate.  

Another attempt at a minimally invasive method of UPJ repair was the laparoscopic method.  Regular laparoscopy involves the placement of a specialized telescope through the belly button, so that the surgical team can insert small instruments to repair the blockage. Laparoscopic pyeloplasty requires considerable skill and training, and is very difficult to perform in two dimensions.

The better alternative usually is robotic pyeloplasty, utilizing the da Vinci robot to perform the delicate operation.  The da Vinci pyeloplasty is similar to the laparoscopic pyeloplasty, in that the instruments are placed through small incisions, avoiding large, painful, unsightly scars.

However, with the da Vinci robotic system, a 3-D telescope affords much better visualization, and the robot's mechanical wrists mimic human wrists, allowing the surgeon to perform delicate precise movements.  Because of the magnification and precision of the procedure, success rates are at least as high if not higher than with an open operation. 

The physicians at Pacific Urology have been performing robotic pyeloplasty since 2002, replacing most other methods, due to its less invasive nature, minimal scaring, minimal pain, and high success rate.