Getting Under Your Skin Without Opening You Up

June 4, 2001 (Anaheim, Calif.) -- Surgeons treating genital and urinary problems -- from prostate cancer to blockages in urinary flow -- are finding new ways to get under your skin without opening you up.

Laparoscopy, the use of sophisticated imaging technology to guide surgical instruments through small openings in the body, is promising faster recovery, less scarring and pain, and a quicker return to normal activity than more conventional surgical methods.

Doctors here for the annual meeting of the American Urological Association tell WebMD the new technology is becoming mainstream. As it does so, they say, specialists are perfecting the procedure, with results that are as good or better than traditional surgery requiring an incision.

"It's no longer seen as experimental," says Thomas W. Jarrett, MD, associate professor of urology at Johns Hopkins University School of Medicine in Baltimore. "This is an established alternative with good results."

The new surgery takes longer and is more expensive than the traditional open operation, but laparoscopy pioneer Ralph Clayman, MD, says he believes the benefits are well worth the extra costs to hospitals and patients.

"For the patient who can go home without a catheter [in their bladder, a common postsurgical occurrence], who has less pain, and who can go back to work quicker, that makes a big difference," says Clayman, professor of urology at Washington University School of Medicine in St. Louis.

Jarrett has used the procedure to treat a rare condition known as ureteropelvic junction obstruction, in which the flow of urine is blocked at the juncture between the kidney and the ureter, the tube that carries urine to the bladder. Normally, the condition is surgically treated by making a large incision in the patient's back and performing an operation called a "pyeloplasty" to repair the blockage.

With laparoscopy, Jarrett says, the same pyeloplasty can be performed by opening three small holes the size of a fingertip in the abdomen. In one opening, a tiny fiber optic camera is inserted that will provide a video image to the surgeon, who guides miniature surgical instruments through the other openings to perform the surgery.

In a study presented at the AUA meeting, Jarrett and colleagues at Johns Hopkins looked at the long-term outcomes of 99 patients who had received a laparoscopic pyeloplasty for urine blockage. After an average of 1.8 years, the success rate was 96%; and after 3.3 years, patients reported feeling substantially less pain than others undergoing conventional surgery.

"The important thing for patients is that with the traditional approach using a large incision, the recovery time is six to eight weeks," Jarrett says. "With the laparoscopic approach, the recovery time is around two weeks with a much better cosmetic appearance. There's just three puncture wounds, one of which is at the belly button so you don't even see it."

The new surgery has even been extended to radical prostatectomy, the removal of the prostate in individuals with prostate cancer. Tulio Sulser, MD, of the University of Basel, Switzerland, presented an evaluation of 1,228 prostatectomies at six European centers, showing that the procedure was feasible with minimal complications.

And another study presented at the AUA meeting looked at using laparoscopy to perform a radical nephrectomy -- the removal of the kidney -- in patients who have kidney cancer.

The surgery is typically performed by making a long incision along the rib cage, explains Andrew Portis, MD. The resulting scar, running across torn muscles, can cause pain when patients breathe. And some patients who have had a kidney removed will have an unsightly bulge where the operation was performed, he says.

As in the pyeloplasty procedure, the laparoscopic approach to removing a kidney requires just a few small puncture wounds in the abdomen.

In the study presented at AUA, the kidneys were cut into small pieces before removal. "So the patients didn't need a to have a hole greater [in size] than the tip of your finger," Portis tells WebMD.

Portis and Jarrett say virtually everything about laparoscopy is better than traditional surgery -- except the time it takes, which is generally twice as long.

"I tell my patients they'll be in the hospital half the time, have half the pain, and be back to work in half the time," says Portis, who is in private practice with Metropolitan Urologic Specialists in St. Paul, Minn. "The downside is that the surgery itself takes about twice as long."

In the study, Portis and colleagues studied 64 patients who had laparoscopic removal of a kidney and compared their outcomes with that of 69 patients who had the traditional operation. Data was gathered from three centers in the U.S., Canada, and Japan.

Five years after the operations, the survival rates among the patients for both operations were nearly identical: 92% for the laparoscopic procedure, and 91% for the traditional operation.

That's important, Portis said, because though there is a consensus that laparoscopy offers quicker recovery and a better cosmetic appearance, what hasn't been known is whether the operation treats the disease as well. Because laparoscopy is so new, there haven't been enough patients to follow for a sufficiently long time to determine this.

This study is the first to do so. "This is the rubber stamp," Portis says.