Use of Minimal Access Surgery in Urology: Current & Future Perspective

Minimal access surgeries are now widely used in several urology procedures. There has been a drastic development of minimally invasive surgery in urology during the last three decades. A lot is expected to come when we look ahead in the coming years.

Common procedures that involve the management of urolithiasis, renal tumour, and localized prostate cancer are now using revolutionary surgical treatments such as upcoming laparoscopic techniques. Recent literature also says that management of urolithiasis has been revolutionized with the introduction of non-invasive extracorporeal shock wave lithotripsy (ESWL).

Today’s minimally invasive endourology is a lot different from the mid-eighties of the last century as it obviates open surgery. This trend has continued with the perfection and miniaturization of endourologic instruments rather than significantly improving ESWL.

Talking about a simple procedure such as removal of kidney stones, the main goal of current procedures is now to get rid of the stone in one session than multiple non-invasive treatment sessions.

In future, 25 years from today it is predicted that stone treatment will be individualized by genetic screening of stone formers, using improved ESWL devices for small stones and transurethral or percutaneous stone retrieval for larger and multiple stones.

Coming to the management of renal tumours, it has changed its course of treatment significantly over the last few years.

• Earlier, open radical nephrectomy was the only therapeutic option for renal masses. Nowadays, tumour size determines the choice of treatment.
• Tumours >4 cm are usually treated by laparoscopic nephrectomy and smaller tumours are treated either by open, laparoscopic or robot-assisted partial nephrectomy.
• For those patients with high co-morbidity, focal tumour ablation or even active surveillance is considered as a viable option.
• In coming years, imaging of tumours will further support early diagnosis and will also be able to determine the pathohistological pattern of the tumour to decide whether the patient requires removal, ablation or active surveillance.

Management of localized prostate cancer underwent significant changes as well. In the past decades, open retropubic nerve-sparing radical prostatectomy was the only option for effective treatment of cancer providing minimal side-effects.

Today, the same operation is performed with robot-assisted laparoscopic techniques providing 7-DOF instruments, 3D-vision, and tenfold magnification and enabling the surgeon to work in a sitting position at the console.

In the coming era, prostate cancer may be managed in most cases by focal therapy and/or genetically targeting therapy. Only a few patients may require robot-assisted removal of the entire gland.

We conclude that there has been a dramatic change in the management of the most frequent urologic diseases, completely replacing open surgery with minimally invasive techniques.

This has promoted the technical realization of physical principles (shock waves, optical resolution, master-slave system) used outside of medicine.

The future of medicine now lies in translational approaches individualizing the management based on genetic information and focalizing the treatment by further advancement of imaging technology.

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Ref:

Rassweiler J et al. Minim Invasive Ther Allied Technol. 2013 Aug;22(4):200-9.