Is laparoscopic urostomy surgery a viable option?

Laparoscopic Urostomy Surgery: Feasibility and Considerations

Laparoscopic urostomy surgery is a viable option in selected cases, but should be considered a second-line approach after traditional open techniques, particularly in emergency settings or complex cases where urological expertise may be limited.

Feasibility of Laparoscopic Approach

Laparoscopic techniques for urinary diversion procedures have been developed and refined over recent years, showing promising results in specific scenarios:

• Laparoscopic repair of urinary tract injuries has been demonstrated to be safe and feasible in appropriate cases 1
• For ureteral procedures, laparoscopic end-to-end ureteroureterostomy has shown good surgical outcomes with shorter operative time and less blood loss compared to laparoscopic ureteroneocystostomy 1
• Minimally invasive approaches (laparoscopic and robotic) for ureteroneocystostomy have demonstrated comparable safety to open techniques with benefits in estimated blood loss, length of stay, and stent duration 2

Patient Selection Criteria

The decision to perform laparoscopic urostomy should be based on:

1. Patient factors:

   • Hemodynamic stability
   • Absence of severe comorbidities
   • No extensive previous abdominal surgeries

2. Surgical factors:

   • Availability of urological expertise
   • Appropriate equipment
   • Complexity of the required reconstruction

3. Institutional factors:

   • Center experience with laparoscopic urological procedures
   • Availability of conversion to open surgery if needed

Limitations and Considerations

Several important limitations should be considered:

• In emergency settings, laparoscopic procedures are technically demanding, and conversion to open surgery is recommended in complex cases 1
• The experience and skills of the operating surgeon are fundamental in deciding whether to use a minimally invasive approach 1
• For complex reconstructions, the "drain now, fix later" philosophy may be more appropriate when urological expertise is unavailable 1

Specific Urostomy Scenarios

Ureteral Injuries and Reconstruction

• For distal ureteral injuries, ureteroneocystostomy (with or without vesico-psoas hitch or Boari flap) is preferred 1
• For mid or proximal lesions, ureteroureterostomy is typically adopted 1
• Laparoscopic repair requires adequate drainage, good vascular supply, and a wide spatulated tension-free mucosa-to-mucosa anastomosis 1

Bladder Injuries

• Direct repair with 2-layer vesicorrhaphy using absorbable suture is standard 1
• Foley catheter placement for 5-14 days ensures continuous bladder emptying 1
• Cystography before catheter removal is recommended 1

Stent Management

Proper stent management is crucial for successful outcomes:

• Partial ureteral lesions: stent for 2-3 weeks 3
• Complete ureteral transection with repair: stent for 4-6 weeks 3
• Ureteral reimplantation: stent for 2-4 weeks 3
• Urinary stents should be removed as soon as possible, ideally within 2-3 weeks for uncomplicated cases 3

Pitfalls and Caveats

1. Conversion threshold: Maintain a low threshold for conversion to open surgery when difficulties arise during laparoscopic approach
2. Expertise requirement: The urologist's presence in repairs of iatrogenic urinary tract injuries is paramount 1
3. Delayed diagnosis risk: Delayed diagnosis of injuries is more common after laparoscopic surgery 1
4. Stent complications: Leaving stents in place for prolonged periods can lead to infection, encrustation, and patient discomfort 3

Conclusion

While laparoscopic urostomy surgery is technically feasible and offers potential benefits in selected cases, it requires significant expertise and appropriate patient selection. In emergency settings or complex cases, open surgical techniques remain the standard approach, especially when urological expertise is limited.