Future developments and perspectives in laparoscopy

Introduction:As urologists head into the new millennium, it has become clea r that laparoscopy will play a significant role in successful urologic prac tice. Issues that are addressed in this article include: (1) What are the n ew limits? (2) Technological advances. (3) Adequate training. (4) How to te chnically simplify the laparoscopic procedures? Materials and Methods:To answer the stated questions a review of the litera ture has been undertaken together with interviews of the leading experts an d laparoscopic working groups in urologic laparoscopy. The gathered informa tion has been sumarized and focussed with the aim of presenting the perspec tives of laparoscopy in urology. Results and Discussion. Standardized! indications for laparoscopic urologic al surgery are benign nephrectomy, nephroureterectomy, cryptorchidism, adre nalectomy, renal cysts, lymphocele and bilateral or relapsing! varicocele. Future indications might include living donor nephrectomy, partial nephrect omy and cyst decortication for adult polycystic kidney disease. Controversy exists about the laparoscopic treatment of malignancies in the urinary tra ct. Whereas pelvic lymph node dissection - even if performed with drecreasi ng frequency - is accepted worldwide, retroperitoneal lymphadenectomy for l ow-stage testis cancer is currently performed only at few centers. The rece nt break-through in uro-oncological laparoscopic surgery has been laparosco pic radical prostatectomy changing our views on the limits of laparoscopic urology. Endoscopic suturing devices (i.e. Endostitch), are further being d eveloped, and a prototype reapproximating micro-clips (VCS stapler) has bee n used to perform a uretero-ureterostomy laparoscopically in a porcine mode l. Nevertheless, the ability of endoscopic suturing using the standard equi pment has still to be considered as a 'conditio sine qua non'. Improvements for tissue division and dissection include an electrosurgical! snare to pe rform a partial nephrectomy, the development of a pneumodissector and hydro dissector. Robotics, including the AESOP 3000 and ZEUS represent a glimpse of the future. By positioning the optique in a voice-controlled full range motion mechanic arm, the image on the screen is very steady and the ergonom ics of the surgeons is increased significantly. The da, Vinci-System, howev er, is the first system that has translated all visions of telepresence sur gery into clinical reality, recently also for laparoscopic radical prostate ctomy. Conclusions:The future of laparoscopic urology is a two-tiered approach. On the first tier, the advancement of complex reconstructive and ablative sur gery such as laparoscopic prostatectomy or, laparoscopic retroperitoneal no de dissection, will be undertaken by referral centers of expertise. It is f rom these individuals that we will look to in order to separate what is fea sible and what is reasonable. The second tier will be focusing on simplifyi ng the procedure for the average urologist. As such, developments such as t he pneumodissector, hydrodissection, and hand assistance will bring exstirp ative laparoscopy into the realm of more urologists. What is critical is th at the urologic community supports both groups of laparoscopists. Copyright (C) 2001 S. Karger AG, Basel.