Laparoscopic Surgeries in Urology: Initial Burgeoning Experience at National Transplant Centre, Nepal

Background This study focuses on laparoscopic surgery experiences at Shahid Dharma Bhakta National Transplant Centre (SDNTC) which could enable the patients to gain knowledge regarding its bene�ts than conventional way of surgery. The present study �nds out the frequency of various forms of nephrectomy based on laparoscopic surgery. Moreover, this study accomplishes lap donor nephrectomy of kidney transplantation which is of its �rst kind in this part of country.


Background
This study focuses on laparoscopic surgery experiences at Shahid Dharma Bhakta National Transplant Centre (SDNTC) which could enable the patients to gain knowledge regarding its bene ts than conventional way of surgery.The present study nds out the frequency of various forms of nephrectomy based on laparoscopic surgery.Moreover, this study accomplishes lap donor nephrectomy of kidney transplantation which is of its rst kind in this part of country.

Methods
We retrospectively reviewed the in-patient medical records at SDNTC from November 2017 to January 2019.Laparoscopic surgery was performed in 50 patients.The demographic data, indication for surgery, duration and peri-operative outcomes were analyzed.

Conclusions
Laparoscopic surgery is feasible and safe procedure at our government setup hospital with least cumbersome procedure and minimum complication associated with it.

Background
In 1990, rst lap nephrectomy was performed by Ralph Clayman. 1 Laparoscopic surgery has signi cant advantages over conventional incisional surgery.Because of this, there has been increasing number of successful laparoscopic radical and simple nephrectomies, partial nephrectomy, laparoscopic donor nephrectomy in case of renal transplantation, excision of renal cyst, ureteral reimplantation, pyeloplasty, stone surgery, ureterolysis and bladder neck suspension [2][3][4] .3][4] In present study, an initial burgeoning experience of fty cases undertaken lap surgery was shared indicating the rst healthy donor nephrectomy for kidney transplantation in Nepal at our centre SDNTC.

Methods
Over a period of 14 months commencing from November 2017 to January 2019, fty laparoscopic cases (32 male, 18 female age ranging from 10-60 years) were performed.We analyzed the demographic data, indications for surgery, route of approach and preoperative outcomes.The lap surgery was carried out in well set-up at SDNTC by using Ethicon Endo-surgery machine procured from Guaynabo, Puerto Rico 00969 USA.

Patient's Preparation and Laparoscopic Surgery Procedure
The patients were placed in a lateral (kidney) position.Pneumoperitoneum was created with visual trocar of 10 mm about 2.5 cm superolateral to umbilicus which was also a camera port.Laparoscopic nephrectomy was performed using 3 to 4 ports 10 mm camera port, other 10 mm and 5 mm working port in subcoastal region, or in hypogastric region (depending on left or right side getting operated) and other 10 mm port was placed as per requirement for bowel, kidney and liver retraction.The renal artery, vein and ureter were secured with hemolock clips (size 10 mm, 5 mm) and divided with scissor.After nishing the procedure, the specimen was extracted through an extension of incision to 4-5 cm of 10 mm (lower or lateral) port.

Discussion
Laparoscopic surgeries can be taken as a safe, attractive and viable alternative to conventional open surgery.In comparison to open surgery the advantage of a less invasive surgical approach to urological disease is based on improved cosmetic results, patient comfort and shorter convalescence. 1,5,6,7,8 the present study, the transperitoneal approach has been taken as we were more familiar with this approach; it represented the standard access during laparoscopic training.The signi cant difference was not detected while comparing the transperitoneal to retroperitoneal laparoscopic approach, which is similar to other comparative studies. 9,10The operating time depended mostly on the individual pathological condition like number of renal arteries, size of the kidney, perirenal adhesion, previous surgeries, BMI of the patient and experience of surgeon rather than the laparoscopic access technique used.
In adult patients, prospective 11,12 and retrosepective 13,14 comparisons between open and laparoscopic nephrectomies have shown that chest complications, hospital stay, analgesic requirement, and time required to return to normal activities are reduced in laparoscopically treated patients.However, these reports have stated that laparoscopic procedure have signi cantly longer operative time (135-335 min).In our study, the median operative time was 122.3 minutes.
In 1992, Bolhme et al reported, 490 living donor nephrectomies series in which a major complication rate was 1.4% and a minor complication rate 13.6%. 12In our study, we did not face any major complication but had 4% of minor complication which was managed conservatively.We have started laparoscopic donor nephrectomy for kidney transplant patient and this is the only centre doing laparoscopic donor nephrectomy in Nepal till date.

Conclusions
Laparoscopic surgery is safe and feasible procedure at our government setup and also challenging for urologists which requires surgical skills and expertise for consistently good outcomes.Regarding the inherent bene ts for patients in terms of reduced pain level, faster recovery and improved cosmetic result, it has become the standard approach for urologic surgery at our institution.

Table 1 :
Characteristic Features and of Lap SurgerySurgical data are shown in Table3; operating time, the rate of intraoperative complications and the rate of conversion to open surgery.The median operating time was 122.3 minutes (IQR: 45-255).Two (4%) patients were converted an open nephrectomy because of adhesion and but only 2 pint of blood was transfused in one patient.The median estimated blood loss was 74.1 cc (IQR: 20-350) whereas median drain was projected to be 137.1 cc (IQR: 0-340).All of 50 patients received adequate analgesic medication viz a viz paracetamol and tramadol.The median hospital stay was 4.64 days (IQR: 2-8).

Table 3 :
Outcome of the Patients