Kidney Stone Surgery:

Ureteroscopy, Percutaneous Nephrolithotomy, (RIRS), Extracorporeal Lithotripsy

Ureteroscopy is an instrument for removing kidney stones. It is used in cases where the stone is too large to be expelled in the urine and therefore requires surgery. It is a minimally invasive technique as it involves inserting a small endoscope into the bladder through the urethra without making any incisions in the body to extract the stone. The success rates of this technique are very high, and the risk of complications is very low.

Treatments for kidney stones have three objectives: to prevent their development, resolve the existing stone and avoid its potential adverse effects, and prevent its recurrence.

Cases in which a ureteroscopy is appropriate:

  • If there are stones in the ureter that are difficult to pass spontaneously or that are causing significant discomfort.
  • If there are kidney stones that cannot be treated with another technique such as shock waves.
  • To determine why there is blood in the patient’s urine.

There are two types of ureteroscopy depending on the type of instrument used. It can be rigid or flexible. Rigid ureteroscopy is literally performed with a rigid telescopic tube that only allows vision in a straight line, while the tube used in flexible ureteroscopy can rotate up to 180° and provides a retrospective view. Flexible ureteroscopy is typically used when stones are in or near the kidney, while rigid ureteroscopy is generally used when stones are in the lower or middle part of the ureter, near the bladder.

In most cases, it allows direct visualization of the stone and therefore the introduction of special instruments or a laser to break it up. The ureteroscopy passes through natural channels in the body and does not require skin incisions. If the stone can be seen, it can most likely be broken up in a single session.

If the stone cannot be accessed with the ureteroscope on the first attempt due to inflammation, a double-J stent may be placed. This allows urine to flow from the kidney to the bladder while widening the ureter, making it easier to push the ureteroscope upward to reach the stone and remove it.

Sometimes, if the stone is very large, it may not be possible to remove it in a single session, requiring a second procedure. In other cases, small fragments or even the entire stone may reach the kidney. If a flexible ureteroscope is available, it can be used to reach the kidney to remove the fragments or break them up with a laser.

Percutaneous nephrolithotomy has very specific indications, replacing traditional open surgery in the case of upper urinary tract stones.

This procedure aims to completely or partially remove stones from the diseased kidney, as well as to eliminate symptoms and prevent potential complications caused by the stones.

It involves the extraction of kidney stones using a nephroscope (metal tube) inserted into the kidney through a small hole in the skin of the lumbar region.

There are two techniques for disintegrating stones: one is the lithotripter (ultrasonic or pneumatic) and the other is laser (holmium or thullium). Lasers pulverize the stone, making it much easier to remove the powder. The lithotripter fragments the stone into several pieces, so these fragments must be removed with metal forceps.

 

This technique is reserved only for large kidney stones, such as:

  • Staghorn stones that occupy all or almost all of the calyces and pelvis of the kidney.
  • Stones larger than 2 cm located in the renal pelvis.
  • Multiple stones in the calyces and renal pelvis.
  • Double-J stent calcification that prevents removal.
  • When other treatments have failed.

Retrograde Intrarenal Surgery (RIRS) is a minimally invasive endoscopic surgical procedure that allows the removal of stones, also known as renal lithiasis, using an instrument called a flexible ureteroscope with a high-definition camera at its tip. A laser fiber can be inserted through it to fragment and pulverize the stone, extracting small fragments, if necessary, for chemical analysis.

The procedure is performed under anesthesia, and the patient can usually go home within the first 24 hours, the next day, or even the same day. It leaves no incisions or external wounds, as it is performed through the urethra and ascends the urinary tract.

This procedure can also be used diagnostically or therapeutically for the conservative treatment of urothelial tumors of the upper urinary tract.

Lithotripsy is a medical procedure that uses shock waves to break up stones that form in the kidney, bladder, or ureter (the tube that carries urine from the kidneys to the bladder).

After the procedure, the tiny stone pieces pass out of the body through the urine.

Ninety-five percent of stones located in the ureter are spontaneously passed within 3 to 4 weeks, depending on their size and position. Any stones not passed within 2 months require therapeutic intervention.

Currently, between 90 and 95% of stones can be removed through noninvasive procedures, such as extracorporeal shock wave lithotripsy, which breaks the stones into small fragments that can be more easily passed.

The most common side effect is urinating blood after treatment. This will disappear with regular water intake and within a few hours or days. Most people can go home the same day of the procedure.

 

PROSTATE CANCER: ROBOTIC PROSTATECTOMY

Robotic prostatectomy in the treatment of prostate cancer overcomes the limitations of conventional laparoscopic surgery with more precise surgical interventions, especially in more complex and difficult-to-access prostates.

With this robotic surgery, we achieve a urinary continence rate close to 100% and preservation of sexual potency of around 90% in patients under 65 years of age. Due to the characteristics of the tumor, it allows us to preserve the nerves and vessels that determine male erection.

Blood loss during the procedure, and therefore the need for transfusions, is 85% lower than with open surgery.

PROSTATE HYPERTROPHY: LASER SURGERY

Prostatic photovaporization (greenlight laser) is considered a minimally invasive endoscopic treatment for lower urinary tract symptoms caused by obstruction due to prostatic hyperplasia.

It consists of the selective application of laser energy to prostate tissue for immediate elimination, thereby reducing prostatic obstruction and symptoms.

It is performed through the urethra without incisions and aims to increase the diameter of the prostatic urethra, allowing the patient to experience symptom relief and quickly return to daily activities.

Minimally invasive surgical treatment with minimal impact on normal activity and minimal hospital stay.

The greenlight laser is best indicated for small and medium-sized prostates, although, depending on the surgeon’s experience, it can be used for large prostates. Although it can be performed on an outpatient basis, we recommend a 48-hour hospital stay so the urinary catheter can be removed the same day, and you can return to your normal activities as soon as possible.

 

KIDNEY TUMOR SURGERY: LAPAROSCOPIC OR ROBOTIC PARTIAL NEPHRECTOMY

This is a minimally invasive surgery that allows for the removal of a portion of the kidney affected by cancer, along with the surrounding adipose tissue (fat), which is important for proper staging and prognosis. Laparoscopic partial nephrectomy is the treatment of choice for kidney cancer measuring less than 7 cm in size; however, it must meet certain technical requirements to make the surgery feasible and requires adequate experience in laparoscopy. It is usually performed under general anesthesia.

The patient will be hospitalized for 2-3 days, with an abdominal drain that will be removed before discharge and a urinary catheter, which is usually placed only for the first 24 hours.

Since the surgical procedure is not as aggressive (since the surgical incision is minimal), postoperative pain is much less, and after the procedure, the patient is able to walk and perform their usual activities independently. Full recovery usually takes two weeks; however, it is important to be cautious and avoid excessive physical activity, as the body still needs time to reduce the inflammatory process from the surgery and heal.

 

ADVANTAGES OF ROBOTIC NEPHRECTOMY

Robotic surgery is playing an increasingly important role in urological surgery. Rather than robotic surgery, the term “robotic-assisted surgery” would be more appropriate, given that the robot is a tool in the hands of the surgeon, who remains the operator of the surgery. The robot consists of three parts: a patient cart consisting of four robotic arms placed close to the patient; a console with a high-definition 3D display from which the seated surgeon directs the movements of the robotic arms; and a screen for the assistant who assists in the procedure.

One of the advantages of the robot is that it performs surgery with very small incisions, generally less than one centimeter: this reduces the patient’s postoperative pain and speeds recovery. Through these small incisions, the robot’s arms allow the surgeon to operate without tremors and with greater freedom of rotation and joint movement than the human wrist. This allows for extremely precise dissection movements, reducing bleeding, helping to remove pathological tissue, and preserving healthy tissue. This feature can contribute to excellent functional results.

The surgeon, seated at the console, can operate, reducing physical and therefore mental fatigue.

Therefore, we could summarize the advantages provided by the robot as follows:

  • Extreme precision in movements
  • Magnified, three-dimensional, and high-definition vision for the surgeon
  • Reduction in postoperative bleeding and pain
  • Rapid functional recovery after surgery
  • Improved ergonomics for the surgeon

Robot-assisted surgery can treat oncological and non-oncological pathologies.

 

BLADDER CANCER SURGERY: TUR, ROBOTIC OR LAPAROSCOPIC CYSTECTOMY

When it comes to bladder cancer, early diagnosis and detailed pathological analysis are vital to determine the prognosis and treatment. For this purpose, TUR, or transurethral resection, is one of the most advanced techniques.

Bladder cancer is the 7th most common cancer in men and the 10th when both sexes are included. Bladder tumors are caused by the uncontrolled proliferation of groups of mucosal cells (transitional cells). These groups of cells may remain confined to the mucosa or may infiltrate the next layer, the muscle. Depending on the location of the tumor and its degree of aggressiveness, the patient will require different treatment. This is why early diagnosis and detailed pathological analysis are vital in bladder cancer.

Transurethral resection of bladder tumors (TURB) is a minimally invasive surgical procedure with a dual purpose. It is used both for definitive diagnosis and as the first step in bladder cancer treatment, removing the tumor tissue.

TURB involves the endoscopic removal of cancer cells from the bladder wall through the penis, without incisions or scarring.

During this treatment, a visual examination of the entire bladder is performed to identify tumor lesions, followed by complete removal of the tumor tissue.

Once the tumor is removed, it is sent for analysis to determine the stage of the cancer and to adjust further treatment, if necessary.

There is less than a 10% risk of infection or injury with this technique.

The patient will be discharged from the hospital in 2-3 days. The postoperative period is quite bearable, with some mild pain and stinging in the area, which is effectively controlled with painkillers.

A urinary catheter is not necessary beyond the first 48 hours after surgery.

After surgery, you can resume your normal life but avoid sudden movements or exertion for about 4 weeks.

There are no sexual problems, including erection, libido, or ejaculation.

 

LAPAROSCOPIC RADICAL CYSTECTOMY

This is a minimally invasive and highly complex surgical procedure that completely removes the urinary bladder affected by severe pathology (metastatic invasive bladder cancer), along with the surrounding lymph nodes and tissue. In men, this involves the seminal vesicles and prostate, and in women, the uterus and vaginal vault, without the need to open the abdomen.

The urinary tract is then reconstructed to allow urine to pass from the kidneys to the outside.

Several types of reconstructive surgery can be performed, depending on the degree of involvement, the pathology, and the surgical team’s discretion at the time of the procedure. The most commonly used are:

  • The creation of a reservoir (new bladder) with fragments of the large intestine, attempting to achieve the most natural diversion of urination possible.
  • If bladder reconstruction is not possible, the ureters are connected to the abdominal wall (stoma), which requires the use of an external urine collection bag.

Statistical profile of patients with bladder cancer:

  • Males are more affected than females.
  • Average age is around 60-65 years.
  • Patients with heavy tobacco use.
  • Patients with exposure to chemicals.

Some of the advantages of laparoscopic surgery over conventional surgery (open surgery) are:

  • Less bleeding during surgery.
  • Less postoperative pain.
  • Fewer postoperative complications.
  • Less cosmetic impact (smaller scars).
  • Faster recovery.

 

ROBOTIC RADICAL CYSTECTOMY

Da Vinci robotic radical cystectomy is the most advanced, sophisticated, and precise minimally invasive surgical procedure currently used for the treatment of muscle-invasive bladder cancer.

This technique involves the removal of the urinary bladder along with surrounding lymph nodes, tissues, and organs that are also affected, with the goal of eradicating all tumor tissue.

Radical cystectomy is considered a highly complex surgery, and the fact that it can be performed using state-of-the-art robotic technology (Da Vinci robot) provides numerous advantages to the surgical process, both during the execution phase, facilitating and enhancing the surgeon’s skill and precision, and during the patient’s recovery phase compared to more conventional non-robotic techniques such as open or laparoscopic surgery.

Benefits of robotic surgery for the surgeon:

  • Greater visualization, precision, and control.
  • Elimination of physiological tremor.
  • Precise identification and dissection of the ureters and bladder.
  • Greater accessibility to deep anatomical planes.
  • Greater radicality in tumor removal.
  • Reduced risk of error.

Advantages for the patient:

  • Less painful postoperative period.
  • Lower risk of complications.
  • Decreased risk of infection.
  • Very small scars (cosmetic improvement).
  • Decreased side effects (incontinence – impotence).
  • Shorter hospital stay.
  • Lower risk of bleeding (fewer transfusions).
  • Shorter recovery process.
  • Quick return to normal daily activities.

Robotic surgery allows the surgeon to remove tumor tissue with maximum precision and facilitates reconstruction of the urinary tract (neo-bladder) to maximize urinary continence.

 

VASECTOMY

A vasectomy involves the sectioning and ligation of the vas deferens through two small incisions made on either side of the scrotum.

As a result, after some time, the ejaculated semen contains no sperm.

It is indicated in cases where the couple decides not to have more children. It is also indicated when the woman is contraindicated in contraceptives, regardless of the type.

 

PHIMOSIS

Phimosis is defined as the difficulty or impossibility of retracting the preputial skin, that is, the skin that covers the tip of the penis or glans. It should not be confused with the presence of balanopreputial adhesions (between the skin of the foreskin and the glans of the penis), which are very common in boys and are independent of the presence or absence of phimosis. In some children, these adhesions are accompanied by a tightness in the skin of the foreskin, which causes intense pain when attempting to retract it. This sometimes causes the foreskin to swell before urination occurs. In milder cases, the only pain experienced is when attempting to retract the foreskin to clean the glans penis.

At birth, difficulty retracting the foreskin is common in boys. In the first 3-4 years of life, the epithelial debris that forms between the glans penis and the foreskin (smegma) gradually separates the two structures. By age 3, 90% of foreskins descend completely. Less than 1% of 17-year-old boys have phimosis.

Phimosis only occurs if the foreskin presses too hard against the shaft of the penis as it descends; if it prevents the glans penis from being uncovered; or if it is difficult to re-cover the penis after the foreskin descends. If the foreskin falls freely and there is no pressure during erection, there is no phimosis. Excess skin is not phimosis.

Only boys who have difficulty retracting the foreskin and who have not responded to less aggressive treatments should undergo surgery. Circumcision can be performed starting at age 11 or 12 with local anesthesia.

CIRCUMCISION, POSTECTOMY OR PHIMOSIS SURGERY

Circumcision consists of the removal of the narrow ring of foreskin and the subsequent suturing of the skin with absorbable material.

 

URINARY INCONTINENCE SURGERY FOR MEN AND WOMEN

Urinary incontinence is the involuntary loss of urine without control over the filling and emptying of the bladder, sometimes accompanied by a strong urge to urinate.

It is caused by age, pregnancy and childbirth, menopause, functional and cognitive decline, and other factors, such as surgery, obesity, certain types of physical exercise, etc.

Due to its association with modesty and social shame, consultations for these problems are often delayed or, sometimes, avoided. For this reason, its true incidence is unknown, although it is estimated that around two million people in Spain suffer from it. Of these, only 10% seek medical attention.

The paradox is that involuntary incontinence, which so greatly affects the quality of life of those who suffer from it, is susceptible to significant improvements and even complete recovery.

Surgery is reserved for patients who have failed conservative treatments.

There are around 200 different surgical procedures.

The most common treatments for this problem are banding surgery, mini-strip surgery, and botulinum toxin.

 

Banding Surgery

Due to its effectiveness, in 90% of cases, the procedure involves placing a synthetic mesh under the urethra, inserted through a small vaginal incision.

The operation takes about 25 minutes and is usually performed under epidural anesthesia, although it can also be performed under local anesthesia.

It involves a strip, usually made of polypropylene, a material well tolerated by the body, which is placed under the urethra without tension. Because it is porous, it stays in place and eventually integrates with the body.

It is a simple and minimally invasive procedure, which facilitates a rapid recovery for the patient at home. Incontinence ceases as soon as the mesh is placed, although it is recommended to avoid excessive straining for the first month after surgery.

 

Mini-strip surgery

Through a single incision under the urethra, a small strip is placed and secured internally, without any holes in the skin.

It has greater advantages than the synthetic mesh technique, including greater comfort for the patient and the advantage of being adjustable.

Botulinum toxin

In some cases, botulinum toxin injection into the bladder reduces the number of episodes of urge incontinence.

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