- •1. Introduction
- •1.2 Levels of evidence and grade of guideline recommendations
- •1.3 References
- •2.3.1 Access to, and development of, working room
- •2.3.2 Dissection
- •2.3.3 Haemostasis
- •2.3.4 Suture technique
- •2.4 Access techniques (1, 3, 5, 6)
- •2.4.1 Retroperitoneoscopy
- •2.4.2 Transperitoneal laparoscopy of the upper tract
- •2.4.3 Transperitoneal access to the pelvis
- •2.4.4 Extraperitoneal access to the pelvis
- •2.5 Management of complications (7-14)
- •2.5.2 Placement of the trocars
- •2.5.3 Insufflation of carbon dioxide
- •2.5.4 Vascular injuries
- •2.5.5 Injuries to organs
- •2.6 Specific training
- •2.7.1 Criteria
- •2.7.2 Scoring system
- •2.8 References
- •15. Guilloneau b.
- •27. Rassweiler j, Coptcoat m, Frede t.
- •36. Janetschek g, Hobisch a, Peschel r, Hittmair a, Bartsch g.
- •3.2 Colposuspension
- •3.3 Cryptorchidism treatment
- •3.4 Hernia repair
- •3.5 Nephrectomy
- •3.5.1 Simple nephrectomy (for benign disease) (Table 3.6)
- •3.5.2 Radical nephrectomy (Table 3.7)
- •3.5.3 Partial nephrectomy (Table 3.8)
- •3.5.4 Nephro-ureterectomy (Table 3.9)
- •3.5.5 Live-donor nephrectomy (Table 3.10)
- •3.6 Nephropexy (Table 3.11)
- •3.7 Pyeloplasty (Table 3.12)
- •3.8 Pelvic lymph node dissection (Table 3.13)
- •3.9 Radical prostatectomy (Table 3.14)
- •3.10 Retroperitoneal lymph node dissection (for testicular cancer) (Table 3.15)
- •3.11 Renal cyst treatment (Table 3.16)
- •3.12 Ureterolithotomy (Table 3.17)
- •3.13 Varicocelectomy (Table 3.18)
- •3.14 References
- •1. Gagner m, Lacroix a, Bolte e.
- •2. Rassweiler jj, Henkel to, Potempa dm, Coptcoat m, Alken p.
- •3. Go h, Takeda m, Takahashi h, Imai t, Tsutsui t, Mizusawa t, Nishiyama t, Morishita h, Nakajima y, Sato s.
- •12. Suzuki k, Ushiyama t, lhara h, Kageyama s, Mugiya s, Fujita k.
- •17. Takeda m, Go h, Watanabe r, Kurumada s, Obara k, Takahashi e, Komeyama t, Imai t, Takahashi k.
- •18. Rayan ss, Hodin ra.
- •23. Su th, Wang kg, Hsu cy, Wei hj, Hong bk.
- •83. Liem msl, Van Vroonhoven tj.
- •101. Gill is, Kavoussi lr, Clayman rv, Ehrlich r, Evans r, Fuchs g, Gersham a, Hulbert jc, McDougall em, Rosenthal t, et al.
- •104. Fornara p, Doehn c, Fricke l.
- •114. Gill is.
- •118. Janetschek g, Daffner p, Peschel r, Bartsch g.
- •128. Jones dr, Moisey cu.
- •136. Yang sc, Park ds, Lee dh, Lee jm, Park k.
- •140. Suzuki k, Ishikawa a, Ushiyama t, Nobutaka o, Suzuki a.
- •167. O'Dea mj, Furlow wl.
- •168. Temizkan m, Wijmenga lf, Ypma af, Hazenberg hj.
- •169. MossSw.
- •170. Soulie m, Thoulouzan m, Seguin p, Mouly p, Vazzoler n, Pontonnier f, Plante p.
- •174. Ben Slama mr, Salomon l, Hoznek a, Cicco a, Saint f, Alame w, Antiphon p, Chopin dk, Abbou cc.
- •202. Boeckmann w, Effert p, Wolff jm, Jakse g.
- •224. Bollens r, Vanden Bossche m, Roumeguere t, Damoun a, Ekane s, Hoffmann p, Zlotta ar, Schulman cc.
- •241. LeBlanc e, Caty a, Dargent d, Querleu d, Mazeman e.
- •245. Janetschek g, Hobisch a, Hittmair a, Holtl l, Peschel r, Bartsch g.
European Association of Urology
GUIDELINES
ON LAPAROSCOPY
Dedicated to: MJ. Coptcoat.
JD. Doublet, G. Janetschek, A. Joyce, A. Mandressi,
J. Rassweiller, D. Tolley.
TABLE OF CONTENTS PAGE
1. Introduction 3
Methods of guideline development 3
Levels of evidence and grade of guideline recommendations 3
References 4
2. Technical aspects 5
Introduction 5
Equipment 5
Instruments 5
Access to, and development of, working room 5
Dissection 5
Haemostasis 6
Suture technique 6
Retrieval of specimens 6
2.4 Access techniques 6
Retroperitoneoscopy 6
Transperitoneal laparoscopy of the upper tract 8
Transperitoneal access to the pelvis 8
Extraperitoneal access to the pelvis 9 Balloon dissection 9 Finger dissection 10
2.5 Management of complications 10
Introduction 10
Placement of the trocars 10
Insufflation of carbon dioxide 10
Vascular injuries 11
Injuries to organs 11
Specific training 13
The difficulty scoring system of laparoscopic procedures 14
Criteria 14
Scoring system 15
2.8 References 16
3 Laparoscopic procedures 18
Adrenalectomy 18
Colposuspension 18
Cryptorchidism treatment 19
Hernia repair 19
Nephrectomy 20
Simple nephrectomy (for benign disease) 20
Radical nephrectomy 20
Partial nephrectomy 20
Nephro-ureterectomy 21
Live-donor nephrectomy 21
Nephropexy 22
Pyeloplasty 22
Pelvic lymph node dissection 22
Radical prostatectomy 22
Retroperitoneal lymph node dissection (for testicular cancer) 23
Renal cyst treatment 23
Ureterolithotomy 23
Varicocelectomy 24
References 24
4 Recommendations 37 Abbreviations 38
1. Introduction
A group of European urologists, each with a special interest in laparoscopy, has reviewed the published literature in order to provide guidelines for this subspeciality. In considering the role of a particular laparoscopic procedure as an alternative to its open counterpart, it must be stated that there is sometimes minimal evidence to support the use of, what historically has been understood to be, an established open procedure. This group has therefore established new standards of quality. Despite the lack of Level One evidence or Grade A recommendations, the Laparoscopy Working Group of the EAU feels that laparoscopy has a significant role to play in the practice of urology. Indeed, laparoscopy is a surgical field with a tremendous continuing development, both technological and methodological; it means that we are dealing with procedures worthy of particular consideration.
In these guidelines, the term 'laparoscopy' is used to describe every surgical technique carried out in a closed space, either enlarged or created, regardless of whether or not the technique is performed either inside or outside the peritoneum.
The Laparoscopy Working Group has browsed all the literature available on laparoscopy, published between 1990 and 2000, as well as some published in 2001. References are quoted according to the criteria described in Sections 1.1 and 1.2 (see below).
1.1 Methods of guideline development (1)
Woolf (1992) described three main methods of guideline development: informal, consensus, formal consensus, and evidence-linked guideline development (2).
In informal consensus development, this means that poorly defined often-implicit criteria for decision-making were available to guide the Laparoscopy Working Group. Formal consensus development methods, which are used by many consensus-development conferences and Delphi groups, provide 'greater structure to the analytical process' but still fail to provide 'an explicit linkage between recommendations and quality of evidence' (2). Evidence-linked guideline development requires the explicit linkage of recommendations to the quality of the supporting evidence (3).
This allows the user to make an informed choice about whether to comply with the individual recommendations within the guidelines by taking account of the level of supporting evidence. Clinicians therefore need a very good reason (which should be adequately documented) for choosing not to comply with a recommendation based upon a clinically relevant randomized trial or meta-analysis. However, the clinician has greater flexibility in using recommendations based upon lower levels of evidence.
1.2 Levels of evidence and grade of guideline recommendations
The levels of evidence are summarized in Table 1.1, and the grading of guideline recommendations is described in Table 1.2.
Table 1.1 Levels of evidence (3)
Level |
Type of evidence |
1a |
Evidence obtained from meta-analysis of randomized trials |
1b |
Evidence obtained from at least one randomized trial |
2a |
Evidence obtained from one well-designed controlled study without randomization |
2b |
Evidence obtained from at least one other type of well-designed quasi-experimental study |
3 |
Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports |
4 |
Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities |
Table 1.2 Grades of guideline recommendations (3)
Grade
Nature of recommendations
Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
Based on well-conducted clinical studies, but without randomized clinical trials
Made despite the absence of directly applicable clinical studies of good quality