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

1. Methods of guideline development 3

2. Levels of evidence and grade of guideline recommendations 3

3. References 4

2. Technical aspects 5

1. Introduction 5

2. Equipment 5

3. Instruments 5

1. Access to, and development of, working room 5

2. Dissection 5

3. Haemostasis 6

4. Suture technique 6

5. Retrieval of specimens 6

2.4 Access techniques 6

1. Retroperitoneoscopy 6

2. Transperitoneal laparoscopy of the upper tract 8

3. Transperitoneal access to the pelvis 8

4. Extraperitoneal access to the pelvis 9 Balloon dissection 9 Finger dissection 10

2.5 Management of complications 10

1. Introduction 10

2. Placement of the trocars 10

3. Insufflation of carbon dioxide 10

4. Vascular injuries 11

5. Injuries to organs 11

6. Specific training 13

7. The difficulty scoring system of laparoscopic procedures 14

1. Criteria 14

2. Scoring system 15

2.8 References 16

3 Laparoscopic procedures 18

1. Adrenalectomy 18

2. Colposuspension 18

3. Cryptorchidism treatment 19

4. Hernia repair 19

5. Nephrectomy 20

1. Simple nephrectomy (for benign disease) 20

2. Radical nephrectomy 20

3. Partial nephrectomy 20

4. Nephro-ureterectomy 21

5. Live-donor nephrectomy 21

6. Nephropexy 22

7. Pyeloplasty 22

8. Pelvic lymph node dissection 22

9. Radical prostatectomy 22

10. Retroperitoneal lymph node dissection (for testicular cancer) 23

11. Renal cyst treatment 23

12. Ureterolithotomy 23

13. Varicocelectomy 24

14. 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