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OBJECTIVE To evaluate the effect of the early use of the vacuum erection device (VED) on erectile dysfunction (ED) and penile shortening after radical retropubic prostatectomy (RP), as these are important concerns for men choosing among treatment alternatives for localized prostate cancer. PATIENTS AND METHODS Twenty-eight men undergoing RP were randomized to early intervention (1 month after RP, group 1) or a control group (6 months after RP, group 2) using a traditional VED protocol. An International Index of Erectile Function (IIEF) score of >11 (no, mild or mild to moderate ED) was required as a baseline criterion for inclusion in the study. Only patients in whom unilateral or bilateral nerves were spared were subsequently randomized. Patients in group 1 followed a daily rehabilitation protocol consisting of 10 min/day using the VED with no constriction ring, for 5 months. Patients were evaluated with the IIEF-5 questionnaire and measurements of penile flaccid length, stretched length, prepubic fat pad, and midshaft circumference before and at 1, 3, 6, 9 and 12 months after RP; the mean (range) last follow-up visit was 9.5 (6–12) months after RP. RESULTS The mean (sd) baseline IIEF scores were similar in groups 1 and 2, at 21.1 (4.6) and 22.3 (3.3), respectively ( P = 0.54). The IIEF scores were significantly higher in group 1 than group 2 at 3 months, at 11.5 (9.4) vs 1.8 (1.4) ( P = 0.008) and at 6 months, at 12.4 (8.7) vs 3.0 (1.9) ( P = 0.012) after RP. There were no significant changes in penile flaccid length, prepubic fat pad, or mid-shaft circumference in either group. Stretched penile length was significantly decreased at both 3 and 6 months, by ≈ 2 cm ( P = 0.013) in group 2. By contrast, stretched penile length was preserved in group 1 at all sample times. At the last follow-up, the proportion of men with a mean loss of penile length of ≥ 2 cm was significantly lower in group 1 than group 2 (two/17, 12%, vs five/11, P = 0.044). CONCLUSIONS Initiating the use of a VED protocol at 1 month after RP improves early sexual function and helps to preserve penile length. [ABSTRACT FROM AUTHOR]

Authors from Cleveland assessed the impact of warm ischaemia on renal function, using their large database of laparoscopic partial nephrectomies for tumour. While agreeing that renal hilar clamping is essential for precise excision of the tumour, and other elements of the operation, the authors indicate that warm ischaemia may potentially damage the kidney. However, they found that there were virtually no clinical sequelae from warm ischaemic of up to 30 min. They also found that advancing age and pre-existing renal damage increased the risk of postoperative renal damage.To assess the effect of warm ischaemia on renal function after laparoscopic partial nephrectomy (LPN) for tumour, and to evaluate the influence of various risk factors on renal function.Data were analysed from 179 patients undergoing LPN for renal tumour under warm ischaemic conditions, with clamping of the renal artery and vein. Renal function was primarily evaluated in two groups of patients: 15 with tumour in a solitary kidney, who were evaluated by serial serum creatinine measurements; and 12 with two functioning kidneys undergoing unilateral LPN, and evaluated by renal scintigraphy before and 1 month after LPN to quantify differential renal function. Also, in all 179 patients, mean serum creatinine data at baseline, 1 day after LPN, at hospital discharge, and at the last follow-up were provided as supportive evidence. Logistic regression analyses were used to assess the effect of various risk factors on renal function after LPN, i.e. patient age, baseline serum creatinine, tumour size, solitary kidney status, duration of warm ischaemia, pelvicalyceal suture repair, urine output and intravenous fluids during LPN.In the group of patients with a solitary kidney the mean warm ischaemia time was 29 min, kidney parenchyma excised 29%, and serum creatinine at baseline, discharge, the peak after LPN and at the last follow-up (mean 4.8 months) 1.3, 2.3, 2.8, and 1.8 mg/dL, respectively. One patient (6.6%) required temporary dialysis. In the second group, assessed by renal scintigraphy, the function of the operated kidney was reduced by a mean of 29%, commensurate with the amount of parenchyma excised. For all 179 patients, a combination of age≥70 years and a serum creatinine level after LPN of≥1.5 mg/dL correlated with a higher serum creatinine after LPN. On logistic regression, baseline serum creatinine and solitary kidney status were the only variables significant for serum creatinine status after LPN.The bloodless field provided by renal hilar clamping is important for precise tumour excision, pelvicalyceal suture repair and securing parenchymal haemostasis during LPN. However, renal hilar clamping causes warm ischaemia. These data indicate that the clinical sequelae of warm ischaemic renal injury of≈ 30 min are minimal. Advancing age and pre-existing azotaemia increase the risk of renal dysfunction after LPN, especially when the warm ischaemia exceeds 30 min. [ABSTRACT FROM AUTHOR]

The article presents concepts in achieving renal hypothermia during laparoscopic partial nephrectomy in the U.S. Based from experiment results, the surface hypothermia achieved with ice-slush duplicates open surgical time-tested principles is the recommended option. On the other hand, better delivery systems for hypothermic solutions are needed for uniform cooling of the kidney.

Introduction: Ptotic kidney is a rare entity and is rarely seen by the practicing urologist. Campbell's Urology defines Ptosis as movement of the kidney beyond two and a half vertebral bodies with respiration. Most incidentally detected ptotic kidneys do not need treatment as they are asymptomatic. However with the advent of bariatric surgery, there are possibly an increasing number of ptotic kidneys seen by urologists at major bariatric surgery centers. This possibly happens as there is sudden and significant weight loss as well as loss of body fat. This leads to a decrease in fat deposits around the body, one of which is the peri-nephric fat deposit. This may possible explain a new onset ptotic kidney after bariatric surgery. If this ptosis is accompanied by pain then the dilemma arises as to who needs surgical treatment. Materials and Methods: Between March 2004 and October 2006, a total of 6 patients who presented with pain to the authors clinic were diagnosed with a ptotic kidney on IVP. All 6 of these patients had previously had a bariatric procedure and had suddenly lost a great deal of weight. No other cause for the pain could be found on imaging. All patients underwent a laparoscopic nephropexy after discussing options. Results: Of the 6 patients, 4 had immediate relief of pain and 1 had no relief. In 1 patient, the pain level actually went up after surgery. Of the 4 patients who had benefited from surgery, 3 eventually had resurgence of their pain within 1 year. Only 1 patient remained pain free. Conclusions: Diagnosis of Ptosis is not an indication for surgery. However when Ptosis is accompanied by symptoms then treatment becomes a clinical dilemma. With the advent of bariatric surgery, urologists may see an increasing number of symptomatic Ptotic kidneys. However extensive workup is required to rule out other causes of pain. Our experience indicates that laparoscopic nephropexy should not be performed in patients with a ptotic kidney after bariatric surgery as results are extremely poor in our small series. [ABSTRACT FROM AUTHOR]

We present a rare case of a laparoscopic ureterectomy for the treatment of unusual chronic pain from a large retained stone in a ureteral stump. The history of long-term co morbidities from retained ureteral stumps is reviewed, as well as a discussion on the possible etiology of the pain for this particular patient. An argument for the change of the standard of care for the management of ureters in relation to nephrectomies is also made in regard to adult patients with a history of stone disease. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic pyeloplasty (LP) is now the standard of care for most patients with either a primary or secondary UPJ obstruction. The advantages of laparoscopic pyeloplasty over open pyeloplasty are well documented in literature and are beyond discussion. Laparoscopy combines the efficacy of open surgery with the advantages of minimally invasive surgery. It also allows for correction of nuances like high inserting ureter, crossing vessel and a large redundant pelvis, which endourological techniques cannot. Patients presenting with a UPJ obstruction with renal calculi present a unique challenge. These patients require removal of their calculi with or without a concomitant pyeloplasty to prevent recurrence of calculi and renal deteoration. Both these issues can be addressed with laparoscopic surgery in the same sitting. Materials and Methods: A retrospective chart review was performed of 49 laparoscopic pyeloplasties performed by the author and his fellows between January 2003 and March 2007. Patients were diagnosed on basis of symptoms, isotope renal scan and CT scan. All patients underwent pre-operative DJ stenting at the time of surgery. All cases were transperitoneal. In 14 of these 49 cases, intraoperative flexible cystoscopic stone removal with a basket was performed after dismembering the ureter from the pelvis. All patients underwent Anderson-Hynes dismembered pyeloplasty. Results: All 49 cases were completed successfully transperitoneally. Complications: There were a total of 6 minor and 1 major complications. Conclusions: Laparoscopic pyeloplasty with concomitant pyelolithotomy is an excellent option for patients with UPJ obstruction and possible secondary calculi 1,2. During the pyeloplasty, the dismembered pelvis provides a wide open portal for introduction of a flexible cystoscope and all stones in any calyx can be basketed out. This technique however requires a flexible cystoscope and cannot be done with a rigid scope. If the stones are free floating and few in number, then a catheter can be introduced into the pelvis and forceful washes given to irrigate the stones out. However one cannot rely on this. Laparoscopic pyeloplasty is an excellent treatment option for almost all patients with UPJ obstruction and the presence of calculi does not constitute a contraindication. [ABSTRACT FROM AUTHOR]

Introduction: Endourology has revolutionized the management of stone disease in the last 15 years. A combination of ESWL, PCNL and ureteroscopy has made open surgery all but redundant. However, for the occasional case with a large ureteral stone or large pelvic stone, laparoscopic surgery provides an excellent minimally invasive option. The typical example is a 2-3 cm ureteral stone in the mid or upper ureter. The endourologist would still argue that this can be tackled with an antegrade approach. However with the advent of retroperitoneal laparoscopic surgery, these stones can be easily managed with via a ureterolithotomy with minimal trauma and minimal operating time. The same can be said for large multiple renal pelvic stones. Materials and Methods: Between January 2003 and January 2007, a total of 17 patients underwent laparoscopic surgery for stone disease by the author and his fellows. Of these 11 had ureteral stone disease and 6 had renal pelvic stone disease. Only patients with a large extra-renal pelvis were included in the study. All patients underwent isotope renal scan to ensure adequately functioning kidney as well as a CT scan/IVP. All patients were stented either before surgery or after surgery. Results: 16 of the 17 procedures were completed successfully. 1 patient required open conversion. Complication: During pyelolithotomy, the pelvis was found to be extremely friable and disintegrated during dissection. This patient required an open uretero-calycostomy. Conclusions: Laparoscopy is ideal for the occasional case of a large ureteral/ renal pelvic stone. 1, 2 Laparoscopic pyelolithotomy is an excellent modality for renal stones with an extra-renal pelvis. [ABSTRACT FROM AUTHOR]

Ureteric injuries are reported at varying incidences depending on the type of pelvic surgeries. 1 Most ureteral injuries are minor and can be treated with temporary stenting. However, a smaller percentage develops a tight stricture and one of the management options is a laparoscopic ureteral reimplant. This can be done fairly easily with an extra-vesical approach. 2, 3 An opening is made in the mobilized bladder and an end to end watertight anastomosis between the ureter and bladder is performed over a DJ stent. These patients have minimum morbidity and are usually discharged home the next day. Long term results are favorable. Laparoscopy is an excellent option for patients requiring ureteral reimplantation either for iatrogenic or congenital causes. [ABSTRACT FROM AUTHOR]

Laparoscopic adrenalectomy is an excellent procedure for most patients with small and medium sized adrenal tumor. Early control of the adrenal vein makes this an excellent choice for patients with pheochromocytoma. The retroperitonal approach is ideally suited for patients with a pheochromocytoma. In the retroperitoneal approach, the adrenal vein can be clipped before even touching the tumor thus potentially preventing blood pressure swings. As mentioned above, in certain centers, select patients with an adrenal tumor who meet certain criteria even undergo this procedure on an outpatient basis. Caution is advised when approaching patients with either Cushings or adrenal cancers as in both these situations, there is tremendous local inflammation and dissection can be difficult. For most adrenal tumors though, laparoscopy should be the first choice. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic partial nephrectomy (LPN) has emerged as an attractive nephron-sparing option for select patients with a small renal tumor. Over the last few years, several technical modifications have reduced the warm ischemia time as well as complications associated with this procedure. With increasing experience, larger and deeper tumors are now being attempted with good results. Published 3 and 5 year data indicate outcomes comparable to open surgery with all the advantages of laparoscopy. The complexity of laparoscopic partial nephrectomy lies in the fact that renal reconstruction has to be completed in a time sensitive manner under renal warm ischemia. Thus excision of the tumor, closure of the collecting system (if needed) and parenchymal hemostatic suturing has to be completed within the limits of acceptable warm ischemia which is about 30 minutes. Materials and Methods: A combined prospective and retrospective chart review was performed of all LPNs performed by the author and his fellows between January 2003 and March 2007. A total of 57 patients underwent laparoscopic partial nephrectomy for a solitary renal tumor. All tumors were solitary. There were no solitary kidneys. Mean age was 69.5 years (47-76). Of these, 38 patients (66.6%) were male. Mean tumor size was 3.2 cms (1.5-4.5). CT angiogram with 3D reconstruction was performed in every case. Patients on pre-operative blood thinners were either asked to stop the blood thinner or excluded from this procedure. Pre-operative ureteral catheter was placed in every case. The ureteral catheter was used to inject methylene blue after excision of the tumor to define possible calyceal entry. All procedures were completed under warm ischemia achieved by hilar clamping of the artery and the vein simultaneously. No ice slush was required in any case. All cases were transperitoneal. Results: All 57 cases were completed laparoscopically and there were no open conversions. Discussion: Laparoscopic partial nephrectomy has gained popularity over the last few years as a modality of managing small renal tumors. With increasing experience and skill, LPN is now being cautiously applied to bigger and deeper tumors. However as our data shows, LPN is a technically complex procedure with the potential for major complications. Hence it should only be attempted after significant laparoscopic experience. Gill et al 1 in their series have quoted a complication rate of 33% in their series of 200 patients. Russo et al 2 have quoted a complication of rate of 17% in a series of over 1000 patients. LPN is here to stay and should be the preferred treatment approach for most patients with the small renal tumor. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic radical nephrectomy (LRN) is now the standard of care for most patients with organ confined renal tumors. While LRN can be attempted by most urologists for the smaller renal tumor, the large tumors still require significant laparoscopic experience. Materials and Methods: Between January 2003 and March 2007, a total of 530 LRN were performed by the author or his fellows. All patients underwent appropriate staging and metastatic workup. Mean age was 54.7 years (39-77), 296 (55.8%) tumors were left sided, 413 patients (77.9%) were male. Mean tumor size was 6.5 cms (3-10.5). CT angiogram with 3D reconstruction was performed in every case. Results: 527 of the 530 cases (99.4) were completed laparoscopically. 3 patients required open conversion. 2 conversions were emergent to control sudden hemorrhage and one was elective due to non progress. 418 cases were transperitoneal and 112 cases were retroperitoneal. Mean operative time was 170 minutes (70-280), mean blood loss was 370 cc (50-2000), 17 patients (3.2%) required either intraoperative or postoperative blood transfusion. Mean hospital stay was 2.8 days (1-18). There were 31 (5.8%) minor complications and 8 (1.5%) major complications. Minor complications included ileus, pnueumothorax, post operative hematoma, cardiac failure, port site hernia and major complications included massive hemorrhage requiring open conversion, bowel injury at time of veres needle insertion, pneumonia. Mean follow up was 3.4 years (1-4). 2 patients had a local recurrence. Conclusions: LRN should be the standard of care for most patients with organ confined renal tumor. [ABSTRACT FROM AUTHOR]

Introduction: With the advent of CT scans, an increasing number of small (<4 cm) renal tumors are now being diagnosed. Nephron sparing surgery is now the treatment of choice for these tumors. Current management options offer open and laparoscopic partial nephrectomy, cryoablation and Radiofrequency ablation for managing these tumors. However partial nephrectomy is a challenging procedure and requires significant technical skill for consistent results. Radiofrequency is an emerging modality nut require real time CT scan monitoring which can limit its usefulness. Laparoscopic/percutaneous cryoablation has emerged as an exciting new option for treating these small renal tumors in select patients. Currently published 3 and 5 year data attest to the efficacy of this technique. Materials and Methods: Between January 2003 and March 2007, a total of 36 patients with a small renal tumor underwent laparoscopic cryoablation by the author or his fellows. Preoperative CT scan was performed in every case. Pre-operative workup was standard as for any other case. Approach was either transperitoneal or retroperitoneal depending on the location of the tumor. Posterior tumors were approached retroperitonealy. After a three port standard laparoscopic approach, the tumor was exposed with an attempt to maintain the overlying fat. All tumors were biopsied before start of cryoablation in an attempt to procure tissue for pathology. For the cryoablation we used the new Ice-Rod system (Minvasive Surgicals, Minneapolis, MN) which uses the 18 gauge cryo needles. Two freeze cycles were followed by two thaws in every case and all cases were done under ultrasound guidance. The first thaw was passive and the second thaw was active by passing Helium through the needles. Results: Laparoscopic cryoablation was successful in all 36 patients. Complications: There were 3 minor complications and no major complications with 1 recurrence. Conclusions: Laparoscopic renal cryoablation is an excellent modality for treating select small renal tumors 1. With the availability of percutaneous cryoablation, this has the potential to become an office based procedure 2. Long term results indicate that for the appropriately selected patient, this modality has excellent cancer outcomes comparable to radical nephrectomy 3. The lack of warm ischemia and the much lower probability of hemorrhage makes it a better option than laparoscopic partial nephrectomy for the select patient. The availability of finer probes also makes it easy to perform the procedure without the risk of substantial hemorrhage. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic radical prostatectomy (LRP) is emerging as an attractive treatment option for patients with organ confined prostate cancer. Initially this modality was available only at select centers; however more and more centers are now offering this modality. LRP is a technically complex operation and should ideally be attempted only after significant laparoscopic experience. Materials and Methods: A retrospective chart review was performed of 312 cases of LRP performed by the author between January 2003 and March 2007. Standard transperitoneal 5 port LRP was performed in all patients. Mean age was 66.5 years (53-71), mean Gleason score was 7 (6-9), mean weight of the patient was 184 lbs (140-288), and mean prostate size was 36 grams (20-78). Results: LRP was successful in 310 of 312 cases. 2 patients required open conversion. Mean operating time was 210 minutes (150-350), mean blood loss was 166 cc (50-1000), mean time to complete the anastomosis was 38.5 minutes (25-55), mean hospital stay was 2.2 days (1-7), mean catheter duration was 12.5 days (7-21). There were a total of 26 (8.3%) minor complications and 6 (1.9%) major complications. Minor complications included ileus (4), DVT (9), post operative hemorrhage not requiring transfusion (4), localized urine leak (6), and reinsertion of catheter after accidental slippage (3). Major complications included rectal perforation (1), major urine leak (3) and post operative hemorrhage requiring exploration (2). Positive margin rate was 14%. Conclusions: LRP is a technically challenging procedure but in experienced hands provides significant benefits to patients over open surgery. [ABSTRACT FROM AUTHOR]