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The development of semirigid and flexible ureteroscopes has permitted easier access to calculi throughout the urinary tract. We compared the use of semirigid and flexible ureteroscopy for the management of shockwave lithotripsy-refractory, isolated renal pelvic calculi by evaluating stone-free rates, operating room times, and associated complications.Ureteroscopic stone treatment was attempted in 47 patients with isolated renal pelvic stones between November 2008 and December 2010. The procedures were performed under general anesthesia. Semirigid ureteroscopy was routinely performed in all patients. If the stones were accessible in the renal pelvis with the semirigid ureteroscope (S-URS), they were then treated with the holmium:yttrium-aluminum-garnet (Ho:YAG) laser through S-URS under direct vision. If the stones were not accessible, flexible ureteroscopy was then performed. Preoperative, operative, and postoperative data were retrospectively analyzed.In 25 of 47 patients, renal pelvic stones were accessible with S-URS, and the stones were fragmented with the Ho:YAG laser using S-URS. In the remaining 22 patients, the stones were accessed with the flexible ureteroscope (F-URS), and the fragmentation of stones was performed with the Ho:YAG laser using the F-URS. There were no significant differences in age, body mass index, grade of hydronephrosis, mean stone size, and stone laterality among the two groups. The mean operative times were 71.90 ± 17.90 minutes in the S-URS group and 93.41 ± 18.56 minutes in the F-URS group (P=0.001). The stone-free rates at postoperative day 1 and at the 1 month follow-up were 72% and 76% in the S-URS group and 81.8% and 86.4% in the F-URS group, respectively (P=0.861 and P=0.368). We found no significant differences among groups with regard to stone-free rates, complication rates, and hospital lengths of stay.Although it is well known that flexible ureteroscopy permits a detailed caliceal examination and therapeutic interventions, semirigid ureteroscopy is also often another sufficient means of reaching the renal pelvis in selected patients.

Retroperitoneal and transabdominal laparoscopic access to retroperitoneal organs became the golden standard for treatment of most adrenal and renal diseases. Natural orifice surgery is a promising concept in the evolution of minimal access surgery. The possibility of a natural orifice transluminal endoscopic surgery (NOTES) transvaginal retroperitoneal access to diagnose and perform retroperitoneal surgery was developed in our institution, aiming an alternative natural orifice less-invasive approach.Institutional review board approval was obtained from the institution for clinical transvaginal NOTES. A 67-year-old woman (body mass index = 35.6 kg/m(2)) found to have a large renal cyst situated in the lower pole with compression symptoms was subjected to the technique. Transvaginal retroperitoneal access was obtained by direct vision open technique, the space was digitally dissected, and a flexible two-channel colonoscope progressed the dissection to the left kidney. The cyst was dissected using endoscopic instruments, and resection was completed with use of two laparoscopic instruments because of peritoneal tear with loss of retropneumoperitoneum.NOTES transvaginal retroperitoneoscopy was performed, and anatomical landmarks, such as left ureter, inferior mesenteric artery (IMA), vena cava, and aorta, were identified. Insufflation and orientation were hazardous, because of constitutional fat, and operative time was 210 minutes. Postoperative course was complicated by postoperative face and neck enphysema, which disappeared after few days. Observation was maintained for 4 postoperative days, and the patient was discharged without other complications. Follow-up at 30 days was uneventful.This first human procedure using flexible transvaginal retroperitoneoscopy showed feasibility of the access, but inadequate instruments led to technical difficulties for therapeutical purposes. However, the new concept of minimally invasive NOTES retroperitoneoscopy may open new therapeutic indications in clinical practice in the near future.

Laparoscopy has been recognized as the modality of choice for the treatment of many diseases in urology, gynecology, and general surgery. Although laparoscopy is minimally invasive, the most frequent complications are associated with entry through the abdominal wall. The Hasson (open) technique was developed to minimize the complications by entering the abdomen under direct vision. We have modified the Hasson technique with a stitch that is easy to perform, creates a tight fascial seal, allows easy exchange of trocars, and produces an effect that is cosmetically appealing.

We demonstrate a safe and reproducible technique for laparoscopic port-site closure. First, we use hemostatic tonsil forceps to deliver a 0-polyglactin suture into the abdomen via a puncture through the rectus fascia parallel to the fascia defect under visual guidance. Second, we perform a similar puncture with the tonsil forceps on the opposite side of the fascia defect under direct vision to grasp the suture. This cost-effective maneuver is safe and eliminates the need for ancillary port-site closure devices.

Urethral strictures are often initially managed with dilation using sequential metal sounds or filiform and follower dilators. While these techniques often successfully achieve at least a temporary increase to the caliber of the area of stricture, they are performed without visual guidance, and complications can include false passage and urethral perforation. We describe the first use of balloon dilator that allows the safe, controlled, and gentle and dilation of urethral strictures under direct vision.

Introduction: Robot-assisted pyeloplasty (RAP) is a minimally invasive approach for repair of ureteropelvic junction obstruction. Ureteral stent placement is a necessary step that may necessitate additional procedures and/or radiation exposure for placement and confirmation of stent location. These may prolong operative times and increase morbidity. Patients and Methods: Unique patient positioning and draping allow access to the urethra for intraoperative cystoscopy. As the surgeon performs the posterior portion of the Anastomosis, the assistant performs simultaneous flexible cystoscopy and retrograde stent placement. Stent location is confirmed by direct vision. Results: This technique has been performed in 30 consecutive patients without difficulty or complication. Conclusion: This novel technique is a simple and efficient method of stent placement during RAP. It is performed simultaneously without the need for additional procedures, repositioning, or radiation exposure. Application of this tec...

The Applied Urology cautery-wire/balloon catheter was used under fluoroscopy (three cases) or direct vision (two cases) to incise ureteral strictures (1.0–2.0 cm) created in pigs. Stents were used postoperatively. In three animals, hydronephrosis was relieved and the results of pressure–flow studies were normal 3 to 4 months postprocedure. The other animals have Grade I hydronephrosis in solitary kidneys 1 to 2 months after treatment, but serum creatinine concentrations are normal. The device has also been used in one patient, with short-term success. The cautery-wire/balloon catheter would seem to offer great potential for managing strictures without ureteroscopy.

When small ports are the only entry (and exit) points during laparoscopic nephrectomy, one is forced either to make an accommodating incision for final renal delivery or to perform renal morcellation. To date, morcellation has been performed in a blind manner with a specimen entrapped in a nonpenetrable, nonpermeable sac within the peritoneal cavity. Through the use of current laparoscopic equipment and a novel rotary shaver-blade system, we studied the safety, feasibility, and efficiency of directly observed renal morcellation.Ten porcine renal units with a mean mass of 143 g (range 92-192 g) were morcellated via a custom 5.5-mmx28-cm Dyonics (SmithNephew, Andover, MA) rotary shaver blade placed through a standard operative laparoscope (ACMI LAP 11-56W). Each kidney was entrapped in a standard 8x10-inch LapSac (Cook Urological, Spencer, Indiana), which was placed in a preconfigured abdomen model. Morcellation was performed under direct visual guidance with continuous-flow irrigation and suction. We then studied the feasibility, safety, technical ease, and efficiency of morcellation; the size of the fragments; and entrapment-bag integrity with each renal morcellation.The mean time required to complete morcellation was 8:02 minutes (range 4:45-14:00 minutes). The morcellation efficiency mean was 20.7 g/min (range 12.00-31.41 g/min), with the Dyonics EP-1 generator system morcellating most effectively at 2000 rpm in its oscillate mode. Of ten random fragments, the mean size was 8.7x4.7 mm. The integrity of one LapSac was lost when the bag was not filled to complete distention, creating susceptible in folding.This novel technique of laparoscopic renal delivery provides a feasible, safe, technically simple, and efficient means of morcellation. Directly viewed renal morcellation must occur with a kidney freely floating within a completely distended entrapment sac in order to preserve the integrity of the sac itself. Tissue fragments are large enough for pathologic review, which may permit superior oncologic surgical margins.

We review our experience with ureteroscopic endopyelotomy using a holmium laser for correction of ureteropelvic junction (UPJ) obstruction in order to further define the immediate and long-term results and complications.From 1999 to 2002, 11 men and 34 women (mean age 42 years) underwent 46 ureteroscopic holmium laser endopyelotomy procedures for treatment of primary (N=40) or secondary (N=5) UPJ obstruction. The inclusion criteria were a short (2-cm) obstruction and absence of ipsilateral renal calculi. Demographic, intraoperative, and postoperative measures were obtained from a prospectively designed and updated database. The endopyelotomy was performed under direct vision using a semirigid (N=40) or flexible (N=5) ureteroscope with a laser setting of 1 J at 10 Hz. Radiographic confirmation of obstruction and the results of intervention was obtained by combinations of intravenous and diuretic urography, diuretic renography, ultrasonography, and CT. The first postoperative and latest radiographic follow-up studies were compared with the preoperative studies to determine whether the obstruction was resolved, unchanged, or worsened. Success was defined as symptomatic relief and radiographic resolution.The mean operative time was 65 minutes (range 10-153 minutes). There were no intraoperative complications, although 5 patients (11.1%) experienced postoperative complications consisting of subcapsular hematoma, pyelonephritis, sepsis, urinary retention, or dysrhythmia. Forty-two patients (93%) had a hospital stay of23 hours. Stents were removed 3 to 8 weeks (mean 5 weeks) postoperatively. The mean length of follow-up was 23.2 months (range 5-43 months). Symptoms were resolved in 65.4% of patients, improved in 7.7%, unchanged in 11.5%, and worse in 15.4%. Radiographically, at latest follow-up, the obstruction was resolved in 73.1% of patients, unchanged in 23.1%, and worse in 3.8%. Primary UPJ obstruction was associated with a symptomatic success rate of 68% compared with only 50% for secondary UPJ obstruction.Ureteroscopic laser endopyelotomy is a minimally invasive, short-stay outpatient procedure associated with a 65.4% symptomatic and 73.1% radiographic success rate. In contrast to the findings in previous reports of results of retrograde or antegrade endopyelotomy, patients treated for primary UPJ obstruction experienced higher rates of success than those with secondary obstruction.

Injury to the epigastric vessels during trocar placement is a recognized complication of laparoscopic surgery. We present a technique for laparoscopic management of this problem utilizing a Stamey urethropexy needle under direct vision. The relevant anatomy and methods to prevent this complication are discussed.

Minilaparotomy with placement of a trocar under direct vision has been felt to be a safe approach for establishing access to the intra-abdominal contents during laparoscopy. However, there is potential for hollow viscus injury. We report a case of a 23-year-old man whose small bowel was injured during placement of a Hasson trocar at the time of laparoscopic varix ligation. The literature on laparoscopic complications is reviewed, and recommendations for avoiding difficulties are outlined.

Two children developed omental evisceration through small periumbilical port sites after peritoneal endoscopy for nonpalpable testes. Factors that predispose to this complication include decompression of the pneumoperitoneum by suction. These factors and steps to avoid it such as closure of all endoscopic fascial defects under direct vision are described.

Use of the ureteroscope to remove ureteral calculi under direct vision has improved the safety and efficacy of transurethral calculus management. As an adjunct to basketing with ureteroscopy, prior placement of a ureteral catheter for several days enables one to avoid the complications associated with rapid ureteral dilatation and immediate calculus extraction. It is also advantageous to leave an indwelling ureteral catheter to lessen postmanipulation colic and to facilitate ureteral healing following more traumatic extractions. In 25 consecutive patients, the original ureteral catheter used for soft dilatation was replaced for postmanipulation stenting immediately after calculus extraction. The only failure in the series was the result of an anesthetic reaction prior to ureteroscopy, and the stone passed spontaneously from the dilated ureter.

A modification of the Lawson retrograde nephrostomy technique using the flexible ureteroscope allows a precise puncture of the chosen calix under direct vision. This technique facilitates an assessment of the renal pelvis and infundibula and potentially assures creation of the optimal nephrostomy tract for a given procedure. Our initial experience with three patients is reported.