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Objectives: Laparoscopy may be complicated by neuromuscular injuries, both to the patient and to the surgeon. We used a survey to estimate the incidence of these injuries during urologic laparoscopic surgery, to assess risk factors for these injuries, and to determine preventive measures., Methods: A survey of neuromuscular injuries associated with laparoscopy submitted to 18 institutions in the United States was completed by 18 attending urologists from 15 institutions., Results: From among a total of 1651 procedures, there were 46 neuromuscular injuries in 45 patients (2.7%), including abdominal wall neuralgia (14), extremity sensory deficit (12), extremity motor deficit (8), clinical rhabdomyolysis (6), shoulder contusion (4), and back spasm (2). Neuromuscular injuries were twice as common with upper retroperitoneal as with pelvic laparoscopy (3. 1% versus 1.5%). Among patients with neuromuscular injuries, those with rhabdomyolysis were heavier (means 91 versus 80 kg) and underwent longer procedures (means 379 versus 300 minutes), and those with motor deficits were older (means 51 versus 42 years of age). Of the surgeons, 28% and 17% reported frequent neck and shoulder pain, respectively., Conclusions: Although not common, neuromuscular injuries during laparoscopy do contribute to morbidity. Abdominal wall neuralgias, injuries to peripheral nerves, and joint or back injuries likely occur no more frequently than during open surgery, but risk of rhabdomyolysis may be increased. Positioning in a partial rather than full flank position may reduce the incidence of some injuries. Measures to reduce neuromuscular strain on the surgeon during laparoscopy should be considered.

Objectives: Xanthogranulomatous pyelonephritis (XGP) is an atypical form of chronic renal infection. The treatment of choice is open nephrectomy, which is challenging, given the extent of the disease and the not uncommon involvement of the renal hilum and contiguous structures. We compared our experience with laparoscopic nephrectomy for histologically confirmed XGP with the open approach., Methods: Review of all nephrectomy specimens at Washington University School of Medicine from July 1990 to March 1998 disclosed 9 patients with a pathologic diagnosis of unilateral XGP, of whom 5 patients underwent laparoscopic nephrectomy and 4 underwent open nephrectomy. XGP was suspected preoperatively in 56% of the patients., Results: For the laparoscopic group, the average operating room time was 360 minutes, average blood loss was 260 mL, and complications occurred in 60% of patients (1 conversion to open, 1 ileus, 1 pulmonary embolus). For the open group, the average operating room time was 154 minutes, average blood loss was 438 mL, and there were no complications. Both groups were similar regarding time to oral intake, analgesia requirement, hospital stay, and time to complete recovery., Conclusions: Our early experience demonstrates that the benefits of laparoscopic nephrectomy, at present, do not extend to patients with XGP. Conventional open surgery is quicker, associated with fewer complications, and results in a similar use of analgesics, hospital stay, and recovery time.

Objectives: To assess technical preferences and current practice trends of retroperitoneal and pelvic extraperitoneal laparoscopy., Methods: A questionnaire survey of 36 selected urologic laparoscopic centers worldwide was performed., Results: Twenty-four centers (67%) responded. Overall, 3988 laparoscopic procedures were reported: transperitoneal approach (n = 2945) and retroperitoneal/extraperitoneal approach (n = 1043). Retroperitoneoscopic/extraperitoneoscopic procedures included adrenalectomy (n = 74), nephrectomy (n = 299), ureteral procedures (n = 166), pelvic lymph node dissection (n = 197), bladder neck suspension (n = 210), varix ligation (n = 91), and lumbar sympathectomy (n = 6). Mean number of total laparoscopic procedures performed in 1995 per center was 41 (range 5 to 86). Major complications occurred in 49 (4.7%) patients and included visceral complications in 26 (2.5%) patients and vascular complications in 23 (2.2%). Open conversion was performed in 69 (6.6%) patients, electively in 41 and emergently in 28 (visceral injuries, n = 16; vascular injuries, n = 1 2). Retroperitoneoscopy/extraperitoneoscopy is gaining in acceptance worldwide: in 1993, the mean estimated ratio of transperitoneal laparoscopic cases versus retroperitoneoscopic/ extraperitoneoscopic cases per center was 74:26; however, in 1996 the ratio was 49:51., Conclusions: Retroperitoneoscopy and pelvic extraperitoneoscopy are important adjuncts to the laparoscopic armamentarium in urologic surgery. The overall major complication rate associated with retroperitoneoscopy/extraperitoneoscopy was 4.7%.

Objectives: Significant obesity is considered to be a relative contraindication to laparoscopic surgery. This study reviews the complications encountered in massively obese patients undergoing urologic laparoscopic surgery., Methods: Body mass index (BMI) was used as an objective index to indicate massive obesity. Eleven institutions compiled retrospective data on 125 patients having a BMI greater than 30. Procedures performed included 76 pelvic lymph node dissections, 14 nephrectomies, 7 bladder neck suspensions, and 28 miscellaneous procedures., Results: For the group as a whole, the mean BMI was 35.1 (range 30.1 to 57.2). Mean operative time was 202 minutes (range 60 to 480). Conversion to open surgery occurred in 15 of the 125 patients (12%). Complication rates (minor and major) were 22% (27 occurrences in 125 patients) intraoperatively and 26% (33 occurrences in 125 patients) postoperatively. The major complications included 2 trocar injuries to abdominal wall vessels, 1 bladder injury, 3 peripheral nerve injuries, 1 dysrhythmia, 1 deep vein thrombosis, 1 wound seroma, 1 nephrocutaneous fistula, 1 incisional hernia, and 1 death., Conclusions: In this review, complication rates for urologic laparoscopic surgery on massively obese patients were higher than in the general population undergoing laparoscopic surgery (0.3% to 21%).

Objectives: To identify whether laparoscopic pyeloplasty is a reasonable treatment option for secondary ureteropelvic junction (UPJ) obstruction., Methods: Since March 1994, we have performed laparoscopic pyeloplasties for secondary UPJ obstruction on 4 symptomatic patients ranging in age from 26 to 39 years. Prior failed procedures included antegrade endopyelotomies (3) and acucise endopyelotomies (3). Two patients underwent two prior endopyelotomies. Techniques of laparoscopic reconstruction included Anderson-Hines dismembered (3) and Culp-Deweerd flap (1) procedures. Repairs were performed with interrupted and running 3.0 and 4.0 Vicryl sutures using intra-corporeal knots and Lapra-Ty absorbable suture clips., Results: Average operating time was 530 minutes (range, 465 to 645), which included preoperative cystoscopic placement of an external 7 F occlusion balloon catheter into the renal pelvis and placement of an internal double pigtail ureteral stent at the conclusion of the procedure. Average blood loss was 111 cc (range, 75 to 150). All 4 patients were found to have anterior crossing vessels intraoperatively. Average postoperative hospital stay was 4 days (range, 3 to 7). All 4 patients have a patent, nonobstructed UPJ by either Whitaker test or diuretic renography at an average of 3.3 months postoperatively (range, 1 to 5). Average return to normal activity was 4.5 weeks (range, 3 to 8). Utilizing an analogue pain scale, 2 of the patients are pain-free, and the other 2 are improved (45% and 85%) at an average of 8 months (range, 2 to 12) postoperatively. One patient developed stones in the renal pelvis and required percutaneous nephrolithotomy 10 weeks postoperatively., Conclusions: Laparoscopic pyeloplasty appears to be feasible and effective, although a technically challenging operative procedure for treating secondary (postendopyelotomy) UPJ obstruction. Further clinical experience and long-term follow-up are needed.