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Objectives: To evaluate the changes in prognostic impression and patient management following PET/CT in patients with vulvar and vaginal carcinoma; and to compare PET/CT findings with those of conventional imaging modalities., Methods: We summarized prospectively and retrospectively collected data for 50 consecutive patients from our institution that enrolled in the National Oncologic PET Registry and underwent FDG-PET/CT for a suspected or known primary or recurrent vulvar/vaginal cancer., Results: 54/83 (65%) studies included had a diagnosis of vulvar cancer, and the remaining 29/83 (35%), a diagnosis of vaginal cancer. Following FDG-PET/CT, the physician's prognostic impression changed in 51% of cases. A change in patient management, defined as a change to/from a non-interventional strategy (observation or additional imaging), to/from an interventional strategy (biopsy or treatment), was documented in 36% of studies. The electronic records demonstrated that 95% of the management strategies recorded in the physician questionnaires were implemented as planned. MRI and/or CT were performed within one month of the FDG-PET/CT in 20/83 (24%) and 28/83 (34%) cases, respectively. FDG-PET/CT detected nodes suspicious for metastases on 29/83 (35%) studies performed. MRI and CT detected positive nodes on 6 and 11 studies respectively. Distant metastases were identified in 10 cases imaged with FDG-PET and 5 cases that had additional conventional CT imaging. All suspicious lesions seen on CT were positively identified on PET/CT. In 4 cases, an abnormality identified on PET/CT, was not seen on diagnostic CT., Conclusions: FDG-PET/CT may play an important role in the management of vulvar and vaginal carcinoma., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: Current medical therapy for congenital adrenal hyperplasia (CAH) attributable to a complete 21-hydroxylase deficiency is not optimal. Difficulties in adequate adrenal androgen suppression are common, causing short adult stature, infertility, and hyperandrogenism. We report the use of laparoscopic bilateral adrenalectomy as a definitive therapy for this condition and argue that it is superior to conventional medical therapy in selected patients., Methods: Participants were 2 adult females with classic, salt-wasting CAH and a history of poor adrenal control were selected for adrenalectomy: case 1 was a 22-year-old woman with mild hirsutism and primary amenorrhea; case 2 was a 28-year-old woman with severe hirsutism, acne, and amenorrhea. Preoperative and postoperative hormonal profiles were performed. Both underwent laparoscopic bilateral adrenalectomy with a mean follow-up of 37 months., Results: Bilateral laparoscopic adrenalectomy was performed in both patients with no complications and an uneventful recovery. Maintenance medications of glucocorticoid and mineralocorticoid replacement were reduced compared with preoperative doses. Three years postoperatively, however, rising adrenal steroid precursor levels in case 1, presumably caused by adrenal rests, prompted an increase in replacement therapy dose. Hirsutism and acne improved in both patients, and regular menstruation began 5 months (case 1) and 2 months (case 2) postoperatively. Pregnancy 3 years postoperatively was successful in case 2, who delivered a unaffected infant, full-term via Cesarian section., Conclusions: Surgical adrenalectomy should be considered in females with classic CAH attributable to 21-hydroxylase deficiency and a history of poor hormonal control. Adrenalectomy may prove to be superior to current medical therapy for these patients.

Purpose: Hand assisted laparoscopy combines aspects of open and laparoscopic surgery. A hand in the abdomen may facilitate laparoscopic live donor nephrectomy, allowing more urologists to participate. We report and compare our initial series of hand assisted laparoscopy donor nephrectomy with nephrectomy performed by standard open methods., Materials and Methods: In the last 18 months 60 patients at 2 institutions underwent hand assisted laparoscopy donor nephrectomy. This cohort was compared to a contemporary group of 31 patients who underwent open donor nephrectomy via a flank incision at our 2 institutions. Demographic and outcome data were compared retrospectively in a nonrandomized fashion in the 2 groups., Results: Demographic data on patient age, male-to-female ratio and body mass index were similar in the 2 groups. Operative time, transfusion rate, time to oral intake and complications were also similar. However, estimated blood loss, change in hematocrit preoperatively to postoperatively, hospitalization, parenteral and oral narcotic requirement, and donor convalescence were significantly less in the hand assisted laparoscopy versus open groups. In terms of allograft function, nadir creatinine, time to nadir creatinine, creatinine clearance at 6, 12, and 18 months, delayed graft function, episodes of acute rejection and ureteral stricture were similar in the groups., Conclusions: Hand assisted laparoscopy is safe, efficacious and reproducible for living related donor nephrectomy. Compared with the open technique hand assisted laparoscopy provides the donor with significantly decreased postoperative morbidity, while enabling excellent allograft function. Further randomized prospective studies are warranted.

Background and Purpose: For patients with upper tract transitional-cell carcinoma (TCC), nephroureterectomy with removal of a bladder cuff is the standard of care. Historically, it has been performed using two incisions or one large incision extending from the lateral flank to the symphysis pubis. We describe an alternative using endoscopic management of the bladder cuff combined with hand-assisted laparoscopic (HAL) nephroureterectomy. We compared our results using these minimally invasive advances with those of a contemporary open nephroureterectomy series., Patients and Methods: Between May 1998 and June 1999, we performed 11 HAL nephroureterectomies with endoscopic management of the bladder cuff for the treatment of upper tract TCC. The results were compared with those in a contemporary series of 11 patients undergoing the traditional open operation at our institution. The patient age, male:female ratio, and ASA classification were similar in the two groups. Intraoperative measures considered were operative time, estimated blood loss, need for transfusion, complications, specimen weight and volume, pathologic stage and grade of the tumor, and the status of the surgical margins. Postoperative endpoints were time to sustained fluid intake; epidural, parenteral, and oral narcotic requirements; length of stay; and complications. Follow-up, specifically disease recurrence and overall survival, was recorded., Results: The mean operative time was 291 minutes for HAL v 232 minutes for the open operation (P = NS). The average blood loss was 144 v 311 mL (P = 0.04), the mean specimen weight 368 v 392 g (P = NS), and the mean specimen volume was 630 v 693 cc (P = NS). No patient in the HAL group had a positive surgical margin, but one patient in the open surgery group did. The time to sustained fluid intake postoperatively averaged 1.4 v 2.3 days for the HAL and open groups, respectively (P = NS). The epidural narcotic requirement was 0 v 2.7 days (P < 0.001), the mean parenteral narcotic requirement was 45 v 44 mg of morphine sulfate equivalent (P = NS), and the oral narcotic requirement was 5.8 v 16 tablets (P < 0.04). The average length of stay was 4.6 days for the HAL group v 6.1 days for the open group (P = 0.04). In both groups, 7 of the 11 patients (63%) were without evidence of disease with a mean follow-up of 13 (HAL) and 17 (open) months., Conclusions: Hand-assisted laparoscopic nephroureterectomy with endoscopic management of the bladder cuff is an efficacious alternative to open surgery. The operative time, specimen weight and size, and risk of recurrence for the two procedures are similar. However, convalescence, as measured by pain medication requirements and length of stay, is significantly better with laparoscopy. Longer follow-up with larger numbers of patients is in progress.

Hand-assisted laparoscopy (HAL) allows surgeons direct hand contact with the operative field, maximizing tactile feedback and minimizing surgical injury to the patient. Indications for HAL include radical, donor, and partial nephrectomies, nephroureterectomy, and, most recently, dismembered pyeloplasties. The advantages of HAL surgical techniques in comparative experience with standard laparoscopic technique are described.

Background and Purpose: The indications for partial nephrectomy are expanding as newer and more complete data come forth. A partial nephrectomy has traditionally required a generous flank incision. We report our experience using hand-assisted laparoscopy (HAL) as a less-invasive approach to partial nephrectomies., Patients and Methods: Between October 1999 and May 2000, we performed 11 HAL partial nephrectomies. The average age of the patients was 55.7 years, the average body mass index was 25.6, and the average ASA class was 2.2. The indications for partial nephrectomy were enhancing solid renal lesions (N = 9) and nonfunctioning renal moiety in a duplicated system (N = 2). In the majority of cases, access to the renal pedicle was obtained prior to the partial nephrectomy. However, in no case did the renal artery or vein require occlusion. Several excisional techniques were employed, but all relied heavily on the Harmonic Scalpel in conjunction with the argon beam coagulator. Different hemostatic agents were applied to the renal defect, including Surgicel, Avitene, and fibrin-soaked Gelfoam activated by thrombin. In several instances, pledget reinforced sutures were placed in the renal capsule to aid with hemostasis., Results: The average operative time was 273 minutes, the estimated blood loss 319 mL, and the change in hematocrit 7.3 points. No patient required a transfusion, and there was one conversion to open. Postoperatively patients, required an average of 35.6 mg of morphine sulfate equivalent and 8.2 narcotic tablets, resumed oral intake in 1.7 days, and were discharged home in 3.3 days. There were no major complications and only two minor complications. Postoperatively, five lesions were found to be benign, four lesions were confirmed to be malignant, and two lesions were consistent with a nonfunctioning duplicated renal moiety. Specimen size averaged 180 cc, and the tumor diameter averaged 1.9 cm. There were no positive surgical margins., Conclusions: Hand-assisted laparoscopic partial nephrectomy is feasible and reproducible. The surgeon's hand in the operative field facilitates dissection, vascular control, hemostasis, and suturing. Further long-term and prospective studies are underway.

Chronic inflammation or prior surgical procedures may complicate the laparoscopic performance of simple nephrectomy. In these difficult cases, hand-assisted laparoscopy may be useful. The position of the hand port depends on the particular situation, but the port must allow flexion of the wrist and access to the entire surgical field. The hand-assisted procedure is similar to standard laparoscopy in analgesic use, time to oral intake, length of stay, and time to full recovery. Hand-assisted laparoscopy allows the inexperienced surgeon to perform laparoscopy with the aid of tactile sensation and three-dimensional spatial orientation. For the experienced surgeon, the technique offers an alternative to open conversion when the laparoscopic procedure fails to progress.

Objectives: Nephroureterectomy with removal of the bladder cuff is the standard of care for patients with upper tract transitional cell carcinoma. Historically, it has been performed using two separate incisions or one large incision extending from the lateral flank to the symphysis pubis. We describe an alternative technique using endoscopic and hand-assisted laparoscopic techniques and present our experience., Methods: During the past 18 months, 22 patients at two institutions underwent hand-assisted laparoscopic nephroureterectomy. In 19 patients, the distal ureter and bladder cuff were managed endoscopically. In 3 patients, the distal ureter and the bladder cuff were removed by an extravesical, laparoscopic technique. The intraoperative parameters assessed included operative time, estimated blood loss, specimen weight, surgical margin status, pathologic grade and stage, and acute complications. Postoperative endpoints included the time to sustained fluid intake, parenteral narcotic requirement (milliequivalents of morphine sulfate), oral narcotic requirement (number of tablets), length of stay, time until return to normal activity, and rate of tumor recurrence., Results: The average age of our patient population was 65 years (range 42 to 86), 10 patients were men and 12 were women, and the average American Society of Anesthesiologists classification was 2.2. All but 2 patients had their specimens removed en bloc. No intraoperative complications occurred. The average operative time was 272 minutes (range 190 to 440), and the average blood loss was 180 mL (range 50 to 400); no patient required a transfusion. The mean specimen weight was 457 g (range 190 to 1420). All 22 patients had negative surgical margins. Postoperatively, the time to sustained fluid intake averaged 2.1 days (range 1 to 7), the mean parenteral narcotic requirement was 55 mEq (range 12 to 107.8) of morphine sulfate, the mean oral narcotic requirement was 5.8 tablets (range 1 to 14), and the average length of stay was 4.1 days (range 3 to 14). One patient developed thrombophlebitis of the right external jugular vein from a central line and required 2 weeks of intravenous antibiotics. The mean time to return to normal activity was 19 days; the mean follow-up was 13 months. Six patients had disease recurrence: four low-grade, low-stage bladder tumors and two metastatic tumors. All patients were alive at 18 months., Conclusions: Hand-assisted laparoscopic nephroureterectomy with endoscopic management of the bladder cuff is a viable and efficacious alternative to open nephroureterectomy. The technique allows the surgeon to perform an en bloc resection of the kidney, ureter, and bladder cuff without compromising oncologic principles. Patients benefit from a decrease in pain and hospital stay and quicker convalescence. Longer follow-up and comparative studies to standard open techniques are underway.

Hand-assisted laparoscopic surgery has been used to perform nephrectomies. This report contrasts the efficacy, postoperative morbidity, length of stay, analgesic use, and time to recovery for hand-assisted laparoscopic nephrectomy, to standard laparoscopic and open nephrectomy. The technique for hand-assisted laparoscopic nephrectomy used at two institutions is described. The results from these two institutions are contrasted to results in the literature for standard laparoscopic and open nephrectomy. Standard and hand-assisted laparoscopic nephrectomy seem similar in terms of efficacy of surgery, time of surgery, estimated blood loss, length of stay, and time to full recovery. The two laparoscopic techniques seem to show advantage over open surgery in respect to shorter hospital stay, faster full recovery, and less analgesic use. The operative time for the laparoscopic surgeries is longer than the open surgery operating time. Hand-assisted laparoscopic surgery seems to be equivalent to standard laparoscopy. As urologists around the world are trained in hand-assisted laparoscopic nephrectomy, a more refined look at these early results will be possible., (Copyright 2000 by W.B. Saunders Company)

Compliance with HCFA's Evaluation and Management (E/M) documentation guidelines presents a tremendous challenge to physicians and their staffs due to the complexity of the guidelines. All too frequently, physicians and staff undercode the services actually provided to prevent additional scrutiny and fraud and abuse charges. This results in significant lost revenue for the practice. This article provides guidance on how to ensure accurate reimbursement while complying with E/M guidelines. Special direction is provided on when and how to bill for a consultation.

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.

Purpose: We assessed the diagnostic accuracy of a ureteroscopic multi-biopsy approach to upper tract urothelial carcinoma compared with subsequently resected surgical specimens., Materials and Methods: From 1990 to 1998, 45 upper tract lesions were ureteroscopically evaluated and biopsied with 3Fr cup forceps and/or an 11.5Fr resectoscope before nephroureterectomy or ureterectomy. A definitive diagnosis of urothelial carcinoma was made by biopsy in 40 lesions (89%). Each tumor was histopathologically graded but only staged if the lamina propria were uninvolved (Ta), and if the lamina propria were invaded by tumor (T1+)., Results: Of the 40 urothelial tumors 16 (40%) were in the renal pelvis, and 8 (20%) in the proximal and 16 (40%) in the distal ureter. Of the lesions 95% were papillary and 65% were grade 2. Ureteroscopic biopsy grade matched surgical pathological grade in 31 of the 40 cases (78%), and was less than surgical pathological grade in the remainder. Lamina propria was detected in 27 of the 40 biopsies, including 21 of the 34 cup (62%) and all 6 resection loop (100%) biopsies. Ureteroscopic biopsy staging in 27 cases revealed Ta and T1+ disease in 22 and 5, respectively. In the 5 cases in which ureteroscopic biopsy stage was T1+ surgical pathological stage was also pT1+ (range pT1 to pT3). Tumors were pathologically up staged to pT1+ (range pT1 to pT3) in 10 of the 22 cases (45%) in which ureteroscopic biopsy stage was Ta. Tumor location did not affect diagnostic accuracy., Conclusions: This multi-biopsy ureteroscopic approach provided the tissue diagnosis of urothelial carcinoma in 89% of cases and predicted exact histopathological grade in 78%. Although it is not accurate as a staging modality, multi-biopsy ureteroscopy may assess lamina propria invasion in two-thirds of cases.

The aim of this study was to compare live donor nephrectomy by hand-assisted laparoscopy to standard laparoscopy in a canine model. Fourteen dogs underwent a left laparoscopic nephrectomy; a standard laparoscopic nephrectomy technique was utilized in seven dogs. In a second group of seven dogs, a hand-assisted laparoscopic technique was used with a Dexterity Pneumo Sleeve hand port. All nephrectomies were performed as "donor" nephrectomies, dividing the vessels last. Total blood loss, operative warm ischemia, time and organ retrieval times were assessed for each group. The average operative time was significantly shorter for hand-assisted laparoscopic donor nephrectomy (32 +/- 8 minutes vs. 61 +/- 8 minutes; p = .02) than for the standard technique. The average warm ischemia (86 +/- 24 seconds vs. 224 +/- 52 seconds; p = .03) and average organ delivery times (4 +/- 3 seconds vs. 45 +/- 9 seconds; p < .01) also were shorter using the hand-assisted laparoscopic technique. No significant differences in average blood loss were found between the two groups (9 +/- 2 cc vs. 6 +/- 1 cc; p = 0.16, NS). Good parenchymal, ureteral, and vascular preservation was achieved by both techniques. Hand-assisted laparoscopy permits shorter operating times and warm ischemia times than standard laparoscopy in a canine model of donor nephrectomy. Hand assistance makes donor laparoscopic nephrectomy technically easier and significantly quicker to perform. If hand-assisted laparoscopy donor nephrectomy is confirmed to be a rapid and safe technique for removing an intact organ, laparoscopic nephrectomy will be a more widely accepted technique among urologists who participate in living related donor kidney transplantation.

Background and Objectives: Adrenalectomy is indicated for patients with large adrenal lesions or functional tumors. Cryoablation is currently used as a surgical alternative for the treatment of prostate, lung, brain, pharynx, and liver tumors. The purpose of this study was to determine if cryosurgery could be delivered to small areas in the adrenal gland in a controllable and reproducible manner, so that tissue could heal in a nonpathological way., Materials and Methods: Fourteen female mongrel dogs underwent acute (N = 8) or chronic (4 weeks) (N = 6) cryoablation using the Cryounit. In the acute study, using an open transabdominal approach, a 2-mm cryoprobe was placed interstitially into the adrenal tissue, while 0.032-inch thermocouples were cannulated into the ipsilateral adrenal artery and vein. Adrenal parenchymal temperature changes were measured using thermocouples placed at 0.4- and 0.8-cm intervals from the cryoprobe. In the chronic study, cryoablation was achieved by transperitoneal laparoscopic access using standard laparoscopic technique., Results: Interstitial cryoprobe temperatures decreased from 33.1 +/- 1.9 degrees C to -148 +/- 1.2 degrees C following 15 minutes of freezing in the acute study. Cryoablation of adrenal tissue achieved temperatures of -41.8 +/- 5.7 degrees C and -21.8 +/- 1 degrees C at distances of 0.4 and 0.8 cm from the cryoprobe, respectively. There were no significant changes in adrenal artery or vein temperatures during cryoablation. Histologically, there was a clear demarcation between viable and nonviable tissue, the latter being characterized by areas of multifocal hemorrhage and pyknosis. After 4 weeks of healing, there was a well-defined line between necrotic and viable tissue., Conclusion: Cryoablation of the adrenal gland can be obtained in an effective, controllable, and reproducible manner. This controllable energy form may provide new modality for tissue destruction where adrenal gland preservation is necessary and can be delivered by the laparoscopic approach. Understanding the effect of adrenal cryoablation may allow us to treat selected patients with small tumors in whom organ preservation is necessary.

Adrenalectomy is indicated for patients with large adrenal lesions or functional tumors. Cryoablation is currently used as a surgical alternative for the treatment of prostate, lung, brain, pharynx, and liver tumors. The purpose of this study was to determine if cryosurgery could be delivered to small areas in the adrenal gland in a controllable and reproducible manner such that tissue could heal in a nonpathologic way. A total of 14 female mongrel dogs underwent acute (n = 8) or chronic (4 weeks, n = 6) cryoablation using the Cryounit. In the acute study using an open transabdominal approach a 2-mm cryoprobe was placed interstitially into the adrenal tissue, whereas 0.032-inch thermocouples were cannulated into the ipsilateral adrenal artery and vein. Adrenal parenchymal temperature changes were measured using 0.032-inch thermocouples placed at 0.4- and 0.8-cm intervals from the cryoprobe. In the chronic study, cryoablation was achieved by transperitoneal laparoscopic access using a standard laparoscopic technique. Interstitial cryoprobe temperatures decreased from 33.1 +/- 1.9 degrees C to -148 +/- 1.2 degrees C following 15 min of freezing in the acute study. Cryoablation of adrenal tissue achieved temperatures of -41.8 +/- 5.7 degrees C and -21.8 +/- 1 degrees C at distances of 0.4 and 0.8 cm from the cryoprobe, respectively. There was no significant change in adrenazl artery or vein temperatures during cryoablation. Histologically there is a clear demarcation between viable and nonviable tissue characterized by areas of multifocal hemorrhage and pyknosis. After 4 weeks of healing a well-defined line of necrotic and viable tissue is visible. Cryoablation of the adrenal can be delivered in an effective, controllable, and reproducible manner. This controllable energy form may provide a new treatment modality for tissue destruction where adrenal gland preservation is necessary and can be performed by the laparoscopic approach. Understanding the effect of adrenal cryoablation may allow us to treat selected patients with small tumors where organ preservation is necessary.

Several laparoscopic approaches to the adrenal gland have been described. The lateral transperitoneal approach has several distinct advantages when contrasted with other techniques for laparoscopic adrenalectomy (LA). We present our technique and results obtained in 50 consecutive transperitoneal LAs. We review 50 consecutive laparoscopic adrenalectomies (28 female, 19 male) performed from 1993 to 1998 S.J. Shichman or R.E. Sosa was either the primary surgeon or the first assistant for all cases. The lateral transperitoneal approach described below was used in all cases. Indications for adrenalectomy included Cushing's syndrome (13), aldosteronoma (15), pheochromocytoma (7), nonfunctioning adenoma (11), hyperplasia (2), and 1 case each of Carney's syndrome and metastasis to the adrenal gland. We performed 5 bilateral, 22 left, and 18 right laparoscopic adrenalectomies. The average time needed for bilateral adrenalectomy was 503 min (range 298-690 min); for left adrenalectomy, 227 min (range 121-337 min); and for right LA, 210 min (range 135-355 min). We demonstrated a yearly trend in lower operative times. The largest adrenal gland removed measured 13.8 x 6.7 x 3.5 cm. Intraoperative blood loss was low. Only one patient received a blood transfusion. Conversion to open adrenalectomy was not required. Postoperative analgesic requirements were low. The average length of stay was 3.8 days for bilateral LA and 3 days for unilateral LA. Complications occurred in 5 patients (2 wound infections, 2 hematomas, and 1 pleural effusion). There was no mortality. Lateral transperitoneal adrenalectomy is a safe and efficient technique for the removal of functional and nonfunctional adrenal masses. This technique is associated with low morbidity, a minimal postoperative analgesic requirement, and a short hospital stay and, in our opinion, is more versatile than the retroperitoneal approach.

We have seen an explosion in technical innovations for the management of urolithiasis. Today, the endourologist possesses an assortment of minimally invasive tools to treat renal stones. Most patients receive fast, safe and effective treatment in the outpatient setting. Despite the many technical advances, however, anatomical malformations and complex stones still provide significant challenges in diagnosis, access to a targeted stone, fragmentation, and clearance of the resulting fragments. This review examines a variety of urinary stone presentations and treatment strategies for cost-effective management.

Abdominal insufflation during laparoscopy has been associated with transient oliguria, which abates after desufflation. Direct renal compression evoking a Page kidney effect was proposed as a mechanism. In an effort to confirm this theory, the left kidney was subjected to 15 mm Hg compression in six anesthetized mongrel dogs. For this, a pressure cuff was placed around the kidney excluding the renal hilar structures. The contralateral kidney was left untouched to serve as a control. After a steady-state period, the pressure cuff was inflated to 15 mm Hg for 2 hours. Cuff desufflation was followed by a 1-hour recovery period. Urine output, glomerular filtration rate (GFR), and effective renal blood flow (ERBF) were measured for both kidneys during each clearance period. For the treated kidneys, the mean urine output decreased 63% (P < 0.05) during compression and increased 109% (P < 0.05) after cuff desufflation. The GFR decreased 21% (P < 0.01) during compression and increased 25% (P < 0.05) during recovery. The ERBF decreased 26% (P < 0.05) during compression, and during the 1-hour recovery period, ERBF did not recover to baseline values. For the control kidneys, there were no significant changes in urine output or GFR during the experimental and recovery periods. These data support the view that direct renal parenchymal compression is an important factor in the development of insufflation-induced oliguria. The clinical implications of insufflation-induced oliguria during laparoscopy deserve further investigation.

Objectives: The purpose of this study is to examine the feasibility of performing a laparoscopic bladder autoaugmentation and to assess the urodynamic characteristics of an autoaugmented bladder., Methods: Laparoscopic bladder autoaugmentation was performed in 9 female canines (20 to 30 kg). Following laparoscopic access to the peritoneal cavity, a midline bladder seromyotomy was performed using the potassium titanyl phosphate 532 nm laser. This produced a large bladder diverticulum. Changes in bladder volume and compliance were quantified over a 3-month period of follow-up., Results: Urodynamic evaluation demonstrated an increase in bladder capacity 6 weeks postoperatively in 8 of 9 dogs, with an average volume increase of 45%. Bladder compliance improved in 7 of 9 dogs with an average increase in compliance of 67%. Three months postoperatively, bladder capacity remained increased in 5 of 9 dogs, with an average increase in volume of only 5.3%. An improvement in compliance was sustained in 5 of 9 animals with an average increase of 13.9%. Laparoscopic exploration revealed grossly normal bladders with adhesions of omentum to the seromyotomy site in all canines and the anterior abdominal wall in 2 of 9 canines. Histologically, the seromyotomy site was devoid of muscle with an intact urothelium and a proliferation of loose connective tissue., Conclusions: The technique of laparoscopic bladder autoaugmentation can be performed easily in the canine model. Although results at 6 weeks show significant improvement, the longer term, 3-month results were not statistically significant. This technique has the potential to offer a minimally invasive correction for patients with low-capacity, high-pressure bladders that have failed pharmacologic treatment.

Laser welding of the genitourinary tract has the potential advantage of forming an immediate watertight seal. It may obviate the need for sutures, eliminate the inherent lithogenic reaction to suture, and potentially improve healing. In the current study we employed a KTP-532 laser in vitro to weld canine ureters. Ureters were transected over a stent and immediately repaired using the KTP-532 laser (power density 7.14 W/cm.2, spot size = 0.5 cm.) alone or in combination with different tissue solders. Solders consisted of 40% human albumin alone or with the addition of iron oxide or fluorescein as light absorbing dyes (chromophores). Following the repairs, intraluminal bursting strength and the total energy required to complete the repairs were measured. The KTP laser alone was not able to achieve a satisfactory repair. Successful ureteral repairs were achieved in all solder groups while maintaining ureteral continuity at supraphysiologic pressures.

1. To determine whether abnormal renal calcium excretion is unique to primary genetic hypertension, blood pressure and 24 h urinary excretion of calcium, magnesium, sodium and creatinine were measured in deoxycorticosterone-saline and two-kidney, one-clip Goldblatt hypertensive rats and in their respective controls on low (0.2%) and high (1.8%) dietary calcium intakes. 2. Calcium supplementation lowered blood pressure (P < 0.05) in deoxycorticosterone-saline rats and in control saline-loaded rats, raised blood pressure in two-kidney, one clip rats, and had no effect in sham-operated control rats. 3. On both diets, calcium excretion was higher in hypertensive than in normotensive rats. The high calcium diet increased urinary calcium excretion in all rats, but the changes in urinary calcium excretion closely paralleled the diet-induced changes in blood pressure. Thus, urinary calcium excretion in deoxycorticosterone-saline animals, in whom calcium lowered blood pressure the most, rose the least (107%). Urinary calcium excretion rose the most in two-kidney, one-clip animals (1113%), whose blood pressure also rose the most. 4. Urinary magnesium excretion was also abnormal in hypertensive rats compared with normotensive rats, falling on the high compared with the low calcium diet in normotensive rats, but not in either hypertensive strain. Furthermore, urinary magnesium excretion was closely linked to urinary calcium excretion in saline-loaded control rats (r = 0.78; P = 0.008), but was dissociated from urinary calcium excretion in deoxycorticosterone-saline rats (r = 0.02; not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

The safety and cost-effectiveness of any new procedure is, of course, brought into question in this era of heightened fiscal concerns. In general, a review of initial results with laparoscopic pelvic lymph node dissection appears to reveal sufficient patient benefits to warrant further work with these less invasive techniques. The principal benefits include the following: Decreased patient morbidity, early and latent; Shorter hospitalization; Faster recovery and return to normal daily functions; Equivalent efficacy to open surgical alternatives; Overall cost-effectiveness Cosmetic effect; minimizes loss of body image; Reproducible results. Perfecting the skills necessary for complicated laparoscopic surgery requires a commitment of time and work on the part of the surgeon. This is not a procedure that will be learned by auditing a few cases. Laparoscopic surgery requires diligence in mentally and physically preparing the skills needed for surgery and caution in the application of these skills. Nurses can help to minimize this learning curve by taking an active interest in the current and future practice of laparoscopic surgery and by sharing their knowledge and enthusiasm.

Angiotensin II (Ang II) and atrial natriuretic factor (ANF) appear to act as functional antagonists in the regulation of fluid and electrolyte homeostasis and blood pressure. To further define the relations between these hormones in vivo, we investigated the effect of low doses of Ang II (1-10 ng/kg/min) on plasma ANF levels. We also evaluated the influence of ANF release on the renal and hormonal responses to ANG II. Studies were performed in anesthetized and conscious instrumented dogs during sustained saline load and converting enzyme inhibition. In the anesthetized dogs, Ang II significantly increased plasma ANF levels and ANF arteriovenous difference without changing either atrial pressures or hematocrit. In both conscious and anesthetized dogs, ANF increases were not correlated with blood pressure responses to Ang II and did not occur in control groups when Ang II was replaced by vehicle. Ang II-induced sodium retention and stimulation of aldosterone production were attenuated, and renin suppression was enhanced in dogs having the largest changes in plasma ANF in response to converting enzyme inhibition or Ang II. These results demonstrate that in volume-replete dogs Ang II can promote ANF release independently of changes in atrial pressures or systemic hemodynamics, suggesting that Ang II may exert a significant modulatory effect on ANF secretion. The results also show significant relations between ANF and renal and adrenal responses to Ang II, which may suggest that, in turn, endogenous ANF modulates the effects of Ang II.

It is now possible to accurately identify patients with renovascular hypertension who need renal angioplasty or revascularization. Evaluation does not require hospitalization and begins with the determination of an ambulatory plasma renin activity (PRA) indexed against sodium excretion and a captopril test. Subsequently differential renal vein renins with matching inferior vena caval (IVC) renins are measured often with converting enzyme inhibition. Identifying criteria are as follows: (1) high PRA indexed against sodium excretion, (2) hypersecretion of renin following captopril administration, (3) absence of renin secretion from the contralateral kidney, and (4) an ipsilateral renal vein renin increment at least 50% greater than the matching IVC renin. Patients who meet the criteria are admitted for percutaneous transluminal renal angioplasty.

The records of 24 patients with renal cell carcinoma involving the inferior vena cava who were free of metastatic disease at presentation were reviewed retrospectively. The over-all 2-year survival for the group was 45.8 per cent, with a mean survival of 38.9 months. When the group was analyzed according to the level of extension of the vena caval thrombus marked differences in the rate of survival and of incidence of local progression of disease were found. The 10 patients with an infrahepatic vena caval thrombus had a 2-year survival rate of 80 per cent and a mean survival of 61.4 months. Two patients (20 per cent) had extension of tumor into the perinephric fat and none had involvement of the regional lymph nodes. The 14 patients with a vena caval thrombus extending to the level of the hepatic veins or beyond had a 2-year survival rate of 21 per cent and a mean survival of 22.9 months. Tumor was present in the regional lymph nodes and/or perinephric fat in 9 of these patients (64 per cent). These results suggest that the level of vena caval involvement by tumor thrombus in patients with renal cell carcinoma has prognostic significance.

The renal arteriogram alone, useful as an anatomic guide for the surgeon or radiologist, is inadequate to predict potential blood pressure reversal by correction of the obstructing lesion. A patient must be identified as having functionally significant renal arterial disease before intervention can be recommended. The authors discuss uncovering functionally significant renal artery stenosis, the pathophysiology of experimental Goldblatt hypertension, and criteria to identify renovascular hypertension, including peripheral plasma renin activity and differential renal-vein renin determinations.

Three children and 4 adult patients with penile curvature without hypospadias were successfully operated on by the Nesbit technique or excision of ellipses of the tunica albuginea. There was no impotence, and a satisfactory result was obtained in all 7 cases.

The efficacy of the carbon dioxide laser used at high power levels for tissue destruction is well established. This laser at lower power levels has been used to incise and anastomose blood vessels, tendons, nerves, dura, bowel, fallopian tube, vasa deferentia, ureters and skin. Laser welding is faster, reduces surgical manipulation and introduces less foreign material into the wound than conventional suturing techniques. We tested the feasibility of laser welding of pedicled flap skin tubes to determine if there is a potential application in reconstruction, particularly for hypospadias repair.

Blood pressure, ionic and hormonal effects of high (1.8%) versus low (0.2%) dietary calcium intakes were explored in uninephrectomized DOC-NaCl rats, in two-kidney, one clip (2K, 1C) Goldblatt hypertensive rats and their respective controls. High-calcium diets lowered blood pressure (P less than 0.05) in DOC-NaCl and in control uninephrectomized rats drinking 1% NaCl. However, calcium loading in renin-dependent 2K, 1C rats elevated blood pressure (P less than 0.05) but had no effect in sham-operated controls. Plasma renin activity rose in all animals, while serum ionized calcium rose significantly only in dietary salt-loaded animals. Intracellular free magnesium levels were consistently, inversely linked to blood pressure (r = -0.92, P less than 0.001). This linkage was independent of plasma renin activity, serum ionized calcium values and dietary calcium content. These results demonstrate that the same alteration in dietary mineral content can produce opposite blood pressure effects in different pathophysiological subtypes of hypertensive disease. We conclude that intracellular free magnesium levels directly participate in the final common pathway of events regulating blood pressure and vasoconstrictor tone.

Hemodynamic responses to synthetic atrial natriuretic factor (ANF), were studied in renin-dependent two-kidney, one-clip (2K,1C) and deoxycorticosterone (DOC) salt-treated hypertensive rats as well as normotensive controls. ANF infusion (800 pmol/kg prime, 120 pmol X kg-1 X min-1 for 60 min) decreased blood pressure (BP) more in conscious 2K,1C (-24 +/- 4%) than in DOC salt-treated (-12 +/- 4%, P less than 0.05) or control rats. Hemodynamic parameters were also evaluated during graded infusion of three doses, each for 30 min. At 24 and 120 pmol X kg-1 X min-1, ANF lowered BP in 2K,1C rats, both conscious (from 156 +/- 6 to 144 +/- 7, P less than 0.05 and 135 +/- 5 mmHg, P less than 0.05) and anesthetized (from 148 +/- 7 to 138 +/- 7, P less than 0.05 and 128 +/- 7, P less than 0.05). In anesthetized 2K,1C, BP changes were associated with reduction in total peripheral resistance (TPR) that became significant at 120 pmol X kg-1 X min-1 (-10 +/- 2%), whereas cardiac output (CO) and stroke volume (SV) were unchanged. In DOC-salt-treated rats these doses did not lower BP despite progressive falls in CO (-7 +/- 3% and -24 +/- 5%, P less than 0.05) and SV (-8 +/- 2% and -23 +/- 5%, P less than 0.05), which were balanced by a simultaneous rise in TPR (+12 +/- 4% and +26 +/- 10%, P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

The degree by which atrial natriuretic factor (ANF)-induced renal hemodynamic changes account for its natriuretic effect was determined by early clamp experiments in six anesthetized dogs. After control periods, perfusion pressure of the left kidney (LK) was reduced to 80-90 mmHg, and synthetic ANF (auriculin A) was infused intravenously (0.3 micrograms X min-1 X kg body wt). After recovery, furosemide (F) was administered as a bolus injection (1 mg/kg body wt). In the right kidney (RK), which served as a time control, ANF increased (P less than 0.05) glomerular filtration rate (GFR) 16 +/- 4% and Na excretion (UNa V) 261 +/- 63%, whereas it decreased urine osmolality (Uosm) 36 +/- 7% without changing free water clearance. ANF also increased diuresis (V) and kaliuresis (UKV). F produced qualitatively the same results without changing GFR. In the clamped LK, ANF failed to increase GFR (22 +/- 4 vs. 26 +/- 4 ml/min), UNaV (30 +/- 9 vs. 33 +/- 11 mueq/min), V, and UKV or to decrease Uosm (841 +/- 97 vs. 840 +/- 114 mosmol/kg H2O). F had similar effects in LK as in RK. The data demonstrate that the natriuretic effect of ANF is abolished when its renal hemodynamic actions are impeded. In addition, the results demonstrate that ANF antagonizes renal vasoconstriction in the dog. The results are consistent with the view that the ANF-induced natriuresis is due in great part to an increase in the filtered load of Na into a washed-out inner medulla.

Atrial natriuretic factor (ANF) decreases renin secretion rate (RSR), plasma renin activity (PRA) and plasma aldosterone (PA) in normal dogs. To clarify further the mechanisms responsible for these effects, the left renal artery was constricted in seven anaesthetized dogs prior to ANF administration. Constriction of the left renal artery decreased (P < 0.05) ipsilateral mean renal perfusion pressure (MRPP, 29 +/- 7%), renal plasma flow (RPF, 42 +/- 11%) and glomerular filtration rate (GFR) and filtered sodium load (FLNa, 21 +/- 8.8%). Ipsilateral RSR and peripheral PRA tended to increase, although not significantly. Atrial natriuretic factor infusion did not alter GFR in the clamped kidney and failed to decrease RSR or PRA. Despite this, PA levels decreased significantly (7.8 +/- 2.4 to 5.6 +/- 1.8 ng%). These results suggest that ANF-induced inhibition of renin secretion is largely consequent on its renal haemodynamic actions and that suppression of aldosterone by ANF in vivo is due, in part, to direct effects on the adrenal cortex.

31P NMR spectroscopy was utilized to evaluate intracellular pH in erythrocytes from normotensive (n = 15) and from untreated (n = 16) and treated (n = 24) human essential hypertensive individuals. Intracellular erythrocyte pH was also measured in normotensive rats on different dietary calcium intakes as well as in volume-dependent deoxycorticosterone/saline and renin-dependent, 2 kidney, 1 clip (2K-1C) Goldblatt hypertensive rat models. Untreated essential hypertensives had significantly lower intracellular pH values compared with normotensive subjects [7.17 +/- 0.02 vs. 7.28 +/- 0.02 (mean +/- SEM), significance level = 0.01]. Treated hypertensives had intracellular pH values indistinguishable from normotensives [7.27 +/- 0.02 (mean +/- SEM)]. Similarly, pH values for each rat model varied inversely with blood pressure, regardless of whether increased dietary calcium intake lowered pressure (normotensive and deoxycorticosterone/saline hypertensive rats) or elevated it (2K-1C Goldblatt hypertensive rats). These results demonstrate that lower intracellular pH values are commonly observed in various hypertensive states and suggest that they may contribute to the pathophysiology of the hypertensive process. Alterations in intracellular pH may also underlie the clinically observed linkage of hypertension with other disease syndromes, such as diabetes mellitus and obesity.

Atrial natriuretic factor (ANF) antagonizes vasoconstriction induced by numerous smooth muscle agonists and also lowers blood pressure in intact animals. ANF has particularly marked relaxant effects on angiotensin II-contracted vessels in vitro. Sensitivity to the blood pressure-lowering effect of ANF in vivo appears to be enhanced in renin-dependent models of renovascular hypertension compared with other experimental hypertensive models. The depressor action of low, possibly physiological doses of ANF in two-kidney, one-clip Goldblatt rats is due to a decrease in total peripheral resistance. On the other hand, high doses of ANF can lower cardiac output, particularly in volume-expanded models such as deoxycorticosterone-salt hypertension. ANF markedly inhibits renin secretion in intact animals, probably via increased glomerular filtration rate and load of sodium chloride to the macula densa. This effect is masked when renal perfusion is impaired (e.g., via unilateral renal artery constriction), in which case ANF may stimulate renin secretion slightly. ANF also reduces plasma aldosterone in vivo and inhibits basal and agonist-induced aldosterone release from isolated adrenal cortical cells. This effect appears to be especially marked for angiotensin-induced aldosterone production in vivo and in vitro. These findings indicate that ANF has potentially important interactions with the renin-angiotensin-aldosterone system and suggest a role for ANF in the homeostatic control of blood pressure as well as of extracellular fluid volume.

Low lying rectal and pararectal tumors can cause constipation, tenesmus and bleeding. Patients who are not candidates for a curative procedure can be offered palliative treatment safely and effectively by transanal resection with a standard urological resectoscope.