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Retroperitoneoscopy is our preferred technique for renal surgery and is routinely performed for living donor nephrectomy. We report a case of a totally bisected left hemidiaphragm during left-sided retroperitoneoscopic donor nephrectomy. This was most likely caused when creating the retroperitoneal working space by balloon dilation. Because the cardiopulmonary situation of the patient remained stable, retroperitoneoscopic donor nephrectomy was performed with the standard technique. This report describes for the first time the retroperitoneoscopic reconstruction of a diaphragmatic injury.

Background: Long-term data of photoselective vaporization of the prostate (PVP) for treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is scanty., Objective: Evaluate the long-term efficacy and the complication rate in 80-watt (W) PVP., Design, Setting, and Participants: 500 consecutive patients with LUTS secondary to BPH underwent PVP between September 2002 and April 2007. The mean follow-up was 30.6+/-16.6 (5.2-60.6) mo., Intervention: All patients underwent 80-W PVP performed by seven surgeons., Measurements: We evaluated perioperative parameters, including operation time, delivered energy, changes of hemoglobin and serum sodium, catheterization, and hospitalization time as well as intraoperative and postoperative complications. Patients presenting for follow-up had data assessed on the International Prostate Symptom Score and quality-of-life questionnaire (IPPS-QoL), maximal flow rate (Q(max)), and post-voiding residual volume (Vres)., Results and Limitations: Mean patient age was 71.4+/-9.6 (46-96) yr, with a mean preoperative prostate volume of 56.1+/-25.3 (10-180) ml. Mean operation time was 66.4+/-26.8 (10-160) min, and mean energy delivery was 206+/-94 (2.4-619.0) kJ. Despite ongoing oral anticoagulation in 45% of the patients (n=225), no severe intraoperative complications were observed. Mean catheterization and postoperative hospitalization time was 1.8+/-1.2 (0-10) and 3.7+/-2.9 (0-35) d, respectively. The mean IPSS after 3 yr was 8.0+/-6.2, the QoL score was 1.3+/-1.3, the Q(max) was 18.4+/-8.0 ml/s, and the Vres was 28+/-42 ml. The retreatment rate was 6.8%. Urethral and bladder neck strictures were observed in 4.4% and 3.6% of the patients, respectively. Localized prostate cancer was diagnosed during follow-up in six patients., Conclusion: PVP is a safe and effective procedure for treatment of LUTS secondary to BPH. Patients on ongoing oral anticoagulation can be safely operated on. PVP leads to an immediate and sustained improvement of subjective and objective voiding parameters. The late complication rate is comparable to that of transurethral electroresection of the prostate.

Objectives: To evaluate quality of life (QoL) after laparoscopic radical prostatectomy (LRP) and investigate whether the learning curve of laparoscopic novices has a negative influence on patients' QoL., Methods: Evaluation of QoL with the EORTC QLQ C-30 and the PR25 preoperatively (t0) as well as postoperatively after 1-3 mo (t1), 4-6 mo (t2), 7-12 mo (t3), 13-24 mo (t4), and yearly thereafter (t5-t7). Surgeons were grouped according to their prior experience in laparoscopy into experienced and novices., Results: LRP was performed in 343 patients; 268 (78%) participated in the study. The mean patient age was 63.3+/-6.3 yr; mean PSA, 10.0+/-9.2 ng/ml; mean follow-up, 26 mo. Global health was impaired for t1 (p<0.001) and then returned to baseline. Emotional functioning improved (p<0.001) for t2-t7 versus baseline. Physical functioning remained impaired for t1-t2, and role and social functioning for t1-t6. Only sexual functioning did not return to baseline for t1-t7. Urinary symptoms were worse at t1 and then improved gradually (p<0.001). No significant difference in any QoL domain could be identified for experienced surgeons versus novices except for financial difficulties at t2-t3, which related to social differences. Thirty-one (9%) patients with adjuvant therapy had significantly worse global health, bowel symptoms, urinary symptoms, fatigue, and sexual functioning., Conclusions: The learning curve of laparoscopic novices does not have a negative impact on patients' QoL. For intermediate- to long-term follow-up, patients reach their baseline or score even better in all domains except for sexual functioning but are significantly impaired if adjuvant treatment is performed.

Objectives: To evaluate outcome after retroperitoneoscopic cryotherapy for small renal tumours., Methods: Fourteen patients underwent cryoablation performed with six ultrathin 1.5-mm cryoprobes. Retroperitoneoscopic access was used for any tumour location. A double freeze-thaw cycle was performed under simultaneous retroperitoneoscopic visual control and real-time ultrasound monitoring., Results: Mean tumour size was 2.8 cm (range: 2.0-4.0), mean patient age was 68 yr (range: 49-83), and six left and eight right kidneys were treated. The mean operative time was 167 min (range: 120-200); mean blood loss was 93 ml (range: 0-300). Cryosurgery was successfully performed in all 14 patients, with 13 patients undergoing assisted retroperitoneoscopy and one patient, after previous open nephropexy, undergoing an open approach. Intraoperative biopsy specimens revealed renal cell cancer (RCC) in 10 (71%) patients. The only intraoperative complication was bleeding after removal of the cryoprobes in four (29%) patients, necessitating one intracorporeal stitch in each. Two (14%) of the first four patients presented postoperatively with superficial skin frostbite, which healed with conservative treatment. During mean follow-up of 21 mo (range: 2-42), 2 (14%) patients died from unrelated disease, and 12 patients remained without evidence of local recurrence. One patient with previous contralateral nephrectomy for RCC developed retroperitoneal lymph node metastasis on that side without recurrence in the cryoablated kidney., Conclusions: Retroperitoneoscopic cryotherapy using multiple ultrathin cryoprobes is safe and effective with encouraging oncologic results on intermediate-term follow-up. Prospective clinical trials and long-term oncologic data are needed to define its definitive role in treatment of renal tumours.

Objectives: Ongoing oral anticoagulation (OA) contraindicates transurethral electroresection of the prostate. We evaluated the safety and effectiveness of photoselective vaporization of the prostate (PVP) in patients on ongoing OA with coumarin derivatives, aspirin, or clopidogrel, complaining of symptomatic benign prostatic hyperplasia (BPH)., Methods: We evaluated perioperative parameters, functional outcome, and adverse events up to 24 mo postoperatively of patients on OA, and compared results with 92 men at normal risk without anticoagulant therapy undergoing PVP for the same indication (control)., Results: Within 40 mo, 116 men on OA were included, with 31% (n=36) receiving coumarin derivatives; 61% (n=71), aspirin; and 8% (n=9), clopidogrel. Mean prostate volume (62+/-34ml vs. 57+/-25ml; p=0.289) and mean operation time (67+/-28min vs 63+/-29min; p=0.313) were comparable with control. We observed no bleeding complications necessitating blood transfusions. Average postoperative decrease of haemoglobin was 8.6% for patients on OA versus 8.8% for control. At 3, 6, 12, and 24 mo postoperatively, improvement of the International Prostate Symptom Score ranged from 60-70%; postvoid residual volume, 80-88%; and average maximum urinary flow rate, 116-140%, respectively. Postoperative complications were low and comparable with control., Conclusions: PVP is characterized by excellent haemostatic properties and very low intraoperative complication rate even in patients on OA. On the basis of our perioperative results, we recommend PVP as first-line procedure for patients with symptomatic BPH at high risk of bleeding.

Objectives: The purpose of this study was to evaluate the feasibility and efficacy of photoselective vaporization of the prostate (PVP) in patients with refractory urinary retention (RUR) secondary to benign prostate hyperplasia (BPH)., Methods: Perioperative data, postoperative outcomes, and adverse events within 24 months in 70 patients with RUR were compared to 113 men with no urinary retention (NUR) before surgery., Results: Follow-up for the two groups was as follows (RUR vs. NUR at 1, 3, 6, 12, and 24 months): peak urinary flow rate: 16.9 vs. 19.4 ml/s, 16.3 vs. 20.9 ml/s, 17.7 vs. 19.7 ml/s, 18.2 vs. 21 ml/s, and 19.4 vs. 23.3 ml/s; International Prostate Symptom Score: 7.6 vs. 10.7, 7 vs. 7.5, 5.7 vs. 6.2, 5.5 vs. 6.5, and 4.4 vs. 6.5, respectively. Postoperative urinary retention and complication rates were comparable for the two groups. In five patients (2.7%), a reoperation with PVP or transurethral resection of the prostate was necessary. Bladder neck contracture and urethral stricture developed in 0.5% (n=1) and 4.9% (n=9), respectively., Conclusion: PVP seems to be a safe and effective surgical tool in patients with RUR caused by prostatic enlargement. The complication rate is comparable to that of patients with NUR before PVP.

Introduction: Recently, some controversy has arisen as to whether pelvic lymphadenectomy is still necessary for patients with prostate cancer who are undergoing radical prostatectomy. We prospectively evaluated the results and morbidity of laparoscopic extended pelvic lymph node dissection in patients with high-risk prostate cancer defined as a serum prostate-specific antigen (PSA) level greater than 10 ng/mL or preoperative biopsy Gleason score of 7 or more., Technical Considerations: In 123 consecutive patients with clinically organ-confined high-risk prostate cancer, laparoscopic extended pelvic lymphadenectomy was performed before laparoscopic radical prostatectomy. The boundaries of the pelvic lymph node dissection were the bifurcation of the common iliac artery superiorly, the node of Cloquet inferiorly, the external iliac vein laterally, and the bladder wall medially. Preparation was done with bipolar forceps and scissors, with meticulous coagulation of all lymphatic tissue. The mean PSA level was 14.8 ng/mL (range 1.5 to 43.4). The mean number of lymph nodes removed was 21 (range 9 to 55). A total of 21 patients (17%) had lymph node metastases. The overall complication rate was 4%., Conclusions: Laparoscopic extended pelvic lymph node dissection is safe and effective. The results and morbidity are equivalent to those of open surgery, with the advantage of a minimally invasive operative technique.

Ureteral obstruction after transurethral injection therapy for primary vesicoureteral reflux is known to occur in less than 1% of cases. We report the first case of a ureteral obstruction after transurethral injection of dextranomer/hyaluronic acid copolymer (Deflux) for the treatment of secondary vesicoureteral reflux after renal transplantation. Loss of transplant function made reimplantation of the ureter necessary. A periureteral phlebitis and moderate foreign body reaction was found histologically, although the patient had received immunosuppressive therapy. Endoscopic therapy of secondary vesicoureteral reflux in patients after renal transplantation is a reasonable minimally invasive treatment option; however, severe complications may occur.

Objectives: To evaluate our current practice in retroperitoneoscopic pyeloplasty in patients with ureteropelvic junction obstruction (UPJO). Special interest was paid to technical difficulties associated with the retroperitoneoscopic approach., Methods: Our retroperitoneoscopic approach for pyeloplasty is explained step for step including the most technically challenging part: the ureteropelvic anastomosis., Results: Within 49 months a total of 47 retroperitoneoscopic pyeloplasties we performed at our institution. Before pyeloplasty an endopyelotomy had failed in five patients (11%). We did not necessarily perform a ventral transposition of the anastomosis in cases with a crossing vessel. Two (4%) conversions to open surgery were required because of scarring after previous endopyelotomy and massive obesity resulting in a limited working space. There were no intraoperative complications. A recurrence of UPJO was observed in 2% (n = 1)., Conclusion: Functional results after retroperitoneoscopic pyeloplasty are excellent and comparable to those of open surgery. However, special knowledge of retroperitoneoscopy is necessary to provide the patient with a safe and effective minimally invasive alternative to open pyeloplasty.

Objectives: To compare the early follow-up and perioperative morbidity of photoselective vaporization (PVP) and transurethral resection of the prostate (TURP) in patients (pts.) suffering from lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH)., Material and Method: 101 pts. underwent PVP (n = 64) and TURP (n = 37) in a prospective, non-randomized bi-centre trial. Inclusion criteria were identical at both centres. Primary outcome parameters were maximum urinary flow rate (Q(max)), post-void residual volume (V(res)), International Prostate Symptom Score (IPSS). Secondary outcomes included intraoperative surgical parameters and perioperative and post-discharge morbidity., Results: Baseline characteristics of both groups were similar. Operating time was slightly shorter in the TURP group (p = 0.047). During TURP significant more irrigation solution was used (p < 0.001). Decrease of serum haemoglobin (p = 0.027) and serum sodium (p = 0.013) was larger after TURP. Catheter drainage was removed significant earlier after PVP than after TURP (p < 0.001). Outcome of Q(max), and IPSS were similar in both groups within 6 months. The sort of perioperative complications was different in both groups, however overall cumulative perioperative morbidity was comparable (PVP 39.1% versus TURP 43.2.1%; ns)., Conclusion: PVP provides excellent intraoperative safety, instant tissue removal, and immediate relief from obstructive voiding symptoms, similar to TURP. Early outcomes 6-months after PVP and TURP are comparable.

A 59-year-old woman complained of increasing pain in the left abdomen and of diarrheal symptoms after left-sided retroperitoneoscopic living donor nephrectomy. Computed tomography revealed chyloretroperitoneum. The fluid was drained percutaneously, followed by recurrent drain replacement surgery. Her diet was changed to short-chain and medium-chain fatty acids without success. After onset of dyspnea due to chylothorax, the donor underwent thoracic drainage, fully parenteral therapy, and finally somatostatin application therapy. The postoperative management of severe chylous fistula is difficult. Therefore, we recommend an early start of maximal conservative therapy. Surgical options depend on pain occurrence or mechanical problems.

Objectives: We retrospectively performed a comparative analysis of retroperitoneoscopic and open donor nephrectomy in terms of donor complications, as well as recipient complications and functional graft outcome., Methods: A total of 134 donor nephrectomies including 69 open (ODN) and 65 retroperitoneoscopic (RDN) nephrectomies was analyzed retrospectively. Both groups were comparable in terms of age, body mass index (BMI), operating time (OPT), warm ischemia time (WIT) and blood loss., Results: There were no statistically significant differences with respect to recipient outcome, mean values for age, BMI, OPT and cold ischemia time (CIT). The overall donor complication rate did not differ. Early functional graft follow-up showed significant differences in 24 h-urine output between the two groups (p<0.001), but serum creatinine was comparable after 7, 30, 180 and 365 days. The early rejection rate in the recipients was similar in the two groups., Conclusion: Retroperitoneoscopic donor nephrectomy (RDN) provides comparable perioperative features, such as operating time, warm ischemia time (WIT) and overall complication rate to the open donor nephrectomy (ODN). Additionally, it has no negative impact on recipients' operating time, graft ischemia and early graft function.

Objectives: This study aims to investigate safety and efficacy of 80 watt high-power potassium titanyl phosphate (KTP) laser vaporization of the prostate in men with lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH)., Methods: 108 patients underwent 80W KTP laser vaporization. Functional follow-up included measurement of maximum urinary flow rate (Qmax), postvoid residual volume (Vres) and International Prostate Symptom Score (IPSS) within a 12 months period., Results: The average prostate volume was 52.2+/-24.3 ml and the preoperative PSA value was 3.6+/-3.6 ng/dl. Mean operation time was 54.5+/-25.0 min. Qmax increased highly significantly (p<0.001) by 111% (+7.9 ml/s) at discharge, 212% (+15.1 ml/s) after three months, 201% (+14.3 ml/s) after six months and 252% (+17.9 ml/s) after 12 months. Correspondingly, Vres, IPSS and Bother Score improved to an extent that was statistically highly significant (p<0.001) immediately after surgery. The observed complication rate within one year was low., Conclusions: 80 W KTP laser vaporization is a virtually bloodless, safe and effective procedure for surgical treatment of LUTS secondary to BPH. A significant improvement of objective and subjective voiding parameters was observed just after surgery. KTP laser vaporization is associated with a low rate of complications.

Objectives: Laparoscopic cryoablation has recently been proposed as a minimally invasive nephron-sparing treatment for selected patients. We report on our experience with a retroperitoneoscopic technique using multiple ultrathin cryoprobes., Methods: Seven patients underwent retroperitoneoscopic renal cryoablation for solid renal masses. Mean tumor size on the CT scan was 2.6 (1.5-3.5) cm. A double freeze-thaw cycle of renal cryoablation was performed under real-time ultrasound monitoring using a total of six 1.5-mm cryoprobes simultaneously., Results: Cryoablation was technically successful in all patients without any need for conversion. Mean duration of surgery was 161 (130-195) minutes and mean blood loss was 107 (50-250) ml. Perioperative biopsy of the tumor confirmed renal cell carcinoma in four patients and angiomyolipoma in two patients; it was inconclusive in one case. Mean follow-up for 13.6 (4-22) months showed no evidence of residual tumor or recurrence., Conclusions: Retroperitoneoscopy-assisted cryosurgical ablation using multiple ultrathin 1.5-mm cryoprobes is a minimally invasive treatment that is suitable to treat small renal tumors.

Pancreatic lesions, particularly cysts, can simulate various diseases. We report a case of a 43-year-old woman with a large, symptomatic, retroperitoneal cyst misdiagnosed as a "renal cyst." During the retroperitoneoscopic marsupialization, the correct diagnosis of a pancreatic cyst was made, leading to an open pancreas tail resection. Histologic evaluation revealed serous cystadenoma. Especially in large retroperitoneal cysts on the left side, the correct diagnosis of a pancreatic cyst can be difficult.