Search

Current methods of suprapubic cystostomy (SPC) catheter insertion may be difficult for patients in poor health and can result in significant morbidity and mortality. These include a highly invasive open procedure, as well as the use of the percutaneous trocar punch methods, commonly associated with short-term SPC. We present the first human experience with the Transurethral Suprapubic endo-Cystostomy (T-SPeC(®)) device, a novel disposable device used for introducing a suprapubic catheter via a retrourethral (inside-to-out) approach similar to the Lowsley technique.Four men at St. Mary's General Hospital in Kitchener Ontario, Canada, received the T-SPeC device (model T7) under general anesthesia.Patients had no complications from catheterization using the T-SPeC T7 Surgical System. The mean surgical time of the four procedures was 9.7 minutes, with a range of 7.9 to 13.5 minutes, including instrument preparation and cystoscopy. All four procedures were highly accurate and rapid. There were no complications and minimal blood loss from the procedure.We found that the T-SPeC device allows for efficient and safe insertion of a suprapubic catheter in an outpatient setting and may be a useful addition to the urologic armamentarium. The T-SPeC Surgical System facilitates rapid and precise suprapubic catheter placement.

Hemostatic agents have been suggested as an adjunct for tubeless percutaneous nephrolithotomy (PCNL). We pathologically evaluated the percutaneous tracts injected with the fibrin sealant (FS) Evicel and hemostatic gelatin matrix (HGM) Surgiflo at various time intervals to determine their absorption and tract closure rates. We also evaluated whether these agents reduced urine leak rates in a porcine model.Percutaneous access was obtained in 19 kidneys in 10 domestic swine. The tracts were dilated to 30F using a balloon dilating catheter. Ten kidneys served as controls. Surgiflo was injected into the tract of four kidneys, and Evicel was injected into the tract of five kidneys. Intravenous urography (IVU) was performed on postoperative days (POD) 1 and 10 to 14. IVU was performed on two pigs at POD 30. The pigs were sacrificed and kidneys were harvested for pathologic evaluation.Two (20%) control kidneys had a urine leak on IVU on POD 1. None of the kidneys treated with HGM or FS had a urine leak on POD 1. None of the kidneys had a leak on POD 10 to 14 or POD 30. On pathologic inspection, the tracts of all the control kidneys and HGM kidneys had closed completely at POD 14. Two kidneys treated with FS had fistula at POD 6 and POD 14. At POD 30, the tracts in the control kidneys and kidney treated with HGM had completely healed. Fibrin sealant remained in the tract at POD 30.Fibrin sealant should be used with caution because it can persist in the tract for up to 30 days and may inhibit wound healing. Hemostatic gelatin matrix is the preferable agent because the tract closed by POD 10 to 14, similar to the findings in the control animals. The use of hemostatic agents in a nephroscopy tract may reduce the risk of early urine leak after tubeless PCNL.

Introduction: The characterization of urinary calculi using noninvasive methods has the potential to affect clinical management. CT remains the gold standard for diagnosis of urinary calculi, but has not reliably differentiated varying stone compositions. Dual-energy CT (DECT) has emerged as a technology to improve CT characterization of anatomic structures. This study aims to assess the ability of DECT to accurately discriminate between different types of urinary calculi in an in vitro model using novel postimage acquisition data processing techniques. Methods: Fifty urinary calculi were assessed, of which 44 had ≥60% composition of one component. DECT was performed utilizing 64-slice multidetector CT. The attenuation profiles of the lower-energy (DECT-Low) and higher-energy (DECT-High) datasets were used to investigate whether differences could be seen between different stone compositions. Results: Postimage acquisition processing allowed for identification of the main different chemical compos...

Robotic-assisted laparoscopic prostatectomy (RALP) is growing in popularity as a treatment option for prostate cancer. As a new technology, little is known regarding the reliability of the da Vinci robotic system. Intraoperative robotic equipment malfunction may force the surgeon to convert the procedure to an open or pure laparoscopic procedure, or possibly even abort the procedure. We report the first large-scale, multi-institutional review of robotic equipment malfunction.A questionnaire was designed to evaluate the rate of perioperative robotic malfunction during RALP. High-volume, experienced surgeons were asked to complete this evaluation based on the analysis of their data. Questions included the overall number of RALPs performed, the number of equipment malfunctions, the number of procedures that had to be converted or aborted, and the part of the robotic system that malfunctioned.Eleven institutions participated in the study with a median surgeon volume of 700 cases, accounting for a total case volume of 8240. Critical failure occurred in 34 cases (0.4%) leading to the cancellation of 24 cases prior to the procedure, and the conversion to two laparoscopic and eight open procedures. The most common components of the robot to malfunction were the arms and optical system.Critical robotic equipment malfunction is extremely rare in institutions that perform high volumes of RALPs, with a nonrecoverable malfunction rate of only 0.4%.

Dietary intake of citrate in the form of citrus juices (eg, lemonade, orange juice) will enhance urinary citrate excretion, a valuable benefit for patients with hypocitraturic calcium oxalate nephrolithiasis. While information on citrate concentrations in select citrus juices is available, data on citrate concentrations of commercially available beverages (juice and otherwise) are limited. Using nuclear magnetic resonance spectroscopy (1H NMR), we report citrate concentrations of several beverages to help guide dietary recommendations aimed at increasing urinary citrate excretion and correcting hypocitraturia.Citrate concentrations of a squeezed lemon, several fruit juices, and common beverages were measured using 1H NMR. Spectra for each sample were obtained in duplicate; citrate peak was identified, measured, and quantified and compared with the citrate concentration in the juice of 1 medium lemon.Quantitative analysis revealed the highest concentration of citrate was in grapefruit juice (64.7 mmol/L), followed in decreasing concentrations by lemon juice (47.66 mmol/L), orange juice (47.36 mmol/L), pineapple juice (41.57 mmol/L), reconstituted lemonade (38.65 mmol/L), lemonade flavored Crystal Light (38.39 mmol/L), ready to consume not from concentrate lemonade (38.24 mmol/L), cranberry juice (19.87 mmol/L), lemon-flavored Gatorade (19.82 mmol/L), homemade lemonade (17.42 mmol/L), Mountain Dew (8.84 mmol/L), and Diet 7Up (7.98 mmol/L), respectively.According to 1H NMR, all of the tested "natural" citrus juices have high concentrations of citrate (38.3-67.4 mmol/L), with grapefruit juice having the highest concentration of the beverages chosen. Lemonade flavored Crystal Light had the highest concentration of citrate in the nonjuice category of tested beverages. In patients with mild to moderate hypocitraturia, dietary supplementation with citrus-based juices may be an effective alternative to medical management while not requiring large serving sizes. Further prospective studies are warranted to evaluate the clinical significance of these findings.

We investigate a ureteral stent with radially expanding baskets producing passive dilation of the ureter for passage, capture, and removal of small ureteral stones.Polyurethane ureteral stents were slit to open 15 to 17 baskets along the length. The baskets are designed to dilate the ureter passively and capture stonesor=5 mm. Forty-two patients had these stents placed for stones at nine medical centers. Stone size ranged from 2 to 30 mm, while fragment size ranged from 1 to 8 mm. The locations of the stones ranged from the kidney to the lower ureter. The Ureteral Expanding Stent was inserted in the closed position, similar to a standard ureteral stent, and left in place for an average of 11 days.The device was inserted and extracted safely in all patients. Most patients experienced pain at an average rating of 3.7 of 10 on a visual analog scale. All stents were removed without significant morbidity. In 36 patients (86%), stones were removed with the stent (n=18) or passed while the stent was in place (n=18). The largest stone captured was 6 mm.The Ureteral Expanding Stent (OPEN-Pass) was used safely in 42 patients with stones. The device captured ureteral stones and facilitated stone passage around it. Stent retention or ureteral injury as a result of stone entrapment did not occur. The Ureteral Expanding Stent represents a new stone-removal and ureteral-dilation tool worthy of further clinical study.

Background and Purpose: The management of acute renal colic is a problem commonly encountered by both urologists and emergency medicine physicians. The classic approach to managing uncomplicated acute renal colic involves hydration, along with imaging and pain control. Previous studies have suggested that hydration has a significant impact on patient comfort, as well as spontaneous stone passage. This study evaluated the effects of maintenance v forced hydration and its effect on the pain experienced from renal colic. Patients and Methods: Forty male and 18 female patients with a mean age of 41 years suspected to have acute renal colic were identified in the emergency department. After screening and informed consent, the patients were enrolled in the study, and 43 patients were eventually available for analysis. Patients received intravenous (IV) analgesia, imaging with a noncontrast CT scan of abdomen and pelvis, and assignment to either forced IV hydration with 2 L of normal saline over 2 hours (N = 20)...

We report the results of a controlled survival study in a porcine model investigating Tisseel or a combination of FloSeal and Tisseel in dealing with vascular and collecting-system injury during partial nephrectomy.We performed an open right lower-pole partial nephrectomy on 15 large female pigs. The defect was repaired using standard open techniques (N = 5; controls), Tisseel only (N = 6; group I), or FloSeal followed by Tisseel (N = 4; group II). A Jackson-Pratt drain was placed. Nephrectomy and retrograde pyelography were performed at 1 week.Operative times were shorter in both study groups, achieving statistical significance in group I (P = 0.008). Warm-ischemia times were significantly improved in both study groups (P = 0.029 and P = 0.00005 in groups I and II, respectively). Time to hemostasis was significantly shorter in group II only (P = 0.002) but approached significance in Group I as well (P = 0.09). Estimated blood loss was not significantly different from the controls in either group. When Tisseel was placed alone after hilar control, hematoma formation under the Tisseel was noted on release of the hilar clamp. After 1 week, there was one urinoma and three urine leaks in the control group. In group I, there was one urinoma and four urine leaks, and there was only one urine leak and no urinomas in group II. There were no hematomas in any of the groups.Tisseel alone is not adequate for either hemostasis or management of major collecting-system injury. FloSeal capped with Tisseel appears sufficient to control major vascular and collecting-system injuries without adjunctive surgical measures. A proposed technique for laparoscopic partial nephrectomy without reconstructive techniques is presented that warrants clinical study.

Hand-assisted laparoscopic (HAL) renal surgery is an accepted standard of practice. We report our complications at the hand port-site incision in various HAL urologic procedures.Data and follow-up were complete for 54 patients who underwent HAL nephrectomy. HAL partial nephrectomy, or HAL nephroureterectomy at our institution from October 2001 to April 2003. A retrospective review of the patients' charts was performed to identify the incidence of postoperative hand port-site complications. The mean patient age was 59 years, and the mean follow-up was 5.4 months.Five complications were observed in four patients (9.3%). One patient had a superficial wound infection (1.9%) and an incisional hernia (1.9%) that was surgically repaired. One patient had a superficial incisional breakdown that healed well after conservative measures. One obese patient with severe chronic obstructive pulmonary disease eviscerated through his hand-port incision after a coughing spell. This was repaired operatively, and the patient healed well with the aid of an abdominal binder. One patient developed an enterocutaneous fistula at her hand-port site that healed well after both operative and conservative management.The technique of HAL renal surgery is safe and effective. Complications associated with the hand-port incision exist, and as they become better defined, the surgeon may take extra steps toward their recognition and prevention.

Purpose Laparoscopic surgery for large renal lesion or kidneys with chronic inflammation has proved to be technically challenging. Hand-assisted laparoscopic surgery might be useful in these complex cases, as it provides surgeons the benefits of tactile feedback, digital retraction, and facilitated dissection of the renal hilar vessels. Patients and methods Twenty-two patients undergoing hand-assisted laparoscopic (HAL) nephrectomy for benign conditions were compared with patients who underwent HAL radical nephrectomy during the same period. The demographic data, laterality, operative time, estimated blood loss, conversion rate, length of stay, histopathology findings, morbidity, and mortality were reviewed. Results The main indications for surgery were chronic inflammation and xanthogranulomatous pyelonephritis. Twenty patients had unilateral nephrectomy (10 each on the right and left), and two patients had bilateral nephrectomy. The mean operative times for unilateral and bilateral nephrectomy were 163 minutes (range 55-261 minutes) and 265 minutes (range, 238-291 minutes), respectively. Nine patients (45%) with inflammation had complications (15% major and 30% minor). The mean length of hospitalization for patients undergoing HAL nephrectomy was 7.2 days (range 2-35 days). The patients with inflammatory pathology had longer mean operative times, higher estimated blood loss, longer hospital stay, and higher morbidity than patients undergoing radical nephrectomy. Conclusion Compared with standard laparoscopy, the hand-assisted approach has been reported to reduce operative times and increase safety. The advantages of minimally invasive surgery, such as reduced analgesia, shorter hospital stay, and faster return to normal activity, appear to be similar to those in patients undergoing a pure laparoscopic nephrectomy. Compared with radical nephrectomy for renal tumor, HAL simple nephrectomy can often be more challenging and associated with greater morbidity. For both the community urologist as well as an experienced laparoscopist, this approach is useful in handling these challenging cases.

Laparoscopic nephrectomy is commonly employed today for both malignant and benign renal conditions, yet the learning curve for all but the simplest procedures remains quite steep. Hand-assisted laparoscopic nephrectomy (HALN) bridges the gap between standard laparoscopy and open surgery, allowing urologists to develop laparoscopic skills while offering the advantages of minimally invasive surgery. Simple laparoscopic nephrectomy, performed for benign disorders, can at times prove to be challenging because of inflammation around the renal hilum. Meticulous dissection during HALN utilizing the intra-abdominal hand for tactile feedback, retraction, and blunt dissection may improve one's capabilities compared with the standard laparoscopic approach.

Transperitoneal laparoscopic nephrectomy is performed much as originally described by Clayman and associates, although preoperative embolization of the kidney is no longer routine. Some surgeons use a hand-assisted technique, especially in difficult cases or when the organ is being removed intact, as in live-donor nephrectomy.

Endoscopic management of ureteropelvic junction (UPJ) obstruction has a success rate of 80% to 86%. We have been performing a ureteral cutting balloon procedure under fluoroscopic control (Acucise endopyelotomy) for UPJ obstruction at Loyola University Medical Center since 1991. The overall success rate in 77 patients was 78%. All patients had a preoperative intravenous urogram or a retrograde pyelogram, but none had vascular imaging studies. Acucise endopyelotomy consisted of a posterolateral incision of the UPJ and placement of an endopyelotomy or double-J stent. Foley catheter placement at the end of the procedure demonstrated significant gross hematuria in three patients (4%). All three remained hemodynamically stable but with significant drops in postprocedure hemoglobin levels, which necessitated blood transfusion. Aggressive management included angiographic studies and embolization of lower-pole branching arteries in two patients (3%). One patient stopped bleeding after being given two units of blood. None of the patients required an open exploratory procedure. Although the risk of vascular injury is low with Acucise endopyelotomy, prolonged postoperative gross hematuria does mandate investigation and observation. Angiographic embolization appears to be the therapeutic modality of choice for patients with hemorrhagic complications after an Acucise endopyelotomy.

Hypothermia is commonly used to prevent ischemic renal damage during complex nephron-sparing surgical procedures requiring temporary renal artery occlusion. We developed a novel Cooling Sheath device, which is compatible with laparoscopy, to protect the kidney hypothermically during 60 minutes of temporary arterial occlusion in a laparoscopic swine model. Comparison of temperature curves and histology to control groups undergoing open slush surface cooling and laparoscopic warm ischemia for similar time periods was performed. Optimal hypothermic temperatures were reached rapidly and maintained with the use of the Cooling Sheath. Ischemic damage, present in all kidneys subjected to warm ischemia, was not found on histopathologic examination of the cooled kidneys. This new device provides hypothermic protection of the kidney during ischemia. The use of the Cooling Sheath combined with temporary arterial occlusion will allow more complex nephron-sparing renal surgery to be performed using laparoscopy.

Laparoscopic surgery is an evolving technique that began to be applied widely in urology in the early 1990s. We have conducted an ongoing multicenter study of laparoscopic urologic surgery to identify any changes in utilization, complications, and short- and long-term outcomes. Laparoscopic urologic surgical procedures were assessed in three successive phases: retrospective initial experience [P1] (before 1991), and prospectively, an intermediate phase [P2] (1991-1992) and a late phase [P3] (1993-1994). The late phase group was followed for 1 year through 1995 to identify any delayed complications. In the P1 group, 114 patients are included; 105 underwent laparoscopic pelvic lymph node dissection (LPLND), 7 underwent laparoscopic variocele ligation (LVL), and 2 underwent other procedures. The complication rates in P1 are 21% (total): 10.5% (major) and 10.5% (minor). The P2 group includes 148 patients; 132 underwent LPLND, 10 underwent LVL, and 6 underwent other procedures. The complication rates decreased to 16.2% (total): 6% (major) and 10.1% (minor). The latest group (P3) includes 326 subjects; 245 had LPLND, 39 had LVL, and 42 had other procedures. More improvement in outcome is shown in this phase with a 7.98% total complication rate: 0.92% major and 7.05% minor. In addition, other parameters such as operative time and hospital stay show improvement through the successive phases. There were no significant long-term complications in the latest study group. This study demonstrates a continual improvement in outcome and changes in utilization patterns as urologists become more experienced with laparoscopic surgery. The complexity of the procedures performed has increased with a decrease in the complication rates overall.

The differentiation between significant mechanical obstruction and nonobstructive dilation of the kidneys and ureters is fundamental to patient management. The diuretic renal scan is a useful test in this situation because it usually is reliable and reproducible and is noninvasive and objective, providing information about the function of each kidney. However, this study has given variable results in a small number of patients. We report our experience with five such patients and recommend an algorithm for evaluating patients with equivocal scan results. This report emphasizes the importance of continued follow-up and the need for periodic reevaluation of patients with unexplained urinary symptoms or persistent flank pain, even when the initial diuretic renal scan is normal.

A patient with a lymphocele after laparoscopic pelvic lymphadenectomy and radical retropubic prostatectomy was treated successfully with a single instillation of diatrizoate meglumine through a Jackson-Pratt drain. The authors review the origin of lymphoceles and various methods for treating them.

Laparoscopic nephrectomy using an entirely retroperitoneal approach was performed in six anesthetized female pigs. In each animal, the kidney was localized using fluoroscopy, following which the retroperitoneum was insufflated with CO2. Subsequently, a retroperitoneal laparoscopic nephrectomy was performed in a 48-year-old man with a chronically obstructed, nonfunctioning kidney. Although the retroperitoneal approach provides excellent exposure for the dissection of the renal hilum, anatomic factors in the human limit port placement and organ entrapment and increase the risk for development of a pneumothorax.

Fibrin glue is used as a hemostatic agent, has potential as a tissue adhesive, and may promote tissue healing. The histologic effects of fibrin glue on the ureter have not yet been fully investigated. We studied the effect of fibrin glue on the thickness of various layers of injured and uninjured ureters and its effect on vessel density in the rabbit model.Rabbits were divided into two groups. The ureters were exposed using a midline abdominal incision. In the study group, one of the ureters was crushed, and fibrin glue was instilled around both ureters. In the control group, one of the ureters was crushed, but no fibrin glue was instilled. The animals were sacrificed at 6 weeks and the ureters examined histologically. Using NIH Image Analysis solftware, the thickness of the urothelium, muscular, and adventitial layers and the cross-sectional area of the ureters were measured. The vessel density of the ureters was also assessed.Whereas the thickness of the epithelium was increased in the crushed ureters treated with fibrin glue (20.7 microm v 15.3 microm), the thickness was reduced in the uncrushed ureters treated with fibrin glue compared with controls (16.3 microm v 19.8 microm). There was no statistically significant difference in the thickness of the muscular or adventitial layers in the study and control groups. There was a reduction in the cross-sectional area of the uncrushed ureters treated with fibrin glue compared with controls (7,095 microm2 v 9,409 microm2). In addition, the vessel density in the crushed ureters was reduced in ureters treated with fibrin glue compared with controls (0.00067/microm2 v 0.00108/micro2). In the uncrushed ureters, the difference was not statistically significant.Fibrin glue has potential as an adhesive agent in the ureter and may promote healing. It may affect epithelial layer thickness and vessel density of the ureter, but these effects were variable. Fibrin glue does not appear to have significant effects on the ureteral muscular and adventitial layers or on the overall cross-sectional area of all three layers. These results indicate that fibrin glue does not appear to have a detrimental effect on the ureter.

The authors describe a laparoscopic technique similar to the Marshall-Marchetti-Krantz operation for the correction of true stress incontinence. In the reported experience with 22 patients, the technique was successful in all, although the follow-up is only 9.5 months. Laparoscopic bladder neck suspension is not appropriate in patients with extensive adhesions, a history of sepsis and peritonitis, a dilated large bowel, or an uncorrectable coagulopathy.

Laparoscopic nephrectomy is a new procedure in which the kidney is removed via a laparoscopic approach using a surgical entrapment sack and a high-speed 10-mm electrical tissue morcellator. Herein, we report the initial clinical experience with this procedure in 10 consecutive patients. The average operating room time was 5.5 hours. The hospital stay averaged 4.9 days, and convalescence occurred over 12 days. Two patients received a blood transfusion(s). At present, laparoscopic nephrectomy is our method of choice for patients requiring a nephrectomy for benign renal disease. The technology developed for this procedure may be helpful to surgeons in other disciplines, as the method of organ entrapment and morcellation can be applied to the removal of other intra-abdominal or pelvic organs.

A randomized study was undertaken to assess the effectiveness and morbidity of stent placement on patients undergoing extracorporeal shock wave lithotripsy (SWL) with nonobstructing upper ureteral ...

This is a case report of a 37-year-old man with severe testicular pain unresolved after conventional investigative and therapeutic methods. On the basis of his history of abdominal trauma followed by emergency splenectomy and evidence of functioning splenic tissue on a radionuclide scan, the diagnosis of splenosis was established. Laparoscopic exploration was done, and the initial diagnosis confirmed. Splenic tissue located at the right inguinal ring was removed. Testicular pain abated after the procedure.

We identified 40 patients (25 men and 15 women) who developed calculi composed totally or partially of sulfonamides (acetylsulfamethoxazole, sulfadiazine, and acetylsulfisoxazole) between 1980 and 1987. The incidence of sulfonamide stones is less than 1% of stones. Patient characteristics were determined from questionnaires sent to the patients and attending physicians. The majority of patients developed symptoms 1 to 4 weeks after beginning sulfonamide therapy. The bladder was the most common stone location. Obstruction of the urinary system by the acetyl derivatives of the drug is the most serious consequence of sulfonamide therapy. Early recognition of drug-related stones is essential to protect patients from recurrences, reduce the risk of renal complications, and avoid continuing ineffective therapeutic regimens.