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Lower extremity neuropathies from prolonged lithotomy positioning have been well documented. When we initiated our robot-assisted laparoscopic prostatectomy (RALP) program in December 2002, we chose to use the split-leg table that allows patient support in a more anatomic position, hypothesizing that this would reduce risk of neurologic compression injuries. We report our incidence of lower extremity neuropathies associated with RALP using split-leg positioning and review patient and surgical variables associated with this complication.We retrospectively reviewed records of 377 patients who underwent RALP using a split-leg table. Patient data including height, weight, body mass index, age, and smoking status; surgical variables such as surgeon operative experience and intraoperative times were also assessed. Intraoperative time was defined as anesthesia induction to anesthesia emergence to more accurately measure total time patients spent in the split-leg position.Of 377 patients, lower extremity neuropathies developed in 5 (1.3%) in the immediate postoperative period. Of all variables examined, only increased intraoperative time was identified as a potential risk factor for the development of this complication (496.2 ± 34.8 min vs 366.3 ± 96.1 min, P0.001). Overall mean operative time for all patients was 368.0 ± 96.6 minutes. Three of the five patients had symptoms suggestive of a femoral mononeuropathy.Intraoperative time as defined in our study is a significant risk factor for development of postoperative neuropathy. We also found that split-leg positioning appears to put the femoral nerve at risk for injury, instead of the common peroneal nerve as has been previously reported from prolonged lithotomy positioning.

Robot-assisted laparoscopic prostatectomy is rapidly gaining favor as a minimally invasive method to surgically address prostate cancer. The sophisticated equipment and unique positioning requirements of this technology require exceptional preparation and attention to detail to minimize the chance of surgical complications. We present the case of a 57-year-old man who developed left calf compartment syndrome after (robot-assisted laparoscopic prostatectomy) requiring fasciotomies. We use this example to highlight specific areas of risk unique to the da Vinci Surgical System® using intraoperative photos to show danger areas as well as review basic positioning requirements common to all prolonged pelvic surgeries performed in Trendelenburg position.

Purpose: With the exponential growth of robotic urological surgery, particularly with robot assisted radical prostatectomy, guidelines for safe initiation of this technology are a necessity. Currently no standardized credentialing system exists to our knowledge to evaluate surgeon competency and safety with robotic urological surgery performance. Although proctoring is a modality by which such competency can be evaluated, other training tools and guidelines are needed to ensure that the requisite knowledge and technical skills to perform this procedure have been acquired. We evaluated the current status of proctoring and credentialing in other surgical specialties to discuss and recommend its application and implementation specifically for robot assisted radical prostatectomy.Materials and Methods: We reviewed the literature on safety and medicolegal implications of proctoring and the safe introduction of surgical procedures to develop recommendations for robot assisted radical prostatectomy proctoring an...

A current dilemma is how to incorporate robot assisted laparoscopic radical prostatectomy (RALP) into residency/fellowship programs while containing costs and maintaining acceptable operative times. We prospectively analyzed factors that affect the time of nine separate RALP steps performed in a residency/fellowship training program incorporating the da Vinci robot.A prospective evaluation of 50 consecutive RALP performed by a single surgeon while incorporating trainees was completed. RALP was divided into nine segments, and time of each segment was recorded in minutes. Who performed each portion of the procedure (resident, fellow, or attending surgeon) was also analyzed. The effects of clinical and prostate cancer characteristics were analyzed statistically to investigate associations with procedure completion times for each of the nine segments. Outcomes, including complications and urinary continence, were recorded.Mean age was 58 years, and body mass index was 30 kg/m(2). Mean prostate size was 49.2 grams. Nine patients (18%) had pathologic T(3) disease, and 10 patients (20%) had positive surgical margins. Median total operative time was 276 minutes (range 245-330 min). There was no statistical association with any clinical parameter prolonging total operative time or those of the nine individual steps of the operation. Locally weighted smooth time plots demonstrate stable decreases in all segments with experience. The slowest decreases were seen in bladder neck and neurovascular bundle times. Anastomosis time fluctuated the most.RALP can be incorporated successfully into a residency/fellowship training program with acceptable operative times and outcomes even while the supervising physician is on his "learning curve."

The field of endourology, which encompasses genitourinary endoscopy and percutaneous, laparoscopic, and robotic surgery, has advanced rapidly over the past quarter century, causing endourology to be considered a subspecialty of urology. The Endourological Society, which is recognized by the American Urological Association, offers numerous clinical and research fellowship opportunities throughout the world. The decision to seek postresidency fellowship training in endourology is complex as is the process of seeking subsequent employment. We offer guidance on the decision-making process to obtain fellowship training as well as on early steps into subsequent academic or private practice settings.

There is a recognizable increase in the incidence of renal cell carcinoma and a parallel rise in the surgical management of renal cell carcinoma has occurred. However, recent literature shows that not all small, suspected renal cell carcinoma needs to be treated surgically, especially in elderly patients or those with multiple medical comorbidities. The surgical options for renal cell carcinoma have expanded from traditional open nephrectomy to partial nephrectomy and, at present, more recent outcomes data are available for the laparoscopic versions of these surgeries. Short-term results of thermal ablative technology (radiofrequency and cryoablation) show real promise as minimally invasive therapies. This review examines the most up-to-date outcomes and future directions of the surgical management of renal cell carcinoma.

OBJECTIVES Medical therapy often fails to cure benign retroperitoneal fibrosis (RPF), necessitating a surgical approach. Preoperative and postoperative adjuvant medical therapy and the timing of surgical intervention are not well-established. We surveyed centers of laparoscopic excellence to determine the current practices in the treatment of RPF. METHODS Surveys were sent to all institutions with Endourological Society-recognized fellowships. The data collected were analyzed for trends in the treatment of RPF. Additional information was collected from participating institutions to better characterize the experience with laparoscopic ureterolysis and adjunctive medical management. RESULTS Of the surveys sent out, 17 completed surveys were returned (41%). A total of 73 patients had been treated for RPF. Most centers (13 of 17) used a conventional laparoscopic approach with rare conversion to hand assistance. The medical management of RPF was directed by urologists, rheumatologists, or other specialists in 59%, 24%, and 18% of institutions, respectively. Steroid therapy was administered preoperatively by 15 of 17 centers. Postoperatively, 10 of 17 centers continued treatment with steroids and/or cytotoxic agents. Eight institutions provided data on 46 renal units in the second part of the study. The success rate of laparoscopic ureterolysis per renal unit was 83% (38 of 46). No difference was seen in the outcomes of patients who received adjuvant medical therapy compared with those who did not (16 of 19 versus 22 of 27; P = 0.48) after a mean follow-up of 17.7 months. CONCLUSIONS The results of this study have shown that no uniform treatment algorithm exists for RPF at centers of laparoscopic excellence. Most institutions recommended an attempt at steroids followed by laparoscopic ureterolysis. Laparoscopic ureterolysis had a high success rate, and adjuvant medical therapy did not appear to contribute to the success rate.

We determined the current status of residency training in laparoscopic and robotic surgery in the United States and Canada.A total of 1,188 surveys were sent via the Internet to all 1,056 current urology residents and 132 program directors with an Internet address registered with the American Urological Association.Responses were received from 372 residents (35%) and 56 program directors (42%). Of respondents 47% reported greater than 100 laparoscopic procedures performed yearly by 1 (36%) or more (51%) faculty members. Robotic procedures were performed at 54% of the institutions, mainly consisting of prostatectomy and pyeloplasty. At all institutions laparoscopic radical nephrectomy was performed and those at 69% of the institutions believed that it is the gold standard for renal tumors today. Urologists were involved in 87% of adrenal surgeries and 54% of respondents believed that is the gold standard approach. However, only 35% of respondents had participated in laparoscopic adrenalectomy. Of respondents 36%, 42% and 17% reported that laparoscopic donor nephrectomy was performed by only urologists, only a nonurology transplant team and shared equally, respectively. Of respondents 41% planned on performing laparoscopic donor nephrectomy in the next year. Laparoscopic needle ablation renal surgery was done in 51% of the programs and percutaneous needle ablation was done in 63%. None of the respondents (0%) believed that it is the gold standard but 51% believed that ablative procedures look promising for renal tumors. Of respondents 39% had participated in robotic radical prostatectomy and 53% thought that it looked promising but was not the gold standard. Of respondents 31% believed that they will be performing robotic surgery after residency, 30% were unsure and 29% will not be using the robot. Overall 38% of residents thought that their laparoscopic experience was at least average or acceptable.A large number of laparoscopic urological procedures are being performed at training institutions with robotic procedures being performed at 54% of respondent facilities. Residents are participating in most cases but only 38% consider their laparoscopic experience to be satisfactory. A need still exists for increased laparoscopic training for residents, which can be accomplished by expanding training facilities and increasing the number of faculty members performing laparoscopic procedures.

We developed models to predict post-laparoscopic radical or simple nephrectomy (LapNx) and post-laparoscopic partial nephrectomy (LapPNx) hospital duration of stay (DOS).We performed a retrospective review (design group) of all 726 patients (July 1997 to April 2004) who underwent LapNx or LapPNx at the Cleveland Clinic Foundation (CCF). Preoperative findings were recorded. Neural network algorithms were designed to predict the DOS before surgery. The models were then tested on a separate 252 patients from 6 different institutions, namely Tulane University Medical School, University of Arkansas for Medical Sciences, Cedars-Sinai Medical Center, University of Iowa, Mayo Clinic at Scottsdale and CCF.In the CCF design groups, the LapNx model accuracy was 73% to 74% and the LapPNx model 73% to 83%. Overall accuracy in the test groups at all 6 institutions was 72% (area under ROC 0.6 to 0.7) for the LapNx model and 52% to 81% (ROC 0.5 to 0.7) for the LapPNx model.The LapNx model provides 72% accuracy in predicting the DOS at all 6 institutions. The LapPNx model provided fair accuracy only at CCF and Tulane University Medical School. These models may streamline the delivery of care and continued testing will allow for further refinement.

Obtaining a negative surgical margin during laparoscopic partial nephrectomy (LPN) is paramount to optimizing the oncologic efficacy of the procedure. Limitations of laparoscopy hinder the ability to extrapolate the intraparenchymal tumor extension from the exophytic portion. We developed a technique wherein ultrasound-confirmed needle localization of the deep tumor margin prior to tumor extirpation ensured negative surgical margins.Our technique was developed and initially tested using an agar-based ultrasound phantom designed to mimic 2-cm exophytic renal tumors. Needle placement was imaged with ultrasonography and subsequently correlated with findings on sectioning of the tumor mimic. Laparoscopic extirpation of the tumor mimic following needle placement was carried out in a pelvic trainer. The technique has subsequently been incorporated into our LPN technique in four patients.Ultrasound-confirmed needle localization of intraparenchymal tumor extension was feasible and reproducible in an ultrasound phantom. Ultrasound findings correlated with gross findings. Needle placement prior to tumor resection helped to ensure negative surgical margins when applied in the pelvic trainer and when used in three patients. In the remaining patient, improper needle placement resulted in a grossly positive deep margin.Ultrasound-confirmed needle placement effectively and reproducibly marks the deep margin of small renal tumors in a mimic as well as in vivo. Our needle technique eliminates the guesswork and unreliability associated with mental visualization and extrapolation of tumor extent during LPN.

We examined the status of laparoscopy in urology and the impact of residency and fellowship training on the performance of laparoscopy as primary surgeon. We also examined whether performing nonsurgical tasks requiring two-handed dexterity had any link to the adoption of laparoscopic techniques by urologists.A total of 8760 laparoscopy questionnaires containing 135 queries were mailed to urologists listed on the American Urological Association practicing urologists mailing list. The questions sought information on area of practice, time in practice, fellowship training, ambidexterity, laparoscopic experience, and experience with robotics. The response rate was 1.8% (155 of 8760).There appeared to be no significant correlation between the performance of laparoscopic surgery and participation in activities requiring bimanual dexterity. However, a correlation of strong statistical significance did exist between laparoscopic residency training and performance of laparoscopy after residency (p=0.003. There also was a correlation between fellowship training in laparoscopy/endourology and doing laparoscopy as primary surgeon.Participation in laparoscopic surgery during residency training is a major determining factor in performance of laparoscopy as a primary surgeon in practice. Younger surgeons trained in laparoscopy during residency are performing more laparoscopy post residency than those without laparoscopic training during residency. At present, there is a need to train more urologists in laparoscopy at the postgraduate level.

A duplex kidney associated with a poorly functioning upper-pole segment is commonly associated with incontinence, voiding dysfunction, and urinary tract infections. A standard treatment option for this condition is upper-pole heminephrectomy. With the continued development of minimally invasive urology, this technique can now be safely performed laparoscopically. This report details step by step our technique of laparoscopic upper-pole heminephrectomy. Key points include placement of a catheter in the normal ureter at the start of the case, full mobilization of the upper-pole ureter away from the renal hilum, and precise identification of the vasculature supplying the upper pole. Laparoscopic upper-pole heminephrectomy for ectopic ureter is safe and reproducible and offers the patient the typical postoperative benefits of laparoscopic surgery.

To determine the current practice patterns of a large group of urologists in the treatment of large renal stones.A survey was sent to all actively practicing members of the North Central Section of the American Urological Association. The questions pertained to age, time in practice, type of practice, time devoted to treating stones, residency training, case scenarios with treatment options, and whether they or a radiologist performed percutaneous access. The data were statistically analyzed.The response rate was 51% (564/1102 surveys returned). Three quarters (73%) of the urologists were comfortable performing percutaneous nephrolithotomy (PCNL), and 35% gave reasons they do not perform PCNL. Only 11% of those performing PCNL routinely obtained the percutaneous access themselves. Trends in the analysis included: (1) those trained to perform PCNL during residency were more often comfortable with this procedure; (2) younger urologists were more comfortable performing PCNL, even if they had been in practice for only a short time; (3) urologists in private practice were nearly as comfortable performing PCNL as were academic urologists; (4) urologists not comfortable with PCNL more often recommended SWL over PCNL as a primary treatment for moderate/large renal stones; and (5) few urologists routinely obtained percutaneous access themselves.Many urologists trained in recent years are comfortable performing PCNL. The type of training received influences treatment recommendations, and percutaneous access is most often obtained by/in conjunction with radiologists. This information may be useful in guiding residency training programs in the preparation of residents for the treatment of large renal stones.

Purpose: In the interest of maintaining our surgical domain we performed a survey aimed at establishing laparoscopic practice patterns as they pertain to urological disease.Materials and Methods: Surveys were mailed to 2,902 surgeons in California who were listed with the American College of Surgeons, including 2,175 general surgeons, 510 urologists and 217 obstetricians-gynecologists.Results: A total of 442 complete responses (15.2%) were tallied. Of urologists and of nonurologists 54% and 11% performed no laparoscopy, while 12% and 80%, respectively, devoted at least 5% of their time to laparoscopic surgery. Urologists and nonurologists performing no laparoscopy were older than those performing a significant volume (p < 0.05). Of urologists 16% thought that they were trained adequately during residency to perform laparoscopic surgery compared with 30% of nonurologists. Of the urologists who performed hand assisted laparoscopy 50% tended to use it as a means of gaining familiarity with these techniques. ...

Partial nephrectomy is a more challenging operation than radical or simple nephrectomy, primarily because of the risk of complications such as bleeding. This problem is even more troublesome with minimally invasive approaches because of the dearth of effective hemostatic instruments and supplies. The location of the lesion determines whether a transperitoneal or a retroperitoneal route will be employed. Centrally located or anterior renal lesions generally are approached transperitoneally whereas peripheral lateral or posterior lesions are accessed by retroperitoneoscopy. The Harmonic Scalpel with slow cutting and high coagulation settings is useful for incising the renal capsule and parenchyma. The argon beam coagulator is helpful to stop any persistent bleeding. The few reported series of laparoscopic partial nephrectomy indicate considerably longer operative times than are needed for open surgery and hospitalization of upwards of 5 days, largely to monitor drainage and urine leakage. It is hoped that this advanced laparoscopic technique will become more user friendly with further developments in techniques and instrumentation to provide patients with the expected benefits of minimally invasive surgery.

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 urologist laparoscopy practice patterns 5 years after a postgraduate training course in urological laparoscopic surgery. Results were compared to findings from similar studies performed on the same cohort at 3 and 12 months after training.Materials and Methods: Between January 1991 and November 1992, 11, 2-day university sponsored, postgraduate laparoscopic surgery training programs were held. A survey was mailed to the 322 North American participants in the summer of 1997 to determine current laparoscopic use and experience.Results: Of the 166 respondents (51% response rate) 53.6% (89) had performed 1 or more laparoscopic procedures in the previous year, compared to 84% 1 year following course completion. Of the respondents 37% believed their laparoscopic experience was sufficient to maintain skills compared to 66% at 1 year. Of the respondents 6% had performed more laparoscopic procedures while 82% had performed fewer than anticipated. Reasons cited for decreased use include...

Objectives. To report the initial series of needlescopic transperitoneal adrenalectomy and to compare the results with a contemporary series of conventional transperitoneal laparoscopic adrenalectomy performed at the same institution. Methods. Fifteen patients underwent needlescopic adrenalectomy over a 4-month period. Outcome data were retrospectively compared with 21 conventional laparoscopic adrenalectomies performed over the preceding 12-month period at the same institution. The needlescopic technique included three subcostal ports (two, 2 mm; one, 5 mm) and one umbilical port for ultimate specimen extraction (10/12 mm). The laparoscopic technique included four subcostal ports (all 10/12 mm). Endoscopic transperitoneal adrenalectomy was completed by the standard technique in both groups. Results. Baseline demographics were comparable between the needlescopic (n = 15) and laparoscopic (n = 21) groups. The needlescopic group had a shorter surgical time (169 versus 220 minutes, P = 0.05), less blood loss (61 versus 183 mL, P = 0.002), and shorter hospital stay (1.1 versus 2.7 days, P < 0.001). Convalescence averaged 2.1 weeks in the needlescopic group and 3.1 weeks in the laparoscopic group (P < 0.001). No significant complications occurred in either group. One patient in the needlescopic group was converted to conventional laparoscopy because of marked obesity; hospital stay in this patient was 2 days. Conclusions. Reported herein is the initial series of needlescopic adrenalectomy. Compared with conventional laparoscopy, needlescopic adrenalectomy results in an overnight hospital stay, rapid recovery, and excellent cosmesis. However, prior experience with conventional laparoscopy is essential before embarking on needlescopic surgery.

Objectives Reports of abdominal wall tumor implantation after laparoscopic procedures have raised questions regarding the safety of laparoscopic surgery when applied to patients with malignancies. Our objective was to determine if laparoscopic pelvic lymph node dissection (LPLND) had a negative effect on tumor behavior and clinical outcome in men with Stage T1-3, N1-3, MO (DI) prostate cancer. Methods Fifty-two men were retrospectively identified at four institutions who had pelvic nodes positive for metastatic prostate adenocarcinoma at LPLND and at least 1 year of follow-up. Operative and clinical records were reviewed to determine morbidity, adjuvant treatment, onset of hormone-resistant disease, and survival. Results During a mean follow-up of 3.1 years, there were no cases of trocar site tumor implantation. There were four perioperative complications, including enterotomy, epigastric vessel injury, abscess, and symptomatic lymphocele formation. There were three deaths from prostate cancer (5.8%) occurring 3 to 4 years after LPLND. For the 45 men treated with early androgen ablation, the 5-year biochemical prostate-specific antigen and clinical progression free rates were 45% and 55%, respectively. Conclusions Abdominal wall tumor implantation after LPLND for prostate cancer was not demonstrated, even in patients who developed hormone-resistant disease. LPLND in men with Stage D1 disease did not alter short-term disease progression. Longer follow-up in a larger cohort is necessary to determine if LPLND will have an impact on the 5 and 10-year disease progression and survival rates for patients with Stage D1 prostate cancer.

In the past 15 years there have been significant advancements in minimally invasive surgery, best characterized by laparoscopic intervention. Urologic diagnostic applications of laparoscopy have existed since the mid-1970s, when it first was used to explore for nonpalpable testes. 4 It was not until the early 1990s, however, with improvement in video-optics and instrumentation, that laparoscopic surgery gained real credibility. Since then, laparoscopic pelvic lymph node dissection, 15 varix ligation, 5 nephrectomy, 3 bladder neck suspension, 1 pyeloplasty, 12 and an ever-growing list of extirpative and reconstructive urologic procedures have been performed and evaluated. 8 With the improvement of cross-sectional imaging (CT and MR imaging scans), incidental adrenal lesions are detected more commonly, whereas functioning adrenal tumors continue to be rare but they normally require medical or surgical treatment. Open adrenalectomy may be performed by a posterior, flank, or transperitoneal anterior approach; however, in many cases a substantial incision must be made to access the deep retroperitoneal location of the often small and elusive adrenal tumor. Postoperative pain is considerable, often requiring the use of epidural catheters for analgesia. Increased risk of infection, especially in patient's with Cushing's syndrome, may result because of large painful incisions in the upper abdomen with development of atelectasis and pneumonia. Morbidity of open adrenalectomy has been reported to be as high as 40%, with mortality in the range of 2% to 4%. 10,11 The laparoscopic approach to the adrenal gland offers a minimally invasive procedure with markedly improved postoperative characteristics. Laparoscopic adrenalectomy first was reported by Gagner 7 in 1992 and has subsequently been found to have great use among European and Asian urologists. 9,13 This article describes the authors' indications for and approach to laparoscopic adrenalectomy and their preliminary results.

Purpose: Laparoscopic pelvic lymph node dissection is an effective and minimally invasive approach to the clinical staging of adenocarcinoma of the prostate. We report our experience with this technique in patients in whom full course pelvic radiotherapy had failed and who were being considered for salvage local therapy.Materials and Methods: In 14 patients disease was staged by transperitoneal laparoscopic pelvic lymph node dissection performed for persistent adenocarcinoma of the prostate at least 20 months (average 49.5) following external beam radiotherapy and/or brachytherapy. All patients were healthy, had no evidence of metastatic disease and were considered to be candidates for salvage therapy.Results: A total of 13 patients underwent successful laparoscopic pelvic lymph node dissection while 1 sustained an enterotomy requiring conversion to open surgery. The normal surgical planes were more difficult to dissect, with the obturator lymph node packets appearing smaller and more fibrotic tha...

The surgical treatment of prostatic obstruction associated with a clinically significant bladder diverticulum has classically combined open diverticulectomy with relief of the bladder outlet obstruction. This report demonstrates that this result may be efficiently achieved by performing transurethral surgery followed immediately by laparoscopic excision of the diverticulum. As assessed by a retrospective comparison with four open bladder diverticulectomies combined with transurethral resection of the prostate, laparoscopic diverticulectomy markedly reduces the postoperative and convalescence period. The overall financial saving that ensues may benefit both the patient and the healthcare system. Sequential laparoscopic bladder diverticulectomy and transurethral resection of the prostate illustrates the increasing possibilities of minimally invasive surgery.

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

In 1994, it was reported that laparoscopic pelvic lymph node dissection (L-PLND) was US $1350 more expensive than open pelvic lymph node dissection (O-PLND) for the staging of prostate cancer. Despite the lower postoperative expenses associated with L-PLND, the intraoperative expenditures were 52% higher, primarily because of the prolonged operating time and the cost of disposable instrumentation. The objective of the present study was to determine if, with increasing laparoscopic experience and a more competitive surgical supply market, the intraoperative as well as the overall hospital expenses would diminish. The study population consisted of 105 men who underwent staging L-PLND for cancer of the prostate. Group I was composed of 50 patients who underwent surgery between 1990 and 1992, and Group II consisted of 55 patients operated on in 1993 and 1994. All hospital-related expenses were reorganized into preoperative, intraoperative, and postoperative and subsequently corrected for inflationary changes to a base year of 1993-1994. The total overall expenses of the two groups were similar, differing by only $65. Despite a lowering of preoperative and postoperative expenses in the 1993-1994 group by 112% and 31%, respectively, the intraoperative expenses were still $571 higher. The operative time decreased by 19 minutes in the contemporary group, but the expense of surgical supplies continued to increase up to $910 (104%) more than the 1990-1992 group. It is hoped that the use of "laparoscopic kits" as well hospital equipment consortiums will help slow the escalating costs of surgical care. However, it is the responsibility of the laparoscopic surgeon to demonstrate that these procedures are as safe, efficient, and cost-effective as their open counterpart.

Young patients with impotence and cavernous arterial insufficiency resulting from trauma-induced arterial occlusive disease are ideal candidates for microvascular arterial bypass surgery. To avoid the long abdominal incision required to harvest the inferior epigastric artery, a laparoscopic approach was used. We report a case of laparoscopically assisted penile revascularization for vasculogenic impotence.

During an 18-month period, 6 laparoscopic partial nephrectomies were attempted, 4 of which were successful. The surgical technique was modified and improved between cases aided by new laparoscopic instrumentation, such as the argon beam coagulator and the 7.5 MHz. ultrasonic sector scanning system. In a retrospective comparison between laparoscopic and open partial nephrectomy, estimated blood loss was 525 ml. for the former versus 708 ml. for the latter procedure. However, operating time was more than 2 hours longer with the laparoscopic approach. The major advantages of the laparoscopic procedure appear to be a more rapid return to full diet, less postoperative pain and less requirement for parenteral narcotics. Despite the small size of this series and limited followup data, convalescence may be shortened by 4 weeks after laparoscopic partial nephrectomy. Patients with benign diseases of the kidney, especially with a duplicated collecting system, who require partial nephrectomy may be considere...

The treatment of intrinsic urethral weakness (Type III stress urinary incontinence) has traditionally been accomplished by the performance of a sling cystourethropexy or the placement of an artificial urinary sphincter. As experience with operative laparoscopy continues to increase, the possibility of performing these procedures from a laparoscopic approach becomes realistic. We report our experience with the laparoscopic performance of a sling cystourethropexy and placement of an artificial urinary sphincter in the canine model. On the basis of initial results, we believe these techniques are feasible in human subjects.

To determine laparoscopic and robotic surgical practice patterns among current postgraduate urologists.There were 9,095 electronic surveys sent to practicing urologists with e-mail addresses registered with the American Urological Association.Responses were received from 864 (9.5%) urologists; 84% report that laparoscopic or robotic procedures are performed in their practice. The highest training obtained by the primary laparoscopist was fellowship (31%), residency (23%), or 2- to 3-day courses (22%). Eighty-six percent report performance of laparoscopic nephrectomy in their practice, and 71% consider it the standard of care. Sixty-six percent of practices have access to at least one robotic unit, and 9% plan on purchasing one within a year. Attitudes toward robotics are favorable, with 80% indicating that it will increase in volume and potential procedures. Thirty-one percent state that robot-assisted prostatectomy is standard of care, while 50% believe this procedure looks promising. Respondents think that optimal training in minimally invasive techniques is fellowships (23%), minifellowships (23%), or hands-on courses (23%). Twenty-nine percent think that they were trained adequately in laparoscopy and robotics from residency, and 62% believe residents should be able to perform most laparoscopic procedures on completion of residency.The practice and availability of laparoscopic and robotic procedures have increased since previous evaluations. Opinions regarding these techniques are favorable and optimistic. As the field of urology continues to see a growing demand for minimally invasive procedures, training of postgraduate urologists and residents remains essential.

On February 12, 1992, a laparoscopic partial nephrectomy was performed on a woman with a lower-pole caliceal diverticulum containing a stone. By incorporating the laparoscopic argon beam coagulator and a tourniquet device, the procedure was completed in 6 hours and 10 minutes. The postoperative course and period of convalescence was markedly improved over that expected from open surgery. This laparoscopic intervention demonstrates the expanding horizons of minimally invasive surgery and the remarkable development of new laparoscopic devices.

Operative laparoscopy offers the patient a minimally invasive alternative to open surgery. We have recently performed a laparoscopic nephrectomy of the upper moiety of a crossed fused renal ectopia. The procedure lasted approximately six hours, and the patient was discharged on postoperative day 3. He was able to resume normal physical activity in one week. This case demonstrates the adbantages of minimally invasive surgery.

We compared the nodal yield and volume of target tissue removed in 3 groups of patients undergoing laparoscopic pelvic lymphadenectomy as a staging procedure for carcinoma of the prostate. With the exception of the type of peritoneotomy used to expose the obturator fossa, surgical management of all patients was identical. Results were evaluated in patients undergoing linear peritoneotomy (40), inverted V peritoneotomy (14) or both procedures (28, 1 approach on each side). Significantly more tissue was removed from patients in the inverted V group (16.3 +/- 8.3 cm.3) compared to the linear peritoneotomy group (7.2 +/- 5.7 cm.3, p = 0.004). This resulted in a significant increase in nodal yield in patients in the inverted V group (11.0 +/- 4.1) relative to the linear peritoneotomy group (6.8 +/- 5.2, p = 0.003). In terms of the volume of tissue removed and the number of nodes obtained, combination patients had values intermediate to those in the other groups (11.6 +/- 10.5 cm.3 and 8.8 +/- 5.6 nodes, respectively). The right-to-left ratio of nodes and tissue volume was reversed in the combination group relative to the other 2 groups. Operative time was significantly decreased for the inverted V technique compared to the linear peritoneotomy approach (p = 0.01). No difference in operative blood loss of complications was identified. The improved exposure obtained with this technique appears to result in a more complete lymphadenectomy without increased risk of complications.

Intraoperative and postoperative complications were assessed in the first 372 patients undergoing laparoscopic pelvic lymph node dissection at 8 medical centers. In 16 patients laparoscopic node dissection could not be completed due to patient body habitus or technical difficulties. Of these aborted procedures 14 occurred during the initial 8 dissections at each institution. A total of 55 complications (15%) occurred: 14 were noted in the intraoperative and 41 in the postoperative period. Of these patients 13 required open surgical intervention for the treatment of a complication. Complications included vascular injury (11 patients), viscus injury (8), genitourinary problems (10), functional/mechanical bowel obstruction (7), lower extremity deep venous thrombosis (5), infection/wound problem (5), lymphedema (5), anesthetic complications (2) and obturator nerve palsy (2). Based on our experience, there is a significant learning curve associated with performing laparoscopic pelvic node dissection. However, with experience and adherence to laparoscopic surgical principles, the risk of complications may be minimized.

Laparoscopic renal surgery has become a standard of care over the past decade worldwide. Although more complex laparoscopic renal procedures are being routinely performed worldwide today, complications can occur with any laparoscopic operation. Intraoperative and postoperative complications may occur in patients undergoing laparoscopic renal procedures by urologic surgeons with all degrees of laparoscopic experience. We reviewed the complication rate in patients undergoing laparoscopic renal procedures at a single institution by an experienced laparoscopic surgeon.We retrospectively reviewed the electronic medical records of patients who underwent laparoscopic renal surgery at the University of Iowa from August 2001 to November 2008.Four hundred twenty-one consecutive laparoscopic renal operations were performed by a single surgeon, consisting of 168 radical nephrectomies, 99 donor nephrectomies, 52 simple nephrectomies, 66 partial nephrectomies, and 36 nephroureterectomies, with a total of 52 complications (12.3%): 20 (11.9%) for radical nephrectomy, 9 (9%) for donor nephrectomy, 3 (5.8%) for simple nephrectomy, 12 (18.2%) for partial nephrectomy, and 8 (22.2%) for nephroureterectomy. The vast majority of complications were minor and resulted in no residual disability.Despite its advantages, laparoscopic renal surgery is not without its inherent risk of complications for the patient, and a thorough informed consent is crucial to maintain realistic patient expectations. Our results reveal complication rates comparable to those of published series in the literature.

In 1991, Schuessler et al. first reported the application of laparoscopic pelvic lymph node dissection (L-PLND) for staging of adenocarcinoma of the prostate (1). Subsequently, laparoscopic-limited obturator PLND, and in select cases, extended obturator and iliopsoas node dissection, has become the primary initial application of urologic laparoscopic surgery as a diagnostic and therapeutic technique (2). Follow-up studies on L-PLND clearly indicated that this procedure was comparable in accuracy and significantly less morbid than open PLND (Table 1) (3–6). While early studies showed a longer operative time for L-PLND, they also demonstrated a significant reduction in postoperative pain, hospitalization, and convalescence compared with open PLND (3–5). As expected, L-PLND initially showed an increased overall cost. However, with gradual refinements of technique, reusable equipment, and a reduced need for specialized instrumentation, overall cost is now likely to be equivalent to or less than open PLND (7–9). More recently, robot-assisted L-PLND has been performed in conjunction with robot-assisted laparoscopic radical prostatectomy, both by the transperitoneal and extraperitoneal routes. The cost effectiveness of this procedure is unclear in light of the need for significant capital investment in the robotic device, its maintenance, and the ongoing need for limited reusable accessories.

Laparoscopic pelvic lymphadenectomy, already becoming established for cancer of the prostate, also can be used in cancers of the bladder, penis, and urethra. The author discusses his experience wit...

We have performed 47 translaparoscopic varix ligations in 35 patients (23 unilateral and 12 bilateral). The spermatic artery has been spared in 94% of cases and in all cases since instituting the use of the Nd:YAG laser with a contact probe for coagulation of small veins adherent to the spermatic artery. Preliminary follow-up indicated only one recurrent varicocele (2.9%). The average time required by the patients to resume their preoperative levels of activity was 3.7 days, and the average analgesic use was 9.2 tablets of acetominophen with codeine. Of 12 patients treated for male factor subfertility who completed 1 year of follow-up, 5 have reported pregnancies (42%). Laparoscopic varix ligation provides an alternative to other operative techniques with reduced time to full recovery and minimal analgesic requirements.

OBJECTIVES To examine whether simple tips and tricks provided in this manuscript and video make robotic reconstruction of the urinary tract possible from the renal calyx to the bladder. The da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) has been widely accepted by urologists for complex reconstructive maneuvers such as radical prostatectomy and pyeloplasty. METHODS The manuscript and accompanying video outline tips and tricks for patient selection, patient evaluation, port placement, dissection techniques, robotic docking, ureteral repair, and stent management for complex urinary tract reconstruction of the upper urinary tract from the level of the renal calyx to the bladder. RESULTS Modifications such as port placement, robotic docking techniques, and ureter reconstruction have simplified the technique of complex robotic-assisted laparoscopic reconstruction of the urinary tract. CONCLUSIONS Numerous scenarios can be encountered during robotic-assisted laparoscopic repair of the upper urinary tract. Simple tips and tricks provided in this manuscript and video make robotic reconstruction of the urinary tract possible from the renal calyx to the bladder.

Many authors who report outcomes of laparoscopic cryoablation for renal tumors comment that real-time intracorporeal ultrasonographic monitoring of the ice-ball formation is imperative. In our experience, ultrasonographic monitoring of the ice-ball formation necessitates significantly more mobilization of the kidney, and the images are difficult to interpret because of artifact and the cryoablation effect on the tissue. We report our intermediate outcomes for laparoscopic cryoablation without real-time ultrasonographic monitoring of the ice ball.Between December 2002 and May 2007, 27 patients underwent laparoscopic renal cryoablation. The cryoablation approach was based on tumor location and surgeon preference. Lesions were identified and overlying fat was excised, without further mobilization. Real-time ultrasonographic measurement and mapping of the renal lesion were performed. All lesions were biopsied before cryoablation. A double 10-minute freeze-thaw cycle was performed. Postoperative follow-up comprised serial imaging at months 1, 3, 6, and 12 and yearly thereafter.Mean patient age was 70.1 years with a mean renal tumor size of 2.2 cm. Sixteen (59.3%) patients had more than three comorbidities and six (22.2%) patients had two comorbidities with at least 1 previous intra-abdominal surgery. An average of four cryoablation probes were used per lesion. The serum creatinine level was 1.3 mg preoperatively and 1.4 mg at last follow-up. At follow-up of 22 months, there were no local recurrences and 1 (3%) metastatic lesion.Laparoscopic cryoablation of small renal masses continues to be a safe and effective technique, even without the use of real-time ultrasonographic monitoring of the ice ball.

Although multiple series of helium insufflation-assisted laparoscopic surgery are reported, we encountered difficulty at many levels when arranging a laparoscopic nephrectomy with helium insufflation. We present our experience with attempting to use helium gas as an insufflant and our successful use of argon gas as an adjunct to CO(2) insufflation with a case report as illustration.The patient is a 66-year-old man with a progressively enlarging 3.1-cm right renal mass. His history is significant for severe chronic obstructive pulmonary disease, necessitating home oxygen and frequent cycles of steroids. In line with the patient's desire for a minimally invasive procedure, we scheduled a laparoscopic nephrectomy with helium gas. Helium tanks need specialized adapters (yoke) to connect to laparoscopic insufflators; once the yoke was located, we were informed that helium is not approved by the Food and Drug Administration for use as an insufflant and we could not proceed with its use without a full hospital institutional review board review. We elected to use low-pressure CO(2) insufflation augmented by argon gas insufflation via the argon beam coagulator.The patient tolerated the low-pressure CO(2) /argon gas pneumoperitoneum without difficulty. There were no significant changes in the hemodynamic variables throughout the procedure. This patient was extubated at the completion of the procedure, and there were no intraoperative or postoperative complications.Although numerous reports and case series exist regarding the use of helium as an alternate insufflation agent to CO(2), the logistics of obtaining the correct helium yoke and hospital approval are cumbersome for this rarely indicated agent. A far simpler alternative, with similar physiologic effects, is the use of argon gas as an adjunct to CO(2) insufflation, or in lieu of CO(2) insufflation.

Since it first was performed in 1995, laparoscopic donor nephrectomy (LDN) has grown to be the standard of care in most transplant centers in the United States. This article reviews the current indications, selection criteria, surgical approaches, outcomes, and complications of LDN.

Symptomatic presentation of a completely duplicated collecting system with upper-pole ectopic ureteral insertion is rare in the adult. We present a case of a 52-year-old man with recurrent prostatitis and hematuria secondary to an ectopic ureteral insertion from a left upper-pole moiety in a completely duplicated collecting system. He underwent a robot-assisted laparoscopic ureteropyelostomy with good results. We describe our technique in this unusual case.

Hyper-reninemic hypertension as a result of renal compression is often referred to as a "Page" kidney. We present a case of a patient with bilateral Page kidneys from subcapsular hematomas as a complication of extracorporeal shock wave lithotripsy. After several attempts at percutaneous and laparoscopic drainage of the fluid collections, she was referred for definitive management with laparoscopic decortication and capsulotomy. Bilateral laparoscopic surgery was performed in a staged fashion, using a novel technique of radial incision inner capsulotomy, with resolution of the patient's hypertension. We report our technique and factors to consider in the management of Page kidney.

Purpose: We investigated the effect of lower extremity joint prostheses on subsequent laparoscopic pelvic lymph node dissection.Materials and Methods: We reviewed the records and pathology studies of 5 patients who underwent laparoscopic pelvic lymph node dissection subsequent to total hip or knee replacement from 1990 through 1995.Results: Four of the 5 laparoscopic operations were complicated, 3 were unsuccessful in obtaining bilateral pelvic lymph nodes and 2 required conversion to an open procedure. Examination of the lymph nodes revealed sinus histiocytosis in the 4 cases in which nodal tissue was removed.Conclusions: The increased risk of complications in certain patients with lower extremity joint prostheses may contraindicate attempted laparoscopic pelvic lymph node dissection.

The technique of laparoscopic partial nephrectomy has matured significantly over the past decade and is emerging as an oncologically sound procedure for the management of small renal tumors. Methods of tumor excision as well as parenchymal reconstruction in a hemostatically controlled field have evolved to make this procedure safer. Improved techniques to minimize warm renal ischemia are being developed. Finally, methods to prevent positive surgical margins during laparoscopic surgery are crucial to a satisfactory oncologic outcome. These important technical issues, as well as the current results of laparoscopic partial nephrectomy, are discussed.The urologic peer-review literature related to nephron-sparing surgery was reviewed. Controversial issues with respect to the surgical approach, methods of hemostatic control, acceptable time of warm ischemia, and cooling techniques were reviewed and collated. Perioperative results from larger series of laparoscopic and open partial nephrectomy were evaluated.Open nephron-sparing surgery for renal tumorsor =4 cm has cancer control equivalent to that of open radical nephrectomy. Evidence is now emerging that laparoscopic partial nephrectomy will provide similar oncologic results, although clinical follow-up is still early. Blood loss, postoperative pain, and convalescence seem to be favor the laparoscopic approach. Complication rates, primarily postoperative bleeding and urine leak, may be higher than for open nephron-sparing surgery. Methods of laparoscopic hemostatic control favor soft vascular clamping for larger tumors that are more endophytic and central. Smaller exophytic lesions may be managed without renal vascular control using a variety of coagulative and hemostatic tools. Data related to warm renal ischemia suggest that the time used for tumor excision and renal reconstruction should be 30 minutes or less. Techniques for laparoscopic renal cooling are being developed.Laparoscopic nephron-sparing surgery is a technique in evolution but with a promising outlook. The urologic peer-review literature reflects an exponential growth in interest, which suggests that this minimally invasive approach is practical and may benefit our patient population so as to allow them to return to normal healthy living more quickly.

Contrast-enhanced three-dimensional magnetic resonance angiography (3D-MRA) with image reconstruction has important applications in laparoscopic urologic surgery. We now use 3D-MRA as part of our preoperative evaluation in selected patients undergoing laparoscopic donor nephrectomy, pyeloplasty, radical nephrectomy, and partial nephrectomy.From June 2001 to December 2002, 50 patients underwent preoperative 3D-MRA at 1.5 T prior to laparoscopic renal surgery. In general, preoperative 3D-MRA was obtained for donor nephrectomies and pyeloplasties and for cases where prior imaging suggested a possible vascular anomaly. Patients who underwent preoperative imaging included those having donor nephrectomy (N = 28), pyeloplasty (N = 12), radical nephrectomy (N = 5), partial nephrectomy (N = 3), and other laparoscopic renal procedures (N = 2). The 3D-MRA studies were interpreted by one radiologist, and all laparoscopic cases were performed by one of two surgeons. The findings of 3D-MRA were correlated with the intraoperative findings with special attention to aberrant vasculature, including duplicated renal arteries or veins, accessory vessels, or crossing vessels.Among patients undergoing laparoscopic donor nephrectomy, 3D-MRA correctly predicted the number of renal vessels in 27 of 28 cases (96%), including all 3 cases of left retroaortic renal vein. Also, 3DMRA correctly predicted the presence or absence of a crossing vessel in 10 of 12 cases (83%) of laparoscopic pyeloplasty. The imaging study also correctly predicted the number of hilar vessels in all five cases of radical nephrectomy, all three cases of partial nephrectomy, and both cases of other renal operations. Overall, 3D-MRA correctly defined the renal hilar anatomy in 48 of 50 patients, for an overall accuracy of 96%.Three-dimensional MRA findings correlate well (96%) with intraoperative findings in laparoscopic renal surgery. The imaging study provides exquisite vascular detail and is highly accurate, making it sufficient imaging prior to laparoscopic donor nephrectomy and useful for pyeloplasty and other complex renal operations.