Search

The development of the surgical entrapment sack has facilitated the removal of large intra-abdominal organs laparoscopically. Herein, we describe our technique for laparoscopic introduction of the surgical entrapment sack, placement of the dissected kidney specimen within the sack, and removal of the sack and tissue from the abdomen.

The percutaneous nephrostomy tract has provided urologists with antegrade access to the upper urinary tract. Via this approach ureteropelvic junction obstruction has been treated with an endoscopically controlled incision with a cold knife. While less invasive than an open operation, we have noted significant discomfort from the 24 to 32F percutaneous tract. Accordingly, we sought to achieve the same results by using a less invasive approach, that is retrograde ureteronephroscopic endopyelotomy. A total of 10 patients (9 women and 1 man) with 5 primary and 5 secondary ureteropelvic junction obstructions underwent ureteroscopic endopyelotomy with a 3 or 5F Greenwald cutting electrode passed through a 12F rigid, 10.8F flexible or 9.8F flexible deflectable ureteronephroscope. Preoperatively, ureteropelvic junction obstruction was documented by a furosemide washout renal scan and/or a Whitaker test in 8 of 10 patients. In 2 patients an excretory urogram or retrograde pyelography was diagnostic. Duration of the procedure averaged 180 minutes (245 minutes with a concurrent Whitaker test). At the conclusion of the procedure a 7/14F indwelling ureteral stent was placed. The nephrostomy tube was removed after 3 days and average hospital stay was 5 days. The ureteral stents were routinely left in place for 6 weeks. Followup in 10 patients averaged 12 months. Flank pain was largely resolved in all patients. A followup Whitaker test, excretory urogram or renal scan ultimately has demonstrated decreased or no obstruction in 9 of 10 patients. In summary, early results with retrograde ureteronephroscopic endopyelotomy, specifically in female patients, appear to be promising. Morbidity is minimal and efficacy is satisfactory given the favorable objective response noted in 90% of the patients.

We compared the efficacy of shock wave lithotripsy and ureteroscopy for treatment of distal ureteral calculi.A total of 64 patients with solitary, radiopaque distal ureteral calculi 15 mm. or less in largest diameter were randomized to treatment with shock wave lithotripsy (32) using an HM3 lithotriptor (Dornier MedTech, Kennesaw, Georgia) or ureteroscopy (32). Patient and stone characteristics, treatment parameters, clinical outcomes, patient satisfaction and cost were assessed for each group.The 2 groups were comparable in regard to patient age, sex, body mass index, stone size, degree of hydronephrosis and time to treatment. Procedural and operating room times were statistically significantly shorter for the shock wave lithotripsy compared to the ureteroscopy group (34 and 72 versus 65 and 97 minutes, respectively). In addition, 94% of patients who underwent shock wave lithotripsy versus 75% who underwent ureteroscopy were discharged home the day of procedure. At a mean followup of 21 and 24 days for shock wave lithotripsy and ureteroscopy, respectively, 91% of patients in each group had undergone imaging with a plain abdominal radiograph, and all studies showed resolution of the target stone. Minor complications occurred in 9% and 25% of the shock wave lithotripsy and ureteroscopy groups, respectively (p value was not significant). No ureteral perforation or stricture occurred in the ureteroscopy group. Postoperative flank pain and dysuria were more severe in the ureteroscopy than shock wave lithotripsy group, although the differences were not statistically significant. Patient satisfaction was high, including 94% for shock wave lithotripsy and 87% for ureteroscopy (p value not significant). Cost favored ureteroscopy by $1,255 if outpatient treatment for both modalities was assumed.Ureteroscopy and shock wave lithotripsy were associated with high success and low complication rates. However, shock wave lithotripsy required significantly less operating time, was more often performed on an outpatient basis, and showed a trend towards less flank pain and dysuria, fewer complications and quicker convalescence. Patient satisfaction was uniformly high in both groups. Although ureteroscopy and shock wave lithotripsy are highly effective for treatment of distal ureteral stones, we believe that HM3 shock wave lithotripsy, albeit slightly more costly, is preferable to manipulation with ureteroscopy since it is equally efficacious, more efficient and less morbid.

The best management for renal tumors is surgical excision. The laparoscopic technique of radical or total nephrectomy for renal cell carcinoma and radical nephroureterectomy for transitional cell carcinoma is rapidly gaining momentum as an effective method of extirpative surgery. The transperitoneal and retroperitoneal approach to either of these procedures is proving to be equally effective to open surgery with respect to tumor removal, providing similar disease-free rates. Laparoscopic surgery leads to a significantly lower intraoperative blood loss, postoperative analgesic requirement, and quicker convalescence. Presently the only drawbacks to laparoscopic surgery are longer operative times and higher costs. Fortunately, these factors are slowly approaching those of open surgery because of increased experience, improved instrumentation, and modification of the surgical technique.

In clinical situations where more than one procedure is required, a properly positioned hand-assist device can be used to obviate the need for two large incisions. We present four cases of hand-assisted laparoscopic nephrectomy combined with a simultaneous second organ extraction. Each of the four primary procedures, as well as one of the four secondary procedures, was performed using a hand-assisted laparoscopic technique. In two cases, the secondary procedure was performed with an open surgical technique through the hand-assist incision. For the remaining secondary procedure, we used a laparoscopically assisted technique.

Laparoscopic nephroureterectomy for upper tract TCC still remains somewhat controversial. Unlike laparoscopic radical nephrectomy, which has become widely accepted, LNU is still in its earliest stages. Although there are obvious benefits for the patient who has LNU--less pulmonary complications, less postoperative discomfort, a shorter hospital stay, a better cosmetic result, and a brief convalescence--there are significant concerns. The longer operative time creates a negative financial and professional inducement to learn this technique. Operative times need to fall into the 4-hour range or less to make the procedure cost-effective. Analysis of the efficacy of laparoscopic nephroureterectomy as a curative treatment modality is important. In the short-run, LNU seems to provide similar results to open nephroureterectomy for upper TCC. Although concerns over port site seeding, bladder recurrence, and intraperitoneal seeding have been voiced, these problems have not occurred. The higher incidence of local recurrence noted in the authors' series, however, is of concern and remains an unsettled issue. Despite these local recurrences, the overall cancer survival for a given grade and stage of upper tract TCC seem to be similar to survivals recorded after open nephroureterectomy. Still, the number of LNU cases remains small, and follow-up is brief. These patients need to be monitored closely, with follow-up CT scans over the next decade. The authors believe that there are still several significant hurdles standing in the path of LNU before it can become a widely accepted procedure. Issues of cost, training, and long-term efficacy must be answered definitively. To obtain these types of data, it will be necessary to create a multi-institutional, cooperative study to obtain sufficient numbers of patients with a more than 5-year follow-up on which to base future recommendations.

The pattern of flow in the stented ureter (intraluminal and/or extra luminal) has only been defined for the standard pigtail stent. No data are available on stent flow for any specialty stents. To our knowledge we present the first investigation characterizing the type of flow through a stent (Poiseuille versus nonPoiseuille flow).Flow was measured in an unstented ureter, a standard 7Fr double pigtail stent and the 7/3Fr Tail stent, 7Fr Spirastent and 14/7Fr endopyelotomy stent using a previously developed stent flow model. In vitro pressure flow studies were also done in nonfenestrated 14/7Fr, Tail and standard 7Fr stents. These stents were infused at a constant flow rate of 2 to 10 ml. per minute with monitoring of the corresponding pressure gradients. Resistance to flow was determined for these stents using pressure flow plots and Poiseuille's law.In vivo the 7Fr pigtail, 14/7Fr endopyelotomy and 7/3Fr Tail stents had statistically similar flow rates. Flow through each of these stents exceeded the flow through an unstented ureter. The Spirastent had the least flow in all categories tested. There was no correlation of Poiseuille flow parameters measured in vitro for nonfenestrated stents with in vivo stent flow.In stented ureters fluid drains through and around the stent regardless of its design. The flow characteristics of these 3 specialty stents were not predictable according to lumen or stent size. In vitro Poiseuille's flow did not correlate with in vivo stent flow.

The laparoscopic approach for renal cell carcinoma is slowly evolving. We report our experience with laparoscopic radical nephrectomy and compare it to a contemporary cohort of patients with renal cell carcinoma who underwent open radical nephrectomy.From 1990 to 1999, 32 males and 28 females underwent 61 laparoscopic radical nephrectomies for suspicious renal cell carcinoma. Clinical data from a computerized database were reviewed and compared to a contemporary group of 33 patients who underwent open radical nephrectomy for renal cell carcinoma.Patients in the laparoscopic radical nephrectomy group had significantly reduced, estimated blood loss (172 versus 451 ml., p0.001), hospital stay (3.4 versus 5.2 days, p0.001), pain medication requirement (28.0 versus 78.3 mg., p0.001) and quicker return to normal activity than patients in the open radical nephrectomy group (3.6 versus 8.1 weeks, p0.001). The majority of laparoscopic specimens (65%) were morcellated. Operating time and cost were higher in the laparoscopic than the open nephrectomy group. Average followup was 25 months (range 3 to 73) for the laparoscopic and 27.5 months (range 7 to 90) for the open group. Renal cell carcinoma in 3 patients (8%) recurred in the laparoscopic group versus renal cell carcinoma in 3 (9%) in the open group. When stratified patients with tumors larger than 4 to 10 cm. experienced similar benefits and results as patients with tumors less than or equal to 4 cm. To date there have been no instances of trocar or intraperitoneal seeding in the laparoscopic radical nephrectomy group.Laparoscopic radical nephrectomy, although technically demanding, is a viable alternative for managing localized renal tumors up to 10 cm. It affords patients with renal tumors an improved postoperative course with less pain and a quicker recovery while providing similar efficacy at 2-year followup for patients with T1 and T2 tumors.

We tested the hypothesis that shock wave lithotripsy machines vary in the ability to fragment stones to small size.Calcium oxalate monohydrate, calcium hydrogen phosphate dihydrate, cystine and magnesium ammonium phosphate hexahydrate calculi were fragmented in vitro with the 22 kV. Dornier HM3, section sign 20 kV. Storz Modulith SLX, parallel, 15.6 kV. Siemens Lithostar C, paragraph sign 24 kV. Medstone STS-T,** 26 kV. HealthTronics LithoTron 160,daggerdagger 20 kV. Dornier Doli section sign and 22.5 kV. Medispec Econolithdouble daggerdouble dagger lithotriptors. Stones were given 500 or 2,000 shocks, or the Food and Drug Administration limit. Post-lithotripsy fragment size was characterized using sequential sieves and compared.Stone mass was statistically similar in the cohorts (p0.94). Fragment size decreased as the number of shocks increased when the machine and stone composition were constant. Magnesium ammonium phosphate hexahydrate calculi were completely fragmented by all devices. At Food and Drug Administration treatment limits the mean incidence per device of calcium hydrogen phosphate dihydrate, calcium oxalate monohydrate, cystine and magnesium ammonium phosphate hexahydrate stones rendered into fragments greater than 2 mm. was 0% for the HM3, Modulith SLX and Lithostar C, 10% for the STS-T, 3% for the LithoTron 160, 29% for the Doli and 18% for the Econolith (p = 0. 04); 0% for the HM3, Modulith SLX, Lithostar C, STS-T and LithoTron 160, 4% for the Doli and 9% for the Econolith (p = 0.15); 1% for the HM3, 0% for the Modulith SLX, 1% for the Lithostar C, 10% for the STS-T, 14% for the LithoTron 160, 3% for the Doli and 9% for the Econolith (p = 0.44); and 1% for the HM3, 0% for the Modulith SLX, 1% for the Lithostar C, 10% for the STS-T, 14% for the LithoTron 160, 3% for the Doli and 9% for the Econolith (p = 0.44), respectively.Shock wave lithotriptors vary in fragmentation ability. The HM3, Modulith SLX and Lithostar C machines yield smaller fragments than other machines.

Flexible ureteroscopes smaller than 9Fr are widely used in endourology. We systematically evaluated the functional durability of these instruments in the clinical setting.We performed ureteronephroscopy 92 consecutive times in 84 patients at our hospital using a flexible Storz model 11274AA,double dagger Circon-ACMI model AUR-7, section sign Wolf model 7325.172 parallel and Olympus model URF/P3 ureteroscope paragraph sign. Preoperatively and postoperatively we evaluated all flexible ureteroscopes for luminosity, irrigant flow at 100 mm. Hg, number of broken image fibers and active deflection range. During the procedure a record was kept of the duration that the endoscope remained in the urinary tract, average irrigation pressure, method of insertion, various devices used within the working channel, need for lower pole access, and surgeon overall impression of visibility and maneuverability.The luminosity and irrigant flow of all endoscopes remained relatively unchanged during consecutive applications, while active deflection deteriorated 2% to 28%. Endoscopes were used for an average of 3 to 13 hours before they needed repair. The most fragile part of these instruments was the deflection unit.Small diameter flexible ureteroscopes are effective for diagnosing and treating upper urinary tract pathology but improved durability is required. Currently they represent a highly effective but high maintenance means of achieving retrograde access to the ureter and kidney with a need for repair after only 6 to 15 uses.

Recently a variety of biodegradable organic materials have been used for bladder wall replacement. We sought to study the effectiveness of 4 different types of biodegradable materials for bladder augmentation using laparoscopic techniques.Thirty one minipigs underwent successful transperitoneal laparoscopic partial cystectomy and subsequent closure (6 control) or patch augmentation (25): porcine bowel acellular tissue matrix (ATM) (6), bovine pericardium (BPC) (6), human placental membranes (HPM) (6) or porcine small intestinal submucosa (SIS) (7). An intracorporeal suturing technique with the EndoStitch device (U.S. Surgical, Norwalk, CT) and Lapra-Ty clips (Ethicon, Enodsurgery Inc. Cincinnati, OH) was used to anastomose the graft to the bladder wall. Postoperatively, a urethral catheter was left for one week. Bladders were evaluated by cystoscopy at 6 and 12 weeks and harvested at 12 weeks.Grafts remained in place in all groups except for the BPC group, where all grafts failed to incorporate. For the ATM and SIS groups, at 6 weeks, there was mucosal coverage of the grafts without evidence of encrustation. In the control group, at 12 weeks, the bladder capacity was 23% less than preoperatively. In the ATM, HPM and SIS groups, at 12 weeks, the bladder capacities were larger than preoperatively by 16%, 51% and 43% respectively; also the grafts had contracted to 70%, 65%, and 60% of their original sizes, respectively. Histologically, there was patchy epithelialization of ATM and SIS grafts with a mixture of squamoid and transitional cell epithelia. The graft persisted as a well-vascularized fibrous band in HPM, ATM, and SIS without evidence of significant inflammatory response.A laparoscopic technique for partial bladder wall replacement using a free graft is feasible. The biodegradable grafts of ATM, HPM and SIS are tolerated by host bladder and are associated with predominantly only mucosal regeneration at 12 weeks post-operatively.

Laparoscopic nephroureterectomy has only recently been done to treat patients with upper tract transitional cell carcinoma. We retrospectively evaluated our experience with and long-term followup of laparoscopic nephroureterectomy, compared our results to those of contemporary series of open nephroureterectomy and reviewed the literature.We reviewed the charts of and followed up by telephone 25 patients who underwent laparoscopic nephroureterectomy between May 1991 and June 1998, and 17 who underwent open nephroureterectomy between March 1990 and January 1997. Demographic, perioperative and followup data were compared. We performed a MEDLINE search and reviewed the literature on laparoscopic nephroureterectomy for upper tract transitional cell carcinoma.Laparoscopic nephroureterectomy required twice the operating time of open nephroureterectomy (7.7 versus 3.9 hours). However, patients who underwent the laparoscopic procedure had a 74% decrease in analgesia requirements (37 versus 144 mg. morphine sulfate equivalent), a 63% shorter hospital stay (3.6 versus 9.6 days) and a 72% more rapid convalescence (2.8 versus 10 weeks). Subsequent bladder transitional cell carcinoma and overall cancer specific survival were similar at a mean followup of 2 years. There was no sign of trocar site or peritoneal seeding after laparoscopic nephroureterectomy.Although laparoscopic nephroureterectomy is a longer operation, it has the same efficacy and is better tolerated by patients than open nephroureterectomy for upper tract transitional cell carcinoma. As operating time decreases due to surgeon experience and the recent development of hand assisted laparoscopy, laparoscopic nephroureterectomy may soon become the procedure of choice for the ablative management of upper tract transitional cell carcinoma.

Open partial nephrectomy is an accepted form of treatment for a variety of benign conditions and for localized renal cell carcinoma. To date, there is limited experience with the clinical application of laparoscopic partial nephrectomy and wedge resection for benign and malignant disease of the kidney. Herein, we report our clinical experience with laparoscopic partial nephrectomy and a review of the current literature. Twelve patients (27 - 81 years) have undergone laparoscopic wedge resection (3) or attempted polar partial nephrectomy (9) since 1993. In the group of 12 patients, 5 had a mass suspicious for a malignancy, 4 patients had symptomatic polar calyceal dilation with or without stone disease, and 3 patients had an atrophic or hydronephrotic upper pole moiety. Among the patients in the polar nephrectomy group, a third were converted to an open procedure. The remaining 6 patients had a mean operative time of 6.5 hours (5.7 - 8.3 hours). These patients resumed their oral intake on average 0.8 days postoperatively. In the 2 patients with a mass, the final pathology was oncocytoma (1), and xanthogranulomatous reaction in a renal cyst (1). Postoperative complications included a nephrocutaneous fistula which was endoscopically fulgurated, a retroperitoneal urinoma which was percutaneously drained, and a two-day bout of ileus. The mean hospital stay was 5.3 days (2-9). Their full convalescence was completed in a mean of 4.2 weeks (2 - 8). Three patients underwent a wedge resection for a superficial < 2 cm mass. The average operative time in this group was 3.5 hours (2 - 5.4). The mean time to resuming oral intake was 0.7 days (0.3 - 0.7). The final pathology was oncocytoma (1), oncocytic renal cell cancer (1), and old infarction (1); none of the patients had any complications. The mean hospital stay was 2.7 days (2- 4). Convalescence was completed in 4 weeks (range 1-8). Laparoscopic wedge resection and polar partial nephrectomy are feasible, albeit currently tedious techniques. While wedge excision of a < 2 cm superficial lesion is relatively straightforward and efficient, laparoscopic polar partial nephrectomy remains a difficult technique and at present remains in evolution. Further development of instrumentation to provide for a reliable, expeditious, and hemostatic partial nephrectomy is needed.

We review the morbidity and long-term outcome of percutaneous caliceal diverticulectomy and associated stone extraction.Percutaneous caliceal diverticulectomy was performed in 19 women and 11 men (age range 20 to 58 years), of whom 26 had stones (all 15 mm. or less). The diverticula were located throughout the kidney, including the upper (11 patients), middle (15) and lower (4) calices. Percutaneous caliceal diverticulectomy included 28 direct and 2 indirect accesses (1 via a previously placed nephrostomy tract and 1 due to stones in other areas of the kidney). In all cases the stone was removed and the diverticular neck was incised or dilated. Fulguration of the diverticular walls was performed in 22 cases. Transdiverticular percutaneous renal and ureteral drainage was maintained from 2 to 7 days until a nephrostogram demonstrated no extravasation.The average operating room time and hospital stay were 171 minutes (range 75 to 330) and 4.1 days (range 2 to 7), respectively. Major complications occurred in 6.6% of the cases, requiring 1 blood transfusion and 1 chest tube placement, and minor complications occurred in 13.4%. There was no mortality. Followup for more than 1 year was available in 27 patients. Stone-free rate was 93% with obliteration of the diverticulum in 76% of patients. Overall, 85% of patients are asymptomatic at average followup of 3.5 years (range 1 to 7.3).Direct percutaneous endosurgical management provides a safe, efficacious and durable means of treating stone bearing caliceal diverticula, regardless of stone size or location of the diverticulum.

Herein we report on a patient with chronic lymphocytic leukemia (CLL) who entered a long-term remission following shock wave lithotripsy (SWL) for a left proximal ureteral stone. In addition, we include data on the effect of SWL on in vitro and in vivo human lymphocyte subpopulations, and discuss the possible mechanisms of this observation.

We determine whether there is a significant relationship between the spatial anatomy of the lower pole, as seen on preoperative excretory urography (IVP), and the outcome after shock wave lithotripsy or ureteroscopy for a solitary lower pole caliceal stone 15 mm. or less.Between January 1992 and June 1996, 34 patients with 15 mm. or less solitary lower pole stone underwent ureteroscopy with intracorporeal lithotripsy (13) or extracorporeal shock wave lithotripsy (ESWL) with a Dornier HM3 lithotriptor (21). On pretreatment IVP lower pole infundibular length and width, infundibulopelvic angle of the stone bearing calix were measured. Stone size and area were determined from an abdominal plain x-ray. A plain x-ray of the kidneys, ureters and bladder was obtained in all patients at a median followup of 12.3 and 8 months in the ureteroscopy and ESWL groups, respectively.After initial therapy the overall stone-free rate was 62 and 52% in the ureteroscopy and ESWL groups, respectively. Stone-free status after ESWL was significantly related to each anatomical measurement. Infundibulopelvic angle 90 degrees or greater, and infundibular length less than 3 cm. and width greater than 5 mm. were each noted to correlate with an improved stone-free rate after ESWL. In contrast, the stone-free rate after ureteroscopy was not statistically significantly impacted by these anatomical features, although a clinical stone-free trend was identified relating to a favorable infundibular length and infundibulopelvic angle. The infundibulopelvic angle was 90 degrees or greater in 4 stone-free patients (12% overall), including 2 who underwent ureteroscopy and 2 who underwent ESWL. On the other hand, in 2 and 4 stone-free patients (18% overall) who underwent ureteroscopy and ESWL, respectively, favorable radiographic features consisted of a short, wide but acutely angulated infundibulum with the infundibulopelvic angle less than 90 degrees, and infundibular length less than 3 cm. and width 5 mm. or greater. In contrast, in 4 and 6 patients (29% overall) who underwent ureteroscopy and ESWL, respectively, all 3 radiographic features were unfavorable with the infundibulopelvic angle less than 90 degrees, and infundibular length greater than 3 cm. and width less than 5 mm. In these cases the stone-free rate was 50 and 17% after ureteroscopy and ESWL, respectively.The 3 major radiographic features of the lower pole calix (infundibulopelvic angle, and infundibular length and width) can be easily measured on standard IVP using a ruler and protractor. Each factor individually has a statistically significant influence on stone clearance after ESWL. A wide infundibulopelvic angle or short infundibular length and broad infundibular width regardless of infundibulopelvic angle are significant favorable factors for stone clearance following ESWL. Conversely, these factors have a cumulatively negative effect on the stone clearance rate after ESWL when they are all unfavorable. In ureteroscopy spatial anatomy has less of a role in regard to stone clearance but it may have a negative impact when there is uniformly unfavorable anatomy.

We evaluate and compare the characteristics and drawbacks of different synthetic and organic materials that have been used for bladder wall replacement.We extensively reviewed the contemporary literature for partial bladder wall replacement with synthetic or organic materials.The concept of bladder wall replacement dates back to the early nineteenth century. Based on the unique regenerative capability of the bladder, many organic and synthetic allografts and xenografts were implanted in the bladder wall with a wide range of outcomes. Recently, various biodegradable allografts have been developed and used successfully in animal models. Despite the favorable animal results, only a few of the materials have been used clinically for bladder wall replacement to date.Further improvements in the use of existing materials and development of new materials will hopefully result in clinically successful grafts for bladder wall replacement and for whole bladder substitution.

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, M0 (D1) prostate cancer.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.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.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.

We report 5 cases of postoperative incisional hernia after laparoscopic nephrectomy with intact removal of the specimen.During the last 5 years 29 patients underwent laparoscopic nephrectomy with intact removal of the resected specimen due to a large kidney and/or malignancy. Of these 29 patients 5 had a postoperative incisional hernia at the site of intact removal, including 3 with renal tumors and 2 with large polycystic kidneys due to adult onset autosomal dominant polycystic kidney disease. The records of these patients were reviewed to determine any specific factors that might relate to the development of this complication.An incisional hernia developed at the wound site in 5 patients (17%) 41 to 73 years old (mean age 53.4). Average body mass index for the patients was 34.2 (range 26 to 47). Average weight and size were 542 gm. and 20.3 x 10.3 cm., respectively, for the 3 resected malignant specimens and 1,975 gm. and 23.8 x 16.5 cm., respectively, for the 2 benign kidneys. A transverse lower flank muscle cutting incision (average 10.4 cm.) was performed to remove the resected kidney. Incisional hernias appeared after an average of 6.6 weeks postoperatively. Risk factors for a postoperative hernia included obesity in 80% of the patients, chronic renal insufficiency due to autosomal dominant polycystic kidney disease in 40%, postoperative pulmonary complication in 40% and metastatic cancer in 20%.Our experience has led us to avoid a lower flank port connecting incision for specimen removal. Instead we changed to a midline or subcostal incision in these patients. In addition, we believe that with the availability of the impermeable organ entrapment sacks there is less need for intact specimen removal even for renal tumors. Currently large benign kidneys (autosomal dominant polycystic kidney disease) are morcellated in situ to a suitable size for entrapment, while renal tumors are entrapped and morcellated directly. Presently our only indication for intact removal is in the case of a renal pelvic or caliceal transitional cell cancer.

The efficiency of laparoscopic procedures has been hindered by a lack of instrumentation for blunt tissue dissection. We evaluated here the efficacy of a new 5-mm laparoscopic dissecting instrument, a pneumodissector. This instrument allows the surgeon to use short bursts of high-pressure carbon dioxide to bluntly dissect fatty tissue.In 20 patients undergoing a variety of laparoscopic procedures, a 5-mm laparoscopic pneumodissector was used. Subjective assessment of the efficacy of the instrument was recorded. In addition, acid-base changes were measured by blood gas determination, and serum chemistries were obtained before, during, and after the procedure.The pneumodissector enhanced dissection of the kidney, ureter, and major blood vessels and shortened the operative time for laparoscopic nephrectomy. Although statistically significant changes in acidbase values occurred with use of the pneumodissector, these changes were not clinically significant and were no different than what is normally seen during carbon dioxide pneumoperitoneum.Laparoscopic pneumodissection is a safe and efficacious technique for rapid blunt tissue dissection.

We assessed the efficacy of a fluoroscopically controlled cutting balloon catheter for the treatment of ureteropelvic junction and ureteral strictures.A multicenter trial was performed that included 66 endopyelotomies and 49 endoureterotomies. To our knowledge this study represents the largest number of patients with ureteropelvic junction obstruction and ureteral strictures tested with this device to date.With a mean followup of 7.8 months (range 1 to 17.9) the patency rate was 77% for endopyelotomy, with 72% of the primary and 100% of the secondary ureteropelvic junction obstructions remaining patent. The endoureterotomy patients were followed for an average of 8.7 months (range 1.2 to 17.0), with a patency rate of 55%.A cutting balloon endoscopic incision is effective in the majority of cases, with patency rates for endopyelotomies and endoureterotomies that mirror current endourological reports using other, albeit more time intensive and more invasive, incisional techniques.

The anatomical characteristics of an ectopic kidney can pose significant challenges to the treatment of calculous disease. This report examines the feasibility of a laparoscopic approach for management of a large renal calculous in a pelvic kidney and reviews current literature regarding this subject., Background and Objectives: Laparoscopic pyelolithotomy was performed in a pelvic kidney with a large renal pelvis calculus. Methods and Results: Laparoscopic pyelolithotomy was successfully performed in a pelvic kidney with an operative time of 310 minutes. The use of intraoperative fluoroscopy and a semi-automatic suturing device greatly facilitated the procedure. The patient's operative pain was managed with 3 doses of ketorolac; she resumed a regular diet the day after surgery, and was discharged on the first postoperative day. Conclusions: For patients with a large stone in the renal pelvis of an ectopic kidney, laparoscopic pyelolithotomy provides an effective approach.

We evaluated fibrin glue, laser welding, and a mechanical suturing device (Endo-Stitch) as alternatives to standard laparoscopic suturing with a free needle.In 14 pigs, 22 linear proximal ureterotomies were closed laparoscopically with one of 4 different methods: fibrin glue, laser welding, Endo-Stitch suture placement (4-0 polyglactin), and free-needle suture placement (4-0 polyglactin). The ureterotomy was left open in 6 ureters. Acute leakage was tested by instillation of methylene blue. After 12 weeks, the ureters were assessed with radiography, ex-vivo pressure-flow studies, bursting pressures, and histology.All alternative closure techniques were more rapid than free-needle suturing, and less frequently allowed acute leakage. Closure with fibrin glue yielded significantly higher flow rates than control, whereas the other closure techniques yielded flow rates similar to that of unclosed ureters. All alternative closure methods demonstrated histological evidence of healing that were superior to free-needle suturing. In multifactorial analysis, leakage at the ureterotomy site was the factor most significantly associated with subsequent poor ex-vivo flow characteristics.All of the alternative laparoscopic ureteral closure methods compared favorably with standard free-needle suturing. Fibrin glue produced better radiographic findings, flow characteristics, and histology, suggesting that it currently has the most promise as an alternative or adjunct to laparoscopic suturing. Development of alternative laparoscopic techniques is ongoing, however, and thus the current state-of-the-art techniques used in this study may well be supplanted by other technologies in the future.

We report our experience with laparoscopic adrenalectomy for malignant adrenal disease.Between June 1995 and January 1996, 2 patients with a solitary metachronous contralateral adrenal metastasis from renal cell cancer were evaluated. Both patients had undergone radical nephrectomy for localized renal cancer 5 years previously. Laparoscopic transperitoneal adrenalectomy was performed.The laparoscopic procedures required 2.5 and 4.3 hours. Hospital stay was 3 and 4 days. The specimens weighed 98 and 81 gm. All surgical margins were free of metastatic clear cell cancer. Both patients were begun on prednisone and fludrocortisone replacement therapy. One patient experienced an increase in creatinine, which has since stabilized at 3.0 mg/dl. Neither patient had recurrent cancer at 11 and 16 months of followup.Laparoscopic adrenalectomy for metastatic renal cell cancer was performed successfully in 2 patients. However, the short-term benefits to the patient of earlier ambulation, decreased pain, minimal incisions and shortened convalescence must be weighted against the as yet unknown long-term (5 years) results.

Background: Increased intraabdominal pressure (IPA) during laparoscopy has been associated with decreased urine output. The purpose of this study was to use a noninvasive MRI technique to measure renal vessel flow velocity and change in differential renal medulla and cortex perfusion during pneumoperitoneum. Study Design: Six female farm pigs underwent general endotracheal anesthesia and dynamic imaging following left ventricular (LV) injection of Gd-DTPA, utilizing a dual echo gradient echo sequence. MRI was repeated after three hours of continuous 15 mm Hg pneumoperitoneum in three study pigs and after three hours of monitored general anesthesia without pneumoperitoneum in three control pigs. Renal artery and renal vein flow velocities were calculated using cine phase-contrast technique. Renal perfusion was independently measured by LV injection of radiolabelled microspheres. Results: There was a decrease in mean renal vein flow velocity in the pneumoperitoneum group as compared to the control group. During pneumoperitoneum there was a similar percentage reduction in the perfusion of the cortex (-28% ) and medulla (-31% ); this corresponded with a decreased urine output. In addition, radiolabelled microspheres corroborated the similar decrease in both cortical and medullary perfusion rates during pneumoperitoneum. Conclusions: Prolonged IAP is associated with a decrease in renal vein flow velocity and urine output. There is a similar decrease in the renal medulla and cortex perfusion rates during pneumoperitoneum of 15 mm Hg.

The development of 1.9F or smaller electrohydraulic lithotripsy probes has facilitated the use of this form of lithotripsy via miniature rigid and flexible ureteroscopes. We report our experience with ureteroscopic intracorporeal lithotripsy using 1.9F electrohydraulic lithotripsy probes.A total of 45 patients (32 ureteral and 57 renal calculi) underwent retrograde rigid (microscopic to 6F short) or flexible (7.5 and 9.4F) ureteroscopy with electrohydraulic lithotripsy using 1.9F electrohydraulic lithotripsy probes. In 17 patients (38%) there were 37 lower pole caliceal calculi (41%). Stone size ranged from 3 to 30 mm. (mean 8.5).Electrohydraulic lithotripsy resulted in successful fragmentation (that is 2 mm. or smaller fragments) in 98% of patients overall. It was successful after failure of HM-3 extracorporeal shock wave lithotripsy in 10 patients and after failed lithotripsy with the 140 mJ. tunable dye laser in 7. Electrohydraulic lithotripsy resulted in successful fragmentation of 94% of lower pole caliceal stones. No intraoperative complications and no significant ureteral or renal mucosal damage were noted. Fever developed postoperatively in 2 patients (4.4%) with negative urine cultures. Postoperatively an indwelling stent was placed for 2 weeks or less in 71% of patients and no stents were placed due to preoperative stenting in 29%. Average hospital stay was 0.8 days (range 0 to 4). Followup imaging in 38 patients (84%) at a mean of 8.7 months (range 2 to 28) revealed stone-free rates of 92% overall and 87% in patients with lower pole renal calculi. No patient had a ureteral or infundibular stricture postoperatively.The development of 1.9F or smaller electrohydraulic lithotripsy probes provides the urologist with a safe, highly effective and inexpensive method for performing intracorporeal lithotripsy throughout the entire upper urinary tract via rigid or flexible ureteroscopes. Furthermore, for the ureteroscopic treatment of lower pole renal calculi electrohydraulic lithotripsy is the only form of intracorporeal lithotripsy sufficiently malleable to allow routine access.

Recently, a number of laparoscopic port-closure techniques have been reported to avoid the complications associated with the port closure after laparoscopic surgery. To evaluate these port-closure techniques, we compared seven new laparoscopic port-closure techniques with the standard technique of a hand-sutured closure.In a prospective, randomized study, 95, 12-mm port sites in 32 patients undergoing transperitoneal laparoscopic procedures were randomized to one of eight different port-site closure techniques. The port-closure techniques included: the Carter-Thomason Needle-Point Suture Passer, Maciol suture needle set, eXit Disposable Puncture Closure device, Endoclose suture carrier, Tahoe Surgical Instruments Ligature device, a long 14-gauge angiocatheter with looped polypropylene suture, Lowsley retractor with hand-sutured closure, and the standard technique of hand-sutured closure. We evaluated the time, the security, and the auxiliary instrumentation required for each closure.Of the port-closure techniques, the Carter-Thomason device was faster overall, resulted in fewer port-closure-related complications and provided a leak proof closure.The Carter-Thomason device is our preferred method for the closure of port sites after laparoscopic surgery.

The duration of stenting after endoureterotomy is a controversial issue. An even more basic question, however, is whether stent placement is needed at all. We performed a porcine study to address this question.A unilateral midureteral stricture was created in 20 minipigs. Six weeks later, 15 pigs underwent endoureterotomy. In 10 animals, a 7F ureteral stent was placed for 1 week. Five pigs remained unstented. Three months later, all 20 ureters were studied radiographically and were harvested.Three of 5 control animals and 2 of 10 stented animals has strictures. In the unstented study group, all 5 animals had a nonobstructing dilation at the site of endoureterotomy. This was corroborated by a normal furosemide washout renal scan in all 3 animals so tested.The result of unstented endoureterotomy in the porcine model suggests that, after endoureterotomy of secondary midureteral strictures, stenting may be unnecessary.

To further understand the biology of ureteral cells, we studied the growth characteristics and in vitro cellular interactions of human ureteral uroepithelial cells, smooth muscle cells and myofibroblasts.The proliferation, morphology and immunohistochemical characteristics of human ureteral cells grown in vitro were evaluated under varying conditions.The growth and morphology of ureteral cells were dependent upon media characteristics, especially the calcium concentration and presence of epidermal growth factor and bovine pituitary extract. Cells demonstrated specific stimulatory interactions via both soluble and insoluble factors. Most important, uroepithelial cells and smooth muscle cells displayed reciprocal enhancement of growth.The favorable interactions between ureteral cell types in vitro have implications for future work involving these cells.

We report our experience with laparoscopic radical nephrectomy in 17 consecutive patients with renal tumors.The clinical data on 17 consecutive patients undergoing laparoscopic radical nephrectomy were reviewed. Of the patients 12 with stage pT1 or pT2 renal cell carcinoma 7 cm. in diameter or smaller undergoing laparoscopic radical nephrectomy were compared to 12 undergoing open radical nephrectomy for stage pT1 or pT2 renal cell carcinoma 6 cm. in diameter or smaller.Among the 17 patients undergoing laparoscopic radical nephrectomy average operative time was 6.9 hours (range 4.5 to 9) and average estimated blood loss was 105 cc (range 50 to 600). Average weight of the surgical specimen was 402 gm. (range 190 to 1,100). In 12 of 16 patients in whom laparoscopic radical nephrectomy was completed the specimen was removed intact. The patients required an average of 24 mg. morphine sulfate equivalent (range 2 to 220) for postoperative pain. Average hospital stay was 4.5 days (range 3 to 11) and average interval to resume normal activities was 3.5 weeks (range 2 to 4). The 12 patients in the open and laparoscopic radical nephrectomy groups were similar with respect to age, American Society of Anesthesiologists score and interval surgery. Laparoscopic radical nephrectomy required significantly more operative time than open radical nephrectomy (6.9 versus 2.2 hours, respectively). However, the laparoscopic radical nephrectomy group compared to the open radical nephrectomy group had significantly less postoperative pain (24 versus 40 mg. morphine sulfate equivalent required for postoperative analgesia), shorter interval to resuming oral intake (1 versus 3 days), more rapid discharge from the hospital (4.5 versus 8.4 days) and more rapid return to normal activities (3.5 versus 5.1 weeks). The laparoscopic nephrectomy group also fully recovered more rapidly than the open surgical group (5.8 versus 39 weeks). To date, during a 4-year period there was no retroperitoneal recurrence or seeding of port site.Laparoscopic radical nephrectomy is a lengthy and demanding procedure. However, it affords patients with renal cell carcinoma a markedly improved postoperative course while accomplishing the necessary surgical goals.

Prolonged, increased intra-abdominal pressure (IAP) during laparoscopic surgery has been associated with oliguria and anuria.The objective of this study was to evaluate the effects of various levels of IAP on renal function. Ten groups of three adult female farm pigs were given a general anesthetic, followed by establishment of an IAP of 0, 5, 10, 15, or 20 mm Hg with CO2, 20 mm Hg with argon gas, abdominal wall lift device, renal vein occlusion (RVO), 15 mm Hg with CO2 plus dopamine administration at 2 microgram/kg/minute, or 20 mm Hg retroperitoneal CO2 insufflation. The following studies were recorded: baseline central venous pressure (CVP), pulmonary wedge pressure (PWP), cardiac output (CO), renal vein flow (RVF), renal artery pressure (RAP), selective urine output (UO), urinary osmolarity, and creatinine clearance; the parameters were repeated every 30 minutes for the four hours of the IAP study and two hours after release of the IAP.The results were analyzed within two main IAP groups: less than 15 mm Hg and greater than or equal to 15 mm Hg. There was no clinically significant variation in the CVP, PWP, and RAP. The CO decreased slightly and this was more significant in the greater than or equal to 15 mm Hg group. The RVF and UO decreased concomitantly and significantly in the greater than or equal to 15 mm Hg group. Even after two hours of desufflation, the RVF did not return to baseline, although the UO improved. Creatinine clearance decreased significantly in the greater than or equal to 15 mm Hg group. The RVO group exhibited similar changes in the study parameters as those seen in the greater than or equal to 15 mm Hg group, although the RVF did not improve on release of the renal vein in the RVO group. Changes were the same with an argon or CO2 IAP of 20 mm Hg. The abdominal wall lift device had an associated decrease in RVF at 15 KG force but no alteration in UO. Retroperitoneal insufflation resulted in the same decrease in RVF and UO as seen with the same IAP. Dopamine did not afford a protective effect on UO during an IAP of 15 mm Hg.The decreased UO during prolonged IAP greater than or equal to 15 mm Hg in the animal model is associated with a corresponding decrease in RVF, but does not appear to be associated with any permanent renal derangement nor any transient histologic changes.

Laparoscopic nephrectomy for benign disease has become an increasingly popular alternative to open surgery as more urologists gain confidence in their laparoscopic skills. However, the idea of laparoscopic extirpation of renal cell cancer caused significant concerns over the adequacy of surgical resection margins, trocar site seeding, and potential tumor spillage. The present chapter is the result of 5 year's experience with laparoscopic nephrectomy for renal tumor. To date, total and radical nephrectomies have been performed at Washington University in 20 patients; in each case, the appropriate surgical margins were obtained. Moreover, there have been, as yet, no instances of tumor spillage or delayed trocar seeding in our or others' experience. Furthermore, the immediate effectiveness of the procedure equals that of open radical nephrectomy; yet the hospital stay, patient discomfort, and convalescence are all markedly decreased. Only two drawbacks to the laparoscopic approach remain: 1) lengthy operative time, and 2) the increased cost associated with the prolonged operating room time. These problems will only be overcome by increased surgeon experience and further technological advances. Lastly, given the newness of the procedure, follow-up of these patients is still brief; however, results to date substantiate the hypothesis that laparoscopic radical nephrectomy is an effective, minimally invasive, long-term therapy for patients with localized renal cell cancer.