Robot-assisted ureteral reconstruction using a tubularized peritoneal flap: a novel technique in a chronic porcine model.

OBJECTIVE: To evaluate the feasibility and functional outcomes in porcine models of a novel robotic surgical technique for the treatment of complex ureteral injuries and strictures. MATERIALS AND METHODS: Six pigs underwent robotic ureteral reconstruction using a long tabularized peritoneal flap and followed for 6-9 weeks after the surgery. Ureteral flap vascularity, intra-renal pressure, patency of the conduct, endoscopic aspect of the flap, renal function and histopathology were evaluated. RESULTS: All animals successfully underwent ureteral reconstruction using a tubularized peritoneal flap. Median operative time was 223 min (162-360). Flap tubularization suture took 31 min (19-47), and proximal anastomosis took 20 min (15-38). Bladder mobilization with psoas hitch and distal anastomosis took 9 min (7-12) and 23 min (13-46), respectively. On follow-up, significant shrinkage of the ureteral flap in both length and width was observed. Antegrade pyelograms confirmed dilation and tortuosity of the proximal ureter, dilation of the renal pelvis, and major and minor calyxes without any definitive strictures. Microscopically, focal urothelial lining was seen in the neoureter. Creatinine level was significantly higher at the end of the follow-up period (p = 0.003). CONCLUSIONS: Robot-assisted ureteral reconstruction using a tubularized peritoneum flap is technically feasible and reproducible. The flap sustained abundant vascular supply after different intervals of follow-up and the peritoneal mesenchymal cells differentiated into urothelium and myofibroblasts. Further studies are needed to address the issue of functional obstruction to improve long-term renal function outcomes.

Validation of the Brazilian version of the Expanded Prostate Cancer Index Composite (EPIC) for patients submitted to radical prostatectomy.

OBJECTIVES: Validation of the Expanded Prostate Cancer Index Composite (EPIC) questionnaire translated to Portuguese. This is an evaluation tool of the effects of treatment on quality of life of patients with prostate cancer. MATERIALS AND METHODS: In order to translate and validate, several recommended methodological techniques in the literature were included: initial translation, synthesis of translation, board committee review and back translation. Sample included 40 patients with localized prostate cancer submitted to surgical retropubic radical prostatectomy from 2008 to 2010. RESULTS: The internal consistency analysis of the scales of the questionnaire resulted in alpha Cronbach coefficients "very good" (> 0.9) and "good" (> 0.8) to 8 of 14 domains. The higher coefficients (0.94) were assigned to sexual score, subscales incontinence and sexual function. Post-operatory follow-up ranged from 3 to 35 months, median 18.7 months. CONCLUSIONS: The Brazilian version of EPIC is reliable and valid, and is a useful tool to evaluate the impact of retropubic radical prostatectomy on quality of life of Brazilian patients with localized prostate cancer, in national and internationals studies.

Effect of smoking on the functional aspects of sperm and seminal plasma protein profiles in patients with varicocele.

STUDY QUESTION: What are the effects of smoking on the functional aspects of the sperm, the levels of lipid peroxidation and the protein profile of seminal plasma in patients with varicocele? SUMMARY ANSWER: In men with varicocele, smoking is associated with altered semen quality, decreased sperm functional integrity and seminal oxidative stress. Alterations in seminal plasma protein profiles are also present and may explain the altered semen phenotype. WHAT IS KNOWN ALREADY: Varicocele is a major cause of male infertility. It reduces testicular blood renewal with a consequent accumulation of toxic substances. Thus, it can potentiate the toxic effects of environmental exposure to genotoxic substances such as those found in cigarette smoke. STUDY DESIGN, SIZE AND DURATION: A cross-sectional study was performed in 110 patients presenting with variococele to the Human Reproduction Section of the Sao Paulo Federal University (2006-2010). The patients were divided into a control group of non-smokers, a moderate smokers group and a heavy smokers group. PARTICIPANTS/MATERIALS, SETTING AND METHODS: Semen parameters were analysed by standard methods. Sperm DNA integrity and mitochondrial activity were assessed by Comet assays and by 3,3'-diaminobenzidine deposition, respectively. The level of lipid peroxidation in semen was determined by malondialdehyde quantification. Proteomic studies were performed by 2D-electrophoresis and mass spectrometry. MAIN RESULTS AND THE ROLE OF CHANCE: Both groups of smokers showed reduced semen quality in comparison with the control group. In the groups of smokers, sperm DNA integrity and mitochondrial activity were also decreased and lipid peroxidation levels were increased. Proteomic analyses revealed 20 proteins differentially expressed between the study groups. LIMITATIONS AND REASONS FOR CAUTION: A study including smokers without varicocele is still warranted as these results apply only to smokers who present varicocele. WIDER IMPLICATIONS OF THE FINDINGS: Patients with varicocele who are exposed to tobacco smoking present more important alterations to semen quality and sperm functional integrity and show changes in the seminal plasma proteome. This suggests testicular, and possibly systemic, adverse effects of smoking. STUDY FUNDING/COMPETING INTEREST(S): Funding for the study was provided by Fundação de Amparo à Pesquisa do Estado de São Paulo (Fapesp) (2007/59423-7) and by the Division of Urology, Human Reproduction Section at the São Paulo Federal University.

The final stage of the laparoscopic procedure: exploring final steps.

Despite significant advances in laparoscopic technique and technologies, laparoscopic Urologic surgery remains technically demanding regarding various surgical steps including the challenge of specimen retrieval and extraction, whether to install a drainage system and the best option for wound closure. Laparoscopic specimen entrapment and extraction occurs at what is falsely considered the ″end of the procedure″. During open surgery, after the specimen has been mobilized, the specimen is simply lifted out of the larger incision which has been made to achieve the surgical objectives. In contrast, significant laparoscopic skill is required to entrapand safely extract laparoscopic specimens. Indeed, the Urologist and surgical team which are transitioning from open surgery may disregard this important part of the procedure which may lead to significant morbidity. As such, it is imperative that during laparoscopic procedures, the ″end of the procedure″ be strictly defined as the termination of skin closure and dressing placement. Taking a few minutes to focus on safe specimen entrapment and extraction will substantially reduce major morbidity. The following review focus on the technology and technique of specimen entrapment and extraction, on the matter of whether to install a drainage system of the abdominal cavity and the options for adequate closure of trocar site wounds. This article 's primary objectives are to focus on how to minimize morbidity while maintain the advantages of a minimally invasive surgical approach.

Children with Cushing's syndrome: Primary Pigmented Nodular Adrenocortical Disease should always be suspected.

Primary Pigmented Nodular Adrenocortical Disease (PPNAD) is a rare form of bilateral adrenocortical hyperplasia that is inherited in an autosomal dominant manner and leads to ACTH-independent Cushing's syndrome (CS). PPNAD may be isolated or associated with Carney Complex (CNC). For the diagnosis of PPNAD and CNC, in addition to the hormonal and imaging tests, searching for PRKAR1A mutations may be recommended. The aims of the present study are to discuss the clinical and molecular findings of two Brazilian patients with ACTH-independent CS due to PPNAD and to show the diagnostic challenge CS represents in childhood. Description of two patients with CS and the many sequential steps for the diagnosis of PPNAD is provided. Sequencing analysis of all coding exons of PRKAR1A in the blood, frozen adrenal nodules (patients 1 and 2) and testicular tumor (patient 1) is performed. After several clinical and laboratory drawbacks that misled the diagnostic investigation in both patients, the diagnosis of PPNAD was finally established and confirmed through pathology and molecular studies. In patient 1, sequencing of PRKAR1A gene revealed a novel heterozygous 10-bp deletion in exon 3, present in his blood, adrenal gland and testicular tumor. The etiologic diagnosis of endogenous CS in children is a challenge that requires expertise and a multidisciplinary collaboration for its prompt and correct management. Although rare, PPNAD should always be considered among the possible etiologies of CS, due to the high prevalence of this disease in this age group.

Differences among patients undergoing perineal or retropubic radical prostatectomy in pain and perioperative variables: a prospective study.

OBJECTIVE: To compare pain in the first 24 h, the perioperative variables and the histopathological results among patients who had perineal (PRP) and retropubic radical prostatectomy (RRP), in a randomized trial. PATIENTS AND METHODS: Patients with localized prostate cancer were accrued after selection using inclusion and exclusion criteria; they were prospectively randomized into four different groups: P1 (PRP with general anaesthesia), P2 (RPP with general plus epidural anaesthesia), R1 (RRP with general anaesthesia), and R2 (RRP with general plus epidural anaesthesia) and data collected for age, body mass index, prostate weight, serum prostate-specific antigen level, Gleason score and clinical stage. Pain after RP was evaluated using numerical and oral scales, and by morphine intake delivered by a patient-controlled analgesia pump. Perioperative features assessed prospectively were operating time, intraoperative bleeding, time to diet, time to ambulation, hospital stay and complications. Immediate oncological results were assessed based on histopathological evaluation, e.g. Gleason score, tumour volume, prostate volume, surgical margins and final pathological stage. RESULTS: Between October 2004 and October 2007 80 patients were accrued (mean age 63 years, range 42-80). The groups were similar for preoperative data, but group R1 had larger prostates (P = 0.001). For postoperative pain, group R1 had a significantly greater intensity of pain, based on the visual analogue scales, and greater morphine intake during the first 24 h than the other three groups. Groups P1 and P2 had significantly less bleeding (511 and 612 mL) than groups R1 and R2 (926 and 1165 mL; P < 0.001), regardless of both prostate size and anaesthesia. Complications occurred in 27.5% and 25% (not significant) of patients after PRP and RRP, respectively. There were no differences in positive surgical margin rate and histopathological evaluation among the groups. CONCLUSIONS: Patients who had RRP with general anaesthesia had a greater intensity of pain and higher morphine intake than the other groups. Men who had PRP had significantly less bleeding and shorter hospital stay than those having RRP.

Cystic phaeochromocytoma is a distinctive subgroup with special clinical, imaging and histological features that might mislead the diagnosis.

OBJECTIVE: To report and analyse cases of cystic phaeochromocytoma at our institution and in previous publications, as adrenal cystic masses are usually associated with nonfunctional lesions, but they can be phaeochromocytoma. PATIENTS AND METHODS: The prospective adrenalectomy database at our institution was reviewed to identify patients with phaeochromocytoma and cystic lesions. The clinical, radiological and histological features of cystic phaeochromocytoma were evaluated. Other previously published data were identified and compared with the present series. RESULTS: In all, there were 107 adrenalectomies at our institution from November 2000 to March 2007; 31 of these patients had a confirmed diagnosis of phaeochromocytoma and six (19%) were cystic phaeochromocytomas. Three of the six cases were asymptomatic and had a negative biochemical evaluation (one male and five females, mean tumour size 6.6 cm); the imaging diagnosis was mainly based on computed tomography and magnetic resonance imaging, and the foremost feature was the enhancement of the tumour rim associated with a central cystic mass. Nine other previously published cases were reviewed. CONCLUSIONS: From the present large series and previous anecdotally reported cases, patients with cystic phaeochromocytomas are more likely to be asymptomatic, to complain of chronic abdominal pain, and to have a negative biochemical evaluation, which might deter physicians from conducting a full evaluation for phaeochromocytoma and mislead the final diagnosis. As such, there could be an even higher prevalence of this entity that is yet to be determined.

Adrenal masses: characterization with in vivo proton MR spectroscopy--initial experience.

PURPOSE: To prospectively determine the accuracy of in vivo proton ((1)H) magnetic resonance (MR) spectroscopy in distinguishing adrenal adenomas, pheochromocytomas, adrenocortical carcinomas, and metastases, with histologic or computed tomographic findings and follow-up data as the reference standards. MATERIALS AND METHODS: This study was approved by the institutional ethics committee, and informed consent was obtained. Sixty consecutive patients (24 male and 36 female patients; mean age, 53 years) harboring adrenal tumors larger than 2 cm in diameter (mean diameter, 4.6 cm +/- 3.4 [standard deviation]) entered the study and were examined with a 1.5-T MR imaging system and point-resolved multivoxel (1)H MR spectroscopy. Thirty-eight patients had adenomas; 10, pheochromocytomas; five, carcinomas; and seven, metastases. Amplitude values for choline, creatine, lipid, and a metabolite peak at precession frequency of 4.0-4.3 ppm were measured. Metabolite ratios (choline-creatine, choline-lipid, lipid-creatine, and 4.0-4.3 ppm/creatine) and cutoff values (obtained by using receiver operating characteristic analyses) were obtained and compared for each type of adrenal mass, which was identified previously on the basis of clinical, hormonal, and pathologic evidence. Results were evaluated with chi(2) and Student t tests. Significance was inferred at P < .05. RESULTS: Cutoff values of 1.20 for the choline-creatine ratio (92% sensitivity, 96% specificity; P < .01), 0.38 for the choline-lipid ratio (92% sensitivity, 90% specificity; P < .01), and 2.10 for the lipid-creatine ratio (45% sensitivity, 100% specificity) enabled adenomas and pheochromocytomas to be distinguished from carcinomas and metastases. A 4.0-4.3 ppm/creatine ratio greater than 1.50 enabled distinction of pheochromocytomas and carcinomas from adenomas and metastases (87% sensitivity, 98% specificity; P < .01). The best distinction was obtained by comparing choline-creatine and 4.0-4.3 ppm/creatine ratios. CONCLUSION: (1)H MR spectroscopy can be used to characterize adrenal masses on the basis of spectral findings for benign adenomas, carcinomas, pheochromocytomas, and metastases.

Advances in pheochromocytoma management in the era of laparoscopy.

PURPOSE: To understand the advances that were made in the management of pheochromocytoma since laparoscopy was initiated at our institution. MATERIALS AND METHODS: Data for all patients who underwent surgical procedure for adrenal diseases had been recorded prospectively since September 2000, when laparoscopy was routinely initiated at our institution; all patients with a diagnosis of pheochromocytoma up to December 2005 had their data assessed (group 1). Charts for all patients with a diagnosis of pheochromocytoma who underwent surgery at our institution from 1990 to 1995 (group 2) were reviewed, and the data were compared with data from patients in group 1. RESULTS: In group 1, 24 patients with pheochromocytoma underwent 26 procedures at our institution, including five patients with extra-adrenal tumor and one patient with bilateral tumor; 18 adrenalectomies (one bilateral) were performed, and two extra-adrenal tumors were removed using a laparoscopic approach. In group 2, ten open adrenalectomies were performed in 9 patients (1 bilateral). The patients who underwent laparoscopy for either adrenal or extra-adrenal tumor had shorter operative times and hospital stay and less bleeding. CONCLUSIONS: Pheochromocytoma is a complex disease with potentially severe complications. Laparoscopic adrenalectomy can be safely performed for removal of either adrenal or extra-adrenal tumors. Patients spend a shorter time in the critical care unit after the procedure.

Evaluation of renal defect healing, hemostasis, and urinary fistula after laparoscopic partial nephrectomy with oxidized cellulose.

BACKGROUND AND PURPOSE: Laparoscopic partial nephrectomy (LPN) has been performed at several institutions using oxidized cellulose (OC) as a means of bleeding and urinary fistula (UF) prevention. However, a foreign-body reaction mimicking either abscess or tumor recurrence has been associated with the use of OC. We evaluated renal-defect healing after LPN with and without OC. MATERIALS AND METHODS: Sixteen female Landrace pigs underwent lower-pole excision; all the collecting systems were entered and then closed with absorbable running suture. In group 1, hemostatic U-shaped stitches were the only method of hemostasis. In group 2, a bolster of OC was added to the renal defect. The pigs were sacrificed at 1, 4, 7, or 21 days, and gross findings such as perirenal collection were observed. A catheter was advanced up to the kidney, and methylene blue was injected with collecting system pressure observation; burst pressure was defined as the appearance of extravasation. High risk for UF was defined as burst pressure <10 mm Hg. RESULTS: Neither hemorrhage nor urinoma was observed during sacrifice. One pig from group 2 had a burst pressure of 4 mm Hg At 7 days (high risk for UF). At 21 days in group 2, the tissue was grossly solid, apparently a granuloma. Suppuration tended to be greater in group 2. The foreign-body reaction was more intense in group 2 and was strongly present at 4, 7, and 21 days. CONCLUSIONS: The use of OC is associated with higher scores of suppuration and foreign-body reaction. After LPN with OC, postoperative day 7 might be a critical time for the development of urinary leakage.

In-vitro renal shrinkage after hypertonic saline perfusion for organ removal during laparoscopic nephrectomy.

BACKGROUND AND PURPOSE: To evaluate the possibility of shrinking the kidney by perfusion with hypertonic solution to facilitate organ removal in laparoscopic surgery. MATERIALS AND METHODS: After 18 open nephrectomies (ONs) in 9 pigs, one of four saline solutions (5%, 7.5%, 10%, and 15%) was infused through a catheter into the renal artery for 5 minutes in four kidneys each. The volumes and weights of the kidneys were measured before and after renal perfusion; the kidneys were then sent for histologic evaluation. Eight ONs were performed, and the kidneys were removed from the abdominal cavity in a plastic bag in order to mimic organ entrapment during laparoscopy. The kidneys were perfused with hypertonic solution and were again put in a plastic bag and removed from the same animal's abdomen through another incision. The incisions were measured with calipers before and after extraction of the unperfused and perfused organs. RESULTS: The kidneys that underwent perfusion with 5% saline had the greatest decrease in both weight and volume, an average of 16% and 17.8%, respectively. The average incision needed for extraction of unperfused kidneys was 44.9 mm (range 40-58 mm), whereas the mean size of the incision needed to remove perfused kidneys was 26.6 mm (range 20-30 mm) (P < 0.001). The relative reduction in the necessary incision size therefore was 44.3% (range 33.3%-55%). CONCLUSION: Perfusion with 5% saline is able to shrink the kidney volume slightly with mild histologic changes. In the pig, it is possible to decrease the renal incision necessary for kidney removal by 44% using this method.

Renoduodenal fistula after renal tumor ablation with radiofrequency.

PURPOSE: To report a renoduodenal fistula after renal tumor ablation with radiofrequency (RFA). METHODS: A 1-inch right anterior renal cell carcinoma was subjected to percutaneous RFA under sedation. We used a 14-gauge probe guided by ultrasonographic images in real time. RESULTS: On the fifth day the computerized tomography with double contrasts showed a fistula between the pelvis and the duodenum. CONCLUSIONS: A major concern regarding this approach relates to the anterior renal tumor and the guided images during the procedure. To our knowledge, there has never been any report of renoduodenal fistula after RFA.

The Boatman's knot: a single knot for renal-vein ligation during laparoscopic nephrectomy: description of technique and evaluation of feasibility and safety.

BACKGROUND AND PURPOSE: The endovascular stapler is the standard of care for renal-vein ligation during nephrectomy, but recently, some reports have addressed the need for lowering the costs in the operating room. The authors describe the first use of "boatman's knot" in renal-vein ligation during laparoscopic nephrectomy and tests of its safety and feasibility. MATERIALS AND METHODS: Sixteen bilateral laparoscopic nephrectomies were performed in female pigs. On the right side, the renal vein was ligated with the boatman's knot, and on the left side, the vein was ligated with conventional intracorporeal technique. The knots were performed by the same surgeon at initial laparoscopic training. The time required to tie the knots was measured. After bilateral nephrectomy, a midline incision was created, and the bursting pressure of the knots was measured with a manometer by saline infusion into the vena cava. RESULTS: The average knot-completion time was 45 seconds (range 30-50 seconds), and the average time needed to carry out the conventional suture was 202.5 seconds (range 186-228 seconds). After renal-vein transection, there was complete hemostasis in all cases. The mean bursting pressure was 179.9 mm Hg (range 126-304 mm Hg). In five cases, the rupture site was in a lumbar vein previously sutured, while in three cases, the rupture happened in the vena cava itself. CONCLUSION: The boatman's knot is feasible, safe, easy to learn, and faster than conventional intracorporeal suturing. This technique may replace the endovascular stapler. However, its clinical applicability remains to be determined.

The "boatman's knot": a new option for renal hilum ligation during laparoscopic nephrectomy.

PURPOSE: The authors present and describe an original adaptation for the use of "boatman's knot" in renal vein ligation during laparoscopic nephrectomy. This procedure may replace the need for the endovascular stapler, which is considered the standard of care, but not available in several institutions in Brazil. The knot presented is also known as the "pig's knot" in several farms in Brazil. METHODS: Fourteen laparoscopic nephrectomies were performed by the same surgeon in a standard fashion in seven female pigs. Both the renal artery and vein were ligated using the "boatman's knot" as the only method for hemostasis with conventional intracorporeal technique. Two knots were applied in each artery and vein; one knot was tied proximally and the other distally. The vessels were then sectioned in between both knots. This technique is based on the intracorporeal confection of two loops by the right hand pair of dissectors with the help of the left hand. The arteries and the veins were then sectioned and the capability to accomplish full hemostasis was observed. RESULTS: All the laparoscopic nephrectomies were performed successfully. The "boatman's knot" was performed by the same surgeon with neither complications nor difficulties during the confection of the knot. In all cases hemostasis was fully achieved using only the "boatman's knot" as the hemostatic method. CONCLUSION: The "boatman's knot" is feasible and safe for hilum control during laparoscopic nephrectomy in pigs and total hemostasis can be achieved using it as the only method of hemostasis. However, the safety and the capacity of others to learn how to apply it should be tested before it may be advised to use it routinely.

Laparoendoscopic single site surgery versus conventional laparoscopy for transperitoneal pyeloplasty: A systematic review and meta-analysis.

We aimed to review studies comparing the outcomes of the laparoendoscopic single site (LESS) pyeloplasty with those of conventional laparoscopic pyeloplasty (CLP). A systematic review of the literature was performed according to the PRISMA (preferred reporting items for systematic reviews and meta-analysis) criteria. The methodological quality of the studies was rated according validated scales. The level of evidence (LE) was reported as described by the Oxford criteria. Preoperative demographic parameters and perioperative outcomes between the two surgical techniques were assessed. A meta-analysis of the included studies was performed. A total of 5 studies were elected for the analysis, including 164 cases, 70 (42.6%) of them being LESS and 94 (57.4%) being CLP. Four studies were observational retrospective comparative studies (LE: 3a-4); one was a prospective randomized controlled trial (LE: 2b). There was no significant difference in age, body mass index, gender, side and presence of the crossing vessel, between the groups. There was no significant difference regarding the operative time (weight mean difference [WMD]: -7.02; 95% confidence interval [CI]: -71.82-57.79; P = 0.83) and length of hospital stay (WMD: 0.04; 95% CI: -0.11-0.20; P = 0.58), whereas the estimated blood loss was statistically lower for LESS (WMD: -16.83; 95% CI: -31.79--1.87; P = 0.03). The postoperative use of analgesic favored the LESS group but without reaching statistical significance (WMD: -7.52; 95% CI: -17.56-2.53; P = 0.14). In conclusion, LESS pyeloplasty offers comparable surgical and functional outcomes to CLP while providing the potential advantages of less blood loss and lower analgesic requirement. Thus, despite being more technically challenging, LESS pyeloplasty can be regarded as a minimally invasive approach for patients seeking fewer incisional scars.

Clinical outcomes of patients with nondiagnostic biopsy during cryoablation of small renal masses.

OBJECTIVE: To compare the outcomes of patients with biopsy-proven renal cell carcinoma (RCC), benign tumors (BTs), and nondiagnostic (ND) biopsies after renal cryoablation (RC). METHODS: We retrospectively reviewed medical records of 114 patients who underwent RC between 2003 and 2013. Patients were stratified according to biopsy histopathology results-RCC, BT, and ND biopsy. We recorded patient demographics and tumor features and examined oncologic outcomes among the 3 groups. RESULTS: RC was performed in 114 patients with 117 tumors. Seventy-two tumors (61.5%) were RCC, 18 (15.4%) were BTs (oncocytoma or angiomyolipoma), and 27 (23.1%) were ND. Patient characteristics and tumor features were similar among the 3 groups. The median follow-up was 26.5, 26.0, and 22.0 months in the RCC, BT, and ND biopsy groups, respectively (P = .18). Residual disease occurred in the RCC (1.4%) and ND biopsy (7.4%) groups, but not in the BT group (P = .19). All 9 patients (12.5%) who developed recurrent disease had biopsy-proven RCC. The 2- and 5-year recurrence-free survival rates (RFS) for patients with biopsy-proven RCC were 90.2% and 81.2%, respectively. Because no patient in the BT and ND biopsy groups had a recurrence, their RFS was 100%. CONCLUSION: No patient with a BT or ND biopsy developed a local recurrence with short-term follow-up, whereas a recurrence developed in 12.5% of biopsy-proven RCC tumors. RFS for patients with biopsy-proven RCC was worse than the other 2 biopsy groups, although not statistically significant. Long-term follow-up in a larger cohort of patients is needed to further evaluate these preliminary findings.

Effect of single-dose subarachnoid spinal anesthesia on pain and recovery after unilateral percutaneous nephrolithotomy.

PURPOSE: We studied the impact of one dose of subarachnoid spinal analgesia on postoperative pain and recovery after percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Between August 1999 and May 2000, 20 PCNL patients were randomized into two groups: Group A (N = 9), who received preoperative subarachnoid spinal analgesia with morphine sulfate, and Group B (N = 11), who received no subarachnoid spinal analgesia. Both groups were given general anesthesia, and the nephrostomy site was infiltrated with bupivacaine hydrochloride. Stone size was similar in the two groups, as were ASA classification, age, and body mass index. Pain analog scales (maximum score 10) were completed preoperatively and on the day of surgery (D0), after 1 day (D1), and after 2 days (D2). The amount of morphine sulfate equivalents (MS eq) needed, the activity level, and adverse effects were recorded. RESULTS: In Group A, the average pain score on D0, D1, and D2 was 2.7, 3.7, and 1.4, respectively; in Group B, the average pain score was 4, 4.5, and 2, respectively (P > 0.05). The average MS eq used in Groups A and B were 8.3 v 33.8 (P = 0.002) on D0; 17.7 v 28.7 (P > 0.05) on D1; and 11.1 v 10.1 (P > 0.05) on D2. On D0, in Group A, 56% of the patients were ambulating and 11% complained of nausea, while in Group B, 0 were ambulating and 46% complained of nausea. CONCLUSIONS: A single preoperative dose of subarachnoid spinal analgesia provides a statistically significant decrease in postoperative parenteral pain medication and earlier ambulation. It also appears to reduce the amount of postoperative pain and decrease nausea.

Laparoscopic partial nephrectomy with a novel electrosurgical snare in a porcine model.

PURPOSE: We evaluated the safety and efficacy of laparoscopic partial nephrectomy with an arcing-gap electrosurgical snare in a porcine model. MATERIALS AND METHODS: A novel electrosurgical snare, optimizing high current density arcing and parenchymal compression, was utilized for laparoscopic renal transection. Five farm pigs underwent unilateral laparoscopic polar partial nephrectomy; 6 weeks later, these same animals underwent contralateral partial nephrectomy just prior to sacrifice. Five additional animals underwent chronic (6-week follow-up) and acute open partial nephrectomies by the conventional surgical technique. RESULTS: The average time for transection with the snare was 5.6 minutes. In 9 of 10 cases, the snare provided satisfactory hemostasis. In the remaining case, additional argon-beam coagulation (ABC) controlled the minimal bleeding present after transection. In all 10 animals, the collecting system was transected. In six cases, application of the snare alone sealed the collecting system. No urinomas developed in the five animals followed for 6 weeks. At 6 weeks, the mean depth of injury at the center of the cut surface was 5.1 mm in the laparoscopic group and 3.9 mm in the open group. CONCLUSIONS: Laparoscopic partial nephrectomy with the arcing-gap electrosurgical snare is feasible in a porcine model. Application of the snare provides excellent hemostasis without the need to control the renal vasculature.

Laparoscopic cyst decortication in autosomal dominant polycystic kidney disease: impact on pain, hypertension, and renal function.

BACKGROUND AND PURPOSE: In patients with autosomal dominant polycystic kidney disease (ADPKD), laparoscopic cyst decortication (LCD) has been proposed as a means to relieve chronic cyst-related pain. We present our 7-year experience with LCD for ADPKD with regard to pain relief, hypertension, and renal function. PATIENTS AND METHODS: Between August 1994 and February 2001, 29 ADPKD patients with chronic pain (N=29), hypertension (N=21), and renal insufficiency (N=10) underwent 35 LCD procedures. Every detectable cyst within 2 mm of the renal surface was treated. Pain relief was assessed using a pain analog scale; relative pain relief (RPR) equaled (preoperative pain score) - (postoperative pain score)/(preoperative pain score). Hypertension was evaluated using the antihypertensive therapeutic index (ATI): [(dose of blood pressure medication 1/max dose 1) + (dose med 2/max dose 2) + etc.] x 10. Renal function was assessed using the Cockcroft and Gault formula for creatinine clearance. RESULTS: The mean operating room time was 4.9 hours (range 2.6-6.6 hours) with no conversions to open surgery. An average of 220 cysts (range 4-692) were treated per patient. The mean follow-up was 32.3 months (range 6-72 months). The RPR was 58%, 47%, and 63% at 12, 24, and 36 months, respectively. At 12, 24, and 36 months, 73%, 52%, and 81% of patients, respectively, noted >50% improvement in their pain compared with the preoperative situation. Five patients became normotensive, and patients improved their ATI by an average of 49% (range 11%-93%). However, six patients had worsening hypertension, with an ATI increase averaging 53% (range 11%-122%), and one patient who was not hypertensive preoperatively has since developed hypertension. The creatinine clearance changed +4%, +7%, and -2% at 12, 24, and 36 months, respectively. Only one patient had a >20% increase in creatinine clearance. The only patients with a >20% decrease in creatinine clearance were those who had a creatinine clearance <30 mg/dL preoperatively (average decrease 34% [range 20%-51%]). CONCLUSIONS: For ADPKD patients with debilitating pain, extensive LCD can provide durable relief. In the majority of patients with pain and hypertension, a marked improvement in blood pressure also occurs. Cyst decortication was not associated with worsening renal function; indeed, renal function remained largely unchanged over the 3-year follow-up period.

Practical and intuitive surgical approach renal ranking to predict outcomes in the management of renal tumors: a novel score tool.

BACKGROUND AND PURPOSE: Surgery continues to be the main form of treatment for patients with renal tumors. We create a more practical and intuitive score for renal tumor classification. PATIENTS AND METHODS: Eighty patients underwent surgery for renal tumors and were prospectively enrolled. The tumors were classified using the following variables: (1) tumor size, (2) endophytic or exophytic tumor, (3) longitudinal location of the tumor, (4) the extent of the impairment of the renal parenchyma, (5) relationship with the renal sinus, and (6) anterior or posterior. RESULTS: The mean operative time, tumor size,and bleeding increased proportionally to the increased complexity of the tumor measured by scores (P<0.0001, P<0.0001, and P=0.036, respectively). The mean total score was 8.7 points for patients undergoing partial nephrectomy (PN) and 14.4 points for those undergoing radical nephrectomy (RN) (P<0.0001). Patients with larger tumors, completely endophytic, which exceeded the renal medulla, and were centrally located, underwent RN more often (86.7% - P<0.0001, 64% - P=0.01, 77% - P<0.0001, and 78.9% - P<0.0001, respectively). In univariate analysis, RN was associated with tumors larger than 7 cm (P=0.001), tumors that exceeded the renal medullary (<0.001), centrally located tumors (odds ration [OR]=150, P<0.001), and tumors of high complexity (P<0.001). Analysis showed no association between complications and variables in the score. The findings were similar when the tumors were evaluated with the R.E.N.A.L. score system. CONCLUSION: Surgical Approach Renal Ranking is a simple, practical and intuitive classification for renal tumors that can be used in the decision-making process and to predict outcomes in the surgical treatment of patients with renal tumors.