Randomized controlled trial of hand-assisted laparoscopic versus open surgical live donor nephrectomy.

BACKGROUND: Laparoscopic live donor nephrectomy for renal transplantation is being performed in increasing numbers with the goals of broadening organ supply while minimizing pain and duration of convalescence for donors. Relative advantages in terms of recovery provided by laparoscopy over standard open surgery have not been rigorously assessed. We hypothesized that laparoscopic as compared with open surgical live donor nephrectomy provides briefer, less intense, and more complete convalescence. METHODS: Of 105 volunteer, adult, potential living-renal donors interested in the laparoscopic approach, 70 were randomly assigned to undergo either hand-assisted laparoscopic or open surgical live donor nephrectomy at a single referral center. Objective data and subjective recovery information obtained with telephone interviews and validated questionnaires administered 2 weeks, 6 weeks, and 6-12 months postoperatively were compared between the 23 laparoscopic and 27 open surgical patients. RESULTS: There was 47% less analgesic use (P=0.004), 35% shorter hospital stay (P=0.0001), 33% more rapid return to nonstrenuous activity (P=0.006), 23% sooner return to work (P=0.037), and 73% less pain 6 weeks postoperatively (P=0.004) in the laparoscopy group. Laparoscopic patients experienced complete recovery sooner (P=0.032) and had fewer long-term residual effects (P=0.0015). CONCLUSIONS: Laparoscopic donor nephrectomy is associated with a briefer, less intense, and more complete convalescence compared with the open surgical approach.

Is radical cystectomy indicated in patients with regional lymphatic metastases?

The records of 21 patients who had radical cystectomies for the treatment of locally advanced bladder cancer and were found to have regional lymphatic metastases have been reviewed. Ten of these patients had only one lymph node involved (N1), and 11 patients had metastases in more than one lymph node (N2-3). Four patients with N1 disease and 1 patient with N2-3 disease survived tumor-free greater than forty months postoperatively. Radical cystectomy can produce long-term disease-free survival in some patients with limited pelvic metastases.

Simultaneous, contralateral hypernephroma and renal transitional cell carcinoma.

The second case of simultaneous, contralateral hypernephroma and renal transitional cell carcinoma is described. Methods of managing bilateral renal tumors are reviewed.

Salvage cystectomy following failed definitive radiation therapy for transitional cell carcinoma of bladder.

Between 1971 and 1983 we performed 18 salvage cystectomies on patients with recurrent transitional cell bladder cancer initially treated with definitive radiation therapy (5,500-6,820 R). The interval between tumor diagnosis and radiation ranged from zero to twenty-one years (mean 3.5 years), and the interval between radiation therapy and cystectomy ranged between six months and twelve years (mean 2.5 years). Early major complications occurred in 5 patients, and there was one early and one late postoperative death. The overall patient survival from the time of diagnosis to death or the present (1985) ranged from two to thirty-one years (mean 9.8 years), and from the time of radiation to the present or death ranged from one to nineteen years (mean 6.2 years). The overall crude five-year survival from the time of cystectomy excluding 2 patients operated on in 1982 and 1983 was 50 per cent, however 3 of these patients died of cancer after five years. Breakdown of survival of these patients by stage demonstrated the best survival in patients with carcinoma in situ and Stage A or no neoplasm at the time of cystectomy. This report confirms the value of salvage cystectomy after radiation failure in invasive transitional cell bladder cancer.

Diagnostic value of routine bone scintigraphy renal imaging in renal cell carcinoma.

Technetium-99m-phosphate compounds used in bone scanning are excreted by the kidney, and excellent renal images can be obtained on routine bone scintigrams. The preoperative bone scans of 49 patients who underwent radical nephrectomy for renal cell carcinoma between 1981 and 1985 were reviewed for renal imaging. Ninety-four percent of the patients had abnormal bone scan renal images (82% had focal decreased uptake, and 12% had focal increased uptake). Six percent of the renal images were symmetrical bilaterally. When bone scans are employed in the postoperative follow-up of patients with renal cancer, they can be used to assess the status of the remaining kidney.

Treatment of renal transplant stones by extracorporeal shock-wave lithotripsy in the prone position.

Two patients with renal transplant lithiasis were successfully treated with extracorporeal shock-wave lithotripsy (ESWL) in the prone position. Pathogenesis and treatment of transplant lithiasis are discussed. Performing ESWL on renal transplant patients in the prone position has advantages over standard positioning techniques.

Stomal construction and reconstruction.

Urinary diversion plays an important role in the therapeutic repertoire of urologists. The stoma is often the weak link of any diversionary procedure. Some of the more common stomal problems include peristomal dermatitis, stomal stenosis, parastomal hernias, malposition, prolapse, and retraction. Depending on the nature and severity of the problem, it may be treated by local wound care, urinary appliance adjustment, dilatation, or surgical intervention. Careful site selection and stomal creation will keep stomal problems to a minimum.

Conservative management of low grade neoplasms of the male urethra: a preliminary report.

Between 1965 and 1977, 8 men with low grade urethral neoplasms were treated with local excision or a combination of local excision and local chemotherapeutic agents. The tumors were in the anterior urethra in 5 cases and the posterior urethra in 3. Histology included 2 transitional cell papillomas, 3 squamous cell carcinomas, 1 transitional cell carcinoma, 1 mesonephric carcinoma and 1 intraductal transitional cell carcinoma in situ. All neoplasms were controlled by local measures for 1 to 13 years. This experience suggests that local treatment may be an acceptable alternative to a radical operation in certain well localized low grade urethral neoplasms in men.

Microsurgical penile revascularization using the central corporeal penile artery.

We treated 9 patients with vasculogenic impotence by penile revascularization using a microsurgical anastomosis between the inferior epigastric artery and the central corporeal penile artery. Diagnostic evaluation included penile brachial indexes and pelvic arteriograms, which were abnormal in all 9 patients. Revascularization was technically possible in 7 of 9 patients; 2 had inadequate central arteries. The penile brachial index initially was improved in all 7 patients, although 1 had an early occlusion at 2 months and 1 had a late occlusion at 4 years. Potency was improved initially in 6 of the 9 patients, with longer term improvement in 5 of 9 followed 1 to 8 years. Two patients remain potent currently. The advantages of this technique are a reasonably high technical success rate in selected patients, with improved initial potency in more than half. The disadvantages include technical difficulty, lack of clear-cut selection criteria and unknown long-term results.

Otis internal urethrotomy in the treatment of urethral stricture disease.

Internal urethrotomy was done on 216 urethral strictures in 192 patients at our medical centers from 1969 to 1978. Of these cases 71 per cent were treated successfully, with a 12 per cent complication rate. Results were analyzed separately for different characteristics of the strictures and for several methods of internal urethrotomy. It is concluded that nearly all types of strictures can be treated by internal urethrotomy, with a reasonable rate of success and a minimum of morbidity.

The use of a portable dental x-ray unit for intraoperative renal roentgenograms.

We herein describe a simplified technique for intraoperative roentgenograms of the kidney using a portable dental x-ray unit.

Malacoplakia of the prostate in an immunosuppressed patient.

Malacoplakia predominantly affects the bladder but occasionally involves other sites. The third case of malacoplakia of the prostate, occurring in a renal transplant patient who was receiving prednisone for immunosuppression, is reported. Modification of phagocytosis and the normal inflammatory response to bacterial infection by the steroid may have been of major importance in the genesis of malacoplakia.

Renal cell carcinoma as an incidental finding.

We reviewed the manner of presentation and tumor stage in 56 consecutive patients with renal cell carcinoma treated surgically between 1961 and 1973 (group 1) and compared them to 46 patients treated similarly between 1980 and 1984 (group 2). In group 1, 7 cases (13 per cent) were discovered incidentally compared to 22 cases (48 per cent) in group 2. The tumor stage was lower in the incidentally discovered cases than in cases when the diagnosis was suspected. The 5-year survival rates of the incidental cases in group 1 tended to be better. Routine use of excretory urography, computerized tomography, ultrasound, bone scans and other effective diagnostic studies has led to earlier diagnosis, lower stage and possibly better survival in incidentally found cases of renal cell carcinoma than in cases when the diagnosis was suspected.

Results of combined Nesbit penile plication with plaque incision and placement of Dacron patch in patients with severe Peyronie's disease.

We treated 9 men with severe curvature of the penis secondary to Peyronie's disease with penile plication and a previously unreported technique of incision of the Peyronie plaque and placement of Dacron patch. All men were potent before penile straightening. At a mean followup of 17.5 months all men achieved good to excellent correction of the deformity and they have remained potent. One patient initially complained of numbness of the glans penis and decreased penile rigidity distal to the Dacron patch but potency returned and the numbness resolved.

Treatment of vasculogenic erectile dysfunction by direct anastomosis of the inferior epigastric artery to the central artery to the corpus cavernosum.

We present a case of vasculogenic erectile dysfunction following trauma, which was treated successfully by direct anastomosis of the inferior epigastric artery to the central artery of the corpus cavernosum. This is the first report of this operative technique. Its theoretical advantages over previously described revascularization techniques include an end-to-side vascular anastomosis, possibly decreasing perianastomotic fibrosis, and regulation of new blood flow into the corporeal bodies by the neurovascular mechanism of the central artery.

Primary carcinoma of the distal male urethra: a case treated with lymphadenectomy and interstitial radiation therapy.

We report a case of primary squamous cell carcinoma of the distal male urethra with a single inguinal node metastasis. Treatment consisted of unilateral pelvic and inguinal lymphadenectomy, and a combined course of external beam and interstitial radiation therapy to the distal urethra and penis by the Henschke modification of the Paris technique.