Laparoscopic nephrectomy for nonfunctioning kidneys is feasible after previous ipsilateral renal surgery: a prospective cohort trial.

PURPOSE: Previous renal surgery is a relative contraindication to laparoscopic nephrectomy because adhesion formation makes surgical dissection difficult. We determined whether previous surgery at the same anatomical site would affected the surgical outcome in patients who underwent transperitoneal laparoscopic nephrectomy. MATERIALS AND METHODS: During the study period 79 consecutive patients who underwent transperitoneal laparoscopic nephrectomy were evaluated prospectively. All patients had symptomatic nonfunctioning small or hydronephrotic kidneys. Patients were divided into 29 with and 50 without prior surgery at the same anatomical site. Previous surgery included open nephrolithotomy in 16 patients, percutaneous nephrolithotomy in 8, open and percutaneous nephrolithotomy in 3, pyelolithotomy in 1 and pyeloplasty in 1. RESULTS: Patients who underwent prior surgery were older than patients who did not (average age 46.6 vs 34.9 years, p=0.008). Other patient characteristics, including gender ratio, body mass index and side of surgery, did not differ significantly between the 2 groups. Mean operative time was longer in patients with previous surgery than in the other group (98.6 vs 62.3 minutes, p=0.03). Other operative data, including blood loss, intraoperative and postoperative complications, open conversion and hospital stay, were similar in the groups. One case per group was converted to open surgery due to difficult pedicle dissection. CONCLUSIONS: Transperitoneal laparoscopic nephrectomy in patients with a history of ipsilateral renal surgery can be done safely in timely fashion. Although mean operative time was longer, there was no significant increase in the operative complication rate in patients with prior surgery.

Pyelovesical bypass graft for palliative management of malignant ureteric obstruction: optimizing the technique by percutaneous access to the bladder using a split Amplatz sheath.

OBJECTIVES: To introduce a simple modification to the original technique of pyelovesical bypass graft placement to make the procedure more minimally invasive. METHODS: During the study period 2 patients with malignant ureteric obstruction underwent pyelovesical bypass graft placement using Detour stent (Mentor-Porges). The technique simply comprised tract dilatation of the previously placed percutaneous nephrostomy to place the proximal end of the graft in the renal collecting system, making a subcutaneous tunnel from a 1-cm suprapubic incision to the flank area, percutaneous access to the bladder under fluoroscopic guide and placement of the distal end of the stent into the bladder through a split Amplatz sheath. The operative outcome was analyzed prospectively. RESULTS: Both patients tolerated the procedures well with no intra- and postoperative complications. Renal function remained stable during the follow-up period with acceptable urine output through the urethra. Abdominal wall complications such as fistula formation or pain along the subcutaneous tract as well as stent encrustation did not occur during the follow-up period. CONCLUSIONS: Despite our small sample size and short follow-up period, percutaneous access to the bladder using a split Amplatz sheath during placement of the Detour stent, may be considered as a promising simple modification to optimize the technique by obviating the need for open cystostomy incision.

Hybrid natural orifice transluminal endoscopic surgery for nephrectomy with standard laparoscopic instruments: experience in a canine model.

OBJECTIVE: The aim of this study was to demonstrate the feasibility of hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy with standard laparoscopic instruments through a modified vaginal trocar in a canine model. MATERIALS AND METHODS: Ten cross-bred adult female dogs were used for right (n = 4) and left (n = 6) transvaginal nephrectomy. After transumbilical peritoneoscopy, a laparoscopic transvaginal trocar was introduced through the posterior vaginal fornix under direct vision. Using a 10-mm working laparoscope lens with a 3-mm working channel as endovision via the umbilical port and the transvaginal port, triangulation and dissection of the kidney and its hilum were performed. The renal artery and vein were closed with Hem-o-lok clips transvaginally. At the end of the procedure, after snaring the kidney in an endobag, the specimen was retrieved through a colpotomy incision by extending the vaginal port site. RESULTS: All procedures were completed without need for conversion. The mean operative time was 101 minutes (75-135 minutes). The mean preoperative/postoperative hemoglobin was 12.01/11.7 g/dL and intraoperative blood loss was minimal. The mean size of the removed kidneys was 9.1 x 5.1 cm and the mean weight was 98.5 g (90-115 g). Exploration of the abdomen and vagina after 1 month showed complete healing of the colpotomy incision with no visceral injury. There were no significant adhesions or fibrotic changes in the renal fossa. CONCLUSION: Hybrid NOTES nephrectomy is technically feasible in canine model with a standard laparoscopic setup and instruments. This study may remove barriers for further investigational work with NOTES technique, especially with a view to adapting it for use in low-resource centers, while offering a strategy to help surgeons train with this novel technology.

Combined use of Mathieu procedure with plate incision for hypospadias repair: a randomized clinical trial.

OBJECTIVES: To introduce a simple and effective technique for urethroplasty of distal hypospadias, using the advantages of both standard techniques of Snodgrass and Mathieu to reduce or eliminate the shortcomings of each. METHODS: Forty patients with primary distal hypospadias were randomized between two groups (20 in each). Patients in group I underwent standard Snodgrass urethroplasty, whereas those in group II were operated with our novel technique, Mathieu-Incised Plate (Mathieu-IP), comprising preparation of a parameatal-based skin flap as in the Mathieu procedure together with modifications (adopted from Snodgrass urethroplasty) such as a complete longitudinal incision on the urethral plate as well as coverage of the neourethra with an inner preputial flap. Operative data and outcomes of both procedures were analyzed prospectively after 1 year of follow-up. RESULTS: Both groups were age matched (group I: 7.05 +/- 4.85 years; group II: 7.31 +/- 2.17 years), and there were no significant differences in mean operative time (95 minutes versus 100 min in groups I and II, respectively). There were significant differences between the two groups in terms of complications. Whereas 3 cases of posturethroplasty meatal stenosis and 2 of urethrocutaneous fistula (5 complications, 25%) were detected in the Snodgrass group, neither of these complications occurred in the Mathieu-IP group. All 40 patients benefited from a slit-like meatus. CONCLUSIONS: Combining the Mathieu procedure with plate incision could be considered a promising simple technique to achieve a normally shaped meatus and to reduce the rate of meatal-related complications, the major concern with the Snodgrass procedure.