Feasibility of felt application for renorrhaphy after laparoscopic partial nephrectomy.

AIM: Laparoscopic partial nephrectomy (LPN) has become a well-established treatment for selected renal malignancies. Aim of the study was to explore feasibility of the application of haemostatic felt pledgets during renorrhaphy after Laparoscopic Partial Nephrectomy (LPN) and evaluate its efficacy. METHODS: Between May 2008 and December 2011, 42 patients underwent LPN as a treatment for renal tumors by a single surgeon. Tumor size and location were assessed by contrast enhanced computed tomography (CT) scan. A rolled Tabotamp was placed on the tumor bed; 2/0 Vycril sutures, secured with 5mm Hem-o-lok clips, were used to perform the renorrhaphy. 7.9x7.9 mm (5/16"x5/16") felt pledgets were placed between the hem-o-lok clips and the renal parenchyma on both needle entrance sites. W.i.t., EBL, OR time, post-operative complications and hospital stay were recorded. RESULTS: Mean w.i.t. was 21±5 min, mean OR time 151±52 min, while EBL was 162±56 cc. Surgical complications were recorded in 11/42 (26%; Clavien-Dindo classification: II-III). Three patients experienced postoperative ileus, 3 had a urinary leakage, 1 a wound infection and 4 tumor bed bleeding: of these, 2 required blood transfusions, 1 was managed by embolization and 1 underwent nephrectomy. Mean LOS was 2 days. CONCLUSION: The application of hemostatic felt pledgets during renorrhaphy after LPN is feasible and safe. This technique may reduce cortical bleeding, and could ameliorate surgical outcomes.

Efficacy and safety of low molecular weight heparin in renal transplantation.

BACKGROUND: Deep venous thrombosis (DVT) is a common problem with potentially devastating results in patients undergoing major surgical procedures. Certain renal transplant recipients are particularly at risk for allograft loss as a consequence of renal vein and artery thrombosis. Over the past few years, low molecular weight heparin has been well established as an accepted modality of treatment and prophylaxis of DVT. The efficacy and safety of low molecular weight heparin in the prophylaxis of DVT following renal transplantation in adults has not previously been reported. METHODS: Dalteparin was administered to 120 adult renal transplant recipients postoperatively at the Oregon Health Sciences University. RESULTS: No patient developed allograft arterial or venous thrombosis. One patient developed subclavian vein thrombosis. No bleeding complications were encountered, and side effects were very minimal. CONCLUSION: Prophylaxis with dalteparin is an effective and safe modality for the prevention of thrombosis in adult patients undergoing renal transplantation.

Safe laparoscopic access in pediatric patients.

The most serious complications of laparoscopy are attributable to gaining access to the peritoneal cavity. This has traditionally been performed with a closed technique utilizing the Verres needle and subsequently with a 5 to 10 mm trocar. The risks of blind peritoneal access are magnified in pediatric patients due to the smaller abdominal cavity and the closer proximity of the great vessels. Open techniques have been devised for adults but often require a larger incision with an undesirable cosmetic result in pediatric patients. We describe a safe, open technique for laparoscopic access to the pediatric peritoneal cavity.

Pediatric hernias and hydroceles. The urologist's perspective.

Pediatric inguinal hernias and hydroceles are due to incomplete or abnormal obliteration of the processus vaginalis. Surgical correction of these conditions is the most common surgical procedure performed on young children. The embryology, anatomy, evaluation, and management of pediatric inguinal hernias and hydroceles are reviewed. A thorough understanding of these topics will aid with the sometimes difficult decisions encountered in the care of these patients.

Ureteroscopy. Development and instrumentation.

Advances in ureteroscope and working instrument designs now allow the treatment of a variety of upper urinary tract disorders in a minimally invasive fashion. This field has benefited from the close cooperation between endourologists, engineers, and manufactures. Continued cooperation should result in even further improvements in ureteroscopic instrumentation. This article also presents the development of flexible and rigid ureteroscopes and working instruments. Knowledge of these features can assist the urologist in choosing the most appropriate tool for different ureteroscopic tasks.

Laser division of intraluminal sutures.

Neodymium:YAG and holmium:YAG lasers were used to remove intraluminal sutures from three patients. In two, the suture was in the bladder and had served as a nidus for stone formation. In the other, the suture was in the ureter. An in vitro study showed that the Nd:YAG laser could divide all types of suture readily, whereas the Ho:YAG laser could divide all materials except Gortex. These cases illustrate another application for lasers.

Device for intraluminal incision guided by endoluminal ultrasonography.

Intraluminal incision is often used for the treatment of strictures of both the upper and the lower urinary tracts. The depth of the stricture and the location of surrounding structures such as blood vessels are important factors in guiding the incision. Endoluminal ultrasonography has been shown to be effective in defining periureteral anatomy accurately. A new device is described that combines an endoluminal ultrasound transducer and cutting device (electrocautery or laser fiber) in 9F catheter. This catheter was evaluated in two live anesthetized pigs (four kidneys) and four ex-vivo kidneys. Incisions were made at the ureteropelvic junction and middle and distal ureter. The ability to image the periureteral structures and to direct the location and the adequacy of the incision were assessed. Endoluminal ultrasound imaging was excellent, and the electrocautery wire was well seen. Well-defined, limited, full-thickness incisions were made using this device and could be directed accurately toward or away from periureteral vessels. This study demonstrates the potential for endoluminal ultrasound guidance of intraluminal incisions.

Small intestinal submucosa plug for closure of dilated nephrostomy tracts: a pilot study in swine.

The aim of this study was to evaluate efficacy of a plug made of small intestinal submucosa (SIS) for closure of dilated nephrostomy tract in the kidney after nephroscopy. Ten kidneys in 5 swine had nephrostomy tracts dilated up to 8 mm. The SIS plug was placed into the dilated renal cortex under nephroscopic control. Follow-up arteriograms, retrograde pyelograms, and macroscopic and histologic studies at 24 h (n = 4), 6 weeks (n = 2), and 3 months (n = 4) were performed to evaluate the efficacy of the plug. The SIS plug effectively closed the dilated nephrostomy tract. Follow-up studies showed minimal changes of the kidneys, except for 1 small infarction, regarding inflammatory and foreign-body reactions and progressive scarring of the SIS. SIS plug is effective for occlusion of dilated nephrostomy tract after nephroscopy. Its efficacy should be compared with other therapeutic options.

Minimizing surgical problems of peritoneal dialysis in children.

We review our experience with peritoneal dialysis catheter placement in children. The most common surgical problems after peritoneal dialysis catheter placement are inguinal hernias, catheter obstruction and dialysate leakage. We describe specific techniques to minimize the development of these problems.

Ureteroscopic endopyelotomy at a single setting.

PURPOSE: Endopyelotomy has become the initial treatment of choice for ureteropelvic junction obstruction. Debate persists regarding the preferred approach (percutaneous or ureteroscopic) and the need for preoperative stenting. We review our experience with ureteroscopic endopyelotomy without preoperative stenting. MATERIALS AND METHODS: We treated 21 patients a mean of 37 years old who had ureteropelvic junction obstruction with ureteroscopy and without preoperative stenting. Endoluminal ultrasound was performed in all cases for imaging the periureteral anatomy. A minimum of 1 year of followup is available in all cases. Success was defined as pain-free status with resolution of obstruction on diuretic renal scintigraphy. RESULTS: Success was achieved in 17 of 21 patients (81%). Complications included stent irritation, postoperative urinary tract infection and stent displacement requiring repositioning in 1 case each. Crossing vessels in 57% of the patients affected success (67 versus 100% in those with and without crossing vessels, respectively). No patient had significant hemorrhage. CONCLUSIONS: Ureteroscopic endopyelotomy without preoperative stenting is effective and safe for ureteropelvic junction obstruction.

Extravesical ureteroneocystostomy for duplicated allograft ureters.

We report a modification of unstented, parallel incision, extravesical ureteroneocystostomy for duplicated ureters. The technique is simple and effective, and requires no routine stenting.

Endoscopic ureteroureterostomy for obliterated ureteral segments.

PURPOSE: Advances in endourological techniques and instrument design have made the endoscopic treatment of complete ureteral obstruction a reasonable alternative to open surgery. We report our experience with endourological management of 10 cases of obliterated ureteral segments. MATERIALS AND METHODS: Endoscopic ureteroureterostomy was performed in 8 patients with complete ureteral obstruction and it was not attempted in 2 because of the length or orientation of the obliterated segment. RESULTS: Access, incision and stenting of the obliterated segment were technically successful in 8 patients. Two patients had patent ureters but required a stent, including 1 who underwent nephrectomy due to problems with stent management. Endoscopic treatment achieved long-term patency in 7 of the 8 cases and it was completely successful in 6 (75%) at a median followup of 87 months (range 4 to 126). CONCLUSIONS: Endoscopic ureteroureterostomy is a safe and effective technique for the management of obliterated ureteral segments less than 2 cm. long with adequate alignment.

Postoperative cystography is unnecessary following renal transplantation with parallel incision extravesical ureteroneocystostomy.

PURPOSE: To determine the need for postoperative cystography following extravesical ureteroneocystostomy for renal transplantation. MATERIALS AND METHODS: The clinical courses of 200 consecutive kidney transplant recipients who underwent urinary tract reconstruction by parallel incision extravesical ureteroneocystostomy were reviewed. RESULTS: Five of the 200 recipients did not have the study because of early mortality (1) or medical problems (4). Grade I vesicoureteral reflux was present in 5 (3%) of 182 unstented allograft ureters and 5 of 13 stented allograft ureters. Two patients (1%) underwent repeat ureteroneocystostomy, one for obstruction and one for extravasation. The cystograms were normal in both patients. CONCLUSIONS: Routine retrograde cystography is unnecessary following urinary tract reconstruction by parallel incision extravesical ureteroneocystostomy.

Treatment of biliary calculi using holmium: yttrium aluminum garnet laser.

BACKGROUND: The holmium: yttrium aluminum garnet laser (Ho: YAG) has been shown to be effective and safe for the treatment of urinary calculi. Its effectiveness for the treatment of biliary calculi was investigated. METHODS: Endoscopic Ho: YAG lithotripsy of biliary stones was performed 7 times in 4 patients. Two patients had biliary duct calculi, and the other two patients had gall bladder calculi. All patients had multiple calculi that ranged in size from 4 mm to 5 cm. All procedures were performed percutaneously under intravenous sedation and local anesthesia. Rigid and flexible endoscopes were used to access the biliary calculi. Postoperative cholangiograms were performed on all patients. RESULTS: All calculi were successfully fragmented with the Ho: YAG laser. The most common settings on the laser were 1.0 J and 10 Hz. Average total laser energy used was 12.24 kJ. Two patients required multiple procedures for the resolution of the biliary calculi. No vascular or biliary injuries were encountered. Three patients were free of biliary calculi on their postoperative cholangiogram. One patient with multiple gallbladder stones refused further treatment after two percutaneous procedures. CONCLUSION: The holmium: yttrium aluminum garnet laser can be used safely and effectively in the endoscopic treatment of biliary calculi. This treatment maybe a suitable option in patients who are not candidates for more invasive procedures.

Endoluminal sonographic evaluation of ureteral and renal pelvic neoplasms.

The objective of this study was to demonstrate the feasibility of endoluminal ultrasonography as an adjunct to endoscopy for the evaluation of urothelial neoplasms. An endoluminal ultrasound system using a 12.5 or 20 MHz transducer housed in a 6.2 French catheter was used intraureterally in 38 patients being evaluated endoscopically for suspected tumors in the renal pelvis or ureter. The ultrasonographic, endoscopic, and pathologic findings were evaluated. The location, size, and sonographic characteristics of the tumors in the upper urinary tract were well demonstrated. The information obtained by this technique can be used to guide endoscopic biopsy and laser ablation of the tumor. Endoluminal ultrasonography also has proved helpful in defining the location of a tumor relative to an adjacent vessel and in identifying crossing vessels that cause extrinsic filling defects in the ureter. In a few pathologically correlated cases, endoluminal ultrasonography was accurate in assessing invasion. We have evaluated successfully a variety of non-neoplastic filling defects in relatively few cases. Determination of the eventual usefulness of this technique awaits greater clinical experience and large clinical trials.

Thirty-seven years of renal transplantation in Oregon.

What we accomplish today as a matter of routine was only imagined by a few 4 decades ago. The journey from that first successful kidney transplant in the 1950s to the multidisciplinary, multiorgan transplant program of today has been a fascinating one. Although we attribute our current results to careful recipient selection and preparation, improvements in organ procurement and preservation, refinement of surgical techniques, improvement in histocompatibility techniques and organ sharing, improvements in immunosuppression and infection control, and careful monitoring of recipients, we and our patients have benefited from significant contributions from our colleagues in government and the law. The 4 that come to mind are the provision of near-universal insurance coverage for end stage renal disease patients in 1972 under the Medicare program, the passage of brain death laws in the mid 1970s, the passage of the National Transplant Act in 1984, and the passage of the Oregon required request law in 1985.