Best practices in near-infrared fluorescence imaging with indocyanine green (NIRF/ICG)-guided robotic urologic surgery: a systematic review-based expert consensus.

PURPOSE: The aim of the present study is to investigate the impact of the near-infrared (NIRF) technology with indocyanine green (ICG) in robotic urologic surgery by performing a systematic literature review and to provide evidence-based expert recommendations on best practices in this field. METHODS: All English language publications on NIRF/ICG-guided robotic urologic procedures were evaluated. We followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement to evaluate PubMed®, Scopus® and Web of Science™ databases (up to April 2019). Experts in the field provided detailed pictures and intraoperative video-clips of different NIRF/ICG-guided robotic surgeries with recommendations for each procedure. A unique QRcode was generated and linked to each underlying video-clip. This new exclusive feature makes the present the first "dynamic paper" that merges text and figure description with their own video providing readers an innovative, immersive, high-quality and user-friendly experience. RESULTS: Our electronic search identified a total of 576 papers. Of these, 36 studies included in the present systematic review reporting the use of NIRF/ICG in robotic partial nephrectomy (n = 13), robotic radical prostatectomy and lymphadenectomy (n = 7), robotic ureteral re-implantation and reconstruction (n = 5), robotic adrenalectomy (n = 4), robotic radical cystectomy (n = 3), penectomy and robotic inguinal lymphadenectomy (n = 2), robotic simple prostatectomy (n = 1), robotic kidney transplantation (n = 1) and robotic sacrocolpopexy (n = 1). CONCLUSION: NIRF/ICG technology has now emerged as a safe, feasible and useful tool that may facilitate urologic robotic surgery. It has been shown to improve the identification of key anatomical landmarks and pathological structures for oncological and non-oncological procedures. Level of evidence is predominantly low. Larger series with longer follow-up are needed, especially in assessing the quality of the nodal dissection and the feasibility of the identification of sentinel nodes and the impact of these novel technologies on long-term oncological and functional outcomes.

Surgeon controlled robot-assisted laparoscopic radical cystectomy: current review of oncologic and functional outcomes.

Surgeon controlled robot-assisted laparoscopic radical cystectomy (RARC) is becoming a viable treatment option for patients with muscle-invasive bladder cancer. There are currently several single-institution reports and a few multi-institutional reports on operative, perioperative, and intermediate-term oncologic outcomes for RARC. While the data appears promising, there is currently no long term oncologic outcomes for RARC. Long-term oncologic outcomes for RARC should be forthcoming in the near future. As the technology improves, and surgeons become more proficient at RARC, the cost effectiveness of RARC should surpass open radical cystectomy. The goal of this article is to review the most recent developments within the past 1 to 2 years surrounding RARC, including important technical advances for performing this operation, current data on oncologic outcomes, and the future direction of RARC.

Outcome of end-to-end urethroplasty: single-center experience.

OBJECTIVE: We review our experience of end-to-end urethroplasty for urethral strictures performed during the last 6 years. MATERIAL AND METHODS: From September 2001 to December 2006, 138 male patients underwent anastomotic urethroplasty at our center. Mean age was 28.1 years (range 6-71), average stricture length was 2.2 cm (range 0.7-6.0). One hundred and one patients (73.2%) had obliterative stricture while 37 (26.8%) still had some urethral passage. Ninety (65.2%) had a history of previous intervention. Sixty patients (43.5%) had associated complicating factors like urethrocutaneous fistula, rectourethral fistula, vesical calculus, blind tract and cavities, bony deformity, or urinary tract infection. RESULTS: The mean operative time was 92 min (range 60-240). Average follow-up was 26.7 months (range 6-60). One hundred and fourteen (82.6%) had excellent outcome, 18 (13%) had acceptable outcome and 6 (4.3%) failed to respond. Seventeen patients developed complications: 5 developed wound infection, 3 epididymorchitis, 2 failed to void, 2 each had incontinence and perineal hematoma, and 1 each had erectile dysfunction, accidentally pulled his catheter out and had urethrocutaneous fistula. CONCLUSION: End-to-end urethroplasty is an ideal procedure for managing strictures of bulbous and posterior urethra in properly selected cases.

Open nephron-sparing surgery in renal tumors with normal contralateral kidney: A single centre experience of 8 years.

INTRODUCTION: We present our eight-year experience with open nephron-sparing surgery (NSS) in renal tumors with contralateral normal kidney to assess its oncological efficacy and safety. MATERIALS AND METHODS: Thirty-six patients undergoing open NSS for small localized renal tumors with normal contralateral kidney from January 1998 to August 2006 were studied regarding demographic, clinical and pathological characteristics along with long-term follow-up. RESULTS: The mean age was 48.28 +/- 9.5 years. The mean tumor size was 3.72 cm (range 1.5-6). The following surgeries were performed: Wedge resection-13, partial polar nephrectomy-15, segmental resection-eight. The following techniques were used for vascular control: clamping and cooling-eight, warm ischemia-12, a novel technique of serial encirclage-16. The mean warm ischemia time was 23.2 +/- 3.2 min. The mean operating time was 190.07 +/- 11.3 min. The mean estimated blood loss was 331 +/- 17.4 ml. The majority of renal tumors were renal cell carcinoma (97.22%). There were no positive surgical margins. There were no major intraoperative and postoperative complications. The mean follow up was 52.1 months (range 4-80) with no case showing progression to renal insufficiency (defined as serum creatinine > 2 mg/dl). There was only one local recurrence. However, four distant metastases were reported. The five-year cancer-specific survival, recurrence-free survival and overall survival were 94.4%, 88.88% and 86.11% respectively. CONCLUSIONS: In patients with solitary, small localized, unilateral renal tumors with normal contralateral kidney, elective open NSS is feasible, safe and provides excellent long-term local control and oncological efficacy with functional benefits.

Beware! Fungal urosepsis may follow endoscopic intervention for prolonged indwelling ureteral stent.

We present a 38-year-old lady with a prolonged indwelling ureteral stent that had been placed for pain relief after development of Steinstrasse following extracorporeal lithotripsy for a 2.5-cm left renal calculus. The patient developed candidal urosepsis within 6 hours after ureteroscopy and percutaneous nephrolithotomy (PCNL) for the removal of residual fragments. She subsequently recovered on systemic antifungal therapy in the form of intravenous amphotericin B and achieved complete stone clearance after repeat ureteroscopy and PCNL. Fungal urosepsis is known to complicate the postoperative course in chronically debilitated patients with poor nutritional status or those with diabetes or other significant comorbities. To our knowledge, this is the first reported case of a patient with no significant comorbities developing fungal urosepsis after endoscopic intervention for a long-term indwelling ureteral stent.

Laparoscopic nephroplication and nephropexy as an adjunct to pyeloplasty in UPJO with giant hydronephrosis.

Giant hydronephrosis due to uretero-pelvic junction obstruction (UPJO) is rare and usually the treatment is nephrectomy. When renal salvage is required, reconstruction of the UPJ alone is usually inadequate to improve drainage from the pelvicalyceal system. Various open surgical techniques have been described to improve gravity-assisted drainage from the giant hydronephrotic kidney. We describe, for the first time, a complete laparoscopic approach for pyeloplasty combined with nephroplication and nephropexy.

Percutaneous antegrade removal of impacted upper-ureteral calculi: still the treatment of choice in developing countries.

PURPOSE: To assess the safety and efficacy of antegrade percutaneous nephrolithotomy (PCNL) of large impacted proximal-ureteral calculi. PATIENTS AND METHODS: Between July 1998 and October 2003, a total of 66 patients (43 male and 23 female; mean age 37.5 years) underwent PCNL for impacted proximal-ureteral calculi. The inclusion criteria were calculi >15 mm that were densely impacted and located between the ureteropelvic junction and the lower border of the 4th lumbar vertebra. The mean drop in hemoglobin, operating time, analgesic requirement, and hospital stay were assessed. RESULTS: Sixty-five patients (98.5%) had complete calculus clearance in a single session through a single tract. The mean operating time and hospital stay were 47 minutes and 46 hours, respectively. The mean analgesic requirement was 65 mg of pethidine (meperidine). The mean follow-up was 14 months. There were no significant postoperative complications. CONCLUSION: Antegrade PCNL is a safe and effective option for large, impacted proximal-ureteral calculi.

Orthotopic neobladder in management of tubercular thimble bladders: initial experience and long-term results.

OBJECTIVES: To describe the indications and long-term results of orthotopic bladder replacement for tubercular thimble bladders. METHODS: Four patients (3 women, 1 man; mean age 32 years) presented with markedly contracted bladders of tubercular etiology. The patients had marked lower tract symptoms, and the mean bladder capacity was 15 mL. All 4 patients had associated upper tract pathology. Four-drug antitubercular treatment (ATT) was started in all 4 patients, and all 4 underwent surgery 4 weeks later. The procedure performed was a cystectomy and orthotopic bladder reconstruction using the ileocecal segment in 3 patients and the sigmoid colon in 1. The ureters were implanted into the taenia of the cecum or the sigmoid in an antireflux fashion. ATT was continued for a total of 9 months. RESULTS: All patients had an uneventful postoperative course. After a follow-up period ranging from 22 to 54 months (mean 38), the average bladder capacity in the 4 patients was 450 mL (range 400 to 600). The mean maximal flow rate was 18.3 mL/s. Potency was preserved in the man and all patients were continent at last follow-up. The male patient had hypercontinence requiring clean intermittent catheterization for a period of 3 months. At last follow-up all patients had residual-free micturition. The female patients were able to void to completion with a Valsalva maneuver. No patient had symptomatic urinary infection or deterioration in renal function. No patient had persistent ureteral reflux or stricture. CONCLUSIONS: Cystectomy with orthotopic bladder replacement offers an alternative to the urologist treating end-stage tubercular bladders (thimble bladders) with a capacity of less than 15 to 20 mL. This treatment removes the source of the symptoms, permits anastomosis to healthy tissue of the proximal urethra, and addresses lower ureteral pathology at the same time. The long-term results in these initial cases are encouraging; however, only a prospective, randomized trial can establish whether these advantages actually translate into long-term clinical benefit in this group of patients.

Laparoscopic management of renal cystic disease.

Laparoscopic management of renal cystic disease is a highly effective, safe, and minimally invasive alternative to open surgery and antegrade or retrograde endoscopic procedures. Simple renal cysts can be accessed either transperitoneally or retroperitoneally. Almost all studies of the laparoscopic approach have demonstrated great satisfaction in terms of efficacy, minimal complications, operative time, minimal blood loss, hospital stay, recuperation, and cosmesis over other methods of treating renal cysts. Laparoscopic unroofing of peripelvic cysts is more challenging owing to their proximity to hilar vessels and the collecting system. Such surgery should be considered an advanced laparoscopic procedure. Access may be achieved either transperitoneally or retroperitoneoscopically. The basic principle of adequate exposure is essential for effective treatment. If the cyst is not completely excised, the surgeon must fulgurate the edge and tack perirenal fat in the residual cyst cavity to prevent recurrence and facilitate drainage. Laparoscopic evaluation of complex cysts seems to be sound. The results are promising, and follow-up does not show any increase in peritoneal seeding, tract recurrence, or distant metastases in the small number of neoplasms diagnosed at laparoscopy. Nevertheless, more studies are required with long-term follow-up. Bosniak type IV renal cysts or malignancy in renal cysts can be managed by laparoscopic radical nephrectomy with either access. Laparoscopic cyst marsupialization in patients with ADPKD is the latest emerging indication for laparoscopy in renal cystic disease. This procedure not only effectively reduces pain in some patients but also improves hypertension and stabilizes renal function, delaying renal replacement therapy. Long-term follow-up and further evaluation are needed.

Recurrent urethral hairball and stone in a hypospadiac: management and prevention.

A 32-year-old perineal hypospadiac man presented with recurrent urethral hair growth, stone, and stricture with a history of multiple urethroplasties. He was treated by urethrolithotomy, internal urethrotomy, laser epilation of the hair-bearing urethral graft, closure of the fistula, and chemical depilation of the neourethral hair. A dilute solution of thioglycolate was prophylactically instilled into the neourethra at intervals of 3 months to ensure complete tricholysis and to prevent recurrent hair growth in the future.

Laparoscopic repair of vesicovaginal fistula and right nephrectomy for nonfunctioning kidney in a single session.

We report a case of failed vesicovaginal fistula repair and nonfunctioning right kidney, which was managed by laparoscopic nephrectomy and fistula repair with omental interposition in a single session.

Retroperitoneoscopic extirpation for adult multicystic calcified dysplastic kidneys with contralateral ureteral abnormalities mimicking genitourinary tuberculosis.

PURPOSE: To identify adult multicystic calcified dysplastic kidneys (AMCDK) with contralateral ureteral abnormalities mimicking urinary tuberculosis and to evaluate the feasibility and efficacy of retroperitoneoscopic extirpation in their management. PATIENTS AND METHODS: We retrospectively identified a group of adult patients who were referred to us as having unilateral nonfunctioning kidney containing calcified cystic masses with a contralateral normally functioning kidney along with segmental dilation of ureter. Two patients had histories of treatment elsewhere with antitubercular drugs on the basis of imaging studies, before being referred to our center for retroperitoneoscopic nephrectomy with a diagnosis of nonfunctioning left kidneys and urinary tuberculosis. The other two cases with similar findings on imaging studies were detected incidentally while the patients were undergoing investigations for vague abdominal symptoms. RESULTS: All these patients had AMCDK on the left side and a contralateral normally functioning kidney with ureteral abnormality. Retroperitoneoscopic extirpation of the nonfunctioning left renal unit was carried out uneventfully with a mean operating time, blood loss, and hospital stay of 124 minutes, 80 mL, and 3 days, respectively. There were no complications. The dissection in these cases was difficult, as the dysplastic calcified kidney was plastered in the retroperitoneum. CONCLUSION: Unilateral AMCDK with contralateral segmental dilation of the ureter may be separate entity or a coincidental finding, and it should not be confused with urinary tuberculosis unless there is microbiological and radiologic or histopathologic evidence of infection. Minimally invasive surgery in the form of retroperitoneoscopic extirpation is feasible, safe, and effective in such cases, although difficult, and it requires skills as well as experience.

Retroperitoneoscopic nephrolympholysis and ureterolysis for management of intractable filarial chyluria.

PURPOSE: To evaluate the feasibility of retroperitoneoscopic lymphatic disconnection in patients with intractable filarial chyluria with the aim of reducing the morbidity of the surgery. PATIENTS AND METHODS: Two patients presented to us with intractable chyluria. They did not respond to conservative measures and endoscopic sclerotherapy. In view of the severe lipid and protein loss associated with recurrent bouts of chyluria, they merited surgical correction by lymphatic disconnection. Because this operation requires extensive mobilization within the retroperitoneum over a large area, it necessitates a large flank or midline incision. In order to reduce the incision-related morbidity, it was decided to undertake the procedure laparoscopically. The retroperitoneal route was chosen for its obvious advantages. RESULTS: Surgery was carried out uneventfully in both patients, with a mean operating time of 2 hours. The patients stayed in the hospital for an average of 2.5 days. Chyluria resolved in the immediate postoperative period, and they have been asymptomatic over a follow-up of 30 and 18 months. One patient had drainage of lymph for 5 days, which resolved spontaneously. CONCLUSIONS: The objectives of open surgery can be achieved by the minimally invasive approach of retroperitoneoscopy. The new approach significantly reduces the incision-related morbidity without compromising the principles of open surgery. We propose five important steps necessary to avoid recurrence and reduce postoperative morbidity.

Laparoscopic radical cystectomy and ileal conduit reconstruction: preliminary experience.

PURPOSE: We present our preliminary experience with laparoscopic radical cystoprostatectomy for muscle-invasive carcinoma of the urinary bladder. Patient and operative data and the surgical technique are presented. PATIENTS AND METHODS: Laparoscopic radical cystoprostatectomy and bilateral pelvic lymph node dissection were performed using five or six ports by a transperitoneal approach. An ileal conduit urinary diversion was constructed at the site of specimen retrieval. RESULTS: The procedure was successful in nine of ten patients with a mean blood loss of 533 mL and an average transfusion of 1.3 units per patient. The mean operating time was 6.48 hours and an average of 33 mg of morphine equivalents was required for analgesia. The mean hospital stay was 10.8 days. One patient had surgical margins positive for cancer, while none had histologic evidence of pelvic nodal metastasis. There were five minor and major intraoperative and postoperative complications. The remaining patient, treated early in our experience, developed hypercarbia necessitating conversion to open surgery. No metastases have been seen after a mean duration of follow-up of 19 months. CONCLUSIONS: Laparoscopic radical cystoprostatectomy with open ileal conduit urinary diversion is a feasible alternative to traditional open radical cystectomy. Urinary diversion can be performed through the small incision necessary to extract the surgical (radical cystoprostatectomy) specimen from the abdomen. With our modified technique, it also is feasible to reduce the cost.

Ergonomic problems associated with laparoscopy.

PURPOSE: Failure to understand the ergonomics of laparoscopic surgery has a potential to pose health problems for the surgeons. This study was planned to assess the prevalence, significance, and awareness of ergonomic problems associated with laparoscopy. MATERIAL AND METHODS: A questionnaire designed to assess the frequency and degree of physical discomfort practicing surgeons experienced and their awareness of the responsible factors was distributed to approximately 350 attendees of the Live International Workshop and CME on Laparoscopic Urologic Surgery. The response sheets were analyzed. RESULTS: Two hundred four attendees completed the questionnaire, of whom 131 were performing laparoscopic surgery (Group A). The rest (N = 73) were practicing only conventional surgery (Group B). The correct answer to the pictorial question, which tested the correct grip technique, was 81% and 56% in Group A and B, respectively (P = 0.0003). Group A surgeons were significantly (P = 0.04) better at answering the questions on neurapraxia. There was a statistically significant (P = 0.004) increase in the frequency of finger numbness and eye strain in Group A surgeons compared with Group B. Within Group A, finger numbness (P = 0.03) and eye strain (P = 0.002) were significantly greater in the junior laparoscopic surgeons than in senior laparoscopic surgeons. Surgeons having <2 years of laparoscopic surgical experience were significantly more affected. CONCLUSIONS: Surgeons performing laparoscopy have significant ergonomic problems, especially finger numbness and eye strain. Junior laparoscopic surgeons and surgeons with <2 years of laparoscopic surgical experience are more affected.

Retroperitoneoscopic nephrectomy for benign diseases of the kidney: prospective nonrandomized comparison with open surgical nephrectomy.

PURPOSE: To describe, define, and evaluate the efficacy of retroperitoneoscopic nephrectomy (RPN) for benign diseases of the kidney and to compare it with open surgical nephrectomy (OSN) via a flank approach. PATIENTS AND METHODS: From August 1995 to November 1997, 29 men and 14 women (mean age 33 years) with severely damaged kidneys underwent RPN. Among these, 11 patients had undergone prior surgery, 3 had chronic renal failure, and 8 patients had a percutaneous nephrostomy. The RPN was performed via three or four ports, with the kidneys being removed intact from the retroperitoneal working space. During the same period, 43 patients underwent OSN through a flank approach (extrapleural and extraperitoneal) for nonfunctioning or poorly functioning kidneys. RESULTS: In the RPN group, two patients required conversion to OSN. The operative time and estimated blood loss ranged from 40 to 210 minutes (mean 114 minutes) and 50 to 450 mL (mean 127 mL), respectively. In the OSN group, the corresponding values were 60 to 100 minutes (mean 104 minutes) and 70 to 600 mL (mean 266 mL), respectively. The mean length of hospitalization after RPN was considerably shorter--2 to 7 days (mean 3.4 days)--than after conventional open surgery--4 to 16 days (mean 8.6 days). The incidences of minor and major complications were 21% and 5%, respectively, in the RPN group and 33% and 2% in the OSN group. The postoperative analgesic requirement was significantly less (P < 0.001) in RPN group. The interval to return to normal activity ranged from 7 to 30 days (mean 20.3 days) and 20 to 60 days (mean 32.9 days) in the RPN and OSN group, respectively, with superior performance status, cosmesis, and quality of life observed in the former group. CONCLUSION: Retroperitoneoscopic nephrectomy is as effective as open nephrectomy for benign kidney diseases with less postoperative pain, a shorter hospital stay, earlier recuperation, and excellent cosmesis. This procedure can also be performed in patients who have undergone abdominal operations previously, in those with chronic renal failure, and in those with a percutaneous nephrostomy. The operation has become our first line of approach for benign diseases of the kidney.

Retroperitoneoscopic ureterolysis and reconstruction of retrocaval ureter.

We report a case of circumcaval ureter in a symptomatic young man who was managed successfully by retroperitoneoscopic ureterolysis and ureteroureteral reconstruction using three-port technique.

Vapor resection: a good alternative to standard loop resection in the management of prostates >40 cc.

BACKGROUND AND PURPOSES: The morbidity of transurethral vesection of the prostate (TURP) necessitates constant attempts at modifications to the standard equipment and technique. Patients with larger prostates (>40 cc) need a longer time for the procedure, and the blood loss, requirement for irrigation fluid, and incidence of postoperative complications tend to be greater. We report on the safety and efficacy of TURP with the thick vapor resection loop compared with the standard wire loop in comparable groups of patients with prostates >40 cc. PATIENTS AND METHODS: We randomized 100 patients with benign prostatic hyperplasia (BPH) into two groups of 50 each which were similar in age. The inclusion criteria included an indication for prostatectomy and prostate size >40 cc. Patients who were on finasteride preoperatively (six) and those who had histopathologic adenocarcinoma of the prostate (three) were excluded. Preoperative evaluation included assessment of International Prostate Symptom Score (IPSS), prostate volume by abdominal ultrasonography, maximum flow rate (Q(max)), and residual urine volume. The two groups were similar in the signs and symptoms of BPH. Patients in Group 1 underwent transurethral vapor resection of the prostate (TUVRP) using the vapor resection loop (Wing trade mark; Richard Wolf, Germany), while patients in Group 2 underwent TURP using a standard wire loop. All procedures were performed by consultant urologists with equivalent experience. We used a Martin ME 401 (Gebruder Martin, Tuttlingen, Germany) electrosurgical generator with settings of 120 to 150 Watts and 50 to 70 W for cutting and coagulating, respectively, for the thick loop and 70 to 80 W and 40 to 50 W for the standard loop. Operating time, resected tissue weight, duration of catheterization, nursing contact time, hospital stay, hemoglobin change, serum sodium concentrations, and any complications were noted and analyzed using the Kruskal-Wallis paired variables test, and P values were calculated. P value <0.04 was considered significant. The IPSS, Q(max), and residual urine volume were reevaluated at 6 months and 1 year after the procedure and compared for the two groups. RESULTS: The median prostate volume was 63 cc and 54 cc in Groups 1 and 2, respectively, and the median resected weight was 20 and 19 g, respectively (P = NS). The differences in operating time (median 45 v 60 minutes; P < 0.0001), intraoperative irrigant use (15 v 21 L; P < 0.0001), and intraoperative blood loss (median 52.5 v 150 mL; P < 0.0001) in the two groups were statistically significant. Peroperative blood loss was estimated by the indicator dilution method of Freedman et al in three 5-mL samples of the irrigant fluid and arriving at the average of the three values and adjusted for the volume of irrigant fluid used. The differences in postoperative irrigant (P < 0.01) and catheter duration (P = 0.04) were also significant. Two patients received blood transfusion in Group 2 and none in Group 1. The difference in the change in hemoglobin and serum sodium postoperatively in the two groups was not statistically significant. The complications were dysuria in six patients lasting for a month and one capsular perforation in Group and incontinence lasting for 6 months in two patients and stricture in one patient in Group 2. The efficacy, assessed with IPSS, Q(max), and residual urine volume, was comparable at 6 months and at 1 year. CONCLUSION: The use of a thick vapor resection loop for TURP coupled with higher generator settings as recommended for them, especially for prostates >40 cc, is beneficial, as it significantly reduces operating time, blood loss, irrigant requirement, nursing contact time, and duration of catheterization, besides providing clear vision during surgery and ease of resection. There was no reduction in efficacy or increase in complications.

Evaluation of laparoscopic retroperitoneal surgery in urinary stone disease.

PURPOSE: To assess the safety and effectiveness of laparoscopic retroperitoneal surgery and attempt to define its role in the management of urolithiasis. PATIENTS AND METHODS: Laparoscopic retroperitoneal surgery (LRS) was undertaken in 72 male and 42 female patients with calculous disease from March 1994 to April 2000 for variety of indications that otherwise would have made them candidates for conventional open surgery. Some of these patients were subjected to retroperitoneoscopic ureterolithotomy (RPUL) (40 patients) and retroperitoneoscopic pyelolithomy (RPPL) (7 patients). Retroperitoneoscopic nephrectomy (RPN) and nephroureterectomy (RPNUT) for a nonfunctioning renal unit secondary to renal and or ureteral calculi was done in 53 and 14 patients, respectively. Most of the procedures were performed with three 10-mm ports. In some cases, an additional 5-mm port was used. RESULTS: The procedure was successful in 75%, 71%, 90.5%, and 86% of cases subjected to RPUL, RPPL, RPN, and RPNUT, respectively. The mean operating time for RPUL was 106.3 minutes and for RPPL was 108.2 minutes, whereas it was 99.7 minutes for RPN and 147 minutes for RPNUT of nonfunctioning kidneys secondary to calculous disease. The major complications encountered were colon injury in one patient with calculous pyonephrosis who had dense adhesions and injury to the external iliac artery in another patient having RPUL. The mean blood loss was 69.8, 127.2, 135.6, and 206.5 mL, respectively, for RPUL, RPPL, RPN, and RPNUT. The average hospital ranged from 3 to 4 days. CONCLUSIONS: Laparoscopic retroperitoneal surgery has a definite role in the management of patients requiring open surgery for calculous disease. It is safe and feasible in spite of the dense adhesions that are frequently encountered in such patients. Often, previous attempts at treatment with shockwave lithotripsy or endourologic procedures also lead to inflammation and adhesions, making surgery difficult. However, these problems can be dealt with by LRS with good results.

Endourologic management of obstetrical ureterouterine fistula: case report and review of literature.

A 32-year-old woman presented to us with complaints of paradoxical incontinence for a period of 6 months following a cesarean section for obstructed labor performed elsewhere and subsequently treated elsewhere. Clinical and urographic assessment revealed an iatrogenic ureterouterine fistula, which was successfully treated endoscopically by dilatation of the ureteral stricture and ureteroscopic double-J stenting. It had been explained to the patient, and she had given consent for, ureteroneocystostomy in the event of failure. The literature regarding the management of this rare genitourinary fistula is reviewed and discussed.