New laparoscopic approach to the pudendal nerve for neuromodulation based on an anatomic study.

AIMS: The aim was to develop a new laparoscopic technique for placement of a pudendal lead. METHODS: Development of a direct, feasible and reliable minimal-invasive laparoscopic approach to the pudendal nerve (PN). Thirty-one embalmed human specimens were dissected for the relevant anatomic structures of the pelvis. Step-by-step documentation and analysis of the laparoscopic approach in order to locate the PN directly in its course around the medial part of the sacrospinous ligament and test this approach for feasibility. Landmarks for intraoperative navigation towards the PN as well as the possible position of an lead were selected and demonstrated. RESULTS: The visible medial umbilical fold, the intrapelvine part of the internal pudendal artery, the coccygeus muscle and the sacrospinous ligament are the main landmarks. The PN traverses the medial part of the sacrospinous ligament dorsally, medially to the internal pudendal artery. The medial part of the sacrospinous ligament has to be exposed in order to display the nerve. An lead can be placed ventrally on the nerve or around it, depending on the lead type or shape. CONCLUSIONS: A precise and reliable identification of the PN by means of laparoscopy is feasible with an easy four-step approach: (1) identification of the medial umbilical fold; (2) identification of the internal iliac artery; (3) identification of the internal pudendal artery and incision of the coccygeus muscle ('white line', arcuated line); and (4) exposition of the medial part of the sacrospinous ligament to display the PN.

Recurrence of a Delayed-Onset Posttraumatic Renal Pseudoaneurysm after Initially Successful Transarterial Embolization.

Hemodynamically stable patients with renal injury can be managed conservatively. Anatomy typically leads to physiologic confinement of urinomas or renal hematomas to the interfascial planes of the retroperitoneum. In the presented case there was unusual reperfusion 14 days after a successful embolization of a renal pseudoaneurysm, at this time 28 days after the initiating trauma. This article discusses the evolution, treatment options and possible underlying causes for the reperfusion of this late-onset renal pseudoaneurysm.

Indications and outcomes of laparoscopic uretero-renal stone surgery.

PURPOSE OF REVIEW: Although most ureteral and urinary stones are managed using endourologic techniques or shockwave lithotripsy in daily clinical practice, stone surgery has not completely disappeared. Laparoscopy, another minimally invasive treatment, is continuously gaining place in the treatment of urinary stones, mainly replacing open surgery. RECENT FINDINGS: Indications for open or laparoscopic stone surgery are anatomic abnormalities, such as horseshoe kidneys, malrotated kidneys, ureteropelvic junction obstruction with stones, or ectopic kidneys; symptomatic stones in diverticula; extremely large stones and all those situations in which conventional endourologic procedures and extracorporeal shock-wave lithotripsy are not available or were unsuccessful or in those conditions where laparoscopy offers a priori the best solution to an endourologic complex condition. SUMMARY: Laparoscopic surgery is effective for complex urinary stones and allows adjunctive procedures. It complements other minimally invasive procedures, and a need for open surgery has strongly diminished.

A new technique for retrograde flexible ureteroscopy after Cohen cross-trigonal ureteral reimplantation.

PURPOSE: Retrograde ureteral access after cross-trigonal ureteral reimplantation can be challenging. We present our experience with retrograde ureteral catheterization and flexible ureteroscopy after Cohen cross-trigonal reimplantation in patients presenting with ureteral stones. MATERIALS AND METHODS: Cystoscopy is performed and a Tiemann ureteral catheter is inserted into the involved ureteral orifice. A retrograde ureterography is performed and hydrophilic guide wire is passed up to the kidney. A dual-lumen ureteral access sheath is then passed under x-ray control underneath the ureteral stone. The flexible ureterorenoscope is passed under x-ray control up to the stone which is then fragmented with a holmium laser. RESULTS: From June 2006 to June 2010, this technique was successful in 8 patients without acute or delayed sequelae. CONCLUSIONS: Where the endourological expertise is readily available, the ureter can be accessed retrogradely even after Cohen cross-trigonal ureteral reimplantation in a safe, straightforward and effective modality.

The learning curve for laparoscopic radical prostatectomy: an international multicenter study.

PURPOSE: It is not yet possible to estimate the number of cases required for a beginner to become expert in laparoscopic radical prostatectomy. We estimated the learning curve of laparoscopic radical prostatectomy for positive surgical margins compared to a published learning curve for open radical prostatectomy. MATERIALS AND METHODS: We reviewed records from 8,544 consecutive patients with prostate cancer treated laparoscopically by 51 surgeons at 14 academic institutions in Europe and the United States. The probability of a positive surgical margin was calculated as a function of surgeon experience with adjustment for pathological stage, Gleason score and prostate specific antigen. A second model incorporated prior experience with open radical prostatectomy and surgeon generation. RESULTS: Positive surgical margins occurred in 1,862 patients (22%). There was an apparent improvement in surgical margin rates up to a plateau at 200 to 250 surgeries. Changes in margin rates once this plateau was reached were relatively minimal relative to the CIs. The absolute risk difference for 10 vs 250 prior surgeries was 4.8% (95% CI 1.5, 8.5). Neither surgeon generation nor prior open radical prostatectomy experience was statistically significant when added to the model. The rate of decrease in positive surgical margins was more rapid in the open vs laparoscopic learning curve. CONCLUSIONS: The learning curve for surgical margins after laparoscopic radical prostatectomy plateaus at approximately 200 to 250 cases. Prior open experience and surgeon generation do not improve the margin rate, suggesting that the rate is primarily a function of specifically laparoscopic training and experience.

The surgical learning curve for laparoscopic radical prostatectomy: a retrospective cohort study.

BACKGROUND: We previously reported the learning curve for open radical prostatectomy, reporting large decreases in recurrence rates with increasing surgeon experience. Here we aim to characterise the learning curve for laparoscopic radical prostatectomy. METHODS: We did a retrospective cohort study of 4702 patients with prostate cancer treated laparoscopically by one of 29 surgeons from seven institutions in Europe and North America between January, 1998, and June, 2007. Multivariable models were used to assess the association between surgeon experience at the time of each patient's operation and prostate-cancer recurrence, with adjustment for established predictors. FINDINGS: After adjusting for case mix, greater surgeon experience was associated with a lower risk of recurrence (p=0.0053). The 5-year risk of recurrence decreased from 17% to 16% to 9% for a patient treated by a surgeon with 10, 250, and 750 prior laparoscopic procedures, respectively (risk difference between 10 and 750 procedures 8.0%, 95% CI 4.4-12.0). The learning curve for laparoscopic radical prostatectomy was slower than the previously reported learning curve for open surgery (p<0.001). Surgeons with previous experience of open radical prostatectomy had significantly poorer results than those whose first operation was laparoscopic (risk difference 12.3%, 95% CI 8.8-15.7). INTERPRETATION: Increasing surgical experience is associated with substantial reductions in cancer recurrence after laparoscopic radical prostatectomy, but improvements in outcome seem to accrue more slowly than for open surgery. Laparoscopic radical prostatectomy seems to involve skills that do not translate well from open radical prostatectomy. FUNDING: National Cancer Institute, the Allbritton Fund, and the David J Koch Foundation.

Extracorporeal shock-wave therapy for treating chronic pelvic pain syndrome: a feasibility study and the first clinical results.

OBJECTIVE: To investigate the feasibility and clinical outcome of extracorporeal shock-wave therapy (ESWT) for patients suffering from chronic pelvic pain syndrome (CPPS). PATIENTS AND METHODS: The study included 34 patients who had had CPPS for >or=3 months, who were investigated in two subsequent studies. ESWT was administered using a perineal approach with two different standard ESWT devices with and without an ultrasonographic positioning system. The follow-up was at 1, 4 and 12 weeks after ESWT, to evaluate the effects on pain, quality of life and voiding. Imaging studies and changes in prostate-specific antigen (PSA) were used to investigate the safety and side-effects of ESWT. RESULTS: All patients completed the treatments and follow-up; there were statistically significant improvements in pain and quality of life after ESWT. Voiding conditions were temporarily improved but with no statistical significance. Perineal ESWT was easy and safe to administer with no anaesthesia on an outpatient basis. Side-effects could be excluded clinically, by imaging studies and by changes in PSA level. CONCLUSION: Perineal ESWT must be considered as a promising new therapy for CPPS, in particular as it is easy to apply and causes no side-effects.

Cryoablation for Small Renal Masses: Selection Criteria, Complications, and Functional and Oncologic Results.

CONTEXT: Cryoablation (CA) is a minimally invasive modality with low complication rates, but its use in urology is relatively recent. OBJECTIVE: To summarize available evidence for CA for small renal masses (SRMs) and to assess the selection criteria, complications, and functional and oncologic results based on the latest CA literature. EVIDENCE ACQUISITION: A systematic literature search of the Medline, Embase, and Scopus databases was performed in August 2014 using Medical Subject Headings and free-text protocol. The following search terms were included: kidney cryosurgery, renal cryosurgery, kidney cryoablation, renal cryoablation, kidney cryotherapy, and renal cryotherapy. EVIDENCE SYNTHESIS: Due to the relatively recent mainstream utilization of CA and lack of long-term efficacy data from large prospective or randomized studies, most of the data available on CA are limited to treatment of SRMs in patients who are often older or are poor surgical candidates. The rates of major complications across the CA literature remain relatively low. Studies assessing renal function after CA suggest a degree of functional decline following CA because proper application includes freezing of a tumor margin; however, often this is not clinically significant. Specific oncologic outcomes should be evaluated in patients with biopsy-proven renal cell carcinoma; when SRM series include benign or unbiopsied tumors, the results of these outcomes are skewed. Although earlier series were suggestive of a higher recurrence rate after CA, some studies have challenged this view reporting recurrence rates comparable with extirpative nephron-sparing surgery. CONCLUSIONS: CA represents an alternative approach to treatment for patients diagnosed with renal neoplasm. There is no consensus within the literature on the best patient selection criteria. Due to higher rates of treatment failure, it is often not offered to patients with minimal comorbidities and good life expectancy. In terms of functional outcomes, CA signifies a modality with minimum impact on renal function; however, well-designed studies precisely assessing this factor are lacking. CA is a minimally invasive modality with suitably low rates of complications, particularly if delivered via the percutaneous route. PATIENT SUMMARY: Cryoablation (CA) represents an alternative approach for treating renal neoplasm. Excellent functional outcomes and low rates of complications make CA an ideal minimally invasive modality. Patient selection criteria and oncologic outcomes require further study.

Treatment of localised renal cell carcinoma.

CONTEXT: The increasing incidence of localised renal cell carcinoma (RCC) over the last 3 decades and controversy over mortality rates have prompted reassessment of current treatment. OBJECTIVE: To critically review the recent data on the management of localised RCC to arrive at a general consensus. EVIDENCE ACQUISITION: A Medline search was performed from January 1, 2004, to May 3, 2011, using renal cell carcinoma, nephrectomy (Medical Subject Heading [MeSH] major topic), surgical procedures, minimally invasive (MeSH major topic), nephron-sparing surgery, cryoablation, radiofrequency ablation, surveillance, and watchful waiting. EVIDENCE SYNTHESIS: Initial active surveillance (AS) should be a first treatment option for small renal masses (SRMs) <4 cm in unfit patients or those with limited life expectancy. SRMs that show fast growth or reach 4 cm in diameter while on AS should be considered for treatment. Partial nephrectomy (PN) is the established treatment for T1a tumours (<4 cm) and an emerging standard treatment for T1b tumours (4-7 cm) provided that the operation is technically feasible and the tumour can be completely removed. Radical nephrectomy (RN) should be limited to those cases where the tumour is not amenable to nephron-sparing surgery (NSS). Laparoscopic radical nephrectomy (LRN) has benefits over open RN in terms of morbidity and should be the standard of care for T1 and T2 tumours, provided that it is performed in an advanced laparoscopic centre and NSS is not applicable. Open PN, not LRN, should be performed if minimally invasive expertise is not available. At this time, there is insufficient long-term data available to adequately compare ablative techniques with surgical options. Therefore ablative therapies should be reserved for carefully selected high surgical risk patients with SRMs <4 cm. CONCLUSIONS: The choice of treatment for the patient with localised RCC needs to be individualised. Preservation of renal function without compromising the oncologic outcome should be the most important goal in the decision-making process.

Laparoscopic radical prostatectomy--the experience of the German Laparoscopic Working Group.

PURPOSE: To present the current status of laparoscopic radical prostatectomy (LRP) in Germany, Austria and Switzerland with respect to transferability, learning curve, and outcome. MATERIAL AND METHODS: The data of 5824 patients who underwent LRP in 18 centers by 50 urologists from March 1999 to August 2004 were analyzed retrospectively. Three centers performed more than 500, and six more than 250 cases. A transperitoneal descending technique with was used in 2701, a transperitoneal ascending in 1234, an extraperitoneal descending in 1814, and an extraperitoneal ascending modification in 75 cases. Specimen showed pT2 in 3535, pT3a in 1555, pT3b in 623, and pT4 in 111 cases. RESULTS: Mean operating time averaged 211 (131-292) minutes, with shorter duration of the extraperitoneal descending technique. Conversion to open surgery averaged 2.4 (0-14.1) %. Re-intervention rate amounted to 2.7 (0.3-7.7) %. Complication rate averaged 8.9 (1.8-10.8) % including bleeding (0.3-2.5%) and rectal lesion (1.5-2.5%). The rate of positive margins was 10.6 (3.2-18) % for pT2- and 32.7 (20-38.5) % for pT3a-tumors Continence after 12 months was 84.9 (72-94) %. Data about potency (7 centers) revealed 52.5 (35-67) % full erections following bilateral nerve preservation. 5 year-PSA recurrence rate (3 centers) was 8.6 (4-15.3) % for pT2-tumors and 17.5 (15-20.6) % for pT3a-stages. CONCLUSIONS: The results confirm the efficacy of the training program with safe transfer of LRP (i.e. low complication rate), however including all known problems of a retrospective study.

Changes of renal blood flow in nephroptosis: assessment by color Doppler imaging, isotope renography and correlation with clinical outcome after laparoscopic nephropexy.

OBJECTIVE: Previously, we have detected changes in renal blood flow secondary to nephroptosis by assessing the renal resistive index (RI) using color Doppler imaging (CDI). The aim of the current study was to compare two diagnostic methods, CDI and isotope renography (IRG), for detection of renal blood flow impairment in patients with nephroptosis. METHODS: 26 patients with nephroptosis and flank pain underwent CDI and isotope renography (IRG) before and after laparoscopic nephropexy. The RI was assessed in segmental arteries with the patient in both the supine and erect position. Pre- and postoperative patient symptoms, results of Doppler measurements and IRG findings were assessed. RESULTS: Preoperatively, 23 of 26 symptomatic patients showed a mean reduction in RI of more than 0.10 on the affected side, while only 7 of 26 patients had abnormal findings on preoperative IRGs. Postoperatively, none of the patients with preoperative changes in Doppler parameters showed any posture-related changes in RI. On postoperative IRG, obtained in 4 of 7 patients, normalization of renal perfusion was documented. Twenty out of 26 patients were asymptomatic postoperatively; in the remaining 6 patients symptoms were markedly improved. CONCLUSION: Impairment of renal blood flow due to nephroptosis was detected with both CDI and IRG. RI measurement by CDI appears to be significantly more sensitive in detecting renal blood flow impairment. RI should be assessed in patients with nephroptosis and may impact on the decision for laparoscopic nephropexy.