Milestones in endoscope design for minimally invasive urologic surgery: the sentinel role of a pioneer.

Endoscopically based techniques have revolutionized the entire field of surgical specialties over the past 50 years. Currently, minimal access surgery is commonplace for considerable segments of surgical procedures across specialty lines. Central to this revolution, and arguably foremost in its impact on the development of minimally invasive endoscopic surgery, was the development of the rod-lens optical system by Professor Harold H. Hopkins and the almost simultaneous development of the fiberoptic cold-light light source by Karl Storz. It was George Berci who acted as the catalyst in bringing these two men together in the early 1960s, and from that meeting ensued one of the most successful cooperations in the design of endoscopic equipment. Innovative surgeons quickly recognized the enormous potential of these inventions, and in this context, George Berci's work and vision provided the hallmark events leading to the clinical applications from which surgeons and their patients so greatly benefit currently. In urology, Berci's early work has been recognized as a sentinel event bringing endoscopic endoluminal surgery from the lower urinary tract (urethra, bladder, prostate) to the upper urinary tract (ureter, kidney), and eventually to extraluminal laparoendoscopic surgery. This work has been recognized by the Journal of Urology as a "milestone in urology" leading to the clinical application in the field of endoscopic surgery currently referred to as endourology. In this article, the current state-of-the-art urologic surgery for the management of stone disease, urologic tumors, and anatomic abnormalities is presented, which to a great extent has its roots in George Berci's contributions to the field of innovative endoscope design.

Intensive nutrition education with or without supplementary feeding improves the nutritional status of moderately-malnourished children in Bangladesh.

This prospective randomized trial was carried out to test the efficacy of a specific intervention for reducing the extent of their malnutrition and to change behaviour of mothers relating to child-feeding practices, care-giving, and health-seeking practices under the Bangladesh Integrated Nutrition Project (BINP). The study was conducted in rural Bangladesh among 282 moderately-malnourished (weight-for-age between 61% and 75% of median of the National Center for Health Statistics standard) children aged 6-24 months. Mothers of the first intervention group received intensive nutrition education (INE group) twice a week for three months. The second intervention group received the same nutrition education, and their children received additional supplementary feeding (INE+SF group). The comparison group received nutrition education from the community nutrition promoters twice a month according to the standard routine service of BINP. The children were observed for a further six months. After three months of interventions, a significantly higher proportion of children in the INE and INE+SF groups improved (37% and 47% respectively) from moderate to mild or normal nutrition compared to the comparison group (18%) (p < 0.001). At the end of six months of observation, the nutritional status of children in the intervention groups improved further from moderate to mild or normal nutrition compared to the comparison group (59% and 86% vs 30%, p < 0.0001). As the intensive nutrition education and supplementation given were highly effective, more children improved from moderate malnutrition to mild or normal nutritional status despite a higher incidence of morbidity. The frequency of child feeding and home-based complementary feeding improved significantly (p < 0.001) in both the intervention groups after three months of interventions and six months of observation. Body-weight gain was positively associated with age, length-for-age, weight-for-length, frequency of feeding of khichuri, egg, and potato (p < 0.05). Ability of mothers to identify malnutrition improved from 15% to 99% in the INE group and from 15% to 100% in the INE+SF group, but reduced from 24% to 21% in the comparison group. Use of separate feed pots, frequency of feeding, and cooking of additional complementary feeds improved significantly in the INE and INE+SF groups compared to the comparison group after three months of interventions and six months of observation. It can be concluded from the findings of the study that intensive nutrition education significantly improves the status of moderately-malnourished children with or without supplementary feeding.

Calyceal diverticula. Ureteroscopic management.

In selected cases, RIRS management of calyceal diverticula and its related problems has been shown to be more efficacious than ESWL monotherapy and avoids the potential complications and discomfort of percutaneous and laparoscopic procedures. The advent of the Holmium laser energy source, with innovations such as the flexible ureteroscope and the tipless stone basket, have expanded the role of RIRS in the management of calyceal diverticula and associated problems. Presently, RIRS is the initial treatment choice for the management of low to moderate stone burdens that are contained in calyceal diverticula or trapped behind any narrowed intrarenal segment (e.g., infundibular stenosis). If repair of the stenotic segment is not successful, thereby excluding stone treatment, then under the same anesthesia, the patient undergoes a percutaneous antegrade renal surgery. The authors feel that the percutaneous approach as a first choice is more suitable for posteriorly located diverticula with a large stone burden. In selected cases of anteriorly located diverticula with large stone burdens, the laparoscopic approach is more expedient.

Anaemia and iron deficiency among adolescent schoolgirls in peri-urban Bangladesh.

OBJECTIVE: To investigate the prevalence of anaemia and iron deficiency among adolescent schoolgirls in peri-urban Bangladesh, and to identify various factors associated with anaemia in this population. DESIGN: A cross-sectional design. SETTING: Girls' high schools in five sub-districts of Dhaka. SUBJECTS: Adolescent girls (n=548) aged 11-16 y from nine schools in Dhaka district participated in the study. Socio-economic, anthropometric and dietary information were collected. Blood haemoglobin (Hb), serum iron, total iron binding capacity (TIBC), transferrin saturation (TS), serum ferritin (SF) and serum retinol (vitamin A) were determined. RESULTS: The prevalence of anaemia (Hb<120 g/l) among the participants was 27%. Seventeen percent had depleted iron stores (SF<12 microg/l). Of all anaemic girls, 32% had iron deficiency anaemia (Hb<120 g/l and SF<12 microg/l). When the girls were classified by serum vitamin A, the third with the lowest serum retinol levels had significantly lower Hb and SF levels. Significant positive correlations were observed between Hb and serum iron, TS, SF and retinol, while there was a negative correlation with serum TIBC. Occupancy, frequency of consumption of large fish, serum iron, TIBC, TS, SF and serum vitamin A were strongly related to Hb by multiple regression analysis. For 1 microg/l change in SF concentration, there was a 0.046 g/l change in Hb, when adjusted for all other factors. CONCLUSION: Anaemia among these adolescent schoolgirls in peri-urban Bangladesh cannot be explained by iron deficiency alone, and other causes may also exist in this population.

Simultaneous bilateral simple nephrectomy.

Bilateral simultaneous nephrectomy is a rare procedure usually performed for end-stage renal disease, most often because of persistent hypertension after renal transplantation. Four trocars generally are inserted, with a lower abdominal and a subcostal port being used by the surgeon. An intra-abdominal pressure of 8 to 10 mm Hg is used during the procedure. The first kidney is left in situ while the other one is being dissected. Unless there is infection or malignancy, a retrieval sac is not used. In our series of 13 cases, the operating times ranged from 240 to 390 minutes (mean 320 minutes), and the mean 125 mL. Surgical discharges criteria usually were met on postoperative day 1 or 2. Laparoscopic bilateral nephrectomy in a single session is feasible in nearly all properly selected cases, even in patients with previous abdominal surgery or peritoneal dialysis. The operation takes longer than open surgery and may have a higher complication rate, but recovery is faster.

Completeness and efficiency of prostate tissue removal: loop resection compared with a new operative technique of transurethral electrovaporization.

OBJECTIVE: To compare the completeness and efficiency of the removal of prostatic adenomatous tissue between transurethral resection (TURP) and a new operative technique of electrovaporization (TUEVAP) using a modified roller electrode. PATIENTS AND METHODS: In a prospective double-blind study, patients with moderate to severe lower urinary tract symptoms and objective evidence of obstruction, were randomized to undergo either TURP (using a standard cutting-wire loop) or TUEVAP (performed with a new operative technique and the spiked-bar electrode). The prostate volume measured using transrectal ultrasonography (TRUS-PV) was used to assess the completeness of tissue clearance after treatment. Results were compared using group median values. For the TURP group, the TRUS-PV estimate of tissue removed was divided by the dry resected weight to derive a correction factor for any discrepancy between the values. This factor was applied to the TRUS-PV reduction in the TUEVAP group (where there was no tissue to be weighed) to estimate the actual tissue removal in this group. The efficiency of tissue removal for each treatment modality was derived by dividing the amount of tissue removed by the operative duration. RESULTS: There was no difference in the reduction in TRUS-PV at 3 months (23.9 cm3 vs 21.45 cm3, P<0.9), or in the operative duration (45 min vs 52.5 min, P<0.2), between TURP and TUEVAP, respectively. The TRUS-PV of tissue removed exceeded the actual dry resected weight after TURP (15 g) by a factor of 1.59. After applying this factor to the TRUS-PV reduction for the TUEVAP group, the calculated dry weight of tissue removed for this group was 13.49 g (P<0.55); the difference in tissue removal rate by TRUS criteria was 0.48 cm3/min vs 0.37 cm3/min (P<0.15). CONCLUSIONS: These data suggest an equivalent completeness of removal of adenomatous prostate tissue between TURP and TUEVAP. The efficiency of tissue removal for TUEVAP was slightly less than that of regular loop resection, but this difference was not statistically significant. These results are specific to the combination of electrode, electrosurgical unit and operative technique used in this study, and may differ if any of these variables are altered.

Long-term supplementation with iron does not enhance growth in malnourished Bangladeshi children.

To evaluate the effect of long-term oral iron supplementation on growth, 250 children aged 6-71 mo were studied in a randomized double-blind controlled trial. The intervention group received 125 mg of ferrous gluconate (15 mg elemental iron) plus multivitamins (vitamins A, D and C); the comparison group received only multivitamins daily for 12 mo. Weight (kg) and height (cm) were measured every month. Eighty three percent of the children continued the treatment for one year. The weight increment over the 12-mo period was 1.35 +/- 0.65 kg (mean +/- SD) in the intervention group and 1.39 +/- 0.54 kg in the comparison group. The height increments were 6.01 +/- 1.47 and 6.18 +/- 1.58 cm in the intervention and comparison groups, respectively. Mean weight and height increments did not differ; in an analysis stratified according to different age and nutritional categories, they also did not differ between the two groups, indicating that long-term iron supplementation does not increase growth in children.

Folic acid in the treatment of acute watery diarrhoea in children: a double-blind, randomized, controlled trial.

One-hundred and six male children aged 6-23 months with a history of acute watery diarrhoea of less than 72 h duration were randomized to receive either folic acid in a dose of 5 mg at 8-h intervals or placebo for 5 d. There were 54 children in the folic acid group and 52 in the placebo group. The admission characteristics were comparable between the two groups. No significant differences were observed in the intake of oral rehydration solution or stool output between the groups. The mean+/-SD of total stool output (g kg(-1)) was 532+/-476 vs 479+/-354 and the duration (h) of diarrhoea was 108+/-68 vs 103+/-53 in the folic acid vs placebo group, respectively. The findings, therefore, should have a positive influence on preventing the inappropriate use of folic acid in acute diarrhoea.

Retroperitoneal and pelvic extraperitoneal laparoscopy: an international perspective.

OBJECTIVES: To assess technical preferences and current practice trends of retroperitoneal and pelvic extraperitoneal laparoscopy. METHODS: A questionnaire survey of 36 selected urologic laparoscopic centers worldwide was performed. RESULTS: Twenty-four centers (67%) responded. Overall, 3988 laparoscopic procedures were reported: transperitoneal approach (n = 2945) and retroperitoneal/extraperitoneal approach (n = 1043). Retroperitoneoscopic/extraperitoneoscopic procedures included adrenalectomy (n = 74), nephrectomy (n = 299), ureteral procedures (n = 166), pelvic lymph node dissection (n = 197), bladder neck suspension (n = 210), varix ligation (n = 91), and lumbar sympathectomy (n = 6). Mean number of total laparoscopic procedures performed in 1995 per center was 41 (range 5 to 86). Major complications occurred in 49 (4.7%) patients and included visceral complications in 26 (2.5%) patients and vascular complications in 23 (2.2%). Open conversion was performed in 69 (6.6%) patients, electively in 41 and emergently in 28 (visceral injuries, n = 16; vascular injuries, n = 1 2). Retroperitoneoscopy/extraperitoneoscopy is gaining in acceptance worldwide: in 1993, the mean estimated ratio of transperitoneal laparoscopic cases versus retroperitoneoscopic/ extraperitoneoscopic cases per center was 74:26; however, in 1996 the ratio was 49:51. CONCLUSIONS: Retroperitoneoscopy and pelvic extraperitoneoscopy are important adjuncts to the laparoscopic armamentarium in urologic surgery. The overall major complication rate associated with retroperitoneoscopy/extraperitoneoscopy was 4.7%.

Air travel and thromboembolic complications after percutaneous nephrolithotomy for staghorn stone.

Thromboembolic complications after percutaneous surgery for staghorn stone are rare. We report a case of silent deep vein thrombosis (DVT) after long-distance air travel that was complicated by both recurrent pulmonary emboli and paradoxical arterial embolus despite full-dose systemic heparin anticoagulation. Management options for thromboembolic complications in the context of percutaneous renal surgery are discussed, and risk factors predisposing to silent deep vein thrombosis after long-distance air travel are outlined.

New techniques for the administration of topical adjuvant therapy after endoscopic ablation of upper urinary tract transitional cell carcinoma.

PURPOSE: We evaluated the role of combining ureteroscopic tumor ablation and new methods of administering topical adjuvant therapy in select patients with transitional cell carcinoma of the upper urinary tract. MATERIALS AND METHODS: Patients with upper tract transitional cell carcinoma and indications for preserving renal function initially underwent ureteroscopic evaluation and tumor ablation. We treated 17 renal units in 13 patients. Three patients with distal ureteral lesions underwent uncomplicated adjuvant bacillus Calmette-Guerin therapy by the combination of Double-J stent placement and bladder instillations in the Trendelenburg position. In the remaining 14 renal units adjuvant topical therapy was administered by low pressure weekly instillations through a transvesical single-J stent whose curl was positioned in an upper calix. Patients were regularly followed with office flexible ureterorenoscopy under local anesthesia and cytology washings once they were confirmed to be tumor-free. RESULTS: Complete ureteroscopic tumor ablation was possible in all patients. Two sessions were needed due to tumor burden in 3 patients. There were intercurrent urinary infectious complications with Candida albicans in the 3 patients treated with bacillus Calmette-Guerin through the single-J stent, including 1 who received only 3 instillations due to persistent unexplained fevers but who remains disease-free at 24 months. In 2 of the 17 renal units multifocal tumor recurred within 12 months, which was treated with nephroureterectomy. At short followup (mean 14.6 months) 15 renal units have been preserved and remain tumor-free. CONCLUSIONS: The new techniques of administering adjuvant topical agents for upper tract transitional cell carcinoma after ureteroscopic tumor ablation in select cases described provide a useful and simple alternative to the percutaneous method preferred in the past. Short-term responses have been favorable but the true value of adjuvant therapy remains uncertain at present. The 2 recurrences within 12 months of treatment were readily detected by outpatient ureterorenoscopy with the patient under local anesthesia using 7.5F flexible endoscopes.

Long-term oral supplementation with iron is not harmful for young children in a poor community of Bangladesh.

The effect of long-term oral iron supplementation on morbidity due to diarrhea, dysentery and respiratory infections in 349 children, aged 2-48 mo, living in a poor community of Bangladesh, was evaluated in this double-blind study. The treatment group received 125 mg of ferrous gluconate (15 mg elemental iron) plus multivitamins and the controls received only multivitamins, daily for 15 mo. House-to-house visits were made on alternate days by trained community health workers for recording symptoms and duration of illnesses and for monitoring medicine intake. Seventy-six percent of the children continued the syrup for over 1 y. No untoward effects were noticed in either treatment group. The attack rates for diarrhea, dysentery and acute respiratory tract infections (ARI) were 3, 3 and 5 episodes per child per year, respectively. Each episode of diarrhea lasted a mean of 3 d, and those of dysentery and ARI, 5 d. The two treatment groups did not differ in the number of episodes, mean duration of each episode, or total days of illnesses due to diarrhea, dysentery and ARI. However, a 49% greater number of episodes of dysentery was observed with iron supplementation in a subset of the study children who were less than 12 mo old (P = 0.03). The results of this study suggest that long-term oral iron supplementation is not harmful for older children in a poor community. Further studies are needed to demonstrate the safety and efficacy of iron administration in young infants.

Laparoscopic aortobifemoral bypass.

PURPOSE: To determine the potential benefits of applying laparoscopic techniques for the intraabdominal insertion of aortofemoral grafts and to compare results with those of conventional surgery. METHODS: Having previously demonstrated the feasibility of a totally laparoscopic aortofemoral bypass technique using carbon dioxide peritoneal insufflation in a porcine model, we now report our first human experience with this laparoscopic technique in a 49-year-old man. RESULTS: The patient's postoperative course was marked by his minimal requirements for analgesia, early ambulation, and discharge from the hospital in the morning of the third postoperative day. CONCLUSIONS: The benefits of a laparoscopic approach to aortobifemoral bypass grafting in terms of financial savings and earlier rehabilitation in this patient was significant. This less-invasive procedure warrants further investigation.

Expanding the horizons of SWL through adjunctive use of retrograde intrarenal surgery: new techniques and indications.

The recognition of high retreatment rates and lower success rates after SWL monotherapy in certain situations led us to explore a new endourologic strategy including retrograde intrarenal surgery (RIRS). Examples of situations in which RIRS + SWL is appropriate are coexistence of stones and coagulopathy, stones associated with intrarenal stenosis, concomitant renal and ureteral stones, renal anomalies, and failed SWL. Lithotripter-specific guidelines for the adjunctive use of RIRS may be appropriate.

Prostate heating patterns comparing electrosurgical transurethral resection and vaporization: a prospective randomized study.

PURPOSE: A prospective study was performed to determine if transurethral electrosurgical vaporization of the prostate is associated with unseen heat damage to vital periprostatic structures compared to conventional loop resection. In addition, energy consumption and its relationship to observed tissue temperature at the prostate periphery were evaluated for each treatment. MATERIALS AND METHODS: Patients with moderate to severe symptoms of benign prostatic bladder outflow obstruction and objective evidence of diminished flow or acute urinary retention were randomized to undergo either transurethral loop resection or electrosurgical vaporization after stratification for gland volume. Instrumentation was standardized for both groups except for the monopolar electrode used. The radiofrequency power source in the study was a new computer controlled generator with a constant power delivery feature. Regional tissue heating patterns were evaluated with optical fiber probes in real time. Four stationary sites were chosen for temperature measurements, namely the lateral lobe of the prostate, neurovascular bundle beside the prostatic apex at the level of the external sphincter, and anterior rectal wall at the level of the prostatic base and apex. A pull back technique was used to search for hot points in the long axis of the probe (3-dimensional temperature mapping) in 2 patients from each group. Incident generator panel power settings for the electrosurgical vaporization treatments were equivalent to those commonly used for loop resection (150 watts) and were adjusted up or down as needed. RESULTS: Prostate electrosurgical vaporization was possible at generator panel settings that were nearly equivalent to those for transurethral resection of the prostate (130 to 190 watts). No significant rectal or sphincteric heating was detected with either procedure. Conductive cooling of the neurovascular bundles was observed in 2 patients in each group toward the end of the operation. More energy was used per minute of treatment during electrosurgical vaporization than with regular loop resection (p < 0.004) but this was not associated with unwanted tissue heating. CONCLUSIONS: Neither conventional loop resection nor electrosurgical vaporization of the prostate appeared to be unsafe treatments with respect to unseen deep heating effects to vital periprostatic structures when performed at equivalent low incident power. The extra energy used during electrosurgical vaporization provided the benefit of improved coagulative hemostasis concurrently with shallow tissue vaporization using pure cutting current alone, without compromising treatment safety.

Laparoscopic aortobifemoral bypass: a case report.

In the past six years, laparoscopic surgery has gained widespread acceptance by both surgeon and patient. When compared to open surgical approaches, laparoscopic techniques for abdominal procedures lessen postoperative pain and morbidity, improve cosmesis, reduce hospital stay, facilitate early rehabilitation and return to normal activities. The application of laparoscopic techniques to intra-abdominal vascular procedures can be expected to provide similar benefits over conventional surgery.

Iron deficiency and anaemia in children with a high prevalence of haemoglobinopathies: implications for screening.

BACKGROUND: Haemoglobin (Hb) concentration is used as a sole test for iron deficiency anaemia (IDA) in most developing countries since most anaemia is believed to be due to iron deficiency and confirmatory testing is generally unavailable. Yet the validity of this approach in regions where haemoglobinopathies are endemic has not been documented. METHODS: Haemoglobin and serum ferritin (SF) were measured in 559 Northern Thai children aged 6 months to 13 years of age. The sensitivity of SF to identify iron deficiency was also assessed in a subsample of children with low or low-normal Hb and normal SF by testing the Hb response to a trial of oral iron. RESULTS: While anaemia was common (27%), IDA constituted 19% and none of all anaemia in preschool and school age children, respectively (P < 0.002). Iron depletion was similarly more prevalent in younger children (P < 0.002). Children with IDA were younger (P < 0.001) and the anaemia more severe (P < 0.0001) compared to those with non-IDA. Of anaemic children with normal SF values who received a therapeutic trial of iron, only 6% responded with an increase in Hb of > or = 1 g/dl. CONCLUSIONS: For populations such as ours most anaemia is not due to iron deficiency and a single Hb determination is therefore not acceptable for a presumptive diagnosis of IDA.

[Current status of laparoscopic surgery in pediatric urology]. / Derzeitiger Stand der laparoskopischen Chirurgie in der pädiatrischen Urologie.

The current world-wide experience with laparoscopy in the field of pediatric urology is summarized. Based on significant personal expertise, the operative technique and instrumentation of the different procedures are described. Herein standard indications (i.e., diagnosis and therapy of cryptochidism, bilateral varicoceles) can be distinguished from rather infrequent procedures (i.e., renal cyst resection, nephrectomy) and experimental indications (case reports) such as bladder "auto" augmentation, antirefluxplasty and pyeloplasty. At the referring centers, laparoscopic surgery in pediatric urology has significantly increased. Therefore, this minimally invasive, delicate technique is becoming more popular.