Symptom Resolution and Recurrence Outcomes after Partial Versus Total Laparoscopic Adrenalectomy: 13 years of Experience with Medium-Long Term Follow up.

PURPOSE: Partial adrenalectomy (PA) is an emerging modality typically performed for the treatment of hereditary and sporadic bilateral tumors, to reduce the risk of adrenal failure. In this study, we evaluated the recurrence and functional outcomes after partial and total adrenalectomy (TA). MATERIALS AND METHODS: From March 2005 to July 2018, 284 patients with functional tumor or > 5 cm adrenal mass underwent clipless and sutureless laparoscopic partial or total adrenalectomy (PLA and TLA). Patients with a pathological diagnosis of pheochromocytoma, Cushing or Conn's disease and more than two year follow up were included in this study. Pre-operative and operative variables were collected retrospectively and functional outcomes and recurrence were gathered prospectively. RESULTS: One hundred forty patients (mean age: 43±5.1years) were included in the study. PLA and TLA were performed for pheochromocytoma (total n=78; PLA=12 (15%), TLA=66 (85%)), Cushing syndrome (toal n=17; PLA = 4 (24%), TLA = 13 (76%)), and Conn's disease (total n=45; PLA=7 (16%), TLA=38 (84%)). In pheochromocytoma patients, improvement of hypertension, palpitation, and headache was not different between patients who underwent PLA versus TLA (all P > 0.05). Two recurrences were observed in patients with pheochromocytoma who had undergone TLA. In patients with Cushing disease, central obesity, fascial plethora, and hypertension were improved in all patients six months after treatment, muscle weakness was improved one year after surgery, and acne and hyperpigmentation only improved two years after surgery. The length of time for resolution of symptoms was not different in patients who underwent PLA versus TLA. In Conn's disease hypertension was resolved in all patients and no patient required potassium supplements post-operatively. In follow up no recurrence was observed in patients with a pathological diagnosis of Cushing or Conn's disease. CONCLUSION: In our experience, PLA can provide excellent control of the symptoms parallel with TLA and with no statistically significant difference in recurrence making PLA an attractive option in patients with an adrenal mass.

Comparing the Efficacy of Tolterodine and Gabapentin Versus Placebo in Catheter Related Bladder Discomfort After Percutaneous Nephrolithotomy: A Randomized Clinical Trial.

PURPOSE: The purpose of this study was to compare the efficacy of tolterodine and gabapentin vs placebo in catheter related bladder discomfort (CRBD) following percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: This study was a double-blind parallel group randomized clinical trial. Patients who were candidates of PCNL were enrolled. Patients were randomized to treatment groups of tolterodine 2 mg orally (PO) (group T, n = 50), gabapentin 600 mg PO (group G, n = 50), and placebo (group P, n = 70) 1 hour before operation using balanced block randomization. The primary endpoint of interest was visual analog pain scale in 1, 3, 12, and 24 hours after the operation. Secondary endpoints included rescue analgesic use (opioid and nonopioid). RESULTS: The frequency of severe CRBD in 1,12, and 24 hours after the operation was 4%, 4%, and 6% in group T vs 4%, 0%, and 2% in group G vs 47%, 14%, and 6% in the P group (p < 0.001). The number of paracetamol injections for CRBD in the T and G groups was significantly lower than the placebo group (1.8 ± 0.8 vs 1.8 ± 0.7 vs 3.6 ± 0.7, p < 0.001). Likewise the number of pethidine injections in the T and G groups was significantly lower than the placebo group (0.42 ± 0.54 vs 0.68 ± 0.62 vs 2.4 ± 0.64, p < 0.001). In patients with history of Double-J insertion, the severity of CRBD was lower in all treatment groups. CONCLUSIONS: Preoperative administration of oral tolterodine or gabapentin reduces postoperative CRBD and the need for rescue analgesics as much as 24 hours after surgery. Patients with history of Double-J insertion experience less CRBD.

Abobotulinum - a toxin injection in patients with refractory idiopathic detrusor overactivity: injections in detrusor, trigone and bladder neck or prostatic urethra, versus detrusor - only injections

ABSTRACT Purpose: To evaluate if the injections of abobotulinum-A toxin in trigone and bladder neck/prostatic urethra in addition to detrusor provides better symptoms relief and urodynamic findings in patients with idiopathic detrusor overactivity (IDO) refractory to medical treatment. Materials and Methods: A total of 74 patients with IDO refractory to anticholinergics received injections in detrusor, trigone and bladder neck/prostatic urethra (Group A, N=36) versus detrusor only injections (Group B, N=38) of abobotulinum-A toxin. All patients were evaluated by a standard overactive bladder symptom score (OABSS) questionnaire and cystometrography before and 6 weeks after the operation. OABSS questionnaire was also completed 20 weeks after the operation. Results: The magnitude of OABSS reduction from baseline to 6 weeks after operation in groups A and B patients was 13.4±2.2 versus 11.7±2.1 (p=0.001). Cystometry results were similar in both groups except for higher volume at urgent desire to void in Group B patients (p <0.001). The mean±SD change in residual volume in Group A at 6 weeks after the operation was −4.8±28.6mL (p=0.33) compared to 21.3±16.9mL in Group B patients (p <0.001). Conclusions: In patients with IDO, adding trigone, and bladder neck/prostatic urethra as sites of abobotulinum- A toxin injection produces greater reductions in OABSS score and less residual urine volume but a lower volume at urgent desire to void in comparison with detrusor only injections.

Bilateral Laparoscopic Stone Surgery for Renal Stones- A Case Series.

PURPOSE: To present our experience with synchronous or metachronous laparoscopic pyelolithotomy and ureterolithotomy for patients with bilateral urolithiasis. MATERIALS AND METHODS: The data of all patients who underwent laparoscopic pyelolithotomy (± ureterolithotomy) for bilateral renal and/or ureteral stones from November 2009 to July 2014 were included. Laparoscopic operations were performed through a transperitoneal approach. RESULTS: 10 patients underwent laparoscopic operations for renal stones (19 kidney stones) and ureteral stones (1 ureteral stone). 4 patients underwent synchronous operations and 6 patients underwent metachronous operations. The mean ± SD of operation duration were 212 ± 51 minutes for synchronous operations and 166 ± 41 minutes for metachronous operations. Residual stone was observed 5 patients. No patient developed urinary leakage. CONCLUSION: Laparoscopic pyelolithotomy and/or ureterolithotomy for bilateral stones is a feasible option in centers with experience in laparoscopy.

Management of Colon Perforation During Percutaneous Nephrolithotomy: 12 Years of Experience in a Referral Center.

INTRODUCTION: The management protocol for colon perforation during percutaneous nephrolithotomy (PCNL) is controversial because of the scarcity of reported cases and their management diversity. We present our management experience of colon perforation during PCNL. MATERIALS AND METHODS: All PCNL operations between April 2004 and September 2016 in our center (N = 11,376) were reviewed for the occurrence and management of colon perforation. We typically performed PCNL with insertion of nephrostomy tube before mid-2007. After mid-2007, we typically performed tubeless PCNL and inspected access tract for evidence of organ injury especially colon perforation during nephroscope removal. RESULTS: Seventeen colon perforations happened during the study period. The first three cases were diagnosed postoperatively and in two patients open surgery was employed for treatment. The next 14 cases were diagnosed intraoperatively (n = 12) or in the early postoperative period (n = 2) and were managed by broad spectrum antibiotics, bowel rest, and urinary Double-J and Foley's catheter insertion. Percutaneous retroperitoneal drain was inserted for only one patient after intraoperative diagnosis of colon perforation. The other 13 patients were managed without insertion of such drains. For one patient, postoperative insertion of retroperitoneal drain was attempted because of collection of urine. In other patients (n = 12), the management was effective with no need for an operation. Complications according to Clavien-Dindo grade in these 17 patients were grades II, IIIa, and IIIb in 13, 1, and 3 patients, respectively. CONCLUSIONS: Colon perforation during PCNL that is diagnosed intraoperatively or in the early postoperative period can be managed conservatively. It seems possible not to insert colostomy or retroperitoneal drains in stable patients with early or intraoperative diagnosis. In cases of delayed diagnosis, or deterioration of the patient on tubeless management, the standard protocol should be performed including insertion of colonic or retroperitoneal drain or surgery especially in patients with signs or symptoms of peritonitis or persistent fever.

Abobotulinum - a toxin injection in patients with refractory idiopathic detrusor overactivity: injections in detrusor, trigone and bladder neck or prostatic urethra, versus detrusor - only injections.

PURPOSE: To evaluate if the injections of abobotulinum-A toxin in trigone and bladder neck/prostatic urethra in addition to detrusor provides better symptoms relief and urodynamic findings in patients with idiopathic detrusor overactivity (IDO) refractory to medical treatment. MATERIALS AND METHODS: A total of 74 patients with IDO refractory to anticholinergics received injections in detrusor, trigone and bladder neck/prostatic urethra (Group A, N=36) versus detrusor only injections (Group B, N=38) of abobotulinum-A toxin. All patients were evaluated by a standard overactive bladder symptom score (OABSS) questionnaire and cystometrography before and 6 weeks after the operation. OABSS questionnaire was also completed 20 weeks after the operation. RESULTS: The magnitude of OABSS reduction from baseline to 6 weeks after operation in groups A and B patients was 13.4±2.2 versus 11.7±2.1 (p=0.001). Cystometry results were similar in both groups except for higher volume at urgent desire to void in Group B patients (p <0.001). The mean±SD change in residual volume in Group A at 6 weeks after the operation was -4.8±28.6mL (p=0.33) compared to 21.3±16.9mL in Group B patients (p <0.001). CONCLUSIONS: In patients with IDO, adding trigone, and bladder neck/prostatic urethra as sites of abobotulinum- A toxin injection produces greater reductions in OABSS score and less residual urine volume but a lower volume at urgent desire to void in comparison with detrusor only injections.

Long-term follow-up of trigonoplasty antireflux operation.

BACKGROUND: Open trigonoplasty antireflux operation has been associated with promising results. However, its success in controlling reflux has not been evaluated in the long term. METHODS: All patients who underwent trigonoplasty for vesicoureteral reflux by one surgeon from 2004 to 2014 were included. Preoperative evaluations included direct radionuclide cystography (DRNC) or voiding cystourethrography, urine analysis and culture and abdominal sonography. Urodynamic study and cystoscopy was performed in selected patients. Trigonoplasty was done by a modified Gil-Verent method. The latest available patients' DRNCs were used to judge for reflux relapse. RESULTS: Ninety-one patients, 142 refluxing units; median (range) age, 10.5 (1-45) years; M/F, (11/80) were followed for 18 to 135 months. Reflux resolution rate was 73.6% for patients and 75.4% for refluxing units. Relapse was associated with reflux grade (67% in grade V), ureteral orifice appearance (40% in golf hole/stadium), and patients with a history of pyelonephritis. Multivariable model based on the above variables had less than 10% sensitivity in predicting relapse. CONCLUSIONS: Trigonoplasty success rate can decrease with long-term follow-up.

Ultrasound - guided access during percutaneous nephrolithotomy: entering desired calyx with appropriate entry site and angle

ABSTRACT Objectives: To evaluate the success of ultrasonography directed renal access in entering the target calyx from proper entry site and in the direction of renal pelvis during percutaneous nephrolithotomy (PCNL). Materials and Methods: PCNL cases who were operated on by one fellow from May-June 2014 were included in this study. A vertically placed ultrasound probe on the patient flank in prone position was used to identify the preselected target calyx. Needle was advanced through needle holder and fluoroscopy was used to document the entered calyx, site and angle of entry. Results: Successful entering to the target calyx was achieved in 43 cases (91%). Successful entry with appropriate entry site and angle was observed in 34 cases (72%). Reasons for failure were minimal hydronephrosis, upper pole access and high lying kidneys. Conclusions: Although it is feasible to access a preselected calyx by ultrasonography guidance during PCNL, but entry to the calyx from the appropriate site and direction is another problem and needs more experience. In cases of minimal hydronephrosis, superior pole access or high lying kidneys, ultrasonography is less successful and should be used with care.

Comparison of acromioaxillosuprasternal notch index (a new test) with modified Mallampati test in predicting difficult visualization of larynx.

BACKGROUND: We aimed to compare the efficacy of a new bedside screening test named acromioaxillosuprasternal notch index (AASI) with modified Mallampati (MMP). METHODS: A total of 603 adult patients, who were candidates for tracheal intubation in elective surgery, were enrolled in this prospective study. Preoperative airway assessment was carried out with AASI and MMP. The new AASI score is calculated based on the following measurements: (1) using a ruler, a vertical line is drawn from the top of the acromion process to the superior border of the axilla at the pectoralis major muscle (line A); (2) a second line is drawn perpendicular to line A from the suprasternal notch (line B); and (3) the portion of line A that lies above the point where line B intersects it is line C. AASI is calculated by dividing the length of line C by that of line A (AASI = C/A). After induction of anesthesia, the laryngeal view was recorded according to the Cormack-Lehane grading system. Receiver operating characteristic curve analysis was employed to compare between AASI and MMP. RESULTS: Difficult visualization of larynx (DVL, Cormack-Lehane III and IV) was observed in 38 (6.3%) patients. The best cutoff point for DVL was defined at AASI > 0.49. AASI had a lower false negative rate and higher predictive values (sensitivity, positive predictive value, and accuracy) in comparison with MMP. CONCLUSION: AASI was associated with higher predictive values than MMP and could be used for estimation of DVL.

Vascular clips are safe and a great cost-effective technique for arterial and venous control in laparoscopic nephrectomy: single-center experience with 1834 laparoscopic nephrectomies.

PURPOSE: To evaluate the safety and cost-effectiveness of Hem-o-lok and metallic titanium clips for both renal arterial and venous control in laparoscopic nephrectomies. PATIENTS AND METHODS: All patients who underwent laparoscopic nephrectomy from June 2000 to March 2011 in our center were included. Before July 2005, we used three medium-large titanium clips for safe control of renal vessels. After July 2005, we used two clips for renal artery control (one 10 mm Hem-o-lok clip and one medium-large titanium clip) and two clips for renal vein control (12 mm and 10 mm Hem-o-lok clips) in all cases. To prevent possible complications, we placed vascular clips 2 to 3 mm away from the aortic root of the renal artery underneath lumbar vessels. Episodes of clip failure were defined as intraoperative or postoperative hemorrhage or exploration because of clip failure. RESULTS: This study included 1834 laparoscopic nephrectomies (1423 donor nephrectomies, 214 simple nephrectomies, and 197 radical nephrectomies). All arteries and renal veins were controlled by titanium and Hem-o-lok clips. One complication that was probably related to vascular clips (titanium and Hem-o-lok), however, involved a delayed hemorrhage from a pseudoaneurysm at the aortic root of the renal artery, which was repaired at exploration. No complication was clearly related to vascular clips. Using Hem-o-lok and titanium clips instead of vascular staplers resulted in $670 savings per operation. CONCLUSIONS: Hem-o-lok and metallic vascular clips applied properly by trained surgeons according to published safety measures provide a safe and considerable cost-saving option for vascular control in laparoscopic nephrectomy.

Impacts of percutaneous nephrolithotomy on the estimated glomerular filtration rate during the first few days after surgery.

Long-term effects of percutaneous nephrolithotomy (PCNL) on renal function have been evaluated in many studies but there are little data on the renal effects of PCNL immediately after surgery in human patients. The aim of this study was to evaluate estimated glomerular filtration rate (GFR) during the first few days after PCNL. From July to September 2008, we gathered preoperative and postoperative serum creatinine data of all the patients who underwent PCNL at our center. Children and patients who received transfusion during surgery were excluded. Creatinine clearance was estimated by Cockcroft-Gault equation and was used to estimate GFR. 94 patients met the inclusion criteria. The mean ± SD of creatinine clearance by Cockcroft-Gault equation was 87.5 ± 32.2 cc/min before operation. It decreased to 85.5 ± 29.4 cc/min, 77.0 ± 26.8 cc/min and 75.9 ± 25.0 cc/min at 6, 24 and 48 h after operation and then increased slightly to 81.9 ± 26.4 cc/min 72 h after operation. Renal GFR decreases immediately after PCNL reaches a nadir 48 h after operation, and then, increases slowly. It seems advisable to avoid factors that can bear a negative influence on renal function during the early postoperative period such as nephrotoxic drugs, contrast agents, shock wave lithotripsy and Re-PCNL.

An assessment of parathyroid hormone, calcitonin, 1,25 (OH)2 vitamin D3, estradiol and testosterone in men with active calcium stone disease and evaluation of its biochemical risk factors.

The aim of this study is to investigate the serum levels of parathyroid hormone (PTH), calcitonin, 1,25 (OH)(2) vitamin D3, estradiol and testosterone in male patients with active renal calcium stone disease compared with controls and investigate their relationship with serum/urinary biochemistry. Male active renal calcium stone formers (ASF) were enrolled from December 2008 to April 2009. Controls were selected from age and sex matched individuals. Two 24-h urine samples and a blood sample were withdrawn from each participant while they were on free diet. Serum 1,25 (OH)(2) vitamin D3 levels in the ASF and control groups were 127 ± 40 and 93 ± 35 pmol/l (p < 0.001). Serum levels of PTH, calcitonin, estradiol and testosterone were not statistically different between the ASF and control groups (all p > 0.05). Serum 1,25 (OH)(2) vitamin D3 was associated with higher urinary excretion of calcium and phosphorus in ASF patients. Serum levels of calcitonin were related to less urinary excretion of calcium in the control group. Serum testosterone was related to higher urinary excretion of uric acid in ASF patients and to higher urinary excretion of oxalate in the control group. 1,25 (OH)(2) Vitamin D3 is an important hormone in the pathogenesis of recurrent renal calcium stone disease and could increase renal stone risk by increasing the urinary excretion of calcium and phosphorus. There is a possibility of testosterone involvement in the pathogenesis of renal stones through higher urinary uric acid and oxalate excretion.

Transperitoneal laparoscopic partial nephrectomy using a new technique.

INTRODUCTION: We report our experience with a new technique for transperitoneal laparoscopic partial nephrectomy with the kidney turned upside down intraoperatively. MATERIALS AND METHODS: Laparoscopic partial nephrectomy was performed in 10 patients with upper pole lesions through a transperitoneal approach. Once complete mobilization of the kidney was achieved, it was rotated 180 degrees around the horizontal axis, so that the upper pole was positioned inferiorly. After performing partial nephrectomy, the resection bed was sutured by 2-0 polyglactin sutures and application of Hem-o-Lok clips. Then, the kidney was returned into its normal position and fixed to the abdominal wall. RESULTS: We performed laparoscopic partial nephrectomy on 9 patients with a contrast-enhancing upper pole kidney mass and 1 patient with a nonfunctioning upper pole. The median tumor size was 58 mm (range, 41 mm to 92 mm). The median operative time was 206 minutes (range, 114 to 262 minutes) and the mean warm ischemia time was 30 minutes (range, 22 to 35 minutes). One patient underwent surgical exploration due to bleeding 6 hours after the operation. Prolonged urine leakage (more than 7 days) was observed in 1 patient, which responded to ureteral stent insertion. Surgical margins were negative in all of the patients. Renal cell carcinoma was histologically diagnosed in patients with a kidney tumor. CONCLUSION: Laparoscopic upper pole partial nephrectomy had acceptable results while the kidney was turned upside down intraoperatively, in terms of operative time and complications. This approach facilitates the procedure by achieving a better field of vision.