Laparoscopic radical prostatectomy: review and assessment of an emerging technique.

BACKGROUND: Several recent reports have affirmed the feasibility of the laparoscopic approach for radical prostatectomy. In this review, we discuss the morbidities associated with this technique and compare outcomes and convalescence with standard open radical prostatectomy. METHODS: We reviewed all currently published data on laparoscopic radical prostatectomy and our series of 45 robotic-assisted radical prostatectomies and compared them to several landmark series of open retropubic and perineal radical prostatectomies. RESULTS: Although the initial series reported long operating times, these times have been significantly reduced in more recent series. Data on blood loss, convalescence, impotence, and incontinence rates have also been promising. CONCLUSIONS: Although follow-up has been short thus far, laparoscopic radical prostatectomy has been shown to be similar to open radical prostatectomy in several areas.

Assessment of optimal balloon size for rupture of the ureteropelvic junction and mid-ureter in a porcine model.

PURPOSE: Balloon dilation potentially represents a safer and simpler technique for the treatment of ureteropelvic junction (UPJ) obstruction and ureteral strictures. Using a porcine model, we sought to establish the optimal balloon size for endoballoon rupture of the UPJ and ureter. MATERIALS AND METHODS: The efficacy of endoballoon rupture of the proximal and middle ureter with 24F, 30F, and 36F balloon catheters was compared in 19 female minipigs. At the proximal ureter, the effect of the rate of dilation also was evaluated for each balloon size. Extravasation of methylene blue-stained contrast material was assessed with retrograde pyelograms and direct laparoscopic vision. After acute sacrifice, the dilated segments were evaluated histologically with hematoxylin and eosin and Masson's trichrome staining. RESULTS: At the proximal ureter, free extravasation of contrast was observed in 61% of the rapid inflation and 72% of the slow inflation trials; contained extravasation was noted in 28% of the rapid inflation and 17% of the slow inflation trials. Except for two of the 24F slow inflation trials, all of the proximal ureteral trials produced at least one full-thickness tear into the periureteral fat. Grossly, the tears appeared linear with various lengths and no consistent orientation. Rapid inflation and increasing balloon size tended to produce a ureterotomy with less damage to the ureter surrounding the tear. At the mid-ureter, none of the balloon sizes consistently produced a transmural tear. CONCLUSIONS: Rapid dilation and use of a 36F balloon capable of maintaining a low profile after inflation may result in a cleaner proximal ureterotomy with less distortion of the untorn neighboring proximal ureter. Both 36F and 30F balloons consistently produced a full-thickness proximal ureterotomy in normal porcine tissue. For mid-ureteral strictures, balloon dilation to even 36F may fail to create a suitable ureterotomy. However, it must be noted that dysplastic or scarred tissue may respond differently to dilation than the more elastic normal porcine tissues used in this study.

Laparoscopic radical nephrectomy.

Although open nephrectomy is the standard of care for localized renal-cell carcinoma, the significant postoperative pain and lengthy convalescence have encouraged the use of laparoscopy, which can yield similar 2- to 5-year survival rates. Either a transperitoneal or a retroperitoneal approach may be used, and sometimes, they are combined. Generally, the technique is limited to tumors <10 cm, but larger tumors can be removed. Nitrous oxide is avoided as an anesthetic agent. The dissection follows accepted oncologic principles: in situ renal dissection within Gerota's fascia, early ligation of the renal vessels, and careful removal of the specimen to prevent tumor spillage. Dissection of the hilum is facilitated by a PEER retractor and an Endoholder. On average, patients having laparoscopic radical nephrectomy return to normal activities approximately 4.5 weeks sooner than those having open surgery, a fact not taken into account in cost analyses. Laparoscopic nephrectomy may offer a special benefit in patients with known metastatic disease, as interleukin-2 administration can be started a month earlier than after open surgery. There may also be immunologic benefits of minimally invasive v open surgery. The technique and instruments continue to evolve, and cost-effectiveness should continue to improve.

Preoperative assessment of ureteropelvic junction obstruction with endoluminal sonography and helical CT.

OBJECTIVE: Our objective was to compare the value of endoluminal sonography with the value of helical CT in the preoperative assessment of crossing vessels in patients with ureteropelvic junction (UPJ) obstruction. SUBJECTS AND METHODS: Thirteen patients with UPJ obstruction underwent contrast-enhanced helical CT with multiplanar reformations and endoluminal sonography. Imaging preceded surgery for UPJ repair. On imaging, vessels were considered significant if greater than or equal to 2 mm in diameter and within 1 cm of the UPJ. RESULTS: Three patients had no crossing vessels revealed by either study. On sonography, another patient had a vessel revealed with a diameter that varied between 1.3 and 2.2 mm; on CT no correlate was detected. The remaining nine patients had vessels revealed by both techniques. On CT, four patients had two vessels revealed and five patients had single vessels revealed for a total of 13 vessels revealed by CT. On sonography, five patients had two vessels revealed and five patients had single vessels revealed. Thus, 15 vessels were revealed by sonography. Both arteries and veins were revealed anterior, posterior, and medial to the UPJ; no lateral vessels were seen. Four patients underwent laparoscopy, during which the absence, presence, and location of vessels were found to correlate with sonography and helical CT. CONCLUSION: Endoluminal sonography and helical CT were similar in revealing crossing vessels in patients with UPJ obstruction.

Acucise endopyelotomy: assessment of long-term durability.

PURPOSE: We evaluated the long-term efficacy of Acucise endopyelotomy. MATERIALS AND METHODS: A total of 28 patients with 28 ureteropelvic junction obstructions was reevaluated 2 or more years after Acucise endopyelotomy (mean 32.5 months). Subjective analysis was done with analog pain scales and objective analysis was performed with diuretic renal scintigraphy. RESULTS: Subjective followup was available for all 28 patients, and 17 (61%) had a favorable response with 36% totally free of pain and 25% markedly improved. Among 26 patients with objective followup (93%) 21 (81%) had a patient ureteropelvic junction based on a diuretic renal scan with a half-time of less than 10 minutes or a normal Whitaker test. Among all regularly followed patients failure occurred uniformly within 1 year. CONCLUSIONS: Acucise endopyelotomy is an effective and durable method for treating ureteropelvic junction obstruction.

Laparoscopic extirpation of renal cell cancer: feasibility, questions, and concerns.

Laparoscopic nephrectomy for benign disease has become an increasingly popular alternative to open surgery as more urologists gain confidence in their laparoscopic skills. However, the idea of laparoscopic extirpation of renal cell cancer caused significant concerns over the adequacy of surgical resection margins, trocar site seeding, and potential tumor spillage. The present chapter is the result of 5 year's experience with laparoscopic nephrectomy for renal tumor. To date, total and radical nephrectomies have been performed at Washington University in 20 patients; in each case, the appropriate surgical margins were obtained. Moreover, there have been, as yet, no instances of tumor spillage or delayed trocar seeding in our or others' experience. Furthermore, the immediate effectiveness of the procedure equals that of open radical nephrectomy; yet the hospital stay, patient discomfort, and convalescence are all markedly decreased. Only two drawbacks to the laparoscopic approach remain: 1) lengthy operative time, and 2) the increased cost associated with the prolonged operating room time. These problems will only be overcome by increased surgeon experience and further technological advances. Lastly, given the newness of the procedure, follow-up of these patients is still brief; however, results to date substantiate the hypothesis that laparoscopic radical nephrectomy is an effective, minimally invasive, long-term therapy for patients with localized renal cell cancer.

Frontiers in laparoscopy: economic issues and future perspectives.

A little over 5 years ago, laparoscopy was introduced into the field of urology via the pioneering work of William Schuessler, and later Howard Winfield, in the realm of laparoscopic pelvic lymph node dissection. Since then, much has happened in this area and in reconstructive laparoscopic surgery. For urologists pursuing laparoscopic training, lymph node dissection remains the primary setting in which to learn the technique. In the first part of this roundtable, our panelists discussed applications of laparoscopy. Here, they examine economic issues related to the technology and give us a glimpse of what the future holds.

Advances in urological laparoscopy.

PURPOSE: Since its introduction 5 years ago, almost all open urological procedures have been performed laparoscopically. We provide an in-depth critical review. MATERIALS AND METHODS: More than 200 articles on laparoscopic urology were reviewed. All laparoscopic procedures were divided into clinically established, clinically anecdotal and laboratory procedures. Comparisons between the laparoscopic and open method were carefully analyzed. RESULTS: There were 5 clinically established procedures identified. In general, the laparoscopic procedures were as efficacious but less morbid and required less convalescence than their open counterparts; however, none was less costly. CONCLUSIONS: Despite the time-consuming and costly nature of laparoscopy, the decreased morbidity and brief convalescence that are the hallmarks of minimally invasive surgery are evident and well documented. Further dissemination of laparoscopic skills through postgraduate urology training programs and during urology residency is of the utmost importance.

Optimal therapy for the distal ureteral stone: extracorporeal shock wave lithotripsy versus ureteroscopy.

Extracorporeal shock wave lithotripsy (ESWL not equal to) is the optimal therapy for renal calculi less than 2 cm. in diameter and for proximal ureteral calculi. Controversy continues over the initial approach to distal ureteral calculi (that is below the bony pelvis): in situ ESWL versus ureteroscopy. Since February 1990, 76 distal ureteral calculi were treated at our institution using either in situ ESWL (Dornier HM3 ESWL with a Stryker frame modification in 27 patients or Siemen's Lithostar electromagnetic ESWL in 22) or ureteroscopy (27 patients). Patient age and stone size were similar among the groups. All ESWL treatments were performed with the patient under intravenous sedation and on an outpatient basis. Stone-free rates were 96% for the HM3 device, 84% for the Lithostar and 100% for ureteroscopy. Retreatment was required in 3 Lithostar cases (14%) and 1 HM3 case (4%). When compared to ESWL ureteroscopy for distal ureteral stones was more time-consuming, entailed routine placement of a ureteral stent, often required general anesthesia, more often led to hospitalization and doubled the convalescence period. From a cost standpoint, ESWL on an HM3 unit was a few hundred dollars more expensive than ureteroscopy. In summary, we believe that in situ ESWL provides optimal first line therapy for distal ureteral calculi, while ureteroscopy is better reserved as a salvage procedure should ESWL fail.

Staging pelvic lymphadenectomy for prostate cancer: a comparison of laparoscopic and open techniques.

The operative morbidity and convalescence of our initial 30 patients who underwent laparoscopic pelvic lymph node dissections were compared to those of 16 patients who underwent open surgical pelvic lymph node dissections performed at our institution for staging purposes between 1990 and 1992. The average time for laparoscopic pelvic lymph node dissection (199.4 minutes) was nearly twice that of surgical pelvic lymph node dissection (102.4 minutes). However, the blood loss in the former group was significantly less. Oral intake occurred after a mean of 0.63 days in the laparoscopic pelvic lymph node dissection group compared to 2.87 days in the surgical group. Also, laparoscopic pelvic lymph node dissection was superior to surgical pelvic lymph node dissection in terms of average postoperative analgesic use (1.55 versus 47 mg. morphine sulfate), average hospital stay (1.7 versus 5.37 days), average return to normal daily activities (4.94 versus 42.9 days) and interval to full recovery (10.8 versus 65.5 days). However, the incidence of significant complications in the laparoscopic pelvic lymph node dissection group was 13%, with no complications seen in the surgical group. Interestingly, all significant problems in the bilateral laparoscopic pelvic lymph node dissection patients were confined to our initial 12 patients, indicating the steepness of the laparoscopic learning curve.

Percutaneous nephrostomy: assessment of renal damage associated with semi-rigid (24F) and balloon (36F) dilation.

In an effort to discern the amount of renal damage incurred by antegrade percutaneous nephrostomy and nephrostomy tract dilation, we studied the long-term effect of acutely created 24F and 36F percutaneous nephrostomy tracts on 12 pig kidneys. Half of the nephrostomy tracts were dilated using a semi-rigid 24F fascial dilating system (Amplatz design) and half were dilated using a 36F balloon dilation system. Animals were killed at six weeks and the nephrostomy tract was dissected, fixed in formalin, and microscopic cross-sections were stained with Masson's trichrome stain for collagen prior to morphometry using computerized planimetry. In this study, renal damage from the nephrostomy tract averaged 0.15% of the total renal cortical surface. Balloon dilation to 36F incurred no more significant damage than fascial dilation to 24F.

Outpatient percutaneous nephrostolithotomy.

Technical advances and operator experience have resulted in a rapid and marked streamlining of the percutaneous approach to renal calculi. The development of nephrostomy tract balloon dilators, improved grasping instruments and the use of assisted local anesthesia have been integral in reducing the morbidity and cost of the procedure. We report our initial favorable experience in the use of percutaneous stone removal on an outpatient basis. All 5 patients underwent an uncomplicated 1-stage stone removal. Cost for outpatient percutaneous stone removal was substantially less than for surgery or extracorporeal shock wave lithotripsy.

Percutaneous nephrostolithotomy vs open surgery for renal calculi. A comparative study.

To evaluate the impact of the percutaneous removal of renal calculi we compared 41 patients who had undergone open renal surgery to 88 patients who had a one- or two-stage percutaneous nephrostolithotomy for symptomatic urolithiasis. The two groups were similar with regard to stone size, stone location, treatment success, and complication rates. However, for patients with calculi 2.5 cm or smaller in diameter, the percutaneous procedure resulted in lower postoperative morbidity, more rapid convalescence, less hospital cost, and greater patient satisfaction. For patients with calculi larger than 2.5 cm in diameter, the percutaneous approach was slightly more expensive than open surgery but resulted in a markedly shortened convalescent period. In our experience, percutaneous nephrostolithotomy performed in a single stage under assisted local anesthesia was the most efficacious and least expensive of the percutaneous approaches.

Outpatient hydrocele and spermatocele repair under local anesthesia.

We performed 20 hydrocele repairs and 18 spermatocelectomies using Lord's techniques on outpatients under local anesthesia. The only complication was delayed wound healing early in the series when tight pressure dressings were used. We now use only a simple dressing and a scrotal support. This method for these operations reduces the cost by 74 per cent compared to inpatient procedures under general anesthesia. This safety and cost-effectiveness argue strongly for performance of most hydrocele repairs and spermatocelectomies as outpatient procedures under local anesthesia.