Laparoscopic reconstructive options for obstruction in children with duplex renal anomalies.

OBJECTIVE: To present our initial experience of laparoscopic reconstructive surgery in children with upper urinary tract obstruction associated with duplex anomalies, as although there is much information on ablative procedures such as laparoscopic heminephrectomy, there is little available about minimally invasive reconstructive options for duplex renal anomalies in children. PATIENTS AND METHODS: We retrospectively reviewed four consecutive patients (aged 6-11 years) with duplex anomalies and laparoscopic reconstruction for obstructed, dilated segments treated at our institution. The port placement and surgical exposure were analogous to that for transperitoneal laparoscopic pyeloplasty. A JJ stent was placed retrogradely into the ureter immediately before each procedure. The procedures performed were pyelo-ureterostomy for incomplete duplication and lower pole pelvi-ureteric junction (PUJ) obstruction, lower pole pyeloplasty for lower pole PUJ obstruction and complete duplication, and ipsilateral uretero-ureterostomy and distal ureterectomy for an obstructed, ectopic upper pole. Foley catheters were left indwelling for 36-48 h and stents were removed at 4-6 weeks. Postoperative imaging included either ultrasonography or intravenous urography. RESULTS: Three children presented with intermittent flank pain due to lower pole PUJ obstruction. The other child presented with pyonephrosis and purulent drainage from her vagina due to an ectopic ureter associated with a functioning upper pole segment. All procedures were successfully completed. The only complication was in the first patient (pyelo-ureterostomy) who had transient urinary extravasation that resolved with bladder decompression for 10 days. With a follow-up of 6-18 months, all had resolution of symptoms with improvement in radiographic variables. CONCLUSIONS: This series shows that children with duplex anomalies and obstruction can undergo successful reconstruction using techniques learned with laparoscopic pyeloplasty.

Launching a successful robotic surgery program.

Robotic-assisted laparoscopic prostatectomy is rapidly becoming the most commonly performed surgical approach to treat clinically localized prostate cancer. The establishment of a robotic surgery program at any institution requires a structured plan and certain key elements to be in place to allow successful development. At least five essential phases are necessary for successful implementation of a robotics program. A thorough initial design and implementation lead to the execution of clinical services that meet previously established goals. Once the execution phase is established, the next step is to focus on maintenance and growth to maximize the benefits of the program. In this paper, we discuss the necessary phases for creating a successful robotic program, paying special attention to the aspects that allowed our facility to create a profitable robotic-assisted laparoscopic prostatectomy program in year 1.

Rethinking the value of sending vasectomy specimens for histologic examination: an analysis of arterial vasculature and failure to transect the vas deferens.

OBJECTIVES: The testicular, deferential, and cremasteric arteries and their branches surround the vas deferens (VD), leaving them susceptible to injury during vasectomy. Literature describing the caliber of arteries seen in vasectomy specimens is lacking, making it difficult to categorize the significance of an observed artery. We aimed to establish reference values for arterial size typically encountered in vasectomy specimens and assess our institutional experience with failure to transect the VD. METHODS: The luminal diameter of the largest artery in 231 consecutive VD specimens from 116 patients was measured microscopically. For comparison, the diameter of the largest artery within 10 spermatic cord cross-sections from inguinal orchiectomies was obtained. The immediate vasectomy failure rate based on histologic assessment was calculated using specimens from 2008 to 2012. RESULTS: The luminal diameter of the largest artery encountered in a vasectomy specimen was 1.00 mm or less in 96.5% of cases. Artery sizes greater than or equal to 2.50 mm were only seen in spermatic cord resections. From 2008 to 2012, three (0.36%) of 837 patients undergoing vasectomy had specimens that showed failure to transect both VD. CONCLUSIONS: Although the American Urologic Association and European Association of Urology state that histologic evaluation of vasectomy specimens is not required, we encourage the surgeon to send VD specimens for histologic examination. Doing so allows early identification of the failure to transect the VD and the resection of surrounding vasculature, providing quality control feedback to the surgeon.

Prostate-specific antigen response after definitive radiotherapy for Skene's gland adenocarcinoma resembling prostate adenocarcinoma.

OBJECTIVES: To assess prostate-specific antigen response after definitive radiotherapy in a patient with localized Skene's gland adenocarcinoma resembling prostate adenocarcinoma. MATERIALS AND METHODS: A 71-year-old patient was evaluated for a 2 year history of painless hematuria and found to have a localized Skene's gland adenocarcinoma resembling prostate adenocarcinoma with a pre-therapy PSA of 54.52 ng/ul. She elected to undergo definitive radiotherapy holding radical surgery for salvage. She received 73.8 Gy of intensity modulated radiotherapy in 41 fractions. Serum PSA, imaging, and cystoscopy were followed at 6 month intervals for 2.5 years. RESULTS: The PSA decreased to 0.65 ng/ul 32 months after treatment, her clinical symptoms resolved, and on imaging and exam she has no evidence of residual disease. The PSA half life was 6.16 months (r(2) = 0.97). CONCLUSIONS: For this rare tumor we show that PSA is a reliable marker for disease response and also show that definitive radiotherapy can be an option for organ and functional preservation in patients with localized disease. Cases of periurethral adenocarcinomas should be pathologically screened to assess if they are of Skene's gland origin, as our results suggest a radiotherapy treatment paradigm may be appropriate management in a select subgroup of women with periurethral adenocarcinoma.

Which is better--retroperitoneoscopic or laparoscopic dismembered pyeloplasty in children?

PURPOSE: Groups at multiple institutions have documented the efficacy of minimally invasive repair of ureteropelvic junction obstruction with a retroperitoneoscopic or laparoscopic approach. To our knowledge no group has compared the 2 operative procedures directly at a single institution. MATERIALS AND METHODS: The records of 49 consecutive patients with a history of retroperitoneoscopic pyeloplasty or transperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction were reviewed retrospectively, of whom 29 underwent attempted retroperitoneoscopic pyeloplasty and 20 underwent laparoscopic pyeloplasty. Retroperitoneoscopic pyeloplasty cases were performed first in the series before changing to the laparoscopic pyeloplasty approach. Retroperitoneoscopic pyeloplasty was performed using an anterolateral approach with retroperitoneal balloon distention. Laparoscopic pyeloplasty repair was performed using a transmesenteric approach for left ureteropelvic junction obstruction or after right colon mobilization for right repairs. Dismembered pyeloplasty was performed over a stent using 5-zero polydioxanone suture. Stents were placed antegrade or retrograde based on anatomy and presenting symptoms. Parameters studied were patient age, operative time, postoperative analgesic requirement during hospitalization, hospital stay and success rate. RESULTS: No difference was observed between the 2 groups in patient age, success rate, hospital stay or analgesic narcotic requirement. Average operative time for retroperitoneoscopic pyeloplasty was significantly longer than for laparoscopic pyeloplasty (239.1 vs 184.8 minutes). Overall success rates were also statistically equivalent (25 of 27 retroperitoneoscopic and 19 of 19 laparoscopic pyeloplasties) with incomplete followup in 1 patient in the retroperitoneoscopic pyeloplasty group and 1 in the laparoscopic pyeloplasty group. Three children, including 2 with retroperitoneoscopic and 1 with laparoscopic pyeloplasty, had transient urinary extravasation postoperatively, which was related to poorly positioned stents. Five patients in the retroperitoneoscopic group and 1 in the laparoscopic group underwent balloon dilation for indistinct but persistent postoperative flank pain with equivocal radiological findings. There were no major complications following either technique. CONCLUSIONS: In our experience no major difference exists between the retroperitoneoscopic and laparoscopic approaches for correcting ureteropelvic junction obstruction. The difference in operative time likely reflects the learning curve for laparoscopic suturing and dissection. Currently we prefer the laparoscopic approach because of the larger working space for suturing, the perceived ease of antegrade stent placement and the subjective improvement in cosmetic outcome. The 2 techniques should be considered equal with regard to the successful correction of ureteropelvic junction obstruction.

Lung-protective ventilation in neurosurgical patients.

PURPOSE OF REVIEW: Concepts of ventilator-induced lung injury have revolutionized our approach to the ventilatory management of patients with acute lung injury and acute respiratory distress syndrome over the past 10 years. The extension of these principles to patients with brain injuries is challenging, as many of them are out of keeping with usual brain-protective management. RECENT FINDINGS: Many patients with acute lung injury or acute respiratory distress syndrome and an acute brain injury may in fact be managed safely within the confines of a lung-protective strategy. Elevated levels of positive end-expiratory pressure in head-injured patients with acute lung injury or acute respiratory distress syndrome also appear to be safe, particularly when the level is set below that of the intracranial pressure, when patients have a low respiratory system compliance, or when positive end-expiratory pressure results in significant lung volume recruitment. Several novel therapies to minimize ventilator-induced lung injury are currently in the early stages of investigation in neurosurgical patients. SUMMARY: In many patients with brain injuries and acute lung injury the goals of lung protection can be achieved without threatening cerebral perfusion. In patients with more refractory raised intracranial pressure the optimal balance between brain and lung is not well established. Further research is needed on lung-protective strategies in this vulnerable population.