Patient Safety in the Operating Room During Urologic Surgery: The OR Black Box Experience.

PURPOSE: To mitigate intraoperative adverse events, it is important to understand the context in which these errors occur. The purpose of this study is to characterize the IAEs and potential distractions that occur in minimally invasive urologic procedures. METHODS: We conducted a prospective cohort study in patients undergoing laparoscopic urologic surgery at an academic health center. The OR Black Box, a unique technology system which captures video and audio recordings of the operating room as well as the operative field, was used to collect data regarding procedure type, critical step, IAEs, and distractions. RESULTS: Of a total of 80 cases analyzed, the majority of these cases were partial nephrectomy (n = 36; 45%), radical nephrectomy (n = 20; 25%), and adrenalectomy (n = 4; 5%). Across all cases, there were a total of 138 clinically significant IAEs, 10 of which (14%) were of the highest severity (five on the SEVerity of intraoperative Events and Rectification Tool (SEVERE) matrix). Of these, 70 (51%) occurred during an a priori defined critical step of the operation. Distractions were common across all cases. The median rate of external communication per case was 16 events (IQR 11-22); and per critical step was 4 (IQR 2.75-8), while median room traffic per case was 65 entries/exits (IQR 42-76); and per critical step was 17 (IQR 10-65). CONCLUSION: Our data demonstrate that IAEs occur frequently during all phases of the operation at hand. Future study will be required to examine the role of distractions and IAE as well as IAE and their relationship to post-operative clinical outcomes.

Fibronectin-mediated Calmette-Guerin bacillus attachment to murine bladder mucosa. Requirement for the expression of an antitumor response.

Adjuvant intravesical Calmette-Guerin bacillus (BCG) is an effective treatment for superficial bladder cancer. The mechanisms by which BCG mediates antitumor activity are not known. We investigated the initial interaction of BCG with the bladder mucosa to determine whether binding was essential for the development of antitumor activity. Herein, we show that bladder urothelial disruption induced by acrolein, adriamycin, or electrocautery resulted in BCG binding in areas of urothelial damage. Binding induced by each method was inhibited by anti-fibronectin (FN) antibodies but not by antibodies to the basement membrane component laminin. Intravesical BCG binding also was inhibited by pretreating BCG with soluble FN. Inhibition of intravesical FN-mediated BCG attachment prevented immunization via the intravesical route. Moreover, the expression of both delayed hypersensitivity in the bladder of BCG-immunized mice and antitumor activity was inhibited by blocking FN-mediated intravesical BCG attachment. These data suggest that intralumenal attachment of BCG appears to be mediated by FN. Moreover, these data suggest that intravesical FN mediated attachment of BCG is a requisite step in BCG-mediated antitumor activity in the murine bladder tumor model.

Should the indications for laparascopic live donor nephrectomy of the right kidney be the same as for the open procedure? Anomalous left renal vasculature is not a contraindiction to laparoscopic left donor nephrectomy.

BACKGROUND: The left kidney is preferred for live donation. In open live donor nephrectomy, the right kidney is selected if the left kidney has multiple renal arteries or anomalous venous drainage. With laparoscopic live donor nephrectomy (LLDN), there is reluctance to procure the right kidney because of the more difficult exposure and further shortening of the right renal vein (RRV) after a stapled transection. An experience with LLDN is reviewed to determine whether the right kidney should be procured laparoscopically. METHODS: From February 1995 to November 1999, 227 patients underwent live donor renal transplants with allografts procured by LLDN. The results of these transplants were analyzed. RESULTS: Of the 227 kidneys transplanted, 17 (7.5%) were right kidneys. In the early experience, three (37.5%) of the eight right renal allografts developed venous thrombosis, two of which had duplicated RRV. Based on these initially unacceptable results, donor evaluation and LLDN techniques were modified. Spiral computerized tomography (CT) replaced conventional angiography to define better the venous anatomy. LLDN was modified in one of three ways: (1) changing the stapler port placement such that the RRV was transected in a plane parallel to the inferior vena cava, (2) relocation of the incision for open division of RRV, or (3) lengthening of the donor RRV with a panel graft constructed of recipient greater saphenous vein. Finally, the recipient operation enjoined complete mobilization of the left iliac vein with transposition lateral to the iliac artery. With these modifications, there were no vascular complications with the subsequent nine right renal allografts (P<0.05). Of the left kidneys transplanted, 31 had multiple renal arteries, 14 had retroaortic or circumaortic veins, 4 had both multiple arteries and venous anomalies, and 1 had a duplicated IVC draining the left renal vein. There were no vascular complications with left renal allografts that had multiple arteries or venous anomalies. CONCLUSIONS: LLDN of the left kidney is technically easier. Left kidneys with multiple arteries or anomalous venous drainage are not problematic. The right kidney can be procured with LLDN; however, a rational approach to preoperative angiographic imaging, donor operation, and recipient operation is crucial.

Interaortocaval renal artery dissection for right laparoscopic donor nephrectomy.

Laparoscopic donor nephrectomy is gaining increasing popularity because the procedure helps reduce disincentives to live kidney donation and has increased the live kidney donor pool. The left kidney of the donor is the preferred allograft because the right renal vein is shorter. Similarly, the right renal artery might be foreshortened because it hides behind the inferior vena cava during laparoscopic transperitoneal dissection. There are instances, however, in which it is not practical to take the left kidney due to vascular anomalies or asymmetric function. We describe a novel technique for obtaining greater renal arterial length utilizing laparoscopic interaortocaval dissection.

Laparoscopic assisted live donor nephrectomy--a comparison with the open approach.

Live donor renal transplantation provides significant advantages when compared with cadaveric donor renal transplantation in terms of improved patient and graft survival, a lower incidence of delayed function, and a shorter waiting time. Yet despite these advantages, live donors continue to be an under utilized source of kidneys for transplantation. Disincentives to live donation include the length of hospitalization, postoperative pain, cosmetic concerns, and the prolonged convalescence associated with the donor operation. In many instances minimally invasive video-assisted techniques have proven more efficacious than standard open procedures in terms of patient discomfort, length of hospital stay, cost, and length of time until the patient can return to full activity. Laparoscopic live donor nephrectomies are being performed at our institution in an attempt to make live donation more attractive to the potential donor. The purpose of this study was to retrospectively review the results of laparoscopic live donor nephrectomy (LapNx) and to compare them with those obtained using the standard open approach (OpenNx). Ten consecutive LapNx were performed from February 1995 through April 1996. The control group consisted of the 20 consecutive OpenNx performed at the same institution from January 1991 through January 1995 immediately before the initiation of the LapNx program. Live donors were considered candidates for LapNx if they possessed at least one kidney with normal renal anatomy with single renal vessels and a single ureter. LapNx was safely performed in all cases. No patients required open conversion or blood transfusions. The allograft warm ischemic time for the laparoscopic cases was 4.2+/-1.3 min. All kidneys harvested laparoscopically produced urine on the table immediately upon revascularization. Presently nine of the ten recipients have functioning allografts. At three months posttransplant the calculated recipient creatinine clearances were 67.0+/-11.5 ml/min and 64.8+/-21.4 ml/min for the LapNx and OpenNx groups, respectively (P=NS). The LapNx donors had a significantly decreased estimated blood loss, shorter time until resumption of oral intake, decreased postoperative pain (in terms of decreased analgesic requirements), shorter hospitalization, and a shorter interval until the resumption of full activities (P<0.05 for all). In addition, the LapNx group donors returned to work sooner than the OpenNx group (3.9+/-1.6 wk vs. 6.4+/-3.1 wk, respectively) (P=0.024). Four individuals agreed to donate a kidney only after learning of the availability of the laparoscopic approach. We conclude that laparoscopic live donor nephrectomy is technically feasible. In addition, it may offer significant advantages over the standard open approach in terms of patient comfort and convenience. These advantages may make live donor renal transplantation more attractive to prospective donors. The potential decrease in hospitalization and convalescence may also prove to be financially advantageous. We believe that further careful study of this procedure is warranted.

Laparoscopic live donor nephrectomy.

A laparoscopic live-donor nephrectomy was performed on a 40-year-old man. The kidney was removed intact via a 9-cm infraumbilical midline incision. Warm ischemia was limited to less than 5 min. Immediately upon revascularization, the allograft produced urine. By the second postoperative day, the recipient's serum creatinine had decreased to 0.7 mg/dl. The donor's postoperative course was uneventful. He experienced minimal discomfort and was discharged home on the first postoperative day. We conclude that laparoscopic donor nephrectomy is feasible. It can be performed without apparent deleterious effects to either the donor or the recipient. The limited discomfort and rapid convalescence enjoyed by our patient indicate that this technique may prove to be advantageous.

Laparoscopic live donor nephrectomy: the recipient.

BACKGROUND: Laparoscopic live donor nephrectomy offers advantages to the donor in terms of decreased pain and shorter recuperation. Heretofore no detailed analysis of the recipient of laparoscopically procured kidneys has been performed. The purpose of this study was to determine whether laparoscopic donor nephrectomy had any deleterious effect on the recipient. METHODS: A retrospective review was conducted of all live donor renal transplantations performed from January 1995 through April 1998. The control group received kidneys procured via a standard flank approach (Open). Rejection was diagnosed histologically. Creatinine clearance was calculated using the Cockroft-Gault formula. RESULTS: A total of 110 patients received kidneys from laparoscopic (Lap) and 48 from open donors. One-year recipient (100% vs. 97.0%) and graft (93.5% vs. 91.1%) survival rates were similar for the Open and Lap groups, respectively. A similar incidence of vascular thrombosis (3.4% vs. 2.1%, P=NS) and ureteral complications (9.1% vs. 6.3%, P=NS) were seen in the Lap and Open groups, respectively. The incidence of acute rejection for the first month was 30.1% for the Lap group and 31.9% for the Open group (P=NS). The rate of decline of serum creatinine level in the early posttransplantation period was initially greater in the Open group, but by postoperative day 4 no significant difference existed. No difference was observed in allograft function long-term. The median length of hospital stay was 7.0 days for both groups. CONCLUSIONS: Laparoscopic live donor nephrectomy does not adversely effect recipient outcome. The previously demonstrated benefits to the donor, and the increased willingness of individuals to undergo live kidney donation, coupled with the acceptable outcomes experienced by recipients of laparoscopically procured kidneys justifies the continued development and adoption of this operation.

Complications of laparoscopic surgery.

As with all surgical procedures, prevention and proper patient selection is the key to avoid complications. High-risk patients should be clearly identified from the outset. Properly maintained equipment, along with a thorough working knowledge of all instrumentation is essential. An often overlooked but vital aspect of laparoscopy is the laparoscopy team, including anesthesia and nursing personnel. A final point: there is no substitute for experience in avoiding laparoscopic complications. A survey by Phillips et al. found the complication rate for physicians who had performed fewer than 100 laparoscopic procedures to be almost four times greater than surgeons with more experience. A survey of eight centers active in urologic laparoscopic surgery reported that 10-20 pelvic lymph node dissections were necessary before they felt comfortable and 25-50 cases before they were proficient with the procedure. Since the learning curve with laparoscopy is initially quite steep, urologists beginning to apply the technique should work closely with experienced laparoscopic surgeons.

Laparoscopic orchidopexy in the prune belly syndrome: a case report and review of the literature.

The management of the testicles in the prune belly syndrome can be problematic after the neonatal period. Laparoscopic orchidopexy has been used for the intra-abdominal testis with success. A case of bilateral laparoscopic orchidopexy in a child with prune belly syndrome is presented. The testes were brought to the scrotum without division of the spermatic vessels, taking advantage of the extensive intra-abdominal dissection possible laparoscopically. This case demonstrates that therapeutic laparoscopic procedures are possible in the prune belly syndrome and that laparoscopic orchidopexy may have promise in older affected children or in those requiring no other concomitant surgery.

Bilateral renal cell carcinoma with metastasis to thyroid.

A case of bilateral synchronous renal cell carcinomas with metastases to the regional lymph nodes and later to the thyroid gland was treated with aggressive surgical extirpation and adjuvant gamma interferon. The patient continues to have an excellent performance status sixteen months after initial diagnosis despite a large tumor burden at presentation.

Laparoscopic bladder augmentation using stomach.

We present a case of bladder augmentation with stomach, via a laparoscopic approach. The patient was a 17-year-old girl with sacral agenesis and a poorly compliant bladder. A wedge of stomach, based on the right gastroepiploic pedicle, was obtained using a stapled technique. The bladder was opened and the gastric segment was sutured in place. A needle suspension was also carried out. Three months later, the patient was dry and catheterizing every 4 hours. Laparoscopic bladder augmentation is technically feasible and, in the properly selected patient, may be the preferred technique for creation of a compliant high-volume urinary reservoir.

Retroperitoneoscopic renal biopsy in extremely obese patients.

OBJECTIVES: Retroperitoneoscopic renal biopsy can be technically challenging in extremely obese patients because of loss of surgical landmarks and difficulty in identifying the kidney within retroperitoneal adipose tissue. We present our experience with retroperitoneoscopic renal biopsy in extremely obese patients and describe our surgical technique. METHODS: We performed retroperitoneoscopic renal biopsies on 8 extremely obese patients (body mass index greater than 40). Mean patient weight was 144.3 kg. Three patients presented with acute renal failure and 5 presented with nephrotic range proteinuria. Retroperitoneoscopic renal biopsy was indicated based on extreme obesity alone in 3 patients, 2 patients had failed previous attempts at percutaneous biopsy, 1 patient had a solitary kidney, 1 patient required chronic anticoagulation, and 1 patient was a Jehovah's Witness. Intraoperative ultrasonography and an anatomic approach facilitated the dissection and identification of the kidney. RESULTS: All eight retroperitoneoscopic renal biopsies were completed successfully without complication and all patients were discharged within 24 hours of the procedure. Sufficient tissue for pathologic diagnosis was obtained in all cases. Mean operating room time was 153 minutes and mean estimated blood loss was 71 mL. The patients returned to normal activity at a mean of 1.8 weeks. CONCLUSIONS: With the use of intraoperative ultrasonography and a systematic, anatomic approach, retroperitoneoscopic renal biopsy can be successfully completed in extremely obese patients. This procedure can be reliably performed on an outpatient basis with minimal morbidity and should be considered a viable alternative to open renal biopsy.

Bowel injury in open technique laparoscopic cannula placement.

Open trocar placement is used by many surgeons during laparoscopy to avoid some of the potential complications of Veress needle and sharp trocar insertion. We describe a case of serosal bowel injury with a holding stitch placed to obtain an airtight peritoneal cavity during open laparoscopic trocar placement in a two-year-old patient. The importance of inspection of the initial umbilical puncture site is emphasized and a rapid, simple technique for repair of minor bowel injuries is described.

Modification of Mitrofanoff principle for continent urinary diversion.

In 1980, Mitrofanoff described a method of achieving continent urinary diversion by surgically closing the bladder neck and creating a continent catheterizable stoma from the appendix, which had been implanted in a non-refluxing manner into the bladder, or from a non-refluxing distal ureter. We describe a modification of the Mitrofanoff procedure for continent urinary diversion in 7 children in whom a standard Mitrofanoff procedure was not possible due to either body habitus or appendiceal anatomy. All 7 patients are continent both day and night. Four have required stomal revisions. Renal function has remained stable or improved in all patients. Although the revision rate was high, this modification of the Mitrofanoff principle has provided good long-term results in these patients and may be useful when patient's anatomy does not allow the creation of a standard appendicovesicostomy.

Comparison of laparoscopic and open retropubic urethropexy for treatment of stress urinary incontinence.

OBJECTIVES: Laparoscopic retropubic urethropexy has recently been described as an alternative method to the surgical correction of pure stress urinary incontinence. This study compares the operative technique and results of laparoscopic colposuspension with traditional open Burch urethropexy to treat women with stress urinary incontinence. METHODS: We assessed the short-term results of 12 women who underwent a modified laparoscopic Burch urethropexy for the correction of stress urinary incontinence and compared these with a similar contemporary group of 10 women who underwent a traditional open Burch colposuspension procedure. RESULTS: Ten women (83%) who underwent the laparoscopic procedure are continent with a mean follow-up of 20.8 months, and 7 women (70%) who had an open Burch colposuspension are continent at a mean follow-up of 35.6 months. The laparoscopic procedure took an average of 1.5 hours longer than the open repair (P < 0.01). Patients who underwent the laparoscopic urethropexy required less postoperative analgesia (mean, 14.2 mg morphine equivalents versus 131.4 mg; P < 0.01), shorter length of hospitalization (mean, 1.9 days versus 4.9 days; P < 0.01), and a more expedient return to normal activity when compared with those who underwent open Burch colposuspension. CONCLUSIONS: Laparoscopic bladder neck suspension offers a less invasive approach to the surgical correction of stress urinary incontinence and can provide successful outcomes in properly selected patients.

Laparoscopic nephrectomy for renal neoplasms.

Laparoscopic nephrectomy has been shown to be an effective minimally invasive technique for treating benign renal disease requiring surgical excision. However, its application to approach renal malignancy has been limited. Herein, we report on 8 patients with renal tumor who underwent a laparoscopic nephrectomy. All kidneys were removed within Gerota's fascia, and in 3 patients with upper pole tumors, the adrenal gland was also removed en bloc. With limited follow-up of seven to thirty-five months (mean 14 months), there has been no clinical or radiographic evidence of tumor recurrence. We believe that laparoscopic radical nephrectomy with strict adherence to oncologic surgical principles is a practical, less invasive alternative in select patients with renal tumors.

New laparoscopic suturing device: initial clinical experience.

OBJECTIVES: New instrumentation and techniques have enabled laparoscopic surgeons to perform complicated reconstructive procedures. Few centers have attempted these procedures because of the excessive time involved with laparoscopic suturing. The Endo stitch suture device was developed to facilitate suture placement. We clinically compared conventional intracorporeal suturing and Endo Stitch suturing for laparoscopic suture placement and knot tying. METHODS: Intracorporeal suturing was used to complete laparoscopic dismembered pyeloplasties and bladder neck suspensions. Sutures were placed with either needle holders and graspers or the automatic suture device. A total of 85 maneuvers were assessed. Operative videotapes were reviewed to assess accuracy of suture placement, knot tying, and time to place suture and tie knots. All suturing was performed by an experienced laparoscopist. RESULTS: Accuracy of stitch placement and knot tying were equivalent. The average time for stitch placement with the Endo Stitch was 43 +/- 27 seconds (n = 41). This was significantly less than the average stitch placement time for conventional suturing, which was 151 +/- 24 seconds (n = 14). The Endo Stitch knot tying was completed in an average of 74 +/- 50 seconds (n = 17), whereas knot tying with the conventional technique took 197 +/- 70 seconds (n = 13). The needle is automatically loaded in the Endo Stitch after each suture and is immediately ready. CONCLUSIONS: The Endo Stitch device reduced the amount of time needed for placement of stitches and knot tying. Reconstructive laparoscopic procedures requiring multiple suture placement may be completed in a shorter time period using this instrument.

Comparison of open and endourologic approaches to the obstructed ureteropelvic junction.

OBJECTIVES: To compare open pyeloplasty with three minimally invasive modalities: antegrade endopyelotomy, Acucise endopyelotomy (Applied Medical, Laguna Hills, Calif), and laparoscopic pyeloplasty. METHODS: Forty-five adult patients with ureteropelvic junction obstruction were managed by one of the above four techniques. Success rates, analgesic use, length of hospital stay, recovery time, and complications were compared between each of the four groups. RESULTS: Successful relief of obstruction was achieved in 100% of patients undergoing open and laparoscopic dismembered pyeloplasty, 78% undergoing Acucise endopyelotomy, and 77% undergoing antegrade percutaneous endopyelotomy. Acucise endopyelotomy results in shorter convalescence (1 week) than antegrade endopyelotomy (4.7 weeks), laparoscopic pyeloplasty (2.3 weeks) or open pyeloplasty (10.3 weeks). Complication rates appear to be similar among all groups. CONCLUSIONS: Our limited data imply that Acucise endopyelotomy offers low morbidity with success rates comparable to antegrade pyeloplasty, whereas laparoscopic pyeloplasty is as effective as open pyeloplasty with diminished morbidity.

Laparoscopic ileal conduit: five-year follow-up.

OBJECTIVES: To report the techniques used for intracorporeal laparoscopic construction of an ileal conduit urinary diversion and long-term patient follow-up after this procedure. METHODS: A 28-year-old man with cerebral palsy, a neurogenic bladder, and voiding dysfunction was referred for definitive management of his urinary tract after several episodes of pyelonephritis. A conduit urinary diversion was performed using a 5-port, transabdominal approach. An appropriate length of ileum was used for diversion, and ureterointestinal anastomoses were performed using a modified Bricker technique. All aspects of the procedure were performed intracorporeally, including isolation of conduit, bowel reanastomosis, ureteral mobilization, and ureterointestinal anastomosis. A 12-mm port site was enlarged and used as the stoma, which was constructed in routine fashion. RESULTS: Five years after surgery, this patient had normal and stable renal function, with a serum creatinine of 0.8 mg/dL. Serial imaging studies continued to reveal prompt and symmetric renal function and no evidence of obstruction or reflux. CONCLUSIONS: Laparoscopic ileal conduit construction is feasible and can provide durable results. Although technically challenging, ongoing technical refinements will make performance of reconstructive laparoscopy more widely applicable. Larger series with substantial follow-up will help illuminate the place of laparoscopic noncontinent urinary diversion in the surgical armamentarium.