Laparoscopic partial nephrectomy for tumors 7cm and above. Perioperative outcomes.

PURPOSE: To assess and report the outcomes of laparoscopic partial nephrectomy )LPN) for T2 renal masses. MATERIALS AND METHODS: Retrospective review of patients undergoing LPN for clinically localized renal masses ≥7cm between the years 2005-2016. Descriptive analyses were generated for demographics, lesion characteristics, perioperative variables (operative time, warm ischemia time (WIT), estimated blood loss (EBL), intra-operative and post-operative complications (IOC and POC) and pathologic variables (pathology, subtype and Fuhrman grade). RESULTS: A total of 27 patients underwent LPN for a T2 renal mass at our institution between 2005 and early 2016 of which 19 were males. The mean age was 66 (52-72). All procedures were transperitoneal with 16 on the right and 11 on the left. Median operative time was 200 minutes (IQR 181-236) and median WIT 19 minutes (IQR 16-23). EBL was 125mL (IQR 75-175). One case was converted to laparoscopic radical nephrectomy due to suspected tumor thrombus in the renal vein. Surgical margins were positive in one renal tumor in a patient with multiple tumors. There was a total of 2 IOC (7.4%) and 3 POC (11%) classified as Clavien grade 3. CONCLUSIONS: To our knowledge, this series is the first to describe the outcomes of LPN for cT2 renal masses. In our series, LPN for larger renal masses appears feasible with favorable perioperative outcomes. Additional data are needed to further explore the benefits of minimally invasive surgical approaches to larger renal masses.

Detecting DNA methylation of the BCL2, CDKN2A and NID2 genes in urine using a nested methylation specific polymerase chain reaction assay to predict bladder cancer.

PURPOSE: Detection of methylated DNA has been shown to be a good biomarker for bladder cancer. Bladder cancer has the highest recurrence rate of any cancer and, as such, patients are regularly monitored using invasive diagnostic techniques. As urine is easily attainable, bladder cancer is an optimal cancer to detect using DNA methylation. DNA methylation is highly specific in cancer detection. However, it is difficult to detect because of the limited amount of DNA present in the urine of patients with bladder cancer. Therefore, an improved, sensitive and noninvasive diagnostic test is needed. MATERIALS AND METHODS: We developed a highly specific and sensitive nested methylation specific polymerase chain reaction assay to detect the presence of bladder cancer in small volumes of patient urine. The genes assayed for DNA methylation are BCL2, CDKN2A and NID2. The regions surrounding the DNA methylation sites were amplified in a methylation independent first round polymerase chain reaction and the amplification product from the first polymerase chain reaction was used in a real-time methylation specific polymerase chain reaction. Urine samples were collected from patients receiving treatment at Wolfson Medical Center in Holon, Israel. RESULTS: In a pilot clinical study using patient urine samples we were able to differentiate bladder cancer from other urogenital malignancies and nonmalignant conditions with a sensitivity of 80.9% and a specificity of 86.4%. CONCLUSIONS: We developed a novel methylation specific polymerase chain reaction assay for the detection and monitoring of bladder cancer using DNA extracted from patient urine. The assay may also be combined with other diagnostic tests to improve accuracy.

Laparoscopic partial nephrectomy: beyond the straightforward T1a.

UNLABELLED: What's known on the subject? and What does the study add? Complex tumour features (e.g. size, hilar location, multifocality) are generally considered contraindicative for LPN and only a handful of studies reporting encouraging outcomes with more complex tumours. Herein we suggest that in experience hands the benefits of minimally-invasive surgery may be safely extended to patients with more complex renal masses. OBJECTIVE: To report on our experience in extending the indications for LPN beyond the single, T1a renal mass assessing the perioperative outcomes in a comparative fashion. PATIENTS AND METHODS: Retrospective review of consecutive patients undergoing LPN for a renal mass in an academic centre between 2005-2010. 150 patients were divided into two groups based on tumours characteristics: straightforward T1a (group 1: single, <4 cm, n = 84) and complex (group 2: multiple and/or hilar and/or ≥4 cm, n = 66). Comparison of demographic, clinical, radiographic and perioperative outcomes (operative times, blood loss, warm ischemia times, intra- and postoperative complications). RESULTS: In group 2, 19 tumours were hilar, 15 were multifocal and 44 measured ≥4 cm; 2 of these criteria were present in 7, and all three in 3 cases. Warm ischemia times and blood loss were comparable (medians of 21 vs 20 min, and 100 vs 100 mL). Operative times were longer in group 2 (190 vs 140min, P < 0.001). Complications occurred in 11.9% and 12.1% of patients in group 1 and 2, with Clavien grade 3 events in 8.3 and 10.9%, respectively (P = 1.00 and P = 0.547). There were 4 conversions to laparoscopic radical nephrectomy (1 in group 1, 3 in group 2). CONCLUSION: With adequate laparoscopic expertise, the indications for LPN can be safely extended beyond the single, small, peripheral T1a renal mass. In this series, more complex masses were effectively treated with LPN combining the advantages of minimally-invasive surgery to those of nephron-sparing approach.

Uretero-vesico-cervical fistula following a caesarean section: a unique case report.

A unique combined fistula involving simultaneously the bladder, ureter, and cervix following cesarean section is described. Evaluation, management, and review of the literature regarding this rare and challenging case are reported. This unique case report emphasizes the potential complexity of iatrogenic genitourinary fistulae, suggesting that these might have unexpected morphology and present with multiple fistulous components. It has been demonstrated that concomitant ureteral involvement is estimated to complicate at least 10 % of vesico-vaginal fistulae. Thus, increased awareness of the possibility of complex iatrogenic fistulae and precise evaluation of the upper urinary tract are necessary to accurately define the extent of all fistulous tracts during the initial evaluation. This in turn may enable tailored management of these challenging cases. Moreover, in the case of surgical treatment, an accurate initial definition of fistula morphology may enable a single-stage reconstructive procedure sparing additional interventions and avoiding any potential complications.

Laparoscopic partial nephrectomy for multiple tumours: feasibility and analysis of peri-operative outcomes.

OBJECTIVE: • To describe our experience with laparoscopic partial nephrectomy (LPN) for multiple kidney tumours and compare the outcomes with LPN performed for single masses. PATIENTS AND METHODS: • Retrospective analysis of medical records of patients undergoing LPN at our institution between 2005 and 2009 was performed. • The cohort was divided in two groups based on tumour focality: group 1, LPN for a single tumour (n= 99) and group 2, LPN for multiple ipsilateral tumours (n= 12). • The groups were compared with regards to demographic and peri-operative variables. RESULTS: • Demographic variables were not different between the groups. Median dominant tumour size was 3.1 cm (interquartile range [IQR] 2.4-4.0) and 4.0 cm (2.3-5.9) in groups 1 and 2, respectively. • Median secondary tumour size in group 2 was 1.0 cm (1.0-1.8). • Operative times were longer in group 2 compared with group 1 (220 vs 160 min, P= 0.009). • Warm ischaemia times (WIT) (23 vs 22 min) and estimated blood loss (EBL) (100 vs 85 mL) were similar. CONCLUSIONS: • LPN is a viable option for the treatment of multiple ipsilateral renal tumours. • Peri-operative outcomes are similar to standard LPN with the exception of longer operative time. • In experienced hands, the advantages of minimally invasive surgery may be extended to select patients with ipsilateral multifocal renal tumours.

A novel reconstructive option for long upper ureter obliteration.

INTRODUCTION: Injuries of the upper (lumbar) portion of the ureter are rare; however, their reconstruction may pose considerable challenges. We describe a novel technique of surgical reconstruction in case of a long upper ureteral obliteration that may be a viable treatment option in select patients. MATERIALS AND METHODS: Reconstruction of a iatrogenic 5 cm injury to the upper ureter, consisting of 2 cm obliteration and 1.5 cm stenotic segments on its sides, unsuitable for an end-to-end reanastomosis, was performed using a novel technique of augmented pelvic flap anastomotic ureteroplasty. The injured ureteral segment was excised, the ureteral stump was spatulated on the medial aspect and the lateral tissue defect was replaced by a flap from the posterior surface of the renal pelvis. RESULTS: The procedure was successfully performed avoiding more aggressive and morbid management choices. To date, patient's renal function is stable and there is no clinical or radiographic evidence of obstruction. CONCLUSIONS: The described augmented anastomotic ureteroplasty using a pelvic flap is a useful surgical solution for select patients with long upper ureteral obliteration that cannot be managed by a direct reanastomosis. This technique may represent a valid addition to the urologic surgical armamentarium.

Transobturator tape procedure with and without concomitant vaginal surgery.

PURPOSE: We evaluated results and complications of the transobturator tape procedure for female stress urinary incontinence and assessed the effect of concomitant vaginal surgery on the outcome. MATERIALS AND METHODS: We prospectively studied consecutive women who underwent the transobturator tape procedure without (group 1) or with (group 2) concomitant vaginal surgery at our institution from 2003 to 2006. Followup was at least 12 months. Preoperative evaluations included medical history, Urogenital Distress Inventory-6, physical examination, urinalysis and culture, and urodynamics. The procedure was performed as an out-in technique. Therapeutic success was defined as complete continence not requiring pad protection. All other outcomes were classified as failures. RESULTS: A total of 96 patients with a mean age of 63 years (range 37 to 89) who fulfilled study entry criteria comprised the study cohort. Group 1 included 35 patients and group 2 included 61 with 1 or more concomitant vaginal surgeries, including hysterectomy in 28, anterior colporrhaphy in 61, posterior colporrhaphy in 11, and excision of a vaginal granuloma with suture thread and excision of the eroded part of the tape in 1 each. There were no intraoperative complications. One patient per group had transient leg pain. Seven group 2 patients had voiding dysfunction, of whom 3 underwent tape release for a presumed obstructed urethra. Postoperatively 29 women (82.86%) in group 1 and 52 (85.2%) in group 2 were continent throughout the 36.1-month followup (range 12 to 54). CONCLUSIONS: Transobturator tape is safe and effective for stress urinary incontinence. Voiding dysfunction is more prevalent after concomitant vaginal surgery but that surgery does not affect the transobturator tape continence outcome.

Laparoscopic removal of local renal cell carcinoma recurrence.

PURPOSE: To describe an entirely laparoscopic technique for excising a recurrence of local renal cell carcinoma (RCC). MATERIALS AND METHODS: The patient is placed in a full flank position. A 10-mm trocar is inserted using Hasson's technique with three additional ports in the upper abdomen. After lysis of adhesions, the psoas muscle, ureteral and gonadal vein remnants, inferior vena cava or aorta, and renal vessel stumps are dissected and isolated. The specimen, including the mass, the adrenal gland, and the ipsilateral pararenal and paracaval or para-aortic tissue within Gerota's fascia remnants, are excised en bloc and removed inside an Endocatch-II bag. RESULTS: To date we have used this technique for excising RCC recurrences in three patients. Pathologic examination showed clear cell type RCC Fuhrman grade 2 in the specimens of two patients and chromophobe type in one. No patient has had further recurrence after 50, 38 and 12 months of follow-up. CONCLUSIONS: An entirely laparoscopic surgical approach for excising local RCC recurrence has not, to our knowledge, been previously described. This method can be effectively applied while adhering to oncologic principles, with minimal blood loss and low morbidity.

Emergent and surgical interventions for injuries associated with eroticism: a review.

BACKGROUND: To review the consequences of sexual activities that can cause severe morbidity and the current emergent and surgical measures for treating them. METHODS: A computerized search of the English and non-English MEDLINE database (January 1973 to October 2005) identified the major sexual activities that caused injuries requiring emergent or surgical intervention, or both. These activities were grouped by type, pathologic findings, and sites of injury. Cause and symptoms are discussed, as are the radiologic, emergent and surgical interventions employed worldwide. RESULTS: Two major groups of sexual-erotic activities, whether self-inflicted or accidental, emerged as culpable for most of the injuries. One was hetero-homosexual relations that were associated with penile fracture and Peyronie's disease. The other was related to the sequelae of autoeroticism and included penile constriction devices, anorectal, urethra-bladder, and vaginal foreign bodies as well as autoerotic asphyxiation. Injuries in both groups affected men more than women (e.g., 1.7:1 for foreign bodies in the urethra and 99:1 for anorectal). Complications were either immediate or delayed. Predisposing factors for injury are described. Emergent medical management and corrective surgical measures (usually by urologists and gynecologists for genital involvement and proctologists and general surgeons for rectal involvement) were similar worldwide and the need for them was surprisingly limited. CONCLUSIONS: Most erotic activity-related injuries are medically or surgically treatable, although some sexual practices can be lethal. Dissemination of information on risk of injury is the best preventive measure.

Analysis of polymorphic patterns in candidate genes in Israeli patients with prostate cancer.

BACKGROUND: The precise genes involved in conferring prostate cancer risk in sporadic and familial cases are not fully known. OBJECTIVES: To evaluate the genetic profile within several candidate genes of unselected prostate cancer cases and to correlate this profile with disease parameters. METHODS: Jewish Israeli prostate cancer patients (n = 224) were genotyped for polymorphisms within candidate genes: p53, ER, VDR, GSTT1, CYP1A1, GSTP1, GSTM1, EPHX and HPC2/ELAC2, followed by analysis of the genotype with relevant clinical and pathologic parameters. RESULTS: The EPHX gene His113 allele was detected in 21.4% (33/154) of patients in whom disease was diagnosed above 61 years, compared with 5.7% (4/70) in earlier onset disease (P < 0.001). Within the group of late-onset disease, the same allele was noted in 5.5% (2/36) with grade I tumors compared with 18% (34/188) with grade II and up (P = 0.004). All other tested polymorphisms were not associated with a distinct clinical or pathologic feature in a statistically significant manner. CONCLUSIONS: In Israeli prostate cancer patients, the EPHX His113 allele is seemingly associated with a more advanced, late-onset disease. These preliminary data need to be confirmed by a larger and more ethnically diverse study.

Laparoendoscopic single-site plus one port nephroureterectomy: single center initial experience.

BACKGROUND AND PURPOSE: Nephroureterectomy (NU) with bladder cuff excision is the gold standard treatment for patients with upper urinary tract urothelial cancer. We report our initial experience with laparoendoscopic single-site plus one port (LESS POP) technique for NU and bladder cuff excision. PATIENTS AND METHODS: We retrospectively reviewed the records of consecutive patients undergoing LESS POP NU between 2011 and 2012. We describe in detail our surgical technique and summarized the outcomes in this initial series. RESULTS: Ten patients (7 male, 3 female) aged 55 to 84 years underwent LESS POP NU. There were no conversions to open technique or additions of conventional laparoscopic ports. Median (range) operative time was 217 minutes. Specimens were extracted through the umbilical incision in five patients and through an extension of the lower quadrant port in five. One patient experienced urine leak followed by umbilical wound dehiscence (Clavien grade IIIb complication). CONCLUSIONS: In this series, LESS POP NU was feasible with encouraging outcomes. We believe that it is possible to extend the benefits of LESS to patients with upper tract tumors while adhering to strict oncologic principles.

Routine diagnostic ureteroscopy for suspected upper tract transitional-cell carcinoma.

BACKGROUND AND PURPOSE: Upper tract transitional-cell carcinoma (utTCC) is uncommon. Standard evaluation includes imaging, cytology, and cystoscopy and gold standard treatment is nephroureterectomy (NU) with solid oncologic outcomes and elevated morbidity. In this study, we report on the value of including routine ureteroscopy (URS) for evaluating suspected utTCC in shifting the treatment toward less morbid options and increasing preoperative diagnostic accuracy. PATIENTS AND METHODS: Records of patients presenting between 2002 and 2013 with suspected utTCC were reviewed. Since 2010, URS has been included routinely in the evaluation protocol. Demographic, clinical, and pathologic characteristics were recorded and compared between earlier experience (group 1) and with routine URS (group 2). In addition, the number needed to treat (NNT) was calculated with respect to shifting the procedure choice from NU to other options as well as in reducing the rates of misdiagnoses. RESULTS: A total of 118 patients were included: 63 in group 1 and 55 in group 2. The pathology-confirmed TCC rates were comparable between the two groups (78 vs 85%). The rates of NU decreased with routine URS use from 89% to 69% (P=0.011, NNT=5.05) whereby patients were treated endoscopically or with distal ureterectomy. Misdiagnoses decreased from 15.5% to 2.1% with routine URS (P=0.021, NNT=7.44). Sepsis occurred in two patients after URS. CONCLUSIONS: In this initial study, routine URS evaluation for suspected utTCC appears to enable an increased use of other treatment choices rather then NU, with an estimated five URS avoiding one NU. Moreover, routine URS reduced the rates of misdiagnosis of TCC. Complications associated with URS may add an additional morbidity burden, however.

Renal mass anatomic characteristics and perioperative outcomes of laparoscopic partial nephrectomy: a critical analysis.

BACKGROUND AND PURPOSE: Anatomic parameters determining renal mass complexity have been used in a number of proposed scoring systems despite lack of a critical analysis of their independent contributions. We sought to assess the independent contribution of anatomic parameters on perioperative outcomes of laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS: Preoperative imaging studies were reviewed for 147 consecutive patients undergoing LPN for a single renal mass. Renal mass anatomy was recorded: Size, growth pattern (endo-/meso-/exophytic), centrality (central/hilar/peripheral), anterior/posterior, lateral/medial, polar location. Multivariable models were used to determine associations of anatomic parameters with warm ischemia time (WIT), operative time (OT), estimated blood loss (EBL), intra- and postoperative complications, as well as renal function. All models were adjusted for the learning curve and relevant confounders. RESULTS: Median (range) tumor size was 3.3 cm (1.5-11 cm); 52% were central and 14% hilar. While 44% were exophytic, 23% and 33% were mesophytic and endophytic, respectively. Anatomic parameters did not uniformly predict perioperative outcomes. WIT was associated with tumor size (P=0.068), centrality (central, P=0.016; hilar, P=0.073), and endophytic growth pattern (P=0.017). OT was only associated with tumor size (P<0.001). No anatomic parameter predicted EBL. Tumor centrality increased the odds of overall and intraoperative complications, without reaching statistical significance. Postoperative renal function was not associated with any of the anatomic parameters considered after adjustment for baseline function and WIT. Learning curve, considered as a confounder, was independently associated with reduced WIT and OT as well as reduced odds of intraoperative complications. CONCLUSION: This study provides a detailed analysis of the independent impact of renal mass anatomic parameters on perioperative outcomes. Our findings suggest diverse independent contributions of the anatomic parameters to the different measures of outcomes (WIT, OT, EBL, complications, and renal function) emphasizing the importance of the learning curve.

Laparoscopic partial nephrectomy for tumors 7cm and above. Perioperative outcomes

ABSTRACT Purpose: To assess and report the outcomes of laparoscopic partial nephrectomy) LPN) for T2 renal masses. Materials and Methods: Retrospective review of patients undergoing LPN for clinically localized renal masses ≥7cm between the years 2005-2016. Descriptive analyses were generated for demographics, lesion characteristics, perioperative variables (operative time, warm ischemia time (WIT), estimated blood loss (EBL), intra-operative and postoperative complications (IOC and POC) and pathologic variables (pathology, subtype and Fuhrman grade). Results: A total of 27 patients underwent LPN for a T2 renal mass at our institution between 2005 and early 2016 of which 19 were males. The mean age was 66 (52-72). All procedures were transperitoneal with 16 on the right and 11 on the left. Median operative time was 200 minutes (IQR 181-236) and median WIT 19 minutes (IQR 16-23). EBL was 125mL (IQR 75-175). One case was converted to laparoscopic radical nephrectomy due to suspected tumor thrombus in the renal vein. Surgical margins were positive in one renal tumor in a patient with multiple tumors. There was a total of 2 IOC (7.4%) and 3 POC (11%) classified as Clavien grade 3. Conclusions: To our knowledge, this series is the first to describe the outcomes of LPN for cT2 renal masses. In our series, LPN for larger renal masses appears feasible with favorable perioperative outcomes. Additional data are needed to further explore the benefits of minimally invasive surgical approaches to larger renal masses.

Laparoendoscopic single-site repair of incisional hernias after urological surgery.

OBJECTIVE: To report the first series of postoperative ventral hernias (POVH) repair with laparoendoscopic single-site (LESS) approach after urological procedures. POVH are well-known complications of urological surgery and often require surgical correction. Minimally invasive repair techniques have been developed to diminish parietal trauma and enhance functional results. METHODS: This study was based on a retrospective review of patients undergoing POVH repair after urological surgery at an academic institution from 2004 to 2010. Patient characteristics, perioperative details, as well as follow-up were reviewed and summarized. Using a transperitoneal approach, abdominal wall defect was identified, prepared, and closed with a mesh tailored to cover 3-5 cm beyond the edge of the defect and secured in a double-crown fashion. RESULTS: In 3 patients POVH was represented by a port-site hernia after laparoscopic partial nephrectomy; in the remaining 2 patients POVH occurred at midline following radical cystectomy. Hernia occurrence was identified within 2 months from the initial surgery in all but 1 patient. Blood loss was minimal, operative times were 30-150 minutes, and no intraoperative complications occurred. Three patients developed a transient seroma and 1 patient had ileus. Over a 1- to 20-month follow-up, there have been no wound or mesh complications, and no hernia recurrences were identified. CONCLUSION: In this initial series, POVH after urological surgery were successfully treated with LESS approach. In experienced hands, LESS may provide a viable alternative to conventional laparoscopy for POVH repair. More studies are needed to confirm these initial results and to determine whether reduced parietal trauma favors LESS in POVH repair.

The Y-V pyeloplasty revisited.

OBJECTIVES: To present a new method of laparoscopic Y-V pyeloplasty to treating ureteropelvic junction (UPJ) stenoses in patients with enlarged renal pelvis. Y-V pyeloplasty for the correction of UPJ stenosis has become well known. Despite its simplicity and good anatomic and functional results, there is no reduction of renal pelvic size and thus Y-V pyeloplasty has not been recommended for treating UPJ stenoses in patients with enlarged renal pelvis. We present a new method of laparoscopic Y-V pyeloplasty that includes simultaneous reduction of the renal pelvis and may extend the use for this procedure. METHODS: A Y-V pyeloplasty, modified by extending the cranial limbs of the Y-shaped incision in an elliptic manner to eliminate redundant pelvic tissue, was used to reduce a hydronephrotic pelvis while widening the UPJ. RESULTS: Three women aged 20-60 years underwent surgery for UPJ with this technique. The postoperative course was uneventful. After 10-43 months of follow-up there has been no evidence of obstruction. CONCLUSIONS: The herein described modification allows extending the use of Y-V pyeloplasty to UPJ stenosis with enlarged renal pelvis.

Female urethral diverticulum: a pathological insight.

INTRODUCTION AND HYPOTHESIS: In this study, we define the histopathological features of female urethral diverticula and attempt to elucidate its pathogenesis and etiology. METHODS: We analyzed 22 clinical records of women diagnosed with urethral diverticula. We collected clinical, surgical, and pathological data. Pathological re-assessment was performed using hematoxylin-eosin and van Gieson stains. RESULTS: The predominant epithelial types were squamous (41.9%), columnar (31.8%), combined squamous and columnar (18.2%), and cuboidal (13.6%). There was no case of the transitional type. Epithelial ulcerations were present in nine cases. The diverticular wall was composed only of fibrous collagen tissue in all cases. Inflammatory signs were noted in 77.3% of specimens. CONCLUSIONS: Histopathological features of female urethral diverticula match the criteria for paraurethral cysts. Concomitant use of synthetic meshes should be avoided due to the possibility of an infectious etiology. Transvaginal excision of the sac is recommended, while transurethral procedures are contraindicated.

Concomitant laparoscopic renal surgery and cholecystectomy: outcomes and technical considerations.

INTRODUCTION: We report our experience with simultaneous laparoscopic treatment of coexisting kidney and gallbladder pathologies, assess the feasibility of this technique, and highlight some technical considerations. METHODS: Our institutional database was searched for the records of simultaneous laparoscopic kidney surgery and laparoscopic cholecystectomy between 2002 and 2008. We retrieved data on patient demographics, preoperative work-up, surgical information, and postoperative outcome in terms of final pathology, complications, and hospital stay. RESULTS: A total of 19 patients had undergone laparoscopic renal surgery combined with cholecystectomy. Renal surgery consisted of a laparoscopic partial nephrectomy in 5 patients (26.3%), a laparoscopic radical nephrectomy in 12 (63.2%), and a simple nephrectomy in 2 (10.5%). Laparoscopic cholecystectomy was performed as a second surgery in all 19 patients. Two patients simultaneously underwent a third procedure: one was a bilateral salpingo-oophorectomy, and the other was a postoperative ventral hernia repair with mesh. The average renal surgery time was 144 minutes, and the average cholecystectomy time was 28.0 minutes. All procedures were successfully completed laparoscopically with no conversions. The mean hospital stay was 4.2 days (median 4, range 2-8). CONCLUSIONS: Combining laparoscopic renal surgery and laparoscopic cholecystectomy is a feasible, efficacious, and safe strategy that requires close collaboration between urologists and general surgeons. This approach offers the patient the benefits of minimally invasive surgery together with the obvious advantages of simultaneous treatment of coexisting pathologies.

A sealed laparoscopic nephroureterectomy: a new technique.

OBJECTIVES: To describe a purely laparoscopic nephroureterectomy approach that avoids the disadvantages of transurethral bladder cuff excision and open/laparoscopic distal ureterectomy using the EndoGIA. METHODS: A standard transperitoneal laparoscopic nephrectomy is carried out through three or four ports in the flank. The ureter is dissected caudally into the pelvis. Two additional (5- and 10-mm) trocars are placed in the ipsilateral lower abdomen. Caudal ureteral dissection continues until the detrusor muscle fibers at the ureterovesical junction are identified. A 1-cm area of bladder adventitia around the ureterovesical junction is cleared. The ureter is retracted upward and laterally, tenting up the bladder wall. The bladder cuff is excised using a 10-mm LigaSure Atlas and detached from the bladder. A 6-cm lower-quadrant incision is used to remove the specimen in an Endocatch bag. An indwelling 16F Foley catheter is then placed. RESULTS: Thirteen adult patients with suspected upper-tract transitional cell carcinoma underwent this surgical technique (operative time: 170-270 min): none had local recurrence, and two had recurrence remote from the bladder cuff scar (follow-up: 1-23 months). CONCLUSIONS: The described procedure adheres strictly to oncologic principles (removal of the affected renal unit without opening the urinary tract), and circumvents the need for transurethral/intraureteral instrumentation and patient repositioning.

Laparoscopic partial nephrectomy for tumour excision in a horseshoe kidney.

A 62-yr-old woman with a 2-cm enhancing renal mass in the right moiety of a horseshoe kidney was treated via a four-port transperitoneal laparoscopic approach. The tumour was excised by cold scissors, and the parenchyma was sutured with Vicryl 1 sutures with Surgicel bolster and by using pledgets of Hem-o-lok((R)) clips. To our knowledge, this is the first report of a partial nephrectomy for tumour excision on a horseshoe kidney by a transperitoneal laparoscopic approach.