Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis-initial results.

PURPOSE: The efficacy of shock wave lithotripsy and percutaneous stone removal for the treatment of symptomatic lower pole renal calculi was determined. MATERIALS AND METHODS: A prospective randomized, multicenter clinical trial was performed comparing shock wave lithotripsy and percutaneous stone removal for symptomatic lower pole only renal calculi 30 mm. or less. RESULTS: Of 128 patients enrolled in the study 60 with a mean stone size of 14.43 mm. were randomized to percutaneous stone removal (58 treated, 2 awaiting treatment) and 68 with a mean stone size of 14.03 mm. were randomized to shock wave lithotripsy (64 treated, 4 awaiting treatment). Followup at 3 months was available for 88% of treated patients. The 3-month postoperative stone-free rates overall were 95% for percutaneous removal versus 37% lithotripsy (p <0.001). Shock wave lithotripsy results varied inversely with stone burden while percutaneous stone-free rates were independent of stone burden. Stone clearance from the lower pole following shock wave lithotripsy was particularly problematic for calculi greater than 10 mm. in diameter with only 7 of 33 (21%) patients becoming stone-free. Re-treatment was necessary in 10 (16%) lithotripsy and 5 (9%) percutaneous cases. There were 9 treatment failures in the lithotripsy group and none in the percutaneous group. Ancillary treatment was necessary in 13% of lithotripsy and 2% percutaneous cases. Morbidity was low overall and did not differ significantly between the groups (percutaneous stone removal 22%, shock wave lithotripsy 11%, p =0.087). In the shock wave lithotripsy group there was no difference in lower pole anatomical measurements between kidneys in which complete stone clearance did or did not occur. CONCLUSIONS: Stone clearance from the lower pole following shock wave lithotripsy is poor, especially for stones greater than 10 mm. in diameter. Calculi greater than 10 mm. in diameter are better managed initially with percutaneous removal due to its high degree of efficacy and acceptably low morbidity.

Using immersive VR as a tool for preoperative planning for minimally invasive donor nephrectomy.

For surgeons approaching minimally invasive donor nephrectomy it is important to identify variant anatomy preoperatively since this anatomy can vary significantly from patient to patient. The goal of this operation is to preserve the architecture and function of the organ so it can be transplanted and function successfully. The ability of the surgeon to navigate through an individual patient's anatomy in a virtual three-dimensional (3D) immersive environment augments understanding of anatomical relationships particular to that individual patient and facilitates conveying that information to other physicians and students. Utilizing automated 3D reconstruction of high contrast computed tomography (CT) scan files viewed in this way, surgeons reported a better preoperative understanding of the anatomical variations and encountered fewer surprises at the time of surgery.

Laparoscopic lymphocelectomy: a multi-institutional analysis.

PURPOSE: Because symptomatic lymphoceles are infrequent, single center studies generally report small numbers of patients. We report a multi-institutional experience with and long-term outcome following laparoscopic lymphocelectomy in 81 patients. MATERIALS AND METHODS: Data were obtained from 9 institutions at which at least 5 cases of laparoscopic lymphocelectomy had been performed. Baseline patient demographics, operative time and blood loss, special operative adjunct techniques, postoperative course, convalescence, complications and lymphocele recurrence data were collected and analyzed. RESULTS: A total of 56 men and 25 women with a mean age of 41 years were included in the study. Lymphocele formed after renal transplantation in 78 patients (96%) and after pelvic lymph node dissection in 3 (4%). Average operating time was 123 minutes with a mean blood loss of 43 ml. Omentopexy was performed in 11 cases (13.6%). No intraoperative stenting of the transplant ureter was performed. Intraoperative complications consisted of laryngospasm, bladder injury, inferior epigastric artery injury and mild renal capsule hematoma in 1 patient each. Conversion to open surgery was required for repair of bladder injury in 1, repair of preexisting hernia in 1, unusually thickened lymphocele wall in 1 and inaccessible lymphocele location in 4 cases. Mean time to ambulation and resumption of regular diet was 1 day, and mean hospital stay was 1.5 days. Postoperative complications included trocar site hernia in 1 and urinary retention in 2. Convalescence averaged 2.5 weeks. During a mean followup of 27 months 5 patients (6%) had lymphocele recurrence. CONCLUSIONS: Laparoscopic lymphocelectomy is safe, minimally invasive and effective. It is an excellent alternative to the conventional open surgical approach.

Urolithiasis associated with the protease inhibitor indinavir.

OBJECTIVES: To report the association between the protease inhibitor indinavir and the development of urolithiasis. METHODS: Case reports of three adult patients infected with the human immunodeficiency virus who developed surgical renal stones while being treated with indinavir are presented. RESULTS: Of the 3 patients requiring surgical intervention, stone analyses were available in 2. One stone revealed an inner core of an unidentifiable crystal surrounded by calcium oxalate, and another was found to have indinavir components as determined by thin-layer chromatography and gas chromatography-mass spectrometry. Metabolic evaluation of all 3 patients identified significant hypocitraturia as an isolated finding. CONCLUSIONS: The widely used protease inhibitor indinavir is associated with the development of urolithiasis and may act as a nidus for heterogeneous nucleation leading to the development of mixed urinary stones. Surgical intervention may be necessary in some cases. Underlying metabolic abnormalities may contribute to the increased incidence of stone formation. Urologists and other health care providers should be aware of this association, as combined medical and surgical intervention may be necessary.

Access technique for retroperitoneoscopy.

PURPOSE: The access technique for retroperitoneoscopy is not well established, and differs from transperitoneal laparoscopic access in 3 key aspects: 1) location and technique of primary trocar placement, 2) optimal positioning of the balloon dilator and 3) technique for safe placement of secondary ports. Our method of obtaining retroperitoneoscopic access addresses these issues. MATERIALS AND METHODS: A total of 37 patients underwent retroperitoneoscopic surgery of the kidney and upper ureter. RESULTS: Our technique facilitates balloon placement within Gerota's fascia, minimizes peritoneal injury and optimizes port placement during retroperitoneoscopic surgery. CONCLUSIONS: Although our success rate for placing the balloon within Gerota's fascia has improved, additional experience is required to achieve subfascial balloon placement more consistently.

Laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction.

The treatment of ureteropelvic junction (UPJ) obstruction has evolved over the past several years with the implementation of endopyelotomy techniques and, more recently, hot wire balloon incision of the stenotic UPJ. Nonetheless, the long-term results suggest, at least for primary treatment, that none of the new techniques provide the long-term outcomes achieved with traditional open pyeloplasty techniques. I describe the technique of laparoscopic dismembered pyeloplasty, a possible bridge between the open and endoscopic approaches. Difficulties associated with laparoscopic reconstructive procedures are discussed as well as innovative developments that may overcome these problems and truly allow laparoscopic procedures to assume a more prominent role in urologic surgery.

Initial experience with retroperitoneoscopic nephroureterectomy: use of a double-balloon technique.

OBJECTIVES: To report the initial experience with retroperitoneoscopic nephroureterectomy for symptomatic, end-stage vesicoureteral reflux. METHODS: Two patients underwent a nephroureterectomy by a four-port retroperitoneal laparoscopic approach. In 1 patient, a double-balloon technique was used to dissect the pelvic extraperitoneal space and gain access to the juxtavesical ureter. In the second patient, the distal ureter was mobilized with routine laparoscopic dissection techniques. RESULTS: Operative time was 6 and 5.5 hours, respectively, and mean hospital stay was 4 days. Mean patient follow-up is 17.5 months. CONCLUSIONS: The technique of retroperitoneoscopic nephroureterectomy is in evolution; until now, a major concern has been the inadequate access to the distal ureter through a completely retroperitoneoscopic approach. Described herein is a double-balloon technique that significantly facilitates dissection of the juxtavesical ureter during a retroperitoneal laparoscopic nephroureterectomy.

A new renal tourniquet for open and laparoscopic partial nephrectomy.

PURPOSE: We describe a novel double loop renal parenchymal tourniquet for obtaining hemostasis during open and laparoscopic partial nephrectomy. METHODS: One loop is positioned around the upper and 1 around the lower renal poles, thus securely entrapping the kidney. During partial nephrectomy the corresponding loop is double looped and cinched, thus achieving a tourniquet effect. The renal artery is not occluded. Intraoperative renal hypothermia is not required. RESULTS: The renal tourniquet was used clinically during 6 open and 1 laparoscopic partial nephrectomies. Furthermore, during laparoscopic nephrectomy (5 porcine and 1 clinical cases) the double loop apparatus allowed for improved maneuverability of the kidney. CONCLUSIONS: The novel renal tourniquet affords adequate renal parenchymal hemostasis during open and laparoscopic partial nephrectomy.

Transperitoneal marsupialization of lymphoceles: a comparison of laparoscopic and open techniques.

This 2-center study compares the relative merits of laparoscopic and open surgical internal marsupialization of pelvic lymphoceles. Laparoscopic lymphocelectomy was performed in 12 patients (group 1). The results were compared with open lymphocelectomy performed in 13 contemporary patients (group 2) as well as 13 historical patients (group 3). Operative time was longer in group 1 compared to groups 2 and 3 (194.6 versus 176.9 versus 133.8 minutes, respectively). However, group 1 had a decreased blood loss (23.1 versus 74.6 versus 61.7 ml.), earlier resumption of oral food intake (0.9 versus 2.5 versus 2.1 days), shorter hospital stay (2 versus 6.1 versus 6.3 days) and abbreviated convalescence (2.2 versus 6.9 versus 4.5 weeks) compared to groups 2 and 3. Complications included cystotomy requiring open repair in 1 patient in group 1, prolonged ileus in 1 in group 2, transection of the ureter of a transplant kidney in 1 in group 3 and pneumonitis in 1 in group 3. Lymphocele recurred in no patient in group 1, 4 in group 2 and 3 in group 3. Mean followup in groups 1 to 3 was 12.8, 25 and 54.5 months, respectively. We conclude that laparoscopic lymphocelectomy is effective, results in minimal patient morbidity and allows for a more rapid recovery compared to open surgical lymphocelectomy.

Use of a stockinette to minimize warm ischemia during renal transplant vascular anastomoses.

Prolonged warm ischemia during renal transplant vascular anastomosis may have a deleterious impact upon allograft function in the immediate post-transplant period. Placing the donor kidney and sterile ice slush in a cotton stockinette obviates renal rewarming during vascular anastomoses. We successfully used this technique in nearly 1,000 patients undergoing renal transplantation. The stockinette facilitates transplant vascular anastomoses by permitting easier handling of the kidney and eliminating warm ischemia during revascularization as documented by continuous core temperature monitoring.

Laparoscopic retroperitoneal partial nephrectomy.

To our knowledge we report the initial case of laparoscopic partial nephrectomy performed completely via the retroperitoneal approach. The retroperitoneal space was developed by inflating a balloon. Renal parenchymal hemostasis was obtained by a newly designed double loop apparatus and the argon beam coagulator. Convalescence was rapid and no complications have been noted during a followup of 7 months.

Safety and efficacy of recombinant human erythropoietin in correcting the anemia of patients with chronic renal allograft dysfunction.

Recombinant human erythropoietin (rHuEPO) is effective in correcting anemia in hemodialysis, peritoneal dialysis, and predialysis patients. Limited studies in patients with failing renal allografts suggest a similar efficacy but provide little information concerning benefits, dose requirements, or adverse events. This study examined these considerations in a group of 40 patients (18 men; 22 women) aged 40.3 +/- 13.8 yr with stable, chronic renal allograft failure. All patients had a hemoglobin < 95 g/L and a serum creatinine > 250 mumol/L at baseline. Patients received rHuEPO (50 U/kg sc) three times weekly for 24 wk along with iron po if serum ferritin was < 100 micrograms/L. Mean hemoglobin rose from 78.9 +/- 10.4 to 102.6 +/- 18.4 g/L after 24 wk. Mean rHuEPO dose at 24 wk was 129.8 +/- 81.9 U/kg per week. With oral iron supplementation only, serum ferritin fell throughout the 24 wk, whereas serum iron, transferrin saturation, and total iron-binding capacity remained stable. Quality of life was assessed by use of the general Sickness Impact Profile and the disease-specific Transplant Disease Questionnaire measures at baseline and every 8 wk during rHuEPO therapy. Significant improvement was noted in global Sickness Impact Profile scores and in four of five dimensions of the Transplant Disease Questionnaire. Serious adverse events were infrequent. No change in mean systolic or diastolic blood pressure was noted, although there was a significantly increased need for antihypertensive drugs in 18 patients (P = 0.0002). A significant inverse correlation was noted between baseline renal function and maintenance rHuEPO dose (r = -0.45; P < 0.05). Twelve patients returned to dialysis during the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessing medical students' and surgery residents' clinical competence in problem solving in surgical oncology.

BACKGROUND: We sought to determine the competence of medical students and surgery residents in evaluating clinical problems (using both real and simulated patients) in surgical oncology. METHODS: Forty-five third-year medical students, 23 first postgraduate year (PGY-1) residents, and seven second postgraduate year (PGY-2) residents were presented with the same four clinical problems (breast evaluation, prostate nodule, colon cancer, and mole evaluation). The two resident groups were presented with two additional patients (breast cancer options and thyroid mass). RESULTS: Mean performance scores for the problems were generally poor (32-72%); most students and residents failed almost all of the problems. Level of training was of some importance; the overall mean scores of the PGY-2 residents were superior to those of the medical students and the PGY-1 residents (p = 0.049). However, in many areas of information gathering, diagnosis, and management, training level appeared to have no impact. Numerous important performance deficits were identified in all groups. CONCLUSION: Medical students and surgery residents are not receiving adequate training in diagnosing and treating important problems in surgical oncology.

Intraperitoneal drainage of recurrent lymphoceles using an internalized Tenckhoff catheter.

Occasionally, lymphoceles recur after renal transplantation in relatively inaccessible pelvic locations, usually in the setting of a transversely oriented allograft that separates the lymphocele from the peritoneal cavity. Such lymphoceles do not share a common wall with the peritoneal cavity and, therefore, are not manageable by conventional open surgical or laparoscopic drainage techniques. We used an internalized Tenckhoff catheter to drain recurrent lymphoceles into the peritoneal cavity in 3 patients who had undergone prior renal transplantation. No evidence of lymphocele recurrence or catheter-induced septic complications have been noted in our immunocompromised patients up to a mean followup of 5.3 years. Our experience with this alternative management option for the recurrent, inaccessible lymphocele is presented along with a single case report of intractable, recurrent perinephric fluid collection in the nontransplant setting treated by the same technique.

Laparoscopic retroperitoneal renal cystectomy.

Laparoscopic manipulation of retroperitoneal organs is usually performed by the transperitoneal approach primarily because of the ease of access by way of the pneumoperitoneum. However, difficulty in adequately accessing structures that are surrounded by bowel, liver, spleen or postoperative adhesions makes this approach suboptimal in certain cases. We describe the use of the retroperitoneal laparoscopic approach to the upper pole of a kidney for marsupialization of a symptomatic, recurrent, complex renal cyst. An algorithm for current management of symptomatic renal cysts is discussed.