Parenchymal transection of the kidney inflicted by endocatch bag entrapment during a laparoscopic donor nephrectomy.

We present a case of inadvertent decapsulation and grade IV renal parenchyma laceration during laparoscopic donor nephrectomy. The kidney was repaired, used and functioned immediately. There were no complications in the donor. To our knowledge, this type of injury has not been reported previously and the purpose of this report is to focus attention on the potential for this unusual injury, which can occur during delivery of the kidney using the endocatch bag.

Retroperitoneal laparoscopic nephroureterectomy and management options for the distal ureter.

Radical nephroureterectomy, including en bloc excision of the ureter with a bladder cuff, is the standard treatment for upper tract transitional-cell carcinoma (TCC). This procedure requires either a flank and lower abdominal incision or an extended flank incision. Laparoscopic surgery for TCC has been used at several medical centers; the most challenging and controversial aspect is the oncologically correct management of the distal ureter. We believe that the Cleveland Clinic technique of securing the distal bladder cuff intravesically while simultaneously occluding the distal ureter prevents tumor spillage and allows accurate and complete resection of the targeted ureter in a manner mirroring the open procedure.

Intact specimen extraction during renal laparoscopy: muscle-splitting versus muscle-cutting incision.

PURPOSE: To determine whether a muscle-splitting extraction incision decreases patient morbidity after renal laparoscopic surgery. PATIENTS AND METHODS: Twenty-one patients undergoing laparoscopic simple nephrectomy, radical nephrectomy, or nephroureterectomy had intact specimen extraction through a muscle-splitting incision. The operative and recovery data of these patients were retrospectively compared with those of a matched cohort of 21 patients who underwent specimen extraction through a muscle-cutting incision. With the exception of a greater percentage of male patients in the muscle-cutting group (86% v 52%), there were no statistically significant differences between the two groups. RESULTS: In the muscle-splitting and muscle-cutting groups, there was no significant differences in regard to analgesic use (9.0 +/- 6.6 mg of morphine sulfate equivalent v 7.9 +/- 4.9; P < 0.51), hospital stay (31.2 hours v 30 hours; P < 0.79), recovery (6.7 +/- 4.7 days v 5.7 +/- 4.7 days; P < 0.38), or convalescence (4.2 +/- 2.2 weeks v 4.1 +/- 2.0 weeks; P < 0.90). CONCLUSION: A muscle-splitting incision for intact renal specimen extraction does not necessarily decrease postoperative morbidity compared with a muscle-cutting extraction.

Simplified approach to percutaneous endopyelotomy.

The purpose of this report was to describe a safe, simple, and rapid approach to percutaneous antegrade endopyelotomy. In contrast to standard percutaneous endopyelotomy techniques, in this procedure, the endopyelotomy stent is placed at the outset. The endopyelotomy incision is then made with an acorn-tipped Bugbee electrode directly down onto the stent, in a manner analogous to a ureteral meatotomy in the bladder. The advantage of this approach is twofold. Primary placement of the stent helps to define the appropriate site and direction for the endopyelotomy incision, allowing marsupialization of the proximal ureter into the renal pelvis. Use of this technique also obviates the need to pass a large-caliber stent after the endopyelotomy incision has been made, thereby avoiding a potential risk of ureteropelvic junction disruption. Clinical and radiographic follow-up was available in 29 (76%) of 38 patients who underwent this procedure. Success, defined as a resolution of symptoms and decrease in calicectasis, was achieved in 24 (83%) of the 29 patients. We have found primary placement of an endopyelotomy stent and use of electrocautery as a cutting mode safely facilitates a precise endopyelotomy incision.

Laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma: the Cleveland Clinic experience.

PURPOSE: We report our single institutional experience with retroperitoneal laparoscopic radical nephroureterectomy in patients with upper tract transitional cell carcinoma and compare results to those achieved by the open technique. MATERIALS AND METHODS: A total of 77 patients underwent radical nephroureterectomy for pathologically confirmed upper tract transitional cell carcinoma. Of these patients 42 underwent laparoscopic nephroureterectomy from September 1997 through January 2000 and 35 underwent open surgery. All specimens were extracted intact. Of the laparoscopic group the juxtavesical ureter and bladder cuff were excised by our novel transvesical needlescopic technique in 27 and radical nephrectomy was performed retroperitoneoscopically in all 42. Data were compared retrospectively with 35 patients undergoing open radical nephroureterectomy from February 1991 through December 1999. RESULTS: Laparoscopy was superior in regard to surgical time (3.7 versus 4.7 hours, p = 0.003), blood loss (242 versus 696 cc, p <0. 0001), specimen weight (559 versus 388 gm., p = 0.04), resumption of oral intake (1.6 versus 3.2 days, p = 0.0004), narcotic analgesia requirements (26 versus 228 mg., p <0.0001), hospital stay (2.3 versus 6.6 days, p <0.0001), normal activities (4.7 versus 8.2 weeks, p = 0.002) and convalescence (8 versus 14.1 weeks, p = 0.007). Complications occurred in 5 patients (12%) in the laparoscopic group, including open conversions in 2, and in 10 (29%) in the open group (p = 0.07). Followup was shorter in the laparoscopic group (11.1 versus 34.4 months, p <0.0001). The 2 groups were similar in regard to bladder recurrence (23% versus 37%, p = 0.42), local retroperitoneal or port site recurrence (0% versus 0%) and metastatic disease (8.6% versus 13%, p = 1.00). Mortality occurred in 2 patients (6%) in the laparoscopic group and 9 (30%) in the open group. Cancer specific survival (97% versus 87%) and crude survival (97% versus 94%) were similar between both groups (p = 0.59). CONCLUSIONS: In patients with upper tract transitional cell carcinoma who are candidates for radical nephroureterectomy the retroperitoneal laparoscopic approach satisfactorily duplicates established technical principles of traditional open oncological surgery, while significantly decreasing morbidity from this major procedure. Short-term oncological and survival data of the laparoscopic technique are comparable to open surgery. Although long-term followup data are not yet available, it appears that laparoscopic radical nephroureterectomy may supplant open surgery as the standard of care in patients with muscle invasive or high grade upper tract transitional cell carcinoma.

Laparoscopic radical cystoprostatectomy with ileal conduit performed completely intracorporeally: the initial 2 cases.

OBJECTIVES: To present the initial 2 patients who underwent laparoscopic radical cystoprostatectomy, bilateral pelvic lymphadenectomy, and ileal conduit urinary diversion, with the entire procedure performed exclusively by intracorporeal laparoscopic techniques. METHODS: Two male patients, 78 and 70 years old, with muscle-invasive, organ-confined, transitional cell carcinoma of the urinary bladder underwent the procedure. The entire procedure, including radical cystoprostatectomy, pelvic node dissection, isolation of the ileal loop, restoration of bowel continuity with stapled side-to-side ileoileal anastomosis, retroperitoneal transfer of the left ureter to the right side, and bilateral stented ileoureteral anastomoses were all performed exclusively by intracorporeal laparoscopic techniques. Free-hand laparoscopic suturing and in situ knot-tying techniques were used exclusively. RESULTS: The surgical time was 11.5 hours in the first patient and 10 hours in the second. The respective blood loss was 1200 mL and 1000 mL. In both patients, ambulation resumed on postoperative day 2, bowel sounds on day 3, and oral intake on day 4; the hospital stay was 6 days. Narcotic analgesia comprised 108.3 mg and 16.5 mg of morphine sulfate equivalent, respectively. Pathologic examination revealed pT4N0M0 (prostate) and pT2bN0M0 transitional cell carcinoma of the bladder with the surgical margins negative for cancer in both patients. No intraoperative or postoperative complications occurred in either patient. CONCLUSIONS: To our knowledge, this is the initial report of laparoscopic radical cystoprostatectomy with intracorporeal ileal conduit urinary diversion. We believe that with further experience and refinement in the operative technique, laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion may become an attractive treatment option for selected candidates with localized muscle-invasive bladder cancer.

Ureteroscopic approach to upper-tract urothelial tumors.

Transitional-cell carcinoma (TCC) of the upper urinary tract has traditionally been managed by nephroureterectomy, whereas nephron-sparing surgery has been reserved for those few patients with solitary kidneys or bilateral lesions. However, with the introduction of improved diagnostic and therapeutic technology, including smaller ureteroscopes and working instruments, and the concomitant ease of surveillance, ureteroscopic treatment of upper-tract urothelial tumors has become a reasonable alternative to open operative intervention in patients requiring conservative management. Furthermore, as preoperative grading and staging have improved, ureteroscopic treatment of upper-tract urothelial tumors is assuming an increasingly important role in the management of some patients who might have otherwise been treated with a nephroureterectomy. The technique of ureteroscopic resection is described in detail.

Laparoscopic ileal ureter.

PURPOSE: We describe the operative technique of laparoscopic ileal ureter replacement. MATERIALS AND METHODS: A transperitoneal 3-port approach was used. Ileovesical and pyeloileal anastomoses were performed with intracorporeal laparoscopic freehand suturing and knot tying techniques. RESULTS: Operating time was 8 hours and blood loss was 200 cc. Both anastomoses were immediately watertight. Hospital stay was 4 days and a cystogram at 14 days confirmed widely patent anastomoses without extravasation. CONCLUSIONS: Laparoscopic ileal ureter replacement satisfactorily duplicates established open surgical principles. The laparoscopic technique is efficient and technically straightforward.

Laparoscopic radical nephroureterectomy.

Because of the high rate of ipsilateral multifocal disease and the low incidence of contralateral disease, upper tract transitional-cell carcinoma has historically been treated with radical nephroureterectomy. This operation has been performed laparoscopically in many medical centers, with various techniques. The difficult concept has always been handling of the distal ureter and bladder cuff. A technique involving transvesical laparoscopy-assisted transurethral dissection with low pressure that mimics the open procedure is used at the Cleveland Clinic. The reported mean operative times range from 2.6 to 8.3 hours, with the longest time being reported from one of the earliest series. Although the cost of laparoscopic nephroureterctomy is higher than that of the open procedure by about 24%, this figure does not include the societal costs of the longer convalescence after the latter operation. Longer follow-up will be required to learn whether the laparoscopic method is as effective from an oncologic standpoint as open surgery.

A comparison of a 3-day course of Mictral with a 7-day course of ampicillin in the treatment of urinary tract infection.

This general practice study compared a 3-day course of a new preparation, Mictral, with a standard 7-day course of ampicillin in the treatment of uncomplicated urinary tract infection. Mictral achieved bacteriological cure in all infected patients by Day 4 while only 69% of infected patients in the ampicillin group were abacteriuric by Day 8. Symptomatic relief and the incidence of side-effects were similar for both groups. It is concluded that Mictral appears to be a useful addition to currently available therapy for urinary tract infection and merits further investigation.

Betamethasone valerate compared with sodium cromoglycate in asthmatic children.

A double-blind, cross-over study was undertaken to compare inhalation of betamethasone valerate (BV, 800 microgram daily) with sodium cromoglycate (SCG, 80 mg daily) in twenty children requiring bronchodilators for perennial asthma. Each treatment period lasted 4 weeks but statistical comparisons were made only in respect of the last 14 days of each therapy. When the children were using BV they required not only less of the bronchodilator drugs but had fewer symptoms and higher daily peak expiratory flow rates when taking SCG. Statistically, all these differences were highly significant. For 2 weeks before the main trial each child was given a placebo aerosol (single-blind) to assess severity of asthma. In comparison with this period, SCG was associated with a significantly increased peak expiratory flow rate a lower symptom score by day but not by night, but their usage of bronchodilators followed a similar pattern. When the BV period was compared with the placebo period, patients had an even more significant rise in peak expiratory flow rate, less day and night symptoms, and took hardly any bronchodilators. The response to the two drugs did seem to depend upon which was given first. No monilial infections were found, nor any measurable defect in adrenal response from either treatment. Betamethasone valerate is considered to be superior to sodium cromoglycate as a treatment for childhood asthma insufficiently controlled on bronchodilators.