Simultaneous bilateral retrograde intrarenal surgery for stone disease in patients with significant comorbidities.

BACKGROUND AND PURPOSE: Advances in endoscopic equipment have allowed urologists to access stones in virtually any location in the upper tracts. Where clinically appropriate, this approach may represent the preferred treatment option, regardless of stone size. We report the first description of simultaneous bilateral retrograde intrarenal surgery (SB-RIRS) in patients with both significant upper-tract stone burdens and comorbidities such as morbid obesity or heart disease. PATIENTS AND METHODS: Between September 2003 and April 2004, three men and one woman with an average of 62 years underwent a total of seven sessions of SB-RIRS. All four patients were referred from other urologists after failing prior treatments, including shockwave lithotripsy (five sessions) and RIRS (two sessions). The average stone burden was 8.8 cm. The procedures were performed by two surgeons operating simultaneously using two sets of video/holmium laser equipment. Flexible (7.5F) ureteroscopes were used to fragment and basket stone debris without the use of ureteral access sheaths. RESULTS: Three patients underwent a scheduled second-stage procedure to ensure adequate stone clearance. The average total and SB-RIRS-specific operative times were 256 and 131 minutes for the initial procedure and 235 and 95 minutes for the second-stage procedure, respectively. No major complications were noted. CONCLUSION: Simultaneous bilateral RIRS is an appropriate treatment option for stone patients with significant comorbidities.

Biaxial mechanical properties of muscle-derived cell seeded small intestinal submucosa for bladder wall reconstitution.

Bladder wall replacement remains a challenging problem for urological surgery due to leakage, infection, stone formation, and extensive time needed for tissue regeneration. To explore the feasibility of producing a more functional biomaterial for bladder reconstitution, we incorporated muscle-derived cells (MDC) into small intestinal submucosa (SIS) scaffolds. MDC were harvested from mice hindleg muscle, transfected with a plasmid encoding for beta-galactosidase, and placed into single-layer SIS cell culture inserts. Twenty-five MDC and/or SIS specimens were incubated at 37 degrees C for either 10 or 20 days. After harvesting, mechanical properties were characterized using biaxial testing, and the areal strain under 1 MPa peak stress used to quantify tissue compliance. Histological results indicated that MDC migrated throughout the SIS after 20 days. The mean (+/-SE) areal strain of the 0 day control group was 0.182 +/- 0.027 (n=5). After 10 days incubation, the mean (+/-SE) areal strain in MDC/SIS was 0.247 +/- 0.014 (n=5) compared to 10 day control SIS 0.200 +/- 0.024 (n=6). After 20 days incubation, the mean areal strain of MDC/SIS was 0.255 +/- 0.019 (n=5) compared to control SIS 0.170 +/- 0.025 (n=5). Both 10 and 20 days seeded groups were significantly different (p=0.027) than that of incubated SIS alone, but were not different from each other. These results suggest that MDC growth was supported by SIS and that initial remodeling of the SIS ECM had occurred within the first 10 days of incubation, but may have slowed once the MDC had grown to confluence within the SIS.

Looped silk tie: surgical technique for management of the renal vein during laparoscopic live-donor nephrectomy.

Laparoscopic live-donor nephrectomy has revolutionized the field of kidney transplantation and has been adopted in many tertiary centers as the method of choice in procuring kidneys. While standard techniques for laparoscopic live-donor nephrectomy have been well described in the literature, there continues to be ample discussion about renal-vein ligation. Endo-GIA and other commonly used vascular stapling devices can be costly and prone to mechanical failures and may not be applicable in certain anatomic situations. Vascular clips, although simple to use for arteries, are difficult to apply to large renal veins. To address these issues, we describe a simple, cost-effective method of control that can be used for both right and left renal veins, using a loop constructed from a 0 silk tie.

Cardiac murmur prompting diagnosis of metastatic nonseminomatous germ cell testicular neoplasia in an 18-year-old patient.

Most retroperitoneal tumors such as renal cell carcinoma have been associated with tumor thrombus extending into the renal vein, inferior vena cava (IVC), and heart. The retroperitoneal metastatic potential of testicular tumors is well known. We report here the first instance of a cardiac murmur prompting diagnosis of metastatic testicular neoplasia in an 18-year-old patient. Chemotherapy was delayed and after successful surgical resection of the ventricular mass, the patient recovered uneventfully. This case underscores the need to pursue abnormal cardiac exams in newly diagnosed testicular cancer patients.

Novel technique for diagnosis and management of Fraley's syndrome: helical CT with three-dimensional volume rendering.

We report on the diagnosis and minimally invasive management of Fraley's syndrome using helical CT with volume-rendering techniques in an 18-year-old patient. Three-dimensional images were generated rapidly and allowed safe planning and execution of a laser infundibulotomy of the upper-pole calix. After 24 months of follow-up, the patient remains pain free.

Spontaneous nephroduodenal fistula in a 27-year-old woman.

Spontaneous nephroduodenal fistula formation is a rare occurrence. An otherwise healthy young patient presented with worsening chronic right flank pain and fevers. Retrograde pyelogram and computed tomography studies eventually led to a diagnosis and successful management of a right nephroduodenal fistula.

Newly designed laparoscopic retractable dissector and suture passer.

We introduce a novel laparoscopic instrument that performs as a dissector and retractable suture passer in preparation for intracorporeal knot tying. The newly designed instrument was developed at our institution to duplicate techniques of vessel ligation in open surgery.

Laparoscopic skills training using a webcam trainer.

PURPOSE: Many sophisticated and expensive trainers have been developed to assist surgeons in learning basic laparoscopic skills. We developed an inexpensive trainer and evaluated its effectiveness. MATERIALS AND METHODS: The webcam laparoscopic training device is composed of a webcam, cardboard box, desk lamp and home computer. This homemade trainer was evaluated against 2 commercially available systems, namely the video Pelvitrainer (Karl Storz Endoscopy, Culver City, California) and the dual mirror Simuview (Simulab Corp., Seattle, Washington). The Pelvitrainer consists of a fiberglass box, single lens optic laparoscope, fiberoptic light source, endoscopic camera and video monitor, while the Simuview trainer uses 2 offset, facing mirrors and an uncovered plastic box. A total of 42 participants without prior laparoscopic training were enrolled in the study and asked to execute 2 tasks, that is peg transfer and pattern cutting. Participants were randomly assigned to 6 groups with each group representing a different permutation of trainers to be used. The time required for participants to complete each task was recorded and differences in performance were calculated. Paired t tests, the Wilcoxon signed rank test and ANOVA were performed to analyze the statistical difference in performance times for all conditions. RESULTS: Statistical analyses of the 2 tasks showed no significant difference for the video and webcam trainers. However, the mirror trainer gave significantly higher outcome values for tasks 1 and 2 compared to the video (p = 0.01 and <0.01) and webcam (p = 0.04 and <0.01, respectively) methods. ANOVA indicated no overall difference for tasks 1 and 2 across the orderings (p = 0.36 and 0.99, respectively). However, by attempt 3 the time required to complete the skill tests decreased significantly for all 3 trainers (each p <0.01). CONCLUSIONS: Our homemade webcam system is comparable in function to the more elaborate video trainer but superior to the dual mirror trainer. For novice laparoscopists we believe that the webcam system is an inexpensive and effective laparoscopic training device. Furthermore, the webcam system also allows instant recording and review of techniques.

Simultaneous bilateral retrograde intrarenal surgery for bilateral complex upper tract stone disease.

Recent advances in retrograde endoscopy have greatly expanded the role of minimally invasive surgery in addressing upper tract stone disease. In an attempt to decrease patient morbidity further, we present our initial experience with simultaneous bilateral retrograde intrarenal surgery in a patient with complex bilateral upper tract stones.

Bladder reconstitution with bone marrow derived stem cells seeded on small intestinal submucosa improves morphological and molecular composition.

PURPOSE: Tissue engineering has been used for bladder augmentations with small intestinal submucosa (SIS). Although favorable short-term outcomes have been reported, long-term followup has been poor. We investigate whether tissue engineering with stem cells improves the morphological and genetic composition. MATERIALS AND METHODS: A total of 33 Lewis rats (Harlan Laboratories, Indianapolis, Indiana) were used to investigate bladder augmentations with 4-layer SIS in certain groups, including the control group (sham operation), partial cystectomy with oversewn defect group (OG), augmentation with unseeded SIS group (USG) and augmentation with stem cell seeded SIS group (SSG). Bladders from 4 rats per group were harvested 1 and 3 months after surgery. Morphological analyses were performed using Masson's trichrome and immunohistochemical staining with cytokeratin AE1/AE3, smooth muscle alpha-actin and S100. Gene expression was evaluated using quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR) for collagen I (CI), collagen III (CIII), cytokeratins 8 and 19, and smooth muscle myosin heavy chain (MHC). RESULTS: At 1 month trichrome staining revealed collagen admixed with indiscrete cells and morphology similar to that in controls in USG and SSG, respectively. Discrete smooth muscles fascicles and S100 staining were found in all groups except USG. Organized urothelium with increased basal cell layer staining was present in controls and SSG only. At 3 months increased collagen formation was present in OG and USG. Immunostaining showed hyperplasia of the urothelium with increased staining of the basal cell layer, discrete muscle fascicles and positive nerve staining in all groups. Using quantitative RT-PCR expression levels in SSG were more improved than in USG, especially for CI, CIII and MHC. This was further evident at 3 months when CI and CIII were over expressed in OG and USG but not in the control group or SSG. Furthermore, RT-PCR showed that cytokeratins 8 and 19, and MHC had greater expression levels in SSG than in USG. CONCLUSIONS: Bladder reconstitution occurs more rapidly using stem cell seeded SIS. Although in USG and SSG all 3 cellular constituents appear to develop by 3 months, only SSG had gene expression levels similar to those in controls. The results suggest an explanation for the fibrosis noted in unseeded SIS bladder augmentations and the possible solution using stem cells.

Laparoscopic assisted reconstructive surgery: a 7-year experience.

PURPOSE: Laparoscopic assisted surgery results in an improved cosmetic appearance by allowing complex reconstruction without a midline upper abdominal incision. We report technique and outcomes in patients undergoing laparoscopic assisted reconstruction during a 7-year period. MATERIALS AND METHODS: A total of 31 consecutive patients with a mean age of 14 years (range 1 to 36) underwent laparoscopic assisted reconstructive surgery through a lower midline or Pfannenstiel incision by a single surgeon (SGD) between June 1995 and July 2002. Diagnoses included myelomeningocele (17), sacral agenesis (2), posterior urethral valves (2), classic bladder exstrophy (5), complicated ectopic ureter with ureterocele (1) and quadriplegia due to trauma (4). A total of 29 patients had 39 continent stomas (antegrade continence enema [ACE] or Mitrofanoff) created as part of the reconstruction. One case was converted to an open procedure due to dense adhesions and was excluded from the study. Continent stoma construction included Mitrofanoff stomas created from appendix (17), ileum (3), sigmoid (5) and bladder (1), and ACE stomas from appendix (12) and ileum (1). Ten patients underwent concurrent Mitrofanoff and ACE procedures. Laparoscopy was used for lysis of adhesions, mobilization of colon and/or harvesting the appendix, nephrectomy in preparation for ureteral augmentation, division of pedicle for gastrocystoplasty takedown and harvesting of omentum for interposition. Bladder augmentation (15), bladder neck reconstruction (7), fascial sling (3), ureteral reimplants (1), revision of epispadias (2) and/or redo orchiopexy (1) were concurrently performed in 19 patients. Data were obtained through chart review and personal communication. RESULTS: Median hospital stay was 6 days (range 2 to 20). Mean followup was 32 months (range 3 to 57). Revisions were required in 3 stomas (7.7%) at a mean of 19 months (range 8 to 36) postoperatively. Minor procedures were required in 10 stomas (25.6%) consisting of indwelling catheterization, dilation, collagen injection and cystoscopy. Of the 39 stomas 37 (94.9%) were continent of urine and/or stool, and easily catheterizable at last followup. Adequate capacity and compliance were maintained in all augmented bladders. No patient experienced delayed small bowel obstruction or other sequela of abdominal adhesions. CONCLUSIONS: At almost 3 years of mean followup laparoscopic assisted reconstructive surgery offers functional outcomes at least equivalent to conventional open surgery in complicated cases with excellent cosmesis. Laparoscopic assisted surgery remains our approach of choice for children and adults who require lower urinary tract reconstruction with a continent catheterizable stoma.

Large cerebellar lesion as original manifestation of transitional cell carcinoma of the bladder.

Patients with transitional cell carcinoma of the bladder classically present with irritative voiding symptoms or painless hematuria. Common sites of vascular metastases include the liver (38%), lung (36%), bone (27%), adrenal glands (21%), and intestine (13%). Vascular metastasis to the brain, without a prior history of chemotherapy, is extremely rare. To our knowledge, this is the first report of a patient with bladder transitional cell carcinoma whose original presentation was from a symptomatic, metastatic, cerebellar lesion.

Delayed intraoperative hydration limits blood loss during radical retropubic prostatectomy.

OBJECTIVES: To evaluate the effects of limiting hydration during prostate mobilization on intraoperative blood loss. METHODS: The patient records of 519 consecutive men undergoing radical retropubic prostatectomy by a single surgeon from January 2000 through April 2003 were reviewed. In the initial 328 cases, intravenous fluids were not limited throughout the case (constant hydration group). In the next 189 cases, intravenous fluids were limited to a target of 1500 mL during prostate dissection (delayed hydration group). After the prostate was removed, hydration was brisk for an additional target of 3500 mL. The patient characteristics, perioperative events, and postoperative recovery were evaluated. RESULTS: Delayed hydration resulted in a statistically significant reduction in estimated blood loss compared with the constant hydration group, averaging 700 mL versus 965 mL, respectively. The immediate postoperative hematocrit values were also significantly greater in the delayed hydration group (31.5%) than in the constant hydration group (30.2%). Furthermore, the delayed hydration group had significantly fewer cases of blood loss greater than 1500 mL and fewer patients needed intraoperative transfusions. No statistically significant difference was found in total intravenous fluids given and no increased morbidity occurred with delayed hydration. CONCLUSIONS: Delayed hydration appears to reduce blood loss during radical retropubic prostatectomy. In the hemodynamically stable patient, limiting intravenous fluids before complete dissection of the prostate is feasible without increasing morbidity.

Mortality from grossly encrusted bilateral pyelitis, ureteritis, and cystitis by Corynebacterium group D2.

This is the first report of death due to gross encrustations of the entire upper urinary tract and bladder by Corynebacterium group D2 in a man with no history of renal transplantation or prolonged catheterizations. This case demonstrates that debilitated patients with a prior endoscopic procedure are at risk for this disease process. Prolonged treatment with appropriate antibiotics, acidification of the urine, and removal of crusts is essential for proper management.

Spontaneous, unremitting gross hematuria occurring one week after laparoscopic donor nephrectomy.

Complications associated with the ureteral stump after nephrectomies rarely occur, especially after donor nephrectomies. The potential for the slippage of clips is a well-known event associated with vascular ligations. We report on the first case of clip slippage from the ureter and describe diagnosis and management of the most extreme of morbid presentations.

Technique of combined pubovaginal sling and cystocele repair using a single piece of cadaveric dermal graft.

OBJECTIVES: To investigate the feasibility of using a single piece of cadaveric dermal allograft for the repair of stress urinary incontinence (SUI) with concurrent cystocele. METHODS: Nineteen patients with combined SUI and symptomatic grade III cystoceles were treated. Eleven of 19 patients had undergone prior repairs for SUI. All patients underwent a combined pubovaginal sling procedure and cystocele repair using a single piece of cadaveric dermal allograft (3 x 7 cm). The single strip of dermal graft was placed in a longitudinal direction along the anterior vagina. The distal segment of the allograft supported the urethra, and the proximal portion supported the central cystocele defect and was sutured to the pubocervical fascia. The mean follow-up was 28 +/- 4 months and patients were monitored by physical examination, videourodynamic studies, and completion of the bladder bothersome visual analog scale. RESULTS: Of the 19 patients, 1 developed an acute infection and failure of the graft after presenting with fever, discharge, dysuria, and incontinence. The autolysed graft was removed, and she subsequently underwent successful autologous fascial repair. Of the remaining 18 patients, 17 were cured of their SUI, including 10 who had had prior repairs, and 16 had no recurrence of cystocele and 2 had asymptomatic grade I and II cystoceles. One patient developed de novo detrusor instability that was successfully treated with anticholinergic medication. No cases of urethral obstruction occurred. CONCLUSIONS: Although the follow-up was short, the use of a single piece of cadaveric dermal graft slings for concomitant pubovaginal sling and cystocele repair is feasible and simple to perform. At more than 2 years of follow-up, documented by videourodynamic studies, neither urethral obstruction nor symptomatic cystocele recurrence was found.

15-year experience with the management of extrinsic ureteral obstruction with indwelling ureteral stents.

PURPOSE: We assessed the success of retrograde placement of indwelling ureteral stents in the management of ureteral obstruction due to extrinsic compression. MATERIALS AND METHODS: Between July 1987 and December 2002 adequate followup was available for 101 patients who underwent primary retrograde ureteral stenting for extrinsic ureteral obstruction. Mean age at presentation was 61.4 years (range 33 to 90). Chart review was performed on all patients for primary diagnosis, symptomatology, degree of hydronephrosis, creatinine levels (baseline, treatment and posttreatment), location of compression, size and number of stents used, progression to percutaneous nephrostomy tube (PNT), stent failure, days to stent failure, post-stent therapy and status at last followup. RESULTS: Mean length of followup was 11 months (range 1 to 127). In 101 patients 138 ureteral units (UU) were stented. Total stent failure occurred in 41 (40.6%) patients and 58 (42.0%) UU. A total of 40 (29.0%) UU required PNTs at a mean of 40.3 days (range 0 to 330) with 18 PNTs placed in less than 1 week. Cases of stent failure that did not undergo PNT placement included 18 (13.0%) UU at a mean of 52.4 days (range 3 to 128). A total of 90 (89.1%) patients had metastatic cancer at stenting with 32.2% dead at 5.8 months (range 1 to 32). Univariate and multivariate analyses identified cancer diagnosis, baseline creatinine greater than 1.3 mg/dl and post-stent systemic treatment as predictors of stent failure. Proximal location of compression and treatment creatinine greater than 3.11 mg/dl were marginal predictors of failure on univariate analysis, while proximal location of obstruction was also marginally significant on multivariate analysis. No predictors were identified for early stent failure (less than 1 week). CONCLUSIONS: At almost 1 year followup stent failure due to extrinsic compression occurred in nearly half of treated patients. Analysis of data revealed a diagnosis of cancer, baseline mild renal insufficiency and metastatic disease requiring chemotherapy or radiation as predictors of stent failure. Managing extrinsic compression by retrograde stenting continues to be a practical but guarded decision and should be tailored to each patient.