Short-term impact of a laparoscopic "mini-residency" experience on postgraduate urologists' practice patterns.

BACKGROUND: To assist practicing urologists incorporate laparoscopic urology into their practice, a 5-day mini-residency (M-R) program with a mentor, preceptor, and proctor experience was established at the University of California, Irvine, and we report the initial results. STUDY DESIGN: Thirty-two urologists underwent laparoscopic ablative (n=17) or laparoscopic reconstructive (n=15) training, including inanimate model skills training, animal laboratory, and operating room observation. A questionnaire was mailed 1 to 15 months (mean, 8 months) after their M-R program, and responses were reviewed. RESULTS: A 100% response rate was achieved. The mean M-R participant age was 49 years (range 31 to 70 years). The majority of the participants (72%) had laparoscopic experience during residency training and had performed between 5 and 15 laparoscopic cases before attending the M-R program. Within 8 months after M-R, 26 participants (81%) were practicing laparoscopic surgery. Participants were performing laparoscopic radical nephrectomy (p=0.008), nephroureterectomy (p<0.0005), and pyeloplasty (p=0.008) at substantially higher rates after training. At the same time, fewer of the M-R participants were performing hand-assisted laparoscopic surgery after training (p=0.008) compared with before the M-R. Ninety-two percent of the participants indicated that they would recommend this training program to a colleague. CONCLUSIONS: A 5-day intensive laparoscopic ablative and reconstructive surgery course seems to encourage postgraduate urologists, already familiar with laparoscopy, to successfully expand the scope of their procedures to include more complex laparoscopic techniques such as nephrectomy, nephroureterectomy, and pyeloplasty into their clinical practice.

Case report: robot-assisted laparoscopic reconstruction of a ureteropelvic junction disruption.

PURPOSE: We present our experience with robot-assisted laparoscopic repair of a ureteropelvic junction (UPJ) disruption in a child. CASE REPORT: An 11-year-old boy was found to have a UPJ disruption after being struck by an automobile. After unsuccessful retrograde ureteral-stent placement, a percutaneous nephrostomy tube was placed for a planned delayed repair because of the patient's multiple injuries. One month later, the patient underwent laparoscopic repair with the DaVinci robotic system using a four-port transperitoneal technique. At 3 months' follow-up, a diuretic renogram demonstrated no obstruction. CONCLUSION: A minimally invasive laparoscopic approach using the DaVinci system is feasible in the repair of a traumatic UPJ disruption.

Laparoscopic removal of extraosseous Ewing's sarcoma of the kidney in a pediatric patient.

In the pediatric population, to the best of our knowledge, only 2 cases of renal extraosseous Ewing's sarcoma/primitive neuroectodermal tumor (EES/PNET) have been published. We report the initial case of renal EES/PNET occurring in a 10-year-old girl treated by a laparoscopic radical nephrectomy. The regimen used is the first documented use of neoadjuvant chemotherapy prior to laparoscopic radical nephrectomy for PNET. This approach obviated the need for a large incision and a prolonged postsurgical recovery. The minimally invasive nature of the laparoscopic procedure allowed for a rapid convalescence and resumption of her chemotherapy regimen within 14 days of the surgery.

Surgical management of bilateral ureteral endometriosis.

Ureteral endometriosis is a rare disease that typically is unilateral. Endometriosis involving both ureters and surgical management after hormone therapy failure has seldom been described. We describe a patient with bilateral ureteral endometriosis who underwent ureteroneocystostomy with psoas hitches of both ureters. A 33-year-old woman with advanced endometriosis and recurrent pyelonephritis was found to have high-grade bilateral ureteral obstruction at the pelvic inlet from ureteral endometriosis. The patient subsequently underwent a supracervical hysterectomy with bilateral salpingo-oophorectomy, ureterolysis, and ureteroneocystostomy with psoas hitches and ureteral stent placements. Surgical therapy is reserved for advanced disease with the optimal choice being a ureteral reimplantation with a psoas hitch. The key operative point for a successful psoas hitch ureteral reimplantation is completely mobilizing the bladder anteriorly and laterally.

Initial impact of a dedicated postgraduate laparoscopic mini-residency on clinical practice patterns.

BACKGROUND AND PURPOSE: Laparoscopic surgical techniques are difficult to master, especially for surgeons who did not receive this type of training during their residencies. We have established a 5-day mentor-preceptor- proctor-guided postgraduate "mini-residency" (M-R) experience in minimally invasive surgery. The initial results from the first 16 participants in the laparoscopic M-R modules are presented. PARTICIPANTS AND METHODS: On the first and the last day of the M-R, all participants underwent surgical skills testing using an open-surgery, standard laparoscopic, and robot-assisted laparoscopic format. A written examination was also administered on the last day. The influence of M-R on the participants' practice pattern was then assessed by a follow-up questionnaire survey 1 to 7 months after their attendance. RESULTS: Data from the first 16 participants were analyzed. Of note, the score was significantly improved for only one of the four tested laparoscopic skills (i.e., threading a suture through loops). Nonetheless, on the follow-up survey, of the 15 respondents, two laparoscopically naïve participants had performed laparoscopic nephrectomy, and of the eight participants who had prior renal-ablative laparoscopic experience, four had performed advanced reconstructive laparoscopic cases. CONCLUSIONS: A 5-day dedicated postgraduate M-R in laparoscopy appears to be helpful for urologists wishing to incorporate this surgical approach into their practices. The "take rate" among participants is initially at the 40% level, similar to what has been previously reported after a 1 to 2-day hands-on didactic laparoscopy course.

Robotic-assisted laparoscopic ureteroureterostomy in an adolescent with an obstructed upper pole system and crossed renal ectopia with fusion.

Ureteropelvic junction obstruction (UPJO) in crossed renal ectopia with fusion is a rare condition. Management of UPJO occurring in ectopic kidneys generally requires open surgical reconstruction. Experience with minimally invasive techniques is minimal for repair of UPJO in ectopic kidneys. We report what we believe to be the first documented case of laparoscopic ureteroureterostomy with the da Vinci robotic system in an adolescent with an obstructed upper pole system and crossed renal ectopia with fusion.

Initial comparison of robotic-assisted laparoscopic versus open pyeloplasty in children.

OBJECTIVES: To compare the initial results of robotic-assisted laparoscopic versus open pyeloplasty in children with ureteropelvic junction obstruction. METHODS: From June 2002 to July 2004, 8 pediatric patients underwent robotic-assisted laparoscopic pyeloplasty and were matched by age group with patients undergoing conventional open pyeloplasty. The mean age was 11.5 years (range 6.4 to 16.5) in the robotic-assisted group and 9.8 years (range 6.0 to 15.6) in the open group. A four-port transperitoneal technique was used to perform the Anderson-Hynes pyeloplasty with the da Vinci Surgical System. RESULTS: The mean operative time and estimated blood loss was 363 minutes (range 255 to 522) and 13.1 mL (range 5 to 25) in the robotic-assisted group versus 248 minutes (range 144 to 375) and 53.8 mL (range 5 to 200) in the open group, respectively. The mean length of hospitalization and pain medication use was 2.4 days (range 1 to 5) and 7.4 mg morphine (range 0 to 23) in the robotic-assisted group compared with 3.3 days (range 1 to 8) and 22.0 mg morphine (range 0 to 100) in the open group, respectively. At a mean follow-up of 14.7 months (range 2 to 24), all robotic procedures were successful as determined by subjective data using pain scales and radiologic data. CONCLUSIONS: Robotic-assisted laparoscopic pyeloplasty appears to decrease the length of hospitalization and use of pain medication, but has a longer operative time. Additional clinical experience is required to determine the long-term efficacy of this method.

Laparoscopic assisted radical cystectomy with ileal neobladder: a comparison with the open approach.

PURPOSE: To date, there have been only a few reports regarding the feasibility of the laparoscopic approach to radical cystectomy. In none of these cases has the laparoscopic approach been contrasted with a contemporary cohort of open cystectomy and diversion. Recently, we initiated laparoscopic assisted radical cystoprostatectomy and ileal neobladder (LACINB) wherein the cystoprostatectomy and pelvic lymph node dissections are performed laparoscopically and the reconstructive portion is performed via a 15 cm Pfannenstiel incision. We present and compare our initial series of LACINB with radical cystectomy performed by the open approach (OCINB) during the same period. MATERIALS AND METHODS: Between September 2001 and February 2003, 13 men underwent LACINB and 11 underwent OCINB at our institution. RESULTS: There was no statistically significant difference in operative time, blood loss or complication rates between the LACINB and OCINB groups. However, postoperative analgesic use was significantly less in the LACINB group. Time to start of a liquid diet, solid diet and length of hospitalization were also significantly less in the LACINB group vs the OCINB group. All margins in both groups were negative for bladder cancer, although 1 patient in the LACINB group had an incidentally found prostate cancer with a positive apical margin. CONCLUSIONS: LACINB is a feasible and reproducible procedure, which results in decreased postoperative pain and quicker recovery without a significant increase in operative time. However, longer followup is needed to assess long-term oncological and functional outcomes.