Laparoscopic reconstruction of the ureter: a survival canine study

Laparoscopic reconstruction of the ureter is a rarely visited domain in literature. Such reconstructive procedures, performed via conventional surgery, are common in our practice for management of Bilharzial and Tuberculous ureteric strictures, congenital malformations and iatrogenic trauma to the ureter. Ureteroneocystostomy, Boari flap and ileal replacement of the ureter are the procedures of choice in management of the whole spectrum of ureteral defects with high success rates for the open surgical procedures. To present our initial experience with experimental laparoscopic ureteroneocystostomy, Boari flap and ileal replacement of the ureter aiming at evaluation of such procedure and gaining experience prior to clinical application. Twelve healthy Mongrel dogs stratified into three groups. Each dog was subjected to one of three different levels of ureteric obstruction for one renal unit. Group 1 included 4 females for which juxtavesical obstruction of one ureter was done, Group 2 included 4 females for which obstruction was made at the lower part of the lumbar ureter and Group 3 which included 3 males and 1 female for which high lumbar obstruction was performed. Laparoscopic ureteroneocystostomy was performed for group I dogs, laparoscopic Boari flap for group 2 and laparoscopic ileal replacement of the ureter for group 3. All dogs survived the procedures, operative time ranged from 140 to 360 minutes [mean 253 +/- 70 minutes] and overall success rate was 83.33% as one renal unit lost function and one dog died on the second postoperative day. Laparoscopic reconstruction of the ureter with simple or complex procedures is technically feasible and safe. Standard laparoscopic armamentarium is quite sufficient for such procedures. Further experimentation is needed to outline the learning curve and to evaluate more techniques. Owing to our initial experience, we can conclude that clinical application of such procedures would be an achievable target in the hands of devoted laparoscopic surgeons who have good experience with reconstructive laparoscopic surgery

Prolonged pneumoperitoneum in exaggerated trendlenburg position; anesthetic implications

Laparoscopic radical cystectomy is a relatively new surgical procedure. Being a procedure of long duration, performed with pneumoperitonium in exaggerated Trendlenberg position; it is expected to pose unfavorable effects. We report pulmonary and haemodynamic changes in addition to postoperative outcome following laparoscopic radical cystectomy in the exaggerated head-down position. A prospective study was conducted on 31 patients anaesthetized with a combination of epidural and total intravenous anaesthesia [using midazolam, fentanyl, ketamine and vecuronium]. Surgery was done while the patient in head down position [40o]. Lungs were ventilated using air-oxygen [FiO2 = 0.35] with a tidal volume of 8 ml kg[-1] at a rate of 12-14 min[-1]. Lung mechanics, gasometric and haemodynamic variables were recorded at different strategic points. Recovery and postoperative outcome were also evaluated. Two patients discontinued because of conversion to open surgery and 29 completed the procedure. Fourteen of 29 patients [48.2%] had preoperative medical diseases and 11 patients [38%] received blood. There were significant decrease in lung compliance and significant increase in peak pressures after pneumoperitoneum and Trendelenburg. Concomitantly, heart rate, arterial pressure and carbon dioxide tension increased significantly. Three patients suffered postextubation airway obstruction and were reintubated. On the first postoperative day, one patient desaturated and one patient suffered severe nausea and vomiting. Laparoscopic radical cystectomy in exaggerated head down position is associated with brisk consequences and potential risks

Laparoscopic radical cystoprostatectomy for muscle invasive bladder tumors: technical aspects and initial experience

To report the initial experience with laparoscopic radical cystoprostatectomy and urinary diversion for muscle invasive bladder tumors. Twenty nine patients with invasive bladder tumors or high grade multicenteric papillary bladder tumors were subjected to laparoscopic radical cystoprostatectomy and urinary diversion. The procedures were performed through transperitoneal approach using 5 ports. The operative time, blood loss and the requirement for blood transfusion were recorded. lntraoperative and postoperative morbidity were monitored and recorded. The patients were followed up for continence status, upper urinary tract condition and development of local pelvic recurrence and/or distant metastasis. All the procedures could be completed by laparoscopy except 2 who required conversion to open surgery. The mean operative time was 242 +/- 22.5 minutes. The average blood loss was 784 +/- 84.5 ml. Eight patients required blood transfusion [27.5%]. Six cases developed intraoperative complications in the form of injury to external iliac artery [2], external iliac vein [2], obturator nerve [1] and deep dorsal venous complex [1]. Four cases developed postoperative major complications while 1 had minor complication. Strictures at the ureteroileal anastomosis were seen in 4 [6.8%] renal units. All the patients with orthotopic bladder substitutions were continent during daytime while 9 had nocturnal enuresis. Local pelvic recurrence and/or distant metastasis developed in 8 patients [27.6%]. Laparoscopic radical cystoprostatectomy could be performed with satisfactory outcome and accepted morbidity

Purse string technique: a modified approach for laparoscopic excision of a bladder mucosal cuff

We described a novel modification for excision of the bladder cuff during laparoscopic nephroureterectomy for management of transitional cell carcinoma of the upper urinary tract. The operative technique, intaoperative and postoperative outcome and morbidity and results of follow up were evaluated. Twelve patients with upper urinary tact transitional cell carcinoma were managed by laparoscopic nephroureterectomy with excision of the bladder mucosal cuff. The renal pedicle was early identified and clipped. The kidney was freed all around. The ureter was dissected distally down to ureterovesical junction. The intramural part of the ureter was sharply freed from the surrounding detrusor muscle of the bladder till the level of the ureteric orifice. Then the detrusor muscle was furtherly dissected away from the underneath bladder mucosa for 1cm around the ureteric orifice. A purse string suture was taken at the edge of the dissected bladder mucosal cuff. The cuff was excised and the suture was secured. All the procedures could be completed by laparoscopy. The mean operative time was 226 minutes. The mean blood loss was 233 ml. There was no major intraoperative or postoperative complication. The average hospital stay was 3.7 days. The median follow up period was 31.5 months. One patient developed recurrence in the renal bed. There was no pelvic recurrence. Two patients developed papillary bladder tumors. Both were managed by transurethral resection of the growths. Purse string technique enables complete nephroureterectomy without opening of the pelvicalyceal system. Short-term follow up depicted the oncologic safety of the procedure. A larger number of the patients and a longer follow up period are required to confirm our preliminary findings