Mini-Flank incision assisted laparoscopy versus transperitoneal laparoscopy for dismembered pyeloplasty

To define the impact of the combined approach on the minimally invasive style of laparoscopic approach. From July 2005 to September 2007, 21 patients with unilateral primary pelvi-ureteric junction [PUJ] obstruction underwent Anderson Hynes pyeloplasty. Patients were divided into two groups. Group 1: consisted of 11 patients who had combined transperitoneal laparoscopic approach and then mini-open approach. The surgical procedure was divided into two steps: laparoscopic dissection of the renal pelvis and proximal ureter and then accomplishing the pyeloplasty through mini-flank [5 cm], muscle splitting incision which was planned under laparoscopic guidance to be accurately overlaying the PUJ. Group 2: consisted of 10 patients who underwent the whole procedure through laparoscopic approach. Perioperative records and postoperative assessment were compared between the two groups. The mean operating time [135 versus 189 min] and Analgesic requirement [90 versus 36 mg, morphine equivalent] were significantly different between group 1 and 2, respectively. There was no intraoperative complication in both groups and the postoperative complications were minor and similar in both groups [10%]. Postoperatively, time to resume the full activity was significantly different between the groups 1 and 2, at 2 weeks [54.0 versus 80%, respectively] however, it was similar [100%] at 4 weeks. Postoperative, assessment of the all patients, based on IVU and diuretic renogram at 3 and 6 months, were similar in both groups. Dismembered pyeloplasty through a combined approach save time and ensures high quality of anastomosis while maintaining the minimally invasive fashion of laparoscopic approach

Transperitoneal laparoscopic pyelolithotomy: initial experience

To define the feasibility, safety and efficacy of transperito-neal laparoscopic pyelolithotomy in treatment of renal pelvic stones. In the period between March 2004 and November 2006, 15 patients were subjected to Transperitoneal laparoscopic pyelolithotomy among them three had an associated upper calyceal stones [8-11 mm]. Inclusion criteria were single renal pelvic stone in partial or complete extrarenal pelvis [with or without associated single calyceal stone] with no history of previous ibsilateral upper tract open surgery or pyelonephritis. The mean stone size was 2.7 cm [range 2-3.5 cm]. Out of the fifteen patients, 4 patients were refractory to ESWL, one had a failed PCNL and the remaining ten patients were managed laparoscopically as first choice. All patients had a double J stent fixation. Transpyelotomy, a rigid nephroscope or short ureteroscope had been used to localize and remove associated calyceal stone. Transperitoneal laparoscopic stone removal was successful In 13 out of 15 patients [86.6%] while the remaining 2 patients [13.4%] had open conversion. The main reason for open conversion was extensive fibrosis. In laparoscopically successful patients, the operative time was ranged from 100-190 min [mean 135 min]. Estimated blood loss was 40-120 mL [mean 65 mL], analgesic intake was 150 +/- 75 mg of diclophenac sodium, hospital stay was 3.1 days and the postoperative urine leakage was ranged from 1-10 days [mean 2.3 days]. No major intraoperative or postoperative complications was detected, however minor postoperative complications in the form of a high grade fever, 3 days ileus and prolonged urinary leakage for 10 days were recorded in 3 patients and all were resobed conservatively. Transperitoneal laparoscopic pyelolithotomy is feasible, safe and effective in treatment of renal pelvis stones either primary or as a salvage procedure after failed ESWL or PCNL

Ureteroscopic lithotripsy of ureteric stones; holmium: Yag laser versus pneumatic lithoclast

To compare efficacy and safety of pneumatic lithoclast [PL] and Holmium: YAG laser lithotripsy [LL]. From May 2004 to October 2006, ninety patients with single ureteric stones of 10 - 20 mm size underwent a single session of ureteroscopic lithotripsy with either pneumatic lithoclast [40 patients] or holmium: YAG laser [50 patients]. A 9/ 9.8 Fr semi rigid ureteroscope was used in all patients. Holmium: YAG laser with 365m probe was employed in LL group and pulse frequency was set between 5-10 HZ at a power of 10 - 12W. Pneumatic lithoclast with single or continuous pulse mode was used accordingly in PL group. Success is defined by fragmentation of the stone into fragment not bigger than 3 mm with stone free status achieved 6 weeks postoperatively by single session lithotripsy without retrograde stone migration to pelvicalyceal system. Patients were followed by plain KUB X ray or plain helical CT all stone free status. Then underwent TVP evaluation 3 months postoperatively. Both groups were demographically homogenous. Fragmentation into small that can be removed easily with stone basket or forceps or pass eventually was higher in LL than PL group [96% versus 80%] and the stone free status was achieved in 94% in LL and 75% in PL group. Partial ureteral perforation was detected in 7.5% versus 2% in PL and LL group. Hospital stay was 2.9 versus 1.7 days in PL and LL group, respectively. Time to achieve stone free status was shorter in LL than PL group [22 versus 37 days]. Holmium YAG lasertripsy is superior to pneumatic lithotripsy since it effectively fragments all stone types and sizes into smaller fragments even if impacted and if used with care, operative and postoperative complications is negligible

Complications and functional results of standard orthotopic diversion: studer`s pouch

Objective: The purpose of this study was to evaluate early and late complications, reservoir functional outcome, continence status and upper tract functional throughout the follow up after Studer ileal neobladder

Patients and methods: Thirty two patients were included in this study and followed at a regular interval of three months for one year postoperatively. Early and late complications, urinary continence and upper tract configuration and function were evaluated. Patients were assessed by interviews and history taking, voiding diary, continence questionnaire, abdominopelvic ultrasound, IVU and urodynamic study

Results: No postoperative mortality. Early and late postoperative complications rates were 28.1% and 12.5% respectively. Out of 32 patients, febrile urinary tract infection occurred in 4 patients, prolonged urinary leakeage in 2 patients, unilateral hydronephrosis in 3 patients, urethroileal stricture in 3 patients, and metabolic acidosis in one patient. The mean functional pouch capacity increased over time from 298 +/- 65ml at 3month postoperatively to 423 +/- 93 at 9 month of follow up and became fixed thereafter. The mean post voiding residual urine estimated by ultrasound was 46 +/- 18 at 6 month of follow up. All patients underwent urodynamic evaluation at 6 and 12 month postoperative. The maximal pouch capacity was 395 +/- 75 ml with the pouch pressure at maximal capacity was 30 +/- 6 cm water at 6 month postoperative with similar value at 12 month and thereafter. Continence status improved over time, meanwhile the night time continence rate was lower than daytime, unsatisfactory night continence who need more than one pad per night was recorded in 12.5% then reduced to 3.1% at 6 month and 12 month postoperative respectively .IVU at 6 month show no upper tract ectasia or dilatation in all patients through out next follow up period

Conclusion: Studer ileal neobladder is easy and satisfactory surgical technique of orthotropic urinary diversion. It provides an acceptable rate of postoperative complications with good functional reservoir outcome and continence status while preserving upper tract function

Predection of extracorporeal shock wave lithotrepsy outcome based on non-contrast helical computed tomography quantitative predictors

Objective: To assess the pretreatment non contrast helical computed tomography [NCCT] measurements, in the form of, stones Hounsfield unite [HU] and skin to stone distance [SSD] to define the effect of each on extracorporeal shock wave lithotripsy [ESWL] results

Patients and Methods: Twenty eight patients with single renal pelvic [10-20mm] or proximal ureteric stone [5-10mm] had pre-extracorporeal shock wave lithotripsy [ESWL] evaluation by non-contrast computed tomography [NCCT]. Stone attenuation value measured in Hounsfield Unit [HU] as well as skin to stone distance[SSD] was measured on selected NCCT image of interest for each patient, these measures were evaluated as predictors of ESWL outcome. Patients with renal pelvic stones received 3000 shocks per ESWL session while those with proximal ureteric stones received 4000 shocks per session, the maximum ESWL session number allowed were 3 .Patients were evaluated by plain X- ray of the kidney, ureter and bladder [KUB] after each ESWL session. Six weeks after ESWL treatment patients with stones greater than 3mm considered residual stone patients [10 out of 28 patients], while those with complete stone clearance or fragment 3mm or less considered stone- free patients [18 out of 28 patients].The stone attenuation value [HU] and skin to stone distance [SSD] in the stone-free and residual- stone patients group were compared

Results: The overall mean HU value for stone-free and residual-stone patients was significantly different 669 +/- 14.9 HU versus 962 +/- 11.5 HU respectively. The body mass index [BMI] as indicator of overweight or obesity status, go hand in hand with SSD and correlated well with each other, the mean SSD for stone free and residual stone patients were 9.3 +/- 2.7 and 11.4 +/- 3.01 cm respectively, which were statistically significantly different. Analysis of the data revealed that stones of greater than 900 HU were less likely to fragment and ESWL failure is probable[5 patients out of 8, 62.5%]. Furthermore, patients with SSD 10 cm or less had 91.6% stone free rate [11 out of 12 patients], while those with SSD greater than 10 cm had only 43.7% stone free rate [7 patients out of 16]

Conclusion: We concluded that, stone HU and the patients obesity status as expressed by the SSD are powerful predictors of NCCT for ESWL results, so we can save; unnecessary exposure to shock waves, time, effort and costs