Complications of laparoscopic procedures after concentrated training in urological laparoscopy.

PURPOSE: To increase the safety and efficiency of laparoscopic surgery clinical training programs have been developed to increase the skill and efficiency of urological trainees. We evaluated the impact of dedicated laparoscopy training on the rate and type of complications after trainees entered clinical practice. MATERIALS AND METHODS: Data were obtained from 13 centers where laparoscopy was performed by a single surgeon with at least 12 months of training in urological laparoscopy before clinical practice. Data included training experience, laparoscopic procedures performed after commencing clinical practice and associated complications. Procedures were classified as easy, moderate and difficult. RESULTS: During training each surgeon participated in a mean of 71 cases. In clinical practice a total of 738 laparoscopic cases were performed with the group reporting an overall complication rate of 11.9%. The rate was unchanged when the initial 20, 30 and 40 cases per surgeon were compared with all subsequent cases (12%, 11.9% and 12% versus 11.8 to 12%, respectively). The re-intervention rate was 1.1%. The complication rate increased with case difficulty. Overall and early complication rates attributable to laparoscopic technique in the initial 20, 30 and 40 cases were identical. The most common complications were neuropathy in 13 patients, urine leakage/urinoma in 9, transfusion in 7 and ileus in 5. CONCLUSIONS: The complication rate of surgeons who completed at least 12 months of laparoscopy training did not differ according to initial versus subsequent surgical experience. Intensive training seems to decrease the impact of the learning curve for laparoscopy.

Factors involved in gas embolism after laparoscopic injury to inferior vena cava.

This study evaluated the incidence and factors involved in the occurrence of gas embolism after laparoscopic injuries. A 5-MHz transesophageal echocardiographic (TEE) probe was placed in 11 anesthetized pigs and used to examine the right cardiac chambers and pulmonary artery. A calibrated carbon dioxide analyzer continuously measured end-tidal carbon dioxide (ETCO2). The ventilatory settings were adjusted to achieve a baseline ETCO2 between 25 and 28 mm Hg. A blinded dose-response curve for TEE and ETCO2 measurements were created by injecting 0.0007 to 1.5 mL/kg of CO2 gas intravenously. Venotomies (N = 22) were created laparoscopically in the inferior vena cava (IVC) of the study animals. All TEE images were videotaped and correlated with laparoscopic events. Embolic episodes were classified by comparison with images recorded during the bolus studies. A variety of methods for obtaining hemostasis and repairing the venotomies were evaluated and their effects on gas embolism were studied. No emboli were noted when the venotomies were bleeding freely, the hole was directly occluded, or the proximal IVC was compressed. Marked embolism was seen with distal IVC occlusion or when there had been significant blood loss. In this situation, manipulation of the hole and higher intraperitoneal pressures led to higher degrees of embolization. No emboli were seen in an open control group except after significant bleeding. The TEE is the most sensitive method of detecting gas emboli; however, the majority of episodes are not clinically significant. Embolism of CO2 occurs when central venous pressure is decreased by blood loss or distal compression. When significant venous bleeding occurs, intravascular volume should be maintained and the bleeding site should be directly occluded.

Teleradiology in urology: comparison of digital image quality with original radiographic films to detect urinary calculi.

PURPOSE: Teleradiology systems are now being evaluated as a mechanism to provide rapid, accurate and cost-effective diagnostic radiographs to off-site physicians. Little data are available on the role and safety of teleradiology in urology. To address these issues a personal computer based system was developed to assess the diagnostic accuracy and ease of use of transmitted digital images when evaluating for urinary calculi. MATERIALS AND METHODS: A total of 100 plain abdominal scout films from excretory urograms performed during acute urological referrals was digitized on a laser scanner. The 10 megabyte files were transferred over public telephone lines and written to compact disks. The images were viewed on a 1280 x 1640 resolution monitor using "Imager-3D" software run on a 133 MHz. pentium personal computer with 32 megabytes of random access memory. Two faculty urologists and 2 urology fellows each looked at 50 original radiographs and 50 digital images. Diagnostic interpretations of the presence and location of calculi were recorded, and confidence in the diagnosis, assessment of image quality and diagnostic difficulty were scored using a numerical scale. RESULTS: The accuracy for all readers was 86.5% for plain radiographs and 81.5% for digital images (p >0.2). There was no statistical difference between faculty and fellows. Diagnostic accuracy did not differ between plain films and screen images when the results were assessed with respect to image quality, diagnostic difficulty or the reader confidence in the diagnosis (p >0.1). Compared to plain films, more screen images were classified as lower image quality (60 versus 40%) and the diagnostic confidence was lower (low and medium grade 50 versus 35%), although this did not interfere with diagnostic accuracy. CONCLUSIONS: These data imply that a high quality affordable teleradiology system is effective and accurate compared to plain films for assessing urinary calculi.

Digital radiographic imaging transfer: comparison with plain radiographs.

Advances in digital imaging and computer display technology have allowed development of clinical teleradiographic systems. There are limited data assessing the effectiveness of such systems when applied to urologic pathology. In an effort to appraise the effectiveness of teleradiology in identifying renal calculi, the accuracy of findings on transmitted radiographic images were compared with those made when viewing the actual plain film. Plain films (KUB) were obtained from 26 patients who presented to the radiology department to rule out urinary calculous disease. The films were digitalized by a radiograph scanner into ARCNEMA-2 file format, compressed by a NASA algorithm, and transferred via a 28.8-kbps modern over standard telephone lines to a remote section 25 miles away, where they were decompressed and viewed on a 1600 x 1200-pixel monitor. Two attending urologists and two endourologic fellows were randomized to read either the transmitted image or the original radiograph with minimal clinical history provided. Of the 26 plain radiographic films, 24 were correctly interpreted by the fellows and 25 by the attending physicians (92% and 96% accuracy, respectively) for a total accuracy of 94% with no statistical difference (p = 0.16). After compression, all but one of the digital images were transferred successfully. The attending physicians correctly interpreted 24 of the 25 digital images (96%), whereas the fellows were correct on 21 interpretations (84%), resulting in a total 90% accuracy with a significant difference between the groups (p < or = 0.04). Overall, no statistical difference between the interpretations of the plain film and the digital image was revealed (p = 0.21). Using available technology, KUB images can be transmitted to a remote site, and the location of a stone can be determined correctly. Higher accuracy is demonstrated by experienced surgeons.

Laparoscopic pyeloplasty: experience with the initial 30 cases.

PURPOSE: We assessed the intermediate effectiveness of laparoscopic pyeloplasty in the treatment of the obstructed ureteropelvic junction. MATERIALS AND METHODS: A total of 30 pyeloplasties was performed for symptomatic ureteropelvic junction obstruction (24 primary and 6 secondary cases). Two separate types of reconstruction were performed, that is dismembered (26 patients) and Y-V (4) pyeloplasty. All patients were followed with excretory urography or diuretic renography. Moreover, factors affecting the learning curve (surgical technique, prior laparoscopic experience and cause of obstruction) were evaluated. RESULTS: A lower pole segmental renal vessel was found at the ureteropelvic junction in 18 patients (60%). Operative time ranged from 2.25 to 8.0 hours (mean 4.5). Postoperative morbidity (mean narcotic requirement 37.3 mg. morphine sulfate, mean hospital stay 3.5 days and convalescence 3 weeks) was minimum. At radiographic followup (mean 16.3 months, range 4 to 73) 97% of the patients demonstrated a patent ureteropelvic junction and resolution of or substantial decrease in hydronephrosis. CONCLUSIONS: In the hands of an experienced laparoscopist, outcomes indicate that laparoscopic pyeloplasty shows success similar to that of open pyeloplasty but longer term outcomes must be assessed.

The role of laparoscopy in the treatment of renal and ureteral calculi.

PURPOSE: We assessed the efficacy of laparoscopy in the treatment of renal and ureteral stones. MATERIALS AND METHODS: Laparoscopic stone extraction was attempted in 11 men and 6 women 22 to 75 years old, including 6 with ureteral and 11 with renal calculi. Of the renal stones 9 were associated with a concomitant pathological condition requiring surgery. Four patients had multiple stones (2 to 93) and stone size ranged from 2 to 60 mm. (mean 15.6). RESULTS: Stones from 15 of 17 patients were removed successfully via laparoscopic techniques. Operative time ranged from 2.33 to 6.35 hours (mean 4.9). Prolonged operating times were associated with ancillary or failed procedures. Blood loss ranged from 20 to 350 ml. (mean 132.9), narcotic requirement from 0 to 100 mg. morphine (mean 26) and hospital stay from 1 to 15 days (mean 4.5). The 3 postoperative complications included prolonged ileus (2) and a retroperitoneal urinoma requiring secondary drainage. CONCLUSIONS: Laparoscopic stone removal is safe and feasible. Indications for this approach include urinary stones associated with an anatomical abnormality requiring urinary tract reconstruction and calculi for which other minimally invasive therapies failed.

Laparoscopic live donor nephrectomy: the initial 3 cases.

PURPOSE: Successful laparoscopic live donor nephrectomy in 3 patients is described. MATERIALS AND METHODS: The procedures were performed completely laparoscopically and the kidneys were extracted via 8 cm. infraumbilical incisions. RESULTS: In all 3 cases warm ischemic time was less than 5 minutes, and the renal vessels and ureter of the harvested kidneys were of adequate length for routine transplantation. Donors required minimal postoperative parenteral analgesia and were discharged home 1 to 3 days after the procedure. All harvested kidneys were successfully transplanted, and functioned well initially and at hospital discharge. CONCLUSIONS: Laparoscopic live donor nephrectomy may be an alternative surgical modality to conventional open nephrectomy. Advantages include less postoperative pain, shorter hospital stay and convalescence, and a more desirable cosmetic result. Additionally, these advantages may encourage more individuals to consider live donation, resulting in an increase in organ supply.