Renorrafia simplificada empleando sutura barbada durante la nefrectomía parcial laparoscópica / Simplified Renorrhaphy Using Self-retaining Barbed Suture During Laparoscopic Partial Nephrectomy

Introducción y objetivos: La nefrectomía parcial laparoscópica (NPL) es una intervención desafiante que requiere sutura intracorpórea rápida y efectiva, lo que limita su aplicación de forma extendida. Refinamientos de la cirugía han mejorado los tiempos de isquemia y facilitado la reconstrucción renal. Se presenta una técnica que simplifica al máximo la renorrafia empleando sutura barbada de auto-retención (SBAR) entrelazando dos hilos. Pacientes y métodos: A dos pacientes con carcinoma de riñón, de 3,4 y 1,5 cm respectivamente, se les realizó la NPL. La SBAR es un poligliconato absorbible con pequeños salientes a lo largo de su eje que se anclan en los tejidos, distribuyendo la tensión de la línea de sutura y eliminando la necesidad de nudos. La renorrafia se realizó con la SBAR mediante dos líneas de sutura continuas sin nudos, fijando los hilos con clips de Hem-o-lok® y ajustándolos con la técnica del «clip deslizante», sin colocación de bolsters dentro del defecto del parénquima renal. Resultados: El tiempo operatorio fue de 156 y 163 minutos, el sangrado intraoperatorio fue de 50 y 850 ml, el tiempo de isquemia caliente fue de 14,3 y 23 minutos y el tiempo de seguimiento fue de 7 y 3 meses, en el primer y segundo caso respectivamente. La estancia hospitalaria fue de 5 días y no hubo complicaciones postoperatorias. Conclusiones: La renorrafia simplificada empleando SBAR es efectiva, hemostática, facilita significativamente la reconstrucción renal y puede ayudar a disminuir los tiempos de isquemia (AU)

Introduction and objectives: Laparoscopic partial nephrectomy (LPN) is a challenging procedure that requires quick and effective intracorporeal suturing, that could limit wides preadadoption. Refinements of surgery have improved warm ischemia times and facilitated renal reconstruction. We present a technique that makes renorrhaphy easier using Self-Retaining Barbed Suture (SRBS) weaving two threads. Patients and methods: Two patients with carcinoma of the kidney, 3.4 and 1.5 cm respectively, were subjected to the LPN. The SRBS is an absorbable polygluconate with small projections along its axis which are anchored in the tissue, distributing the tension of the suture line and eliminating the need for knots. Renorrhaphy was performed using the SRBS by two continuous suture lines without knots, setting the sutures with clips of Hem-o-lok® and adjusting it with the technique of «sliding clip», without placing «bolsters» inside the renal parenchymal defect. Results: Operative time was 156 minutes and 163 minutes, intraoperative bleeding was 50 ml and 850 ml, the warm ischemia time was 14.3 minutes and 23 minutes and follow-up time was7 months and 3 months in the first and second cases respectively. The hospital stay was 5 days and there were no postoperative complications. Conclusions: Simplified renorrhaphy using SRBS is effective, hemostatic, facilitates the renal reconstruction, and can help reduce the warn ischemia time (AU)

[Simplified renorrhaphy using self-retaining barbed suture during laparoscopic partial nephrectomy]. / Renorrafia simplificada empleando sutura barbada durante la nefrectomía parcial laparoscópica.

INTRODUCTION AND OBJECTIVES: Laparoscopic partial nephrectomy (LPN) is a challenging procedure that requires quick and effective intracorporeal suturing, that could limit widespread adoption. Refinements of surgery have improved warm ischemia times and facilitated renal reconstruction. We present a technique that makes renorrhaphy easier using Self-Retaining Barbed Suture (SRBS) weaving two threads. PATIENTS AND METHODS: Two patients with carcinoma of the kidney, 3.4 and 1.5 cm respectively, were subjected to the LPN. The SRBS is an absorbable polygluconate with small projections along its axis which are anchored in the tissue, distributing the tension of the suture line and eliminating the need for knots. Renorrhaphy was performed using the SRBS by two continuous suture lines without knots, setting the sutures with clips of Hem-o-lok(®) and adjusting it with the technique of «sliding clip¼, without placing «bolsters¼ inside the renal parenchymal defect. RESULTS: Operative time was 156 minutes and 163 minutes, intraoperative bleeding was 50 ml and 850 ml, the warm ischemia time was 14.3 minutes and 23 minutes and follow-up time was 7 months and 3 months in the first and second cases respectively. The hospital stay was 5 days and there were no postoperative complications. CONCLUSIONS: Simplified renorrhaphy using SRBS is effective, hemostatic, facilitates the renal reconstruction, and can help reduce the warn ischemia time.

Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi.

PURPOSE: We compared the efficacy of shock wave lithotripsy and ureteroscopy for treatment of distal ureteral calculi. MATERIALS AND METHODS: A total of 64 patients with solitary, radiopaque distal ureteral calculi 15 mm. or less in largest diameter were randomized to treatment with shock wave lithotripsy (32) using an HM3 lithotriptor (Dornier MedTech, Kennesaw, Georgia) or ureteroscopy (32). Patient and stone characteristics, treatment parameters, clinical outcomes, patient satisfaction and cost were assessed for each group. RESULTS: The 2 groups were comparable in regard to patient age, sex, body mass index, stone size, degree of hydronephrosis and time to treatment. Procedural and operating room times were statistically significantly shorter for the shock wave lithotripsy compared to the ureteroscopy group (34 and 72 versus 65 and 97 minutes, respectively). In addition, 94% of patients who underwent shock wave lithotripsy versus 75% who underwent ureteroscopy were discharged home the day of procedure. At a mean followup of 21 and 24 days for shock wave lithotripsy and ureteroscopy, respectively, 91% of patients in each group had undergone imaging with a plain abdominal radiograph, and all studies showed resolution of the target stone. Minor complications occurred in 9% and 25% of the shock wave lithotripsy and ureteroscopy groups, respectively (p value was not significant). No ureteral perforation or stricture occurred in the ureteroscopy group. Postoperative flank pain and dysuria were more severe in the ureteroscopy than shock wave lithotripsy group, although the differences were not statistically significant. Patient satisfaction was high, including 94% for shock wave lithotripsy and 87% for ureteroscopy (p value not significant). Cost favored ureteroscopy by $1,255 if outpatient treatment for both modalities was assumed. CONCLUSIONS: Ureteroscopy and shock wave lithotripsy were associated with high success and low complication rates. However, shock wave lithotripsy required significantly less operating time, was more often performed on an outpatient basis, and showed a trend towards less flank pain and dysuria, fewer complications and quicker convalescence. Patient satisfaction was uniformly high in both groups. Although ureteroscopy and shock wave lithotripsy are highly effective for treatment of distal ureteral stones, we believe that HM3 shock wave lithotripsy, albeit slightly more costly, is preferable to manipulation with ureteroscopy since it is equally efficacious, more efficient and less morbid.

Flexible ureteroscopes: a single center evaluation of the durability and function of the new endoscopes smaller than 9Fr.

PURPOSE: Flexible ureteroscopes smaller than 9Fr are widely used in endourology. We systematically evaluated the functional durability of these instruments in the clinical setting. MATERIALS AND METHODS: We performed ureteronephroscopy 92 consecutive times in 84 patients at our hospital using a flexible Storz model 11274AA,double dagger Circon-ACMI model AUR-7, section sign Wolf model 7325.172 parallel and Olympus model URF/P3 ureteroscope paragraph sign. Preoperatively and postoperatively we evaluated all flexible ureteroscopes for luminosity, irrigant flow at 100 mm. Hg, number of broken image fibers and active deflection range. During the procedure a record was kept of the duration that the endoscope remained in the urinary tract, average irrigation pressure, method of insertion, various devices used within the working channel, need for lower pole access, and surgeon overall impression of visibility and maneuverability. RESULTS: The luminosity and irrigant flow of all endoscopes remained relatively unchanged during consecutive applications, while active deflection deteriorated 2% to 28%. Endoscopes were used for an average of 3 to 13 hours before they needed repair. The most fragile part of these instruments was the deflection unit. CONCLUSIONS: Small diameter flexible ureteroscopes are effective for diagnosing and treating upper urinary tract pathology but improved durability is required. Currently they represent a highly effective but high maintenance means of achieving retrograde access to the ureter and kidney with a need for repair after only 6 to 15 uses.

Clinical effectiveness of new stent design: randomized single-blind comparison of tail and double-pigtail stents.

BACKGROUND AND PURPOSE: Stent morbidity appears to be secondary to lower urinary tract irritation. In an effort to decrease stent morbidity, a "one size fits all" Tail stent (Microvasive [Boston Scientific] Natick, MA) was developed with a 7F proximal pigtail and 7F shaft which tapers to a lumenless straight 3F tail. PATIENTS AND METHODS: We randomized 60 patients in a single-blind fashion to a 7F tail stent or 7F double-pigtail Percuflex stent. Patients were evaluated at the time of stent removal and 2 weeks later with a standardized questionnaire assessing: irritative lower tract symptoms individually and on a total scale of 0 (no symptoms) to 30 (worst symptoms), obstructive lower tract symptoms (on a total scale of 0-20), and upper tract irritative symptoms (on a total scale of 0-10). RESULTS: Patient age, weight, and height were similar in the two groups. Complications, including fever, urinary tract infections, emergency room visits, and the need for antispasmodics and pain medication, also demonstrated no significant difference. At the time of stent removal, patients who received a tail stent had significantly less urinary frequency and a statistically significant (21%) decrease in overall irritative voiding symptoms (12.2 v 15.4; p = 0.048). Two weeks after stent removal, the total irritative voiding symptoms was markedly decreased in both groups (7.1 in the Tail v 5.3 in the double-pigtail group; p = 0.15). Obstructive bladder and flank symptoms were not significantly different in the two stent groups, either at the time of stent removal or at 2 weeks after removal. CONCLUSION: In this randomized, single-blind study, the 7F Tail stent produced significantly less irritative symptoms than did the standard 7F double-pigtail stent. Obstructive symptoms tended to be less with the new stent, while flank symptoms were similar.

Laparoscopic exploration in the management of retroperitoneal masses.

BACKGROUND AND OBJECTIVES: The isolated finding of a retroperitoneal mass (RM) often represents a diagnostic challenge. Image-guided biopsy is frequently inadequate for diagnosis. With increasing experience, the use of laparoscopy for exploration of an indeterminate RM may provide a minimally invasive alternative to open exploration. Herein, we present a retrospective review of our initial four laparoscopic explorations, comparing our experience to four contemporary open explorations for an RM. PATIENTS AND METHODS: From July 1995 to January 1998, four patients, aged 50 to 62 years old, with an RM of undetermined etiology underwent laparoscopic exploration. Another four patients underwent open exploration at the same hospital. The medical records of these patients were reviewed. RESULTS: The tumors were smaller in the laparoscopic group, averaging 3.7 cm (range 2-6 cm) vs 6.5 cm (range 1-10 cm) in the open group. A definitive diagnosis was obtained for all eight patients. Postoperative complications were observed in one of the laparoscopic explorations, and in three of the open explorations; there was no operative mortality. The blood loss (90 vs 440 ml), fall in hematocrit (5.1 vs 7.8%), time to resumption of a regular diet (3 vs 5 days), amount of morphine sulfate equivalents required for analgesia (128 mg vs 161 mg), time to ambulation (2.3 vs 6 days) and hospital stay (4.8 vs 6 days) were all less among the laparoscopy patients. However, the operative time was longer for the laparoscopic procedure; this time included stent placement and patient repositioning in addition to the time for laparoscopic excision of the mass (7.8 vs 4.3 hours). CONCLUSION: Laparoscopic exploration appears to be a viable alternative to open exploration in patients presenting with a retroperitoneal mass. It is as effective as an open procedure and provides benefits with regard to patient morbidity and convalescence. However, operative time for this laparoscopic procedure is lengthy.

Is the laparoscopic approach justified in patients with xanthogranulomatous pyelonephritis?

OBJECTIVES: Xanthogranulomatous pyelonephritis (XGP) is an atypical form of chronic renal infection. The treatment of choice is open nephrectomy, which is challenging, given the extent of the disease and the not uncommon involvement of the renal hilum and contiguous structures. We compared our experience with laparoscopic nephrectomy for histologically confirmed XGP with the open approach. METHODS: Review of all nephrectomy specimens at Washington University School of Medicine from July 1990 to March 1998 disclosed 9 patients with a pathologic diagnosis of unilateral XGP, of whom 5 patients underwent laparoscopic nephrectomy and 4 underwent open nephrectomy. XGP was suspected preoperatively in 56% of the patients. RESULTS: For the laparoscopic group, the average operating room time was 360 minutes, average blood loss was 260 mL, and complications occurred in 60% of patients (1 conversion to open, 1 ileus, 1 pulmonary embolus). For the open group, the average operating room time was 154 minutes, average blood loss was 438 mL, and there were no complications. Both groups were similar regarding time to oral intake, analgesia requirement, hospital stay, and time to complete recovery. CONCLUSIONS: Our early experience demonstrates that the benefits of laparoscopic nephrectomy, at present, do not extend to patients with XGP. Conventional open surgery is quicker, associated with fewer complications, and results in a similar use of analgesics, hospital stay, and recovery time.

Laparoscopic replacement of urinary tract segments using biodegradable materials in a large-animal model.

OBJECTIVE: We elected to evaluate laparoscopic segmental bladder and ureteral replacement with free biodegradable graft materials in a large-animal model. MATERIALS AND METHODS: In 18 Yucatan minipigs, a 1.5- to 2.8-cm segment of the upper ureter was excised. In 15 study animals, the ureter was laparoscopically replaced: by a stinted (6F double-J stent) tube graft made of acellular matrix (AMX) prepared from minipig ureters (MUMX) in 6 animals, acellular matrix prepared from domestic pig ureters (DUMX) in 3, and small-intestinal submucosa (SIS) in 6. In 3 control animals, the ureteral gap was bridged only by an indwelling stent. The stent was removed at 6 weeks, and retrograde ureteropyelography was performed preoperatively and at 8 and 12 weeks postoperatively, when animals were sacrificed. In 18 Yucatan minipigs, 3 x 3-cm bladder dome segments were laparoscopically replaced: by acellular matrix prepared from minipig small bowel (MBMX) in 6 animals, and SIS in 6 animals. The bladder was closed primarily in 6 control animals. Bladder capacity was assessed preoperatively and at 6 and at 12 weeks, when the animals were sacrificed. RESULTS: The average operating time for ureteral replacement was 187 (range 105-360) minutes. At 12 weeks, all animals had complete obstruction at the level of the replacement, with fibrosis +/- bone formation at the level of the stricture. For the bladder replacement groups, the average operating time was 147 (range 85-200) minutes. At 12 weeks, the bladder capacity was 60% of the preoperative capacity in the control group, 118% in the MBMX group, and 142% in the SIS group. Histologic examination showed regeneration of urothelium and some muscle with both MBMX and SIS. CONCLUSIONS: We were able to develop a reliable laparoscopic technique for both segmental ureteral and partial bladder replacement in a porcine model. With AMX and SIS replacement, regeneration of urothelium occurred in both ureter and bladder. However, functional replacement was successful only in the bladder.

The effect of patient position on intrarenal anatomy.

BACKGROUND AND OBJECTIVE: Although flexible ureteroscopes are designed with mechanisms for active and passive tip deflection, one of the major problems is the not infrequent inability to enter the lower pole calices. Accordingly, we measured the change in the lower pole infundibulopelvic (LIP) angle when the patient's position was varied (i.e., prone, supine, head down) during intravenous urography (IVU). PATIENTS AND METHODS: The LIP angle was measured in 20 right and 26 left adult kidneys during an IVU with the patient in six different positions: supine level, supine 20 degrees head down, supine 45 degrees head up, prone level, prone 20 degrees head down, and prone 45 degrees head up. None of the patients had a history of renal surgery. RESULTS: In all cases, the broadest angle of entry to the lower pole infundibulum was obtained with the patient in a prone position and 20 degrees head down. CONCLUSIONS: The LIP angle broadens when the patient lies in a prone 20 degrees head down position. This maneuver could improve the surgeon's ability to access the lower pole calices when performing flexible ureteronephroscopy.

Mechanism of ureteral stent flow: a comparative in vivo study.

BACKGROUND AND OBJECTIVES: The flow characteristics of ureteral stents have yet to be clearly defined. In this study, flow mechanics were studied in several silicone-based stents including 4.8F, 7F, and 10.3F pigtail; 7F Tower; and a prototype mesh stent. MATERIALS AND METHODS: Forty-five female Yucatan minipigs underwent bilateral laparoscopic occlusion of their renal vessels to stop urine production. A nephrostomy tract was established by retrograde puncture. A stent was placed in the ureter, and three measurements were taken with flow from a bag of irrigant 20 cm above the kidney: stent occluded with a guidewire (extraluminal flow), stent unobstructed (total flow), and laparoscopically placed extraureteral ligature (luminal flow). RESULTS: Luminal flow and, to a lesser extent, total flow appeared to increase as the internal and external diameters of the stent increased. The Tower stent, which had no sideholes, had much lower flow rates in all categories, while the prototype mesh stent showed greater total flow compared with the other stents. Extraluminal flow did not increase with stent size greater than 7F. CONCLUSIONS: Luminal flow, but not extraluminal flow, increased with an increase in the internal diameter of the stent. In general, the least favorable flow occurred with a Tower stent, which had the smallest internal diameter. The greatest flow was seen with the prototype mesh stent.

Bilateral percutaneous nephrolithotomy for multiple cystine stones in an infant presenting with anuria.

We report the first case of simultaneous, bilateral percutaneous management of multiple urinary cystine stones in a 7.6-kg, 9-month-old infant who presented with anuria. A stone-free state was successfully achieved.