Conversion from pure laparoscopy to hand-assisted laparoscopy for control of bleeding in renal surgery: an attractive alternative to open conversion.

PURPOSE: To assess the safety and efficacy of conversion from pure laparoscopy to hand-assisted laparoscopy to control mild-to-moderate bleeding during renal surgery. PATIENTS AND METHODS: Between August 2006 and August 2008, we performed 94 laparoscopic nephrectomies (44 partial and 50 radical). A total of three radical nephrectomies were converted from pure to hand-assisted laparoscopy for control of bleeding. The first patient was a 44-year-old man with a 14-cm cystic renal mass. The second patient was a 52-year-old man with a 3.8-cm renal mass, and the third patient was an 86-year-old woman with a 7-cm renal mass. RESULTS: In all three procedures, the indication for conversion was bleeding from the renal hilum or the kidney parenchyma during dissection. The bleeding was difficult to control using pure laparoscopy, and therefore a hand port was inserted. Time for conversion and placement of the hand port averaged less than 7 minutes. Total estimated blood loss for the three patients was 800 mL, 2000 mL, and 650 mL, respectively. One patient needed a transfusion with three units of packed red blood cells. The postoperative course was uneventful in all patients, except for one patient who had prolonged ileus and stayed in the hospital for 6 days. The remaining two patients were discharged on postoperative days 2 and 3. CONCLUSIONS: Conversion from pure to hand-assisted laparoscopy for bleeding control is feasible and effective. It adds minimal morbidity while maximizing cosmesis, and it should be considered as an alternative to open conversion in cases of mild-to-moderate bleeding.

External validation of a model for tailoring the operative approach to minimally invasive partial nephrectomy.

STUDY TYPE: Therapy (case series). LEVEL OF EVIDENCE: 4. What's known on the subject? and What does the study add? In comparison to open partial nephrectomy, renal hypothermia is not routinely performed when completed laparoscopically, making warm ischemia time (WIT) a critical issue. Given that the duration of renal ischemia is the strongest modifiable surgical risk factor for decreased renal function after partial nephrectomy, efforts to limit ischemic time are of paramount importance. One technical modification during laparoscopic partial nephrectomy (previously reported by Weizer et al.), sought to simplify the technique by obviating the need for hilar clamping and/or suturing based on preoperative tumour characteristics. Ideally this modification would allow the surgeon to significantly decrease or even eliminate WIT in selected cases without compromising oncological efficacy or adversely impact treatment outcomes. This study adds to the growing body of literature that seeks to minimize WIT during minimally-invasive partial nephrectomy (MIPN). We feel that this approach, which simplifies a technically challenging operation while maintaining a low rate of adverse events and positive surgical margins, could potentially have MIPN applied more broadly throughout the urological community and ultimately decrease the preference for radical nephrectomy in cases of T1a tumours. OBJECTIVE: To externally validate and modify an existing technical strategy of prospectively tailoring one's operative approach to minimally invasive partial nephrectomy (MIPN). PATIENTS AND METHODS: We prospectively applied the model used in this strategy to evaluate 44 consecutive patients who underwent MIPN between August 2006 and August 2008. Patients were divided into four groups according to tumour depth of penetration or entry into the collecting system. Group 1 (n=9, 20%) underwent MIPN without clamping the renal hilum or parenchymal suturing. Group 2 (n=2, 5%) underwent clamping but not suturing. Group 3 (n=21, 48%) underwent clamping and suturing. Group 4 (n=12, 27%) underwent clamping, renal sinus reconstruction and suturing. We then assessed the peri- and postoperative outcomes, tumour histopathology and complications for each group. RESULTS: All patients had successful procedures according to the strategic model. The mean operative time was 246 (105-420) min and the mean estimated blood loss was 177 (25-1000) mL. When patients were stratified by clamping vs no clamping, the only significant variables between the two groups were operative time (245 vs 203 min) and pathology (83% vs 44% malignant). Six patients in the clamping group had postoperative complications (three had delayed bleeding, two had pneumonia, and one had infected urinoma) vs one patient in the no-clamping group who had prolonged ileus (P>0.05). Mean hospital stay was comparable in both groups (2.6 vs 3 days). CONCLUSION: Minimally invasive partial nephrectomy can be tailored according to tumour location, avoiding unnecessary clamping and/or suturing of the kidney without negatively affecting treatment outcomes.

Penile fracture with associated urethral rupture.

Penile fracture of the erect penis is an uncommon but emergent urological trauma. Potential outcomes include erectile dysfunction, penile curvature, and urethral injury. Treatment is emergent surgical repair. We present the case of a 42-year-old man with a penile fracture complicated by a urethral rupture and subsequent repair. A discussion of the key aspects of this condition is presented.

Extracorporeal stereotactic radiosurgery for small renal masses.

Over the past decade we have witnessed both a grade and stage migration for renal cell carcinoma. This shift in clinicopathology has been met with a paradigm shift in the treatment of these renal mass lesions. This trend has evolved from laparoscopic extirpation to needle-based and now extracorporeal ablation. At the forefront of the extracorporeal, minimally invasive treatment modalities is radiosurgical ablation. Still in its inaugural phase, renal radiosurgery is devoid of any long-term studies; however, short-term studies thus far show enormous potential. Herein we present the current status of radiosurgical ablation of small renal masses.