Ureteral complications with operative gynecologic laparoscopy.

OBJECTIVE: The study assessed the incidence, diagnosis, management, and causes of ureteral injuries during major laparoscopic operations at our department in a 6-year period. STUDY DESIGN: The study was a chart review of 790 consecutive major laparoscopic procedures in 711 patients (mean age 37.4 +/- 11.6 years, mean weight 64.3 +/- 29.1 kg). RESULTS: There were four ureteral complications in three patients during or after laparoscopic operations: three of 711 patients (0.42%) and four of 790 procedures (0.38%). All three ureteral complications (one transection and a total of three ureterovaginal fistulas in two patients) occurred during laparoscopically assisted vaginal hysterectomies, for an incidence of 4.3%. There were no ureteral injuries in 291 salpingo-oophorectomies, 414 ovarian cystectomies, and 15 colposuspensions. Both delayed ureteral complications occurred in the lower segment of the ureter after laparoscopic bipolar coagulation and division of the cardinal ligament. CONCLUSION: We conclude that in laparoscopic surgery the ureter is most at risk when the cardinal ligament is dissected and divided below the uterine vessels.

Endovascular treatment of renal artery aneurysms with conventional non-detachable microcoils and Guglielmi detachable coils.

OBJECTIVE: To evaluate the efficacy and safety of endovascular occlusion of true renal artery aneurysms (RAAs) with conventional non-detachable microcoils (NDCs) and Guglielmi detachable coils (GDCs). PATIENTS AND METHODS: Over a 5-year period, 12 RAAs were treated by endovascular selective embolization. Four RAAs were occluded using NDCs and eight were treated with GDCs. All coils were delivered through a microcatheter. Eight RAAs were located in the bifurcation of the main renal artery, two in the main renal artery and two were intrarenal. Before treatment, four patients presented with hypertension, one associated with renal infarction and a second had flank pain due to microembolization. Two other patients had renal infarction, associated with haematuria in one; one other patient also had haematuria and five patients were asymptomatic. All patients were followed using clinical and angiographic examinations after 6 months, 1 and 2 years. RESULTS: All RAAs were occluded successfully. In two patients treated with NDCs there were minor complications, i.e. one subsegmental peripheral infarction and one misembolization, both without clinical symptoms. In the group treated with GDCs there were no complications. Five of seven patients were clinically improved, while two patients remained clinically unchanged. CONCLUSION: Superselective endovascular treatment of RAAs with microcoils is a safe, efficient, and less invasive alternative to surgical treatment. The high flexibility and softness of the GDC and the controlled detachment enables a safer and more complete occlusion of RAA than current alternatives.

Multiphasic helical CT of the kidney: increased conspicuity for detection and characterization of small (< 3-cm) renal masses.

PURPOSE: To evaluate the potential of thin-section multiphasic helical computed tomography (CT) in the detection and characterization of small (< 3.0-cm) renal masses. MATERIALS AND METHODS: Identically collimated helical CT of the kidney was performed before and after administration of contrast material in 93 patients with small renal masses. Helical CT scans were obtained during the corticomedullary and nephrographic phases. Differences between attenuation of the lesion and that of the kidney were measured quantitatively. The presence of a mass or absence of disease was confirmed with clinical, imaging, and histologic findings. RESULTS: The number of masses smaller than 3.0 cm detected on corticomedullary-phase scans (n = 211) was statistically significantly fewer than those on nephrographic-phase scans (n = 295) (P < .01). Mean differences in enhancement between the renal cortex and masses were 148 HU +/- 54 and 137 HU +/- 44 during the corticomedullary and nephrographic phases, respectively, and the difference in attenuation of the renal medulla and that of the masses was statistically significantly greater during the nephrographic phase (P < .01). False-positive results (n = 9) occurred only on corticomedullary-phase scans because of lack of enhancement of the renal medulla. CONCLUSION: Nephrographic-phase scans enabled greater lesion detection and better characterization of small renal masses than corticomedullary-phase scans. Nephrographic-phase scans should be obtained when only monophasic scanning is used to detect small renal masses.

The use of polydimethylsiloxane in the treatment of incontinence after radical prostatectomy.

OBJECTIVE: To report the results of transurethral submucosal injection therapy of polydimethylsiloxane (PDS) to treat incontinence after radical prostatectomy (RP). PATIENTS AND METHODS: Since 1993, about 80 retropubic RPs have been carried out at our institution each year. Severe post-operative incontinence occurred in six patients, with a mean duration of incontinence after RP of 28 months. The pre-operative evaluation consisted of cysto-urethroscopy and urodynamics. Because we have no experience with artificial sphincter implantation, transurethral injection therapy was used to treat the post-operative incontinence, using PDS (vulcanized silicone rubber particles). This material has a mean particle size of 188 microns, providing stability of the material at the injection site. The six patients with severe post-operative incontinence were treated using injection therapy with PDS. RESULTS: After a mean follow up of 15.5 months, five patients, who suffered from day and night incontinence and required at least five pads per day, were dry after injection therapy. One patient improved significantly but still required two pads during the day, but was continent during the night; three patients required a second injection. A mean of 7.5 mL of PDS was used per patient and the side-effects of therapy (dysuria and urinary retention) were minimal. CONCLUSION: Because PDS has excellent biocompatibility, few side-effects or complications, transurethral injection therapy using silicone particles is a justifiable procedure for treating incontinence after RP.

[Indications and results of ex-vivo surgery of the kidney]. / Indikation und Ergebnisse der Ex-vivo-Chirurgie der Niere.

394 renal transplantations have been performed in our unit between 1974 and 1995. In all instances extra-corporal surgical procedures on the graft, its vessels and, in rare instances, on the collecting system were necessary. The surgical procedures, which took up to 90 minutes on the work-bench, ranged from repair of minor iatrogenic vascular injuries to major vascular reconstructions, in order to facilitate the subsequent implantation of the graft. During the same period work-bench surgical procedures with subsequent autotransplantation were performed in 8 patients. The indication for such a procedure was a renal cell carcinoma in 2 patients with a solitary kidney and bilateral renal cell carcinoma in 1 patient, as well as renovascular disease (renal artery stenosis, aneurysm of the renal artery) in the remaining 5 cases.

[Amputation of the leg in arterial occlusive disease]. / Amputationen der unteren Extremität bei arterieller Verschlusskrankheit.

The until recently held opinion that above-knee amputations were the method of choice for treating stage IV chronic occlusive arterial disease, is outdated. Determining the appropriate level for amputation in patients with peripheral arterial obstruction is difficult, and requires much experience. Successful fitting of a prosthetic device and subsequent rehabilitation depend not only on the patient's bodily and emotional reserves, but also on the operative technique employed. The more distal the amputation, the better is the prognosis for satisfactory prosthetic function and social reintegration. A total of 280 amputations on 268 patients was performed over a 48-month period. In 181 patients (68%) primary healing occurred without complications. Total mortality was 10%, occurring mainly in the group of above-knee amputees. The majority of local wound complications was found in transmetatarsal resections and below-knee amputations. A total of 42 patients (15%) underwent re-amputation. Only half of the above-knee amputees could be fitted with a prosthesis and rehabilitated, whereas nearly all patients amputated more distally experienced satisfactory outcomes in this respect.