[Management of vaginal vault prolapse repair with robotically-assisted laparoscopic sacrocolpopexy]. / Traitement du prolapsus du dôme vaginal par sacrocolpopexie laparoscopique assistée par robot.

Transabdominal sacrocolpopexy offers an excellent definitive treatment option for patients with high grade vaginal vault prolapse with long-term success rates ranging from 93-99%. However, because it is a transabdominal procedure it is associated with increased morbidity compared with vaginal repairs. We describe a novel minimally invasive technique of vaginal vault prolapse repair and present out initial experience. The surgical technique involves placement of five laparoscopic ports: three for the Da Vinci robot and two for the assistant. A polypropylene mesh is then attached to the sacral promontory and to the vaginal apex using Gortex sutures. At the end of the case, the mesh material is the covered by the peritoneum. We also present our initial experience with this technique in 18 consecutive patients. The analysis focused on complications, urinary continence, patient satisfaction, and morbidity. Follow-up was conducted by provider-patient interview. Twenty-five patients underwent a robotic-assisted laparoscopic sacrocolpopexy at our institution in the past 24 months for severe symptomatic vaginal vault prolapse. 10/25 (40%) underwent a concomitant anti-incontinence procedure. Mean follow-up was 5. (1-12) months and mean age was 66 (47-82) years. Mean total operative time was 3.2 (2.25-4.75) hours. One patient had to be converted to an open procedure secondary to unfavorable anatomy. All but one patient were discharged from the hospital after an overnight stay; one patient left on postoperative day #2. Complications were limited to mild port site infections in two patients, which resolved with oral antibiotic therapy. One patient developed recurrent grade 3 rectocele, but had no evidence of cystocele or enterocele. We present a novel technique for vaginal vault prolapse repair that combines the advantages of open sacrocolpopexy with the decreased morbidity and improved cosmesis of laparoscopic surgery. It is associated with decreased hospital stay, low complication and conversion rates, and high patient satisfaction. While our early experience is encouraging, long-term data is needed to confirm these findings and establish longevity of the repair.

Ureteroscopic treatment of upper tract urinary calculi.

Ureteroscopic treatment of upper urinary tract calculi is continuously evolving. Initial reports were limited to the treatment of distal ureteral stones. These cases had mixed success, and compared to modern ureteroscopy, had significant associated morbidity. The entire urinary tract can now be safely accessed via ureteroscopy almost always. Improvements in ureteroscope technology have certainly made this possible. These advances include smaller steerable scopes and sharper optics and video. The enhanced view of the upper urinary tract in combination with advances in lithotripsy, in particular, the holmium laser, has resulted in increased treatment success and reduced procedure related morbidity. This review describes the advances in ureteroscopic technology and provides data regarding treatment success and associated complications.

Imaging-guided radiofrequency ablation of solid renal tumors.

OBJECTIVE: We performed a retrospective review of imaging-guided radiofrequency ablation of solid renal tumors. MATERIALS AND METHODS: Since May 2000, 35 tumors in 20 patients have been treated with radiofrequency ablation. The size range of treated tumors was 0.9-3.6 cm (mean, 1.7 cm). Reasons for patient referrals were a prior partial or total nephrectomy (nine patients), a comorbidity excluding nephrectomy or partial nephrectomy (10 patients), or a treatment alterative to nephron-sparing surgery (one patient who refused surgery). Tumors were classified as exophytic, intraparenchymal, or central. Sixteen patients had 31 lesions that showed serial growth on CT or MR imaging. Of these 16 patients, four patients with 10 lesions had a history of renal cell carcinoma, and two patients with 11 lesions had a history of von Hippel-Lindau disease. Four patients had incidental solid masses, two of which were biopsied and shown to represent renal cell carcinoma, and the remaining two masses were presumed malignant on the basis of imaging features. Successful ablation was regarded as any lesion showing less than 10 H of contrast enhancement on CT or no qualitative evidence of enhancement after IV gadolinium contrast-enhanced MR imaging. RESULTS: Of the 35 tumors, 22 were exophytic and 13 were intraparenchymal. Twenty-seven of the 35 were treated percutaneously using either sonography (n = 22) or CT (n = 5). Two patients had eight tumors treated intraoperatively using sonography. Patients were followed up with contrast-enhanced CT (n = 18), MR imaging (n = 5), or both (n = 5) with a follow-up range of 1-23 months (mean, 9 months). No residual or recurrent tumor and no major side effects were seen. CONCLUSION: Preliminary results with radiofrequency ablation of exophytic and intraparenchymal renal tumors are promising. Radiofrequency ablation is not associated with significant side effects. Further follow-up is necessary to determine the long-term efficacy of radiofrequency ablation.

Interaortocaval renal artery dissection for right laparoscopic donor nephrectomy.

Laparoscopic donor nephrectomy is gaining increasing popularity because the procedure helps reduce disincentives to live kidney donation and has increased the live kidney donor pool. The left kidney of the donor is the preferred allograft because the right renal vein is shorter. Similarly, the right renal artery might be foreshortened because it hides behind the inferior vena cava during laparoscopic transperitoneal dissection. There are instances, however, in which it is not practical to take the left kidney due to vascular anomalies or asymmetric function. We describe a novel technique for obtaining greater renal arterial length utilizing laparoscopic interaortocaval dissection.

Percutaneous endoscopic management of urothelial tumors of the renal pelvis.

Although nephroureterectomy remains the reference standard for the treatment of transitional cell cancer of the renal pelvis, advances in technology and techniques have made percutaneous management of select lesions feasible. We report our technique of staged percutaneous resection of a large renal pelvic transitional cell cancer.

The Cleveland Clinic experience with papillary (chromophil) renal cell carcinoma: clinical outcome with histopathological correlation.

OBJECTIVES: A review of the Cleveland Clinic experience with papillary (chromophil) renal cell carcinoma (PRCC) is performed with emphasis on correlation of histopathologic features with prognosis. METHODS: Retrospective chart review was performed on 99 patients (85 male, 14 female) identified as having papillary renal cell carcinoma. All patients underwent renal surgery (partial or radical nephrectomy) at The Cleveland Clinic Foundation. Review of archival pathologic material was performed on all patients, and the reviewing pathologist was blinded to previous pathology reports. The reviewing pathologist evaluated tumor size, nuclear grade, TNM stage, tumor vascularity, multifocality, degree of papillary histology, macrophage infiltration, and presence of adenomata. Disease free survival data were generated via Kaplan-Meier estimates. Statistical significance was evaluated by the log rank test. RESULTS: Ninety-four (81 male, 13 female) of the original 99 patients were included in the study. Mean follow-up was 28.25 months. Most tumors were organ-confined (T1=24, T2=53, T3a=7, T3b=3, T3c=6). Histologically, most of the tumors were pure papillary histology (54.3%). Multifocality was present in 30 patients (31.9%). Overall cancer-specific survival (CSS) was 93.7% at 1 year, 89.9% at 2 years, and 78.6% at 5 years. Age (P=0.48), sex (P=0.41), tumor size (P=0.15), presence of adenomata (P=0.53), degree of pure papillary histology (P=0.73) and multifocality (P=0.93) did not significantly affect survival. Grade did not significantly affect survival (P=0.67). Low grade (Gr 1 or 2) lesions had a 5 year CSS of 75.7%, and high grade lesions had a 5 year CSS of 83.8%. Stage significantly impacted survival (P=0.017). T1-2 lesions had a 5 year CSS of 82.3%, T3a lesions 100%, T3b/T3c 66.7%. Patients with N1-2 disease (N=5) had 1 year CSS of 33.3%, and 2 year CSS of 0%. Extranodal metastases were associated with poor prognosis; 5 year CSS was 12.5% in M1 patients. CONCLUSIONS: Papillary renal cell carcinoma has a propensity to be both low grade and low stage with a less aggressive clinical course. The strongest predictor for cancer-specific survival is tumor stage. Due to the high incidence of multifocality, nephron-sparing surgery is often necessary. It is suggested that genetic differences between PRCC and other RCC variants may be exploited in the future for surgical decision making.

Prospective double-blind study of effect of ketorolac administration after laparoscopic urologic surgery.

BACKGROUND AND PURPOSE: To decrease postoperative dependence on narcotics for analgesia, we have evaluated ketorolac as an adjunct to perioperative pain control in patients undergoing laparoscopic urologic surgery. PATIENTS AND METHODS: Sixty-five patients (34 male, 31 female) were randomized to receive either ketorolac tromethamine (15-30 mg IV q 6 h) or placebo prior to laparoscopic surgery. Patient-controlled analgesia in the form of morphine sulfate was provided. Operative factors such as the type of surgery, operative time, and estimated blood loss were recorded. Postoperative factors such as analog pain score (range 0-10), narcotic usage, and length of stay were evaluated. RESULTS: Fifty-five patients completed the study. The average pain score was 2.2 and 4.5 for the ketorolac and placebo groups, respectively (P < 0.005). The mean amounts of total morphine used were 39.2 mg (ketorolac) and 62.5 mg (placebo) (P = 0.077). The length of stay was not significantly different in the ketorolac (2.5 days) and placebo (2.6 days) groups (P = 0.74). Operative times (P = 0.21) and estimated blood loss (P = 0.60) were not significantly different in the two groups. Ketorolac did not adversely affect renal function; serum creatinine changes were not significantly different from those in the patients receiving placebo (P = 0.50). Laparoscopic pyeloplasty necessitated more narcotic analgesia than did other laparoscopic procedures (P = 0.05). CONCLUSION: Ketorolac decreases the subjective perception of pain after laparoscopic urologic surgery. It is suggested that ketorolac administration decreases the amount of narcotic usage as well. Time to resumption of oral intake and length of hospital stay were not influenced by use of ketorolac.

Extracorporeal lithotripsy. Update on technology.

The development of shock-wave lithotripsy was a serendipitous event. Fortunately, the significance of this accidental discovery was not overlooked by the engineers at Dornier and their medical counterparts. There are many components that make up a lithotripter, but the heart of the lithotripter is its energy source. These machines often are categorized by the type of shock-wave generator used, and each type of generator has its own advantages and disadvantages. Unfortunately, no quantitative value of a shock-wave generator can be correlated to its qualitative effect. Interestingly, each type of energy source delivers its shock-wave energy with such distinctiveness that even the crater pattern it leaves in a stone is unique. New technology and ideas have transformed lithotripters in form and function so that they bear little resemblance to the original HM-1 prototype. Ongoing research is attempting to improve ESWL in several different ways, and advances in shock-wave generation, shock-wave measurement, and stone localization should result in even more efficient lithotripsy. The application of the time-reversal process to lithotripsy ultimately may enable lithotripters to track stones and electronically steer shock waves toward the target. Advances like these herald a time when ESWL, fortunately or unfortunately, will become automated completely.

Laparoscopic live donor nephrectomy: outcomes equivalent to open surgery.

A shortage of kidney donors has contributed to the interest in laparoscopic live-donor nephrectomy. Three transperitoneal ports are used, as is an AESOP robot. To maintain urine flow, the donor is kept volume expanded during the procedure, and the pneumoperitoneum pressure is minimized. The most critical and hazardous part of the surgery is dissection of the renal artery and vein. Abundant periureteral tissue should be left to protect the blood supply. Harvest of the right kidney is more difficult. Placing the extraction incision in the right upper quadrant and using a Satinsky clamp instead of a stapling device at the origin of the renal vein will provide maximum venous length and help prevent postoperative thrombosis of the allograft. In the first 175 laparoscopic renal harvest procedures at Johns Hopkins, the complication rate was 14%, the rate of open conversion was 2%, and 3% of the patients required transfusions. These rates improved with experience. There was no significant difference in the performance of the allografts or the recovery of the recipients from what is seen after open kidney harvest. Wider acceptance of laparoscopic renal harvest will increase the number of donors and will be helped by development of methods and devices that shorten the learning curve.

Endopyelotomy outcome as a function of high versus dependent ureteral insertion.

OBJECTIVES: To determine whether a high versus a dependent ureteral insertion significantly affects the outcome of endopyelotomy for management of ureteropelvic junction (UPJ) obstruction. METHODS: Sixty patients with UPJ obstruction were treated with an endopyelotomy by way of either an antegrade percutaneous approach (n = 36) or a retrograde hot-wire balloon incision (n = 24). In these 60 patients, the ureteral insertion was high on the renal pelvis in 19 (32%), dependent in 25 (42%), and indeterminate in 16 (26%). Intravenous urography was performed 4 to 6 weeks after stent removal (8 to 12 weeks after endopyelotomy) and then at 6 to 12-month intervals. Success of the procedure was defined as resolution of symptoms and decrease in hydronephrosis compared with pre-endopyelotomy studies. RESULTS: With a follow-up range of 2 to 41 months (mean 10.3), the overall success rate was 80%. This rate was independent of whether the procedure was performed in an antegrade or retrograde fashion. A successful result was achieved in 15 (78.9%) of those with a high insertion, 19 (76%) of those with a dependent insertion, and 14 (87.5%) of those with an equivocal insertion; these differences were not statistically significant (P = 0.72). CONCLUSIONS: The type of ureteral insertion (ie, high versus dependent) had no significant impact on the outcome of endopyelotomy by way of either a percutaneous or retrograde approach. As such, these anatomic variations need not play a role in a decision-making algorithm for contemporary management of UPJ obstruction.

Contemporary urological intervention for cystinuric patients: immediate and long-term impact and implications.

PURPOSE: We determined the immediate efficacy of contemporary urological intervention for cystine stones and the impact of such intervention on the subsequent rate of recurrent stone formation. MATERIALS AND METHODS: A total of 31 cystinuric patients underwent selected intervention for 61 stone events. Patients were subsequently followed at 6 to 12-month intervals while being treated with standard medical therapy. Logistic regression models were used to correlate potential risk factors with the efficacy of the intervention in achieving a stone-free status. Kaplan-Meier estimates of the probability of recurrence-free survivals at 1 and 5 years were generated, and risk factors for stone recurrence were analyzed using the log rank test. RESULTS: Overall stone-free rate was 86.9%, which was not significantly influenced by the initial stone burden or type of intervention selected. The probability of recurrence-free survival at 1 and 5 years was 0.73 and 0.27, respectively, and again this probability was independent of initial stone burden or type of intervention selected. Urinary cystine levels before intervention and post-procedure residual stone status also failed to impact significantly on the risk of recurrence. However, a stone-free result, in contrast to residual stones, prolonged the mean time to stone recurrence from 346 to 1,208 days. CONCLUSIONS: While cystine stones are not amenable to all currently available minimally invasive therapeutic modalities, high stone-free rates can be achieved without the need for open surgery and as such cystinuric patients clearly benefit from contemporary intervention. When such intervention is used selectively, with consideration given primarily to stone burden and location, rates of recurrence will relate primarily to the natural history of the medically treated cystinuric patient, and not the type of intervention applied.

Increased intra-abdominal pressure during pneumoperitoneum stimulates endothelin release in a canine model.

Prolonged pneumoperitoneum during laparoscopic surgery has been associated with oliguria in clinical experimental studies. Although the pathophysiology of this oliguria is thought to be renal parenchymal and venous compression, the role of the potent vasoconstrictor endothelin (ET) has not been studied. The purpose of this study was to investigate the effect of pneumoperitoneum on endothelin release and renal function in a canine model. Two groups of dogs were studied during pneumoperitoneum (Group 1, N = 7) or isolated left renal vein compression (Group 2, N = 6). Urine and plasma samples were collected for urine output, glomerular filtration rate (GFR), urine sodium, and plasma endothelin measurements. In Group 1, GFR fell significantly (p < 0.05) by 49% from a control of 0.88 +/- 0.12 mL/min per gram of kidney weight. Urine volume fell by 79% (p < 0.05) from a control value of 0.014 +/- 0.003 mL/min/gkw. Sodium excretion was decreased by 88%. Sodium reabsorption was significantly enhanced during pneumoperitoneum (99.56 +/- 0.15% v 98.44 +/- 0.25%). Arterial plasma ET concentrations were elevated by 8% during the first 20 minutes of pneumoperitoneum (30.8 +/- 3.6 v 33.3 +/- 3.4 pg/mL; p < 0.05). In Group 2, left renal vein compression resulted in a 31% decrease (p < 0.05) in GFR in the left kidney and a 25% decrease in the right kidney. Urine volume fell by 67% in the left kidney and 40% in the right. Renal venous ET concentrations also increased after renal vein compression. Although the mechanism by which oliguria occurs during pneumoperitoneum is not fully understood, the ET concentration was elevated. Because ET can decrease RBF, GFR, and sodium excretion, it may contribute to the oliguria observed during long periods of pneumoperitoneum.

Medical treatment of cystinuria: results of contemporary clinical practice.

PURPOSE: We determined the efficacy of a contemporary medical regimen for treatment of cystinuria. MATERIALS AND METHODS: A total of 16 patients with cystinuria was followed for 7 to 141 months (mean 78.1). Standard therapy included hydration and alkalization. D-penicillamine or alpha-mercaptoproprionylglycine was added for failure of hydration and alkalization to prevent new stones or stone growth, or to cause dissolution. Captopril was added for failure of or intolerance to D-penicillamine or alpha-mercaptopropionylglycine. Radiography was performed every 6 to 12 months, at which time stone events were documented. RESULTS: During hydration and alkalization 46 stone events occurred in 8 of 9 patients (1.6 events per patient-year). With addition of thiol derivatives 7 of 9 patients experienced 24 stone events, all 6 treated with hydration, alkalization and captopril experienced 10 events, and 4 of 5 treated with alkalization, thiols and captopril experienced 8 events (0.52, 0.71 and 0.54 events per patient-year, respectively). During a total treatment time of 104.1 patient-years 88 stone events occurred in 14 of 16 patients (0.84 events per patient-year). CONCLUSIONS: D-penicillamine and alpha-mercaptopropionylglycine are effective in decreasing the rate of stone formation in patients in whom hydration and alkalization failed. While captopril may also be beneficial in this setting, it does not appear to be as effective as D-penicillamine or alpha-mercaptopropionylglycine, and it does not clearly add clinical benefit to those thiols. Our study demonstrates that patients with cystinuria are at high risk for recurrence when treated with any contemporary medical program. This natural history must be considered when evaluating the long-term efficacy of newer or alternative modes of medical and urological treatment.