Laparoscopic practice patterns among North American urologists 5 years after formal training.

PURPOSE: We assessed urologist laparoscopy practice patterns 5 years after a postgraduate training course in urological laparoscopic surgery. Results were compared to findings from similar studies performed on the same cohort at 3 and 12 months after training. MATERIALS AND METHODS: Between January 1991 and November 1992, 11, 2-day university sponsored, postgraduate laparoscopic surgery training programs were held. A survey was mailed to the 322 North American participants in the summer of 1997 to determine current laparoscopic use and experience. RESULTS: Of the 166 respondents (51% response rate) 53.6% (89) had performed 1 or more laparoscopic procedures in the previous year, compared to 84% 1 year following course completion. Of the respondents 37% believed their laparoscopic experience was sufficient to maintain skills compared to 66% at 1 year. Of the respondents 6% had performed more laparoscopic procedures while 82% had performed fewer than anticipated. Reasons cited for decreased use included decreasing and/or lack of indications, increased cost, decreased patient interest, higher complication rates, decreased institutional support and increased operative time. Respondents practicing in academic or residency affiliated centers, or those who had completed residency after 1980 were more likely to have performed more procedures than anticipated (p = 0.044) compared to community based colleagues. CONCLUSIONS: Laparoscopic use by urologists trained in the postgraduate setting is decreasing. Few respondents are maintaining the skills acquired during the original training course. Decreased use appears to be multifactorial.

Retroperitoneal and pelvic extraperitoneal laparoscopy: an international perspective.

OBJECTIVES: To assess technical preferences and current practice trends of retroperitoneal and pelvic extraperitoneal laparoscopy. METHODS: A questionnaire survey of 36 selected urologic laparoscopic centers worldwide was performed. RESULTS: Twenty-four centers (67%) responded. Overall, 3988 laparoscopic procedures were reported: transperitoneal approach (n = 2945) and retroperitoneal/extraperitoneal approach (n = 1043). Retroperitoneoscopic/extraperitoneoscopic procedures included adrenalectomy (n = 74), nephrectomy (n = 299), ureteral procedures (n = 166), pelvic lymph node dissection (n = 197), bladder neck suspension (n = 210), varix ligation (n = 91), and lumbar sympathectomy (n = 6). Mean number of total laparoscopic procedures performed in 1995 per center was 41 (range 5 to 86). Major complications occurred in 49 (4.7%) patients and included visceral complications in 26 (2.5%) patients and vascular complications in 23 (2.2%). Open conversion was performed in 69 (6.6%) patients, electively in 41 and emergently in 28 (visceral injuries, n = 16; vascular injuries, n = 1 2). Retroperitoneoscopy/extraperitoneoscopy is gaining in acceptance worldwide: in 1993, the mean estimated ratio of transperitoneal laparoscopic cases versus retroperitoneoscopic/ extraperitoneoscopic cases per center was 74:26; however, in 1996 the ratio was 49:51. CONCLUSIONS: Retroperitoneoscopy and pelvic extraperitoneoscopy are important adjuncts to the laparoscopic armamentarium in urologic surgery. The overall major complication rate associated with retroperitoneoscopy/extraperitoneoscopy was 4.7%.

Comparison of microscopic epididymal sperm aspiration and intracytoplasmic sperm injection/in-vitro fertilization with repeat microscopic reconstruction following vasectomy: is second attempt vas reversal worth the effort?

Since 1986, we have performed microscopic reconstruction in 18 men following failed microscopic vasectomy reversal. Between 1994 and 1996, nine couples have undergone microscopic epididymal sperm aspiration (MESA)/ intracytoplasmic sperm injection (ICSI) treatment for male infertility due either to congenital absence of the vas deferens (CAVD) or inoperable excurrent duct obstruction. We compared the cost efficiency of repeat vasectomy reversal to that for MESA combined with ICSI/in-vitro fertilization (ICSI/IVF). The cost of male partner procedures (vasectomy reversal, MESA) was based on physician and hospital charges, while the cost of ICSI/IVF included preparation of the female partner (medications and physician charges) and procedures (physician and hospital charges including oocyte retrieval, micromanipulation, and embryo transfer). Our cost examination does not include charges related to follow-up visits, prenatal monitoring, complications of pregnancy (i.e. miscarriage) or delivery in either group. Overall patency and pregnancy rates in the repeat vasectomy reversal group were 78 and 44% respectively. The cost per delivered baby (including multiple metachronos deliveries per couple) was $14892. Fertilization of oocytes has been achieved in 37/72 (51%) and pregnancies have occurred in 6/9 (67%) attempts and 5/9 (56%) report delivery. The average cost per pregnancy was $25637 and the average cost per delivered baby (or ongoing pregnancy) was $35570. The cost per delivery by MESA/ ICSI/IVF is 2.4 times the charges per delivery obtained through repeat vasectomy repair. Couples attempting to overcome infertility caused by vasal obstruction should be informed that vas reconstruction remains a cost effective means of re-establishing fertility even in men who have previously failed vasectomy reversal.

Hip and knee replacement as a relative contraindication to laparoscopic pelvic lymph node dissection.

PURPOSE: We investigated the effect of lower extremity joint prostheses on subsequent laparoscopic pelvic lymph node dissection. MATERIALS AND METHODS: We reviewed the records and pathology studies of 5 patients who underwent laparoscopic pelvic lymph node dissection subsequent to total hip or knee replacement from 1990 through 1995. RESULTS: Four of the 5 laparoscopic operations were complicated, 3 were unsuccessful in obtaining bilateral pelvic lymph nodes and 2 required conversion to an open procedure. Examination of the lymph nodes revealed sinus histiocytosis in the 4 cases in which nodal tissue was removed. CONCLUSIONS: The increased risk of complications in certain patients with lower extremity joint prostheses may contraindicate attempted laparoscopic pelvic lymph node dissection.

Laparoscopic nephrectomy of a horseshoe kidney.

The role of laparoscopic surgery in the treatment of benign renal diseases continues to evolve with the development of equipment and refinement of techniques. A minimally invasive approach to the treatment of these lesions offers several advantages, including shorter convalescence. We describe the first laparoscopic nephrectomy involving a horseshoe kidney.

Laparoscopic pelvic lymph node dissection following definitive radiotherapy for carcinoma of the prostate.

PURPOSE: Laparoscopic pelvic lymph node dissection is an effective and minimally invasive approach to the clinical staging of adenocarcinoma of the prostate. We report our experience with this technique in patients in whom full course pelvic radiotherapy had failed and who were being considered for salvage local therapy. MATERIALS AND METHODS: In 14 patients disease was staged by transperitoneal laparoscopic pelvic lymph node dissection performed for persistent adenocarcinoma of the prostate at least 20 months (average 49.5) following external beam radiotherapy and/or brachytherapy. All patients were healthy, had no evidence of metastatic disease and were considered to be candidates for salvage therapy. RESULTS: A total of 13 patients underwent successful laparoscopic pelvic lymph node dissection while 1 sustained an enterotomy requiring conversion to open surgery. The normal surgical planes were more difficult to dissect, with the obturator lymph node packets appearing smaller and more fibrotic than in nonirradiated patients, yielding an average of 7.1 total nodes. Average operative time was 167 minutes and postoperative hospitalization was comparable to reported series of nonirradiated patients. Four patients (28%) with metastatic pelvic lymph nodes underwent subsequent orchiectomy. Nine patients with negative lymph nodes underwent ultrasound guided transperineal placement of radioactive gold or palladium seeds. One patient underwent salvage radical retropubic prostatectomy. CONCLUSIONS: Laparoscopic pelvic lymph node dissection following full course pelvic irradiation is technically feasible, albeit more difficult than in nonirradiated patients. This approach appears to be an excellent minimally invasive technique for the clinical restaging of persistent adenocarcinoma of the prostate in patients being considered for salvage therapy.

Carbon dioxide homeostasis during transperitoneal or extraperitoneal laparoscopic pelvic lymphadenectomy: a real-time intraoperative comparison.

The primary goal of this study was to evaluate differences in carbon dioxide metabolism between patients undergoing transperitoneal or extraperitoneal laparoscopic pelvic lymph node dissection (L-PLND) for staging of adenocarcinoma of the prostate (CaP). Eighteen candidates undergoing L-PLND were divided between the transperitoneal (N = 12) and extraperitoneal (N = 6) approaches. End-tidal partial pressure of CO2 (PeCO2) and minute volume of expired CO2 (VCO2) were considered indicators of CO2 absorption. These two parameters were monitored intraoperatively utilizing a metabolic cart and Ohmeda Rascal-II. The cardiostimulatory effect of increasing serum CO2 and the ventilatory countermeasures used to correct the iatrogenic hypercapnia associated with CO2 insufflation were also measured. With the exception of the region of CO2 insufflation, the operative procedure and perioperative care were identical for the two groups. Preoperative patient characteristics were similar. The mean time of CO2 insufflation was 136 minutes for the transperitoneal group and 120 minutes for the extraperitoneal group. The absorption of CO2 was significantly greater and more rapid during extraperitoneal L-PLND. This may be attributable to more profound CO2 absorption from the parietal peritoneal surface compounded by subcutaneous CO2 emphysema. Disruption of microvascular and lymphatic channels during the development of the extraperitoneal working space facilitates direct CO2 absorption into the intravascular space. A minor increase in heart rate and systolic blood pressure was noted during CO2 insufflation. In all but one patient (extraperitoneal group), hypercarbia and acidemia were prevented by an increased ventilatory rate. The potential dysrhythmogenicity of hypercarbia may contraindicate the extraperitoneal approach in patients with cardiopulmonary disease.

Physical determinants of solute and water clearance by the perfused dog jejunum.

We systematically compared the individual effects of infusion rate, solution osmolality, and temperature on plasma solute secretion during luminal perfusion of an isolated 90-cm jejunal segment in the conscious and otherwise normal dog. The control state was perfusion at a rate of 3 ml/min of a 25 degrees C temperature solution containing (mM): NaCl, 40; NaHCO3, 10; and mannitol, 220 (320 mosm/kg). Increasing infusion rate from 3 to 9 ml/min increased secretion of Na-, K+, and urea (P < 0.05); further elevation of infusion rate to 18 ml/min increased only Cl- and urea secretion (P < 0.05). Thus, increasing infusion rate of the control solution had only a limited role in promoting solute secretion. In contrast, perfusion solutions elevated in osmolality to 600 and 1200 mosm/kg by mannitol progressively augmented the secretions of water, Na-, K+, Cl-, HCO3(-), Ca2+, and urea (P < 0.05). Perfusion of the 1200 mosm/kg solution produced solute secretions either equivalent to or greater than secretions obtained during 18-ml/min perfusion with the control solution, despite the fact that 1200 mosm/kg perfusion yielded about one-third the effluent volume. Warming of the control solution to progressively increase infusion temperatures from 29 to 41.9 degrees C increased (P < 0.05) water, Na+, K+, and Cl- secretion and HCO3 absorption linearly. Urea secretion increased (P < 0.05) above a temperature threshold of 38-38.9 degrees C. In conclusion, perfusion solution infusion rate, osmolality, and temperature are unique independent determinants of plasma solute secretion by jejunum. These data are the basis for optimizing the physical determinants of jejunal clearance for applying jejunal perfusion to treatment of renal failure.

Continent small-intestine reservoir construction: a tapered intussusceptum promotes sustained continence.

Developed for the study of dialysis in the continent jejunal reservoir (CJR), a novel, uncomplicated approach to achieve continence in construction of a small-bowel reservoir is presented. We utilize a technique of constructing a continent nipple valve, which entails the reduction or tapering of the intussusceptum prior to invagination into the reservoir. We have thus far performed the procedure successfully in 21 dogs. All animals have achieved absolute continence. Complications have occurred in two animals, neither complication involving the nipple valve. Pressure-volume cytometry in nine animals demonstrates continence in the awake animal at pressures of up to 40 cm H2O (volumes being limited by animal discomfort due to reservoir distention). In postmortem studies, reservoir capacities of > 1000 ml and pressures of > 70 cm H2O have been attained without loss of continence or prolapse of the nipple valve. Continence is sustained even when the reservoir and nipple valve are subjected to high intraluminal pressures. Incorporating a tapered intussusceptum, the continent reservoir provides absolute continence without the use of cumbersome mesh fixation or lithotropic intraluminal staples.

Splenectomy complicating left nephrectomy.

PURPOSE: We attempted to clarify the details of incidental splenectomy complicating left nephrectomy. MATERIALS AND METHODS: We reviewed the literature and operations involving splenectomy performed during left nephrectomy between 1984 and 1994 at our university. Factors reviewed included patient characteristics, renal pathology, mechanisms of injury, blood transfusions and postoperative complications. RESULTS: Of the 418 left nephrectomies 18 (4.3%) resulted in splenectomy via a transperitoneal approach. Patients with a large or upper pole renal lesion, malignancy or advanced age are increasingly likely to undergo unanticipated splenectomy. CONCLUSIONS: Our results, combined with recommendations from the Centers for Disease Control and Prevention, suggest that all patients older than 65 years undergoing left transperitoneal nephrectomy or those at increased risk for splenic injury should receive preoperative pneumococcal vaccination.

Laparoscopically assisted penile revascularization for vasculogenic impotence.

Young patients with impotence and cavernous arterial insufficiency resulting from trauma-induced arterial occlusive disease are ideal candidates for microvascular arterial bypass surgery. To avoid the long abdominal incision required to harvest the inferior epigastric artery, a laparoscopic approach was used. We report a case of laparoscopically assisted penile revascularization for vasculogenic impotence.

Laparoscopic partial nephrectomy: initial experience and comparison to the open surgical approach.

During an 18-month period, 6 laparoscopic partial nephrectomies were attempted, 4 of which were successful. The surgical technique was modified and improved between cases aided by new laparoscopic instrumentation, such as the argon beam coagulator and the 7.5 MHz. ultrasonic sector scanning system. In a retrospective comparison between laparoscopic and open partial nephrectomy, estimated blood loss was 525 ml. for the former versus 708 ml. for the latter procedure. However, operating time was more than 2 hours longer with the laparoscopic approach. The major advantages of the laparoscopic procedure appear to be a more rapid return to full diet, less postoperative pain and less requirement for parenteral narcotics. Despite the small size of this series and limited followup data, convalescence may be shortened by 4 weeks after laparoscopic partial nephrectomy. Patients with benign diseases of the kidney, especially with a duplicated collecting system, who require partial nephrectomy may be considered candidates for the laparoscopic approach. The advantages to the patient, however, may be offset by the technical demands on the surgeon.

Laparoscopic urologic surgery. The financial realities.

Since 1990, laparoscopic surgery has gained an important role in the specialty of urology. This article provides a financial analysis of the three most common urolaparoscopic procedures compared with their open surgical counterpart. The intraoperative costs of laparoscopic surgery are more expensive, but the postoperative expenses are less compared with open surgery. The financial ramifications of a shorter period of convalescence following laparoscopic surgery must be considered.

Deoxycholate effects on plasma solute clearance by gut perfusion in dog.

In vivo luminal perfusion of in situ intestinal segments isolated from continuity with the alimentary tract has been used to treat uremia. One prior study showed that 2 mM deoxycholate markedly increased clearances of inorganic phosphorus, urate, urea, and creatinine. The other investigation failed to confirm the increased inorganic phosphorus or urate clearance. Because of the clinical potential of the findings, we systematically examined the effects of perfusing deoxycholate (2, 7, 15, and 30 mM) on clearance of plasma solutes by a 90-cm jejunal Thiry-Vella loop in the conscious dog. During control perfusion, clearance of all solutes was in a steady state in the final five of seven successive 30-min samples. During deoxycholate perfusion, all solutes except inorganic phosphorus and urate also attained a steady state of clearance in these final five samples. Inorganic phosphorus and urate clearances were elevated several orders of magnitude above control, but only during the first two 30-min collection periods. This increase was deoxycholate concentration-dependent and progressively declined during the subsequent five 30-min collection periods (P < 0.0001). Steady-state clearances of sodium, potassium, calcium, chloride, and creatinine were increased (P < 0.05) by 2 mM deoxycholate. Clearance of urea was decreased by deoxycholate. In summary, (a) deoxycholate increased clearances of most solutes, but steady-state increases were modest; (b) clearances tended to increase further with increasing deoxycholate; (c) the markedly increased clearances in a prior study were probably non-steady state; (d) urea clearance was decreased by deoxycholate. We conclude that detergents such as deoxycholate cause only modest increases in steady-state gastrointestinal clearance of plasma solutes.