Management of pelvic stones larger than 20 mm: laparoscopic transperitoneal pyelolithotomy or percutaneous nephrolithotomy?

UNLABELLED: Large pelvic stones are frequently managed with percutaneous nephrolithotomy (PCNL) but laparoscopic transperitoneal pyelolithotomy (LTP) can be an alternative. We compared PCNL and LTP for the treatment of pelvic stones >20 mm in diameter. PATIENTS AND METHODS: Between November 1999 and November 2004, 16 consecutive patients, mean age 42, with a single pelvic stone >20 x 10 mm (group I), underwent LTP as first-line treatment or after shockwave lithotripsy failure. They were compared with a similar population of 16 consecutive patients, mean age 45 (group II), who underwent PCNL for the same indication and were assessed retrospectively. We evaluated operative characteristics, complications, and results for each technique. RESULTS: There was no difference between the two groups regarding the characteristics of patients and stones. Operative time duration was significantly longer in group I (129 vs. 75 min; p = 0.001) and conversion was required in 2 patients (12%). The main postoperative complications were urinary leakage (2 patients, 12%) in group I and bleeding (3 patients, 18%) in group II, but only 1 required blood transfusion. Mean hospital stay was respectively 6.5 and 5.6 days in groups I and II (p = 0.17). Stone-free rates were assessed at 3 months and were not different between group I and group II (88 vs. 82%). CONCLUSIONS: The operative time of LTP is longer and the results of both techniques are comparable but postoperative morbidity is different. Specific indications of each technique must be determined although PCNL remains the gold standard for most large pelvic stones.

Laparoscopic management of primary hyperaldosteronism: clinical experience with 212 cases.

PURPOSE: Laparoscopy is now widely used to remove benign adrenal tumors. We assessed the value of transperitoneal partial or total adrenalectomy for primary hyperaldosteronism. MATERIALS AND METHODS: From September 1994 to October 2001, 212 consecutive patients with a mean age of 48 years who presented with primary hyperaldosteronism and related arterial hypertension underwent transperitoneal laparoscopic adrenalectomy (193) or tumor enucleation (20) performed by a single surgeon, including 1 who underwent bilateral adrenalectomy. In all cases preoperatively high plasma and urine aldosterone was associated with low plasma renin and hypokalemia. RESULTS: Mean followup was 44 months. Conversion to open surgery was necessary in 30 patients (14%) due to bleeding or adhesion and a procedure duration of greater than 3 hours. Mean operative time was 102 minutes (range 30 to 260). Six patients (2.8%) required blood transfusion. No deaths occurred. Postoperatively complications were observed in 10% of patients and the most frequent one was electrical myocardial ischemia without infarction. Mean postoperative pain medication was 17 mg. morphine sulfate equivalents (range 0 to 60). Mean and median hospital stay was 3.6 and 2.9 days, respectively (range 2 to 20). Postoperatively blood pressure was normal in 58% of patients without any drug, while treatment was decreased in the remainder. Kalemia was normalized in all cases. CONCLUSIONS: Although some complications can occur, mostly at the beginning of the learning curve, laparoscopic transperitoneal adrenalectomy is effective treatment for primary hyperaldosteronism.

Diagnosis of pheochromocytoma and laparoscopic adrenalectomy in two anephric patients with von Hippel-Lindau disease.

This study reports the first two cases of laparoscopic treatment of functional pheochromocytomas in patients with von Hippel-Lindau (VHL) disease receiving regular dialysis treatment. The genetic changes predisposing to pheochromocytoma, diagnostic procedures, and surgical management were analyzed. Both patients were considered at low risk of developing pheochromocytoma because they belonged to VHL families with 10 and 25 affected relatives without pheochromocytoma (VHL type 1 families). The mutation responsible for the disease was a stop codon in one case and a missense change in the other. Multiple renal cell carcinomas had required removal of the kidneys at age 37 in one patient and age 25 in the other patient. Computed tomography scan was crucial for diagnosis, showing a unilateral enlarged adrenal gland after 3 and 6 years on regular dialysis. No change in blood pressure was observed. MIBG scintigraphy was negative. Plasma epinephrine in one case and dopamine in the other were increased compared with patients on hemodialysis without pheochromocytoma. Pheochromocytomas were removed successfully by laparoscopic adrenalectomy. Lifelong follow-up of all affected tissues is required in all VHL patients, and pheochromocytoma should be screened for even in the absence of family history in large kindreds. Computed tomography scan allows early recognition, and patients on hemodialysis are responsive to laparoscopic adrenalectomy.