Radially expanding laparoscopic access for renal/adrenal surgery.

OBJECTIVES: To use a radially expanding system (Step) and a modified port location for intra-abdominal access to decrease the access-related complications in renal and adrenal surgery. Access-related complications during laparoscopic renal surgery are frustrating and are more common in patients with previous abdominal surgery and associated adhesions. METHODS: Laparoscopic upper tract procedures were performed in 62 patients using radially expanding trocars, and the results were reviewed with regard to access, port placement, and associated complications. For initial access, a Veress needle was placed subcostally in the midclavicular line. An expandable mesh sleeve trocar was used for trocar insertion after a pneumoperitoneum was established. A blunt-tipped fascial dilator was used to dilate to 10 or 12 mm. Additional ports were placed in an L shape (nephrectomy) or a subcostal configuration (adrenalectomy) under direct vision using the Step ports. RESULTS: Of 62 patients, 24 had had prior abdominal surgery. Open insertion of the mesh sleeve was necessary in 20%, of whom 60% had had prior abdominal surgery. In 9% of cases, the liver was punctured with the initial pass of the Veress needle. Only minimal bleeding from the injury site was noticed. The liver punctures did not require cauterization and did not result in conversion to an open procedure. At a mean follow-up of 12 months, no access-related complications or port-site hernias were noted. CONCLUSIONS: Placement of the initial access subcostally at the level of the midclavicular line helps to prevent visceral injury, especially in patients with previous abdominal surgery. The use of the radially expanding access system with the modification of port location allows safe and rapid laparoscopic access for upper urinary tract surgery. This trocar system is an excellent alternative to the standard laparoscopic trocars.

Radially expanding single-step nephrostomy tract dilator.

OBJECTIVES: To compare the radial and axial forces produced by balloon, Amplatz, and radially expanding single-step nephrostomy (RESN) systems and report our initial clinical results using the new RESN device. Balloon, Amplatz, and Alken dilators are commonly used to establish nephrostomy tracts in percutaneous surgery. They require multiple steps, with the potential for kinking and displacement of the working guidewire. In contrast, the new RESN tract dilator expands a unique sleeve conduit and places an Amplatz-like sheath in a single step with less dependence on a guidewire for dilation. METHODS: An experimental model was designed using a perforated silicon disc with a 10F central opening to measure the axial force transmission as 30F balloon, Amplatz, and RESN systems were inserted through the silicon discs. We also report our first 9 patients who underwent percutaneous dilation with the RESN system. RESULTS: Thirty French expansion was achieved with each dilator tested. Substantially lower axial forces were transmitted with the RESN device compared with the balloon and Amplatz dilators (5.2 versus 13.1 and 19.2 lb, respectively, P <0.001). Intraoperatively, all 9 patients were successfully dilated, and the kidney was relatively stationary as imaged with fluoroscopy. One patient with multiple prior renal procedures was successfully dilated with RESN system after failed attempts with balloon dilation. CONCLUSIONS: The RESN dilator is a rapid, single-step access system successfully used in our first 9 patients. Intraluminal sleeve dilation eliminates guidewire dependence for maintaining access, limits renal displacement, and facilitates appropriate vector force for percutaneous dilation.

Retrograde renoscopic fragmentation of moderate-size (1.5-3.0-cm) renal cystine stones.

PURPOSE: We present a series of cystinuric patients with renal cystine calculi between 1.5 and 3.0 cm treated with retrograde renoscopy and intracorporeal lithotripsy and report our results, complications, and inpatient utilization with this approach. PATIENTS AND METHODS: The hospital and office charts of five consecutive patients with six treated renal units who underwent retrograde renoscopy and electrohydraulic lithotripsy for renal cystine stones between 1.5 and 3.0 cm were reviewed. Data on stone size and location, procedures performed, results, complications, and inpatient hospital days were compiled. RESULTS: Five of the six renal units were either rendered stone free or had fragments totalling 3 mm or less. Three renal units required only a single procedure, one required repeat ureteroscopy for Steinstrasse, and one required SWL and repeat ureteroscopy for Steinstrasse. One renal unit was left with a 6-mm fragment for which the patient refused further treatment. There were no major complications. The mean hospital stay was 1 day, and the mean number of procedures per patient was 1.3. CONCLUSION: Retrograde renoscopy and intracorporeal lithotripsy for renal cystine stones 1.5 to 3.0 cm is safe and effective and should be considered as an alternative to percutaneous nephrolithotomy in these patients.