Contemporary use of ultrasonic versus standard electrosurgical dissection in laparoscopic nephrectomy: Safety, efficacy and cost.

OBJECTIVE: To assess the safety, efficacy and cost-effectiveness of ultrasonic dissection (USD) compared with standard monopolar electrosurgery (ES) in laparoscopic nephrectomy (LN). PATIENTS AND METHODS: Retrospective analysis of patients' records who underwent elective LN was performed. Patients were divided in to two groups: USD and ES groups depending on the energy source used during LN. The preoperative (demographics, indication for surgery), intraoperative (conversion to open surgery, operative time, estimated blood loss [EBL], complications), and postoperative (morbidity/mortality, volume of drainage, hospital stay, cost) data were collected and analysed. RESULTS: Between February 2004 and February 2008, 136 patients were included. The indications for nephrectomy were: inflammatory (51 patients), non-inflammatory (64), and tumours (21). The two groups were similar for preoperative data. The conversion rate to open surgery (12.5%) and mean operative time did not differ significantly between the groups. However, intraoperative mean EBL was significantly less with USD, at 140.8 mL vs 182.6 mL for ES. There were no differences in postoperative parameters and morbidity. USD was significantly more expensive than ES (59 000 vs 26 000 Indian Rupees). CONCLUSIONS: ES is a safe and feasible tool like USD in LN when used with caution. USD facilitates completion of difficult cases and reduces intraoperative blood loss. However, the majority of LNs can be completed safely with ES. ES is sturdy and cheap; therefore, selective use of USD appears to be the most cost-effective policy in the developing world.

Laparoscopic ureterolysis and omental wrapping in patients with retroperitoneal fibrosis and obstructive uropathy: a single-center experience.

OBJECTIVES: To analyze the outcomes with mid- to long-term follow-up of laparoscopic ureterolysis (LU) and omental wrapping in retroperitoneal fibrosis (RPF) with obstructive uropathy. PATIENTS AND METHODS: Records of 9 patients with RPF who had obstructive uropathy at presentation and had undergone LU and omental wrapping at our center during January 2004 to June 2012 were collected and analyzed. RESULTS: Six females and three males underwent LU for RPF. Underlying causes of RPF could not be found in 8 (89%) cases. Two patients underwent bilateral LU. Mean operative time and estimated blood loss were 213 minutes (range, 180-280 minutes) and 119 mL (range, 70-200 mL), respectively. No case required conversion to open surgery. The only significant intraoperative complication (1/9 [11%]) was ureteral injury, which was easily repaired intraoperatively. The postoperative complication rate was 44% (4/9). Most complications (75% [3/4]) were minor and did not need specific treatment. The mean follow-up period was 46 months (range, 4-72 months). The success rate at last follow-up was 89%. CONCLUSIONS: Treatment of RPF is still controversial. Any future prospective randomized comparative trials seem unlikely in view of the low incidence of RPF. LU and omental wrapping in the setting of obstructive uropathy are safe and an effective alternative with a high success rate at mid- to long-term follow-up.

Laparoscopic nephrectomy for pyonephrosis during pregnancy: case report and review of the literature.

The maternal and fetal complications of pyonephrosis during pregnancy can be devastating, thus the call for urgent but safe intervention. Laparoscopic nephrectomy has been used safely and effectively in nonpregnant patients with pyonephrotic kidney. We report on a case of a 28-year-old pregnant woman with pyonephrotic kidney that we believe to be the first such case managed by transperitoneal laparoscopic nephrectomy. A review of the reported cases of laparoscopic nephrectomy for different indications and by different approaches during pregnancy is also presented.

Laparoscopic nephrectomy in xanthogranulomatous pyelonephritis: 7-year single-surgeon outcome.

OBJECTIVE: To evaluate the outcome of laparoscopic nephrectomy in patients with xanthogranulomatous pyelonephritis (XGPN). METHODS: The medical and procedural records of patients with pathologically confirmed XGPN from February 2004 to December 2010 were reviewed retrospectively. During this period, 19 patients (mean age 37.5 years, range 14-77) underwent surgical management of XGPN. The records of the clinical history, mode of presentation, surgical management, hospital stay, and complications were analyzed. RESULTS: Laparoscopic nephrectomy was performed successfully in 14 patients (73.2%); 5 patients required conversion to open surgery. Of these 5 patients, 3 electively underwent conversion to open surgery because of nonprogression of the procedure, and in 2 patients, conversion was performed on an emergency basis because of bleeding from hilar vessels in 1 patient and diaphragmatic injury in the other. The operative time was 284 minutes (range 181-340), with a mean estimated blood loss of 220 mL (range 90-500) and mean analgesic (tramadol) requirement of 150 mg (range 50-500). Clavien grade I complications occurred in 2 patients, grade II in 3, and grade IIIa in 1 patient. Two patients had grade IVb complications. One patient required a blood transfusion. The mean hospital stay duration and the return to routine activities was 4.4 days (range 2-37) and 21 days (range 12-66), respectively. CONCLUSION: Laparoscopic nephrectomy, although challenging, can be performed safely in most patients with XGPN. A greater conversion rate and longer operative time should be expected, and early conversion to an open approach might be required in difficult cases owing to a failure to proceed.

Ascites in ventriculoperitoneal shunt.

OBJECTIVE: To fetch out the factors responsible for ascites, following shunt CSF diversion in cases of intracarnial lesions. Four children developing ascites/abdominal psuedocyst following ventriculoperitoneal shunt were analyzed to see the factors responsible for such complication. METHODS: Records of 4 cases developing ascites were studied retrospectively. These children developed ascites at 8 months, 6 months, 1 year and 1 year 2 months interval following their shunt installation. RESULTS: The primary etiology of hydrocephalus was demonstrated as thalamic glioblastoma, choroid plexus papillomas of third ventricle, post tubercular meningitis hydrocephalus and suprasellar craniopharyngioma. CONCLUSION: The proposed etiology of ascites in these cases was peritoneal metastasis from thalamic glioblastoma through ventriculoperitoneal shunt in first case, excessive production of CSF by choroid plexus papilloma in second, infection in the third case and craniopharyngioma causing excessive production of CSF in the fourth child. All the children were treated by reasonable laparotomy and fenestration of cyst along with the repositioning of shunt tip at another site.