Experience with 750 consecutive laparoscopic donor nephrectomies--is it time to use a standardized classification of complications?

PURPOSE: Laparoscopic living donor nephrectomy offers patients the benefits of decreased morbidity and improved cosmesis, while maintaining equivalent graft outcomes and complication rates similar to those of open donor surgery. With expressed concern for donor safety, using a standardized complication scale would allow combining data in a donor registry so potential donors could be adequately followed and counseled. We present the largest series to our knowledge of laparoscopic living donor nephrectomy by a single surgeon. MATERIALS AND METHODS: The institution's initial 750 laparoscopic living donor nephrectomies were included in the study, and a retrospective and prospective chart and database analysis was performed. RESULTS: Mean donor age was 40.5 years and average body mass index was 25.7 kg/m(2). There were 175 patients (23%) with 2 or more renal arteries while 161 (21.5%) had early arterial bifurcations. There were 3 open conversions (0.4%) and the overall complication rate was 5.46%. Median hospital stay was 1 day and the readmission rate was 1.2%. There were 5 reoperations (0.67%), none of which was for the control of bleeding. No patients required a blood transfusion and there were no mortalities. Using a modified Clavien classification of complications for living donor nephrectomy 65.8% were grade 1, 31.7% grade 2 (12.2% grade 2a, 14.6% grade 2b, 4.9% grade 2c) and 2.4% grade 3. There were no grade 4 complications. CONCLUSIONS: With appropriate patient selection and operative experience, laparoscopic living donor nephrectomy is a safe procedure associated with low morbidity. The use of a standardized complication system specific for this procedure is encouraged and could aid in counseling potential donors in the future.

Positive margins in laparoscopic partial nephrectomy in 855 cases: a multi-institutional survey from the United States and Europe.

PURPOSE: Open partial nephrectomy has emerged as the standard of care in the management of renal tumors smaller than 4 cm. While laparoscopic radical nephrectomy has been shown to be comparable to open radical nephrectomy with respect to long-term outcomes, important questions remain unanswered regarding the oncological efficacy of laparoscopic partial nephrectomy. We examined the practice patterns and pathological outcomes following laparoscopic partial nephrectomy. MATERIALS AND METHODS: A survey was sent to academic medical centers in the United States and in Europe performing laparoscopic partial nephrectomy. The total number of laparoscopic partial nephrectomies, positive margins, indications for intraoperative frozen biopsy as well as tumor size and position were queried. RESULTS: Surveys suitable for analysis were received from 17 centers with a total of 855 laparoscopic partial nephrectomy cases. Mean tumor size was 2.7 cm (+/-0.6). There were 21 cases with positive margins on final pathology, giving an overall positive margin rate of 2.4%. Intraoperative frozen sections were performed selectively at 10 centers based on clinical suspicion of positive margins on excised tumor. Random biopsies were routinely performed on the resection bed at 5 centers. Frozen sections were never performed at 2 centers. Of the 21 cases with positive margins 14 underwent immediate radical nephrectomy based on the frozen section and 7 were followed expectantly. CONCLUSIONS: Early experience with laparoscopic partial nephrectomy in this multicenter study demonstrates oncological efficacy comparable to that of open partial nephrectomy with respect to the incidence of positive margins. The practice of intraoperative frozen sections varied among centers and is not definitive in guiding the optimal surgical treatment.

Complications of laparoscopic living donor nephrectomy and their management: the UCLA experience.

OBJECTIVES: Because of the shortage of cadaveric kidneys, laparoscopic living donor nephrectomy (LLDN) has become a more common option for transplant recipients. The complication rate has been reported at 6.4% to 16.5%. We present the initial University of California, Los Angeles experience with the complications and their management during LLDN. METHODS: From January 2000 to December 2005, a single surgeon performed 300 consecutive LLDNs at our institution. A committee of urologists, nephrologists, and support staff approved each donor before surgery. After LLDN was completed, the patients received 30 mg of ketorolac intravenously every 6 hours until discharge. We reviewed the intraoperative and postoperative complications and their management at our institution. RESULTS: Three patients required open conversion, for an overall conversion rate of 1%. Two of the three conversions were a result of a major vascular complication (0.6%). The first major vascular complication resulted from an endovascular stapler malfunction during transection of an accessory left renal artery. The second vascular complication was a Veress needle injury to the left common iliac artery. Three postoperative major complications (1%) occurred, including 1 case of rhabdomyolysis and 2 cases of chylous ascites. Also, 7 minor postoperative complications (2.3%) occurred. Our overall complication rate was 4%. No patients died, and the mean hospital stay was 1.1 days. CONCLUSIONS: Our results have shown that LLDN is a safe procedure associated with low morbidity and a quick recovery. Appropriate patient selection is essential to ensure the safety of this procedure.

Complications of laparoscopic procedures after concentrated training in urological laparoscopy.

PURPOSE: To increase the safety and efficiency of laparoscopic surgery clinical training programs have been developed to increase the skill and efficiency of urological trainees. We evaluated the impact of dedicated laparoscopy training on the rate and type of complications after trainees entered clinical practice. MATERIALS AND METHODS: Data were obtained from 13 centers where laparoscopy was performed by a single surgeon with at least 12 months of training in urological laparoscopy before clinical practice. Data included training experience, laparoscopic procedures performed after commencing clinical practice and associated complications. Procedures were classified as easy, moderate and difficult. RESULTS: During training each surgeon participated in a mean of 71 cases. In clinical practice a total of 738 laparoscopic cases were performed with the group reporting an overall complication rate of 11.9%. The rate was unchanged when the initial 20, 30 and 40 cases per surgeon were compared with all subsequent cases (12%, 11.9% and 12% versus 11.8 to 12%, respectively). The re-intervention rate was 1.1%. The complication rate increased with case difficulty. Overall and early complication rates attributable to laparoscopic technique in the initial 20, 30 and 40 cases were identical. The most common complications were neuropathy in 13 patients, urine leakage/urinoma in 9, transfusion in 7 and ileus in 5. CONCLUSIONS: The complication rate of surgeons who completed at least 12 months of laparoscopy training did not differ according to initial versus subsequent surgical experience. Intensive training seems to decrease the impact of the learning curve for laparoscopy.

Laparoscopic radical nephrectomy.

Most of the open renal procedures have been duplicated or approximated by laparoscopy. Past concerns about increased operative time, cost, resection completeness, and port site metastases are being overruled or put into perspective as experience with laparoscopic radical nephrectomy (LRN) is gained: necessary skills can be acquired, operative times are approaching those for open procedure, and a 14% difference in cost is counterbalanced by reduced postoperative expenditures. Moreover, LRN is acknowledged by its quality-of-life advantages-reduced morbidity and improved cosmetic outcome. Disease-free rate with LRN at last follow-up is 100% for TNM stage I and 89% +/- 6.6 for stage II (1997 classification). Complications are acceptable with an 8% to 35% incidence of minor complications and a 3% to 19% incidence of severe complications. Conversion to an open procedure occurs in 0% to 10% of cases. The procedure's limitations and the appropriate criteria for patient selection are evident. The learning process is believed to last for approximately 20 procedures and patient selection is based on both clinical criteria and one's insight on his location on the learning curve. Therefore, LRN is becoming the treatment of choice for most TNM stages I and II renal tumors. Moreover, recent data advocating pre-immunotherapy nephrectomy in metastatic patients may permit laparoscopic nephrectomy to further benefit selected metastatic patients by potentially shortening the time interval from nephrectomy to immunotherapy and improving immune responsiveness.

Giant bilateral renal angiomyolipomas associated with tuberous sclerosis.

Renal angiomyolipomas in patients with tuberous sclerosis can be associated with significant morbidity, mostly related to complications from bleeding. We describe a patient with tuberous sclerosis and massive bilateral renal angiomyolipomas (total tumor burden 5500 g) who presented with acute right renal hemorrhage. She was treated with right renal artery embolization followed immediately by right nephrectomy and left partial nephrectomy. The patient had a creatinine nadir of 1.3 mg/dL postoperatively. We demonstrate that nephron-sparing surgery is feasible, even in the setting of very large angiomyolipomas, such as the one presented here, currently the largest such tumor by weight reported.

Laparoscopic infrared imaging.

BACKGROUND: As an adjunct to direct visual imaging, an infrared endoscope was developed to assist in the identification of various anatomic structures and to assess tissue viability during laparoscopic procedures. A camera sensitive to emitted energy in the mid-infrared range (3 to 5 microm) was incorporated into a two-channel visible-light laparoscope. METHODS AND MATERIALS: Laparoscopic procedures were performed in a porcine model, inexperienced laparoscopists being asked to localize and differentiate structures before dissection using the visible-light system and then the infrared system. To determine clinical utility, nine laparoscopic urologic procedures were performed with the assistance of the infrared system. RESULTS: In the clinical evaluation, infrared imaging proved to be useful in differentiating between blood vessels and other anatomic structures. In contrast to the experience with the conventional endoscope, vessel identification, assessment of organ perfusion, and transperitoneal localization of the ureter was successful in all instances using the infrared system. In the porcine model, this system also permitted assessment of bowel perfusion during laparoscopic occlusion of mesenteric vessels and distinguished between the cystic duct and artery. CONCLUSION: Infrared imaging is a potentially powerful adjunct to laparoscopic surgery. It may improve the differentiation and localization of anatomic structures and allow assessment of physiologic features, such as perfusion, not previously attainable with laparoscopic techniques.

Telesurgery. Remote monitoring and assistance during laparoscopy.

In comparison to open surgery, laparoscopy results in less postoperative pain, shorter hospitalization, more rapid return to the work force, a better cosmetic result, and a lower incidence of postoperative intra-abdominal adhesions. These advantages are indisputable when comparing large series for cholecystectomy and smaller series for pelvic lymph node dissection, nephrectomy, and bladder neck suspension in experienced hands. Urologists have an obligation to explore the application of these methods to urologic disease and to adjust the standard of care accordingly. Several barriers to the expansion of urologic laparoscopic surgery exist. The experience in extirpative and reconstructive urologic procedures is limited when compared with the data on cholecystectomy. These procedures are technically complex and demand advanced laparoscopic skills and familiarity with laparoscopic anatomy. The steep learning curve translates into long operative times and an unacceptably high rate of complications for inexperienced laparoscopic surgeons. Most practicing urologists have no formal training in advanced laparoscopy, and no formal credentialing guidelines exist. Telesurgical technology may provide one solution to this problem. Through telesurgical mentoring, less experienced surgeons with basic laparoscopic skills could receive training in advanced techniques from a world expert without the need for travel. These systems could also be used to proctor laparoscopic cases for credentialing purposes and to provide a more uniform standard of care. This review has outlined some of the exciting progress made in the field of telesurgery over the past 10 years and described some of the technical and legal obstacles that remain to be surmounted. During the 1990s, urologists were at the forefront of innovation in remote telepresence surgery. As the scope of minimally invasive urologic surgery expands during the first few decades of the twenty-first century, telesurgical mentoring should have an increasingly important role.

Laparoscopic nephrectomy for renal cell carcinoma.

Since the first reported case of laparoscopic nephrectomy by Clayman et al. in 1991, laparoscopy is gaining acceptance as a viable alternative to open surgery for renal cell carcinoma. The benefits of laparoscopy include improved quality of life and lower incidence of perioperative morbidity. The perceived risks of laparoscopic nephrectomy for renal cell carcinoma include port-site metastasis, increased operative time, and the concern for inadequate surgical resection. The preliminary data concerning laparoscopy in renal cell carcinoma, however, indicate that rates of tumor recurrence are equivalent to open surgery while resulting in better cosmesis, decreased level of perioperative analgesic use, and decreased length of time to full convalescence.

Laparoscopic management of urachal cysts in adulthood.

PURPOSE: Managing persistent and symptomatic urachal anomalies requires wide surgical excision. Such intervention is recommended to prevent symptom recurrence and complications, most notably malignant degeneration. However, traditional open excision is associated with significant morbidity and prolonged convalescence. We report our experience with the laparoscopic excision of urachal remnants as a less morbid, minimally invasive surgical alternative. MATERIALS AND METHODS: Between October 1993 and December 1999, 4 patients with a mean age of 43.3 years who had a symptomatic urachal cyst underwent laparoscopic radical excision of the urachal remnant. Using 2, 10 mm. and 1 or 2, 5 mm. ports the urachus and medial umbilical ligaments were divided at the umbilicus cephalad to the cyst. The specimen, which included the urachus, cyst and medial umbilical ligaments, was then separated from the bladder dome with or without the bladder cuff and removed intact. We reviewed the perioperative records to assess morbidity, recovery and outcome. RESULTS: All 4 procedures were completed successfully. No intraoperative or postoperative complications were reported at a mean followup of 15 months (range 2 to 24). Mean operative time was 180 minutes (range 150 to 210) and average hospital stay was 2.75 days (range 1 to 4). Pathological evaluation confirmed a benign urachal remnant in each case. All patients resumed normal activity within 2 weeks. CONCLUSIONS: To minimize the morbidity of radical excision the laparoscopic management of benign urachal remnants in adulthood is efficacious and our preferred method of management.

Laparoscopic radical prostatectomy.

Laparoscopic radical retropubic prostatectomy (LRRP) is a new technique for treating organ-confined prostate carcinoma. The procedure was first described and proven to be feasible in 1997. To date, the results from over 150 cases have been reported in the literature. LRRP appears to be an efficacious procedure and deserves careful consideration. However, open radical retropubic prostatectomy (RRP) is routinely performed with excellent results and minimal morbidity. Whether LRRP offers any compelling benefit over open RRP remains to be determined, and will require a systematic comparison of technical advantages, morbidity, and long-term functional outcomes.

Radially dilating trocar system for open laparoscopic access.

Laparoscopic access can be obtained quickly and without complication by placing a radially dilating trocar sleeve into the peritoneum through a 3-mm umbilical incision and dilating to 5 or 10 mm. This provides a tight seal without purse-string sutures. This is our preferred method of open laparoscopic access.

Laparoscopic assisted reconstructive surgery.

PURPOSE: We describe the use of laparoscopy to assist in performing complex pediatric reconstructive cases with the goals of improved cosmesis, and limited postoperative morbidity and adhesion formation. MATERIALS AND METHODS: Eight patients a mean age of 13.4 years underwent 8 laparoscopic assisted reconstructive procedures at our institution from June 1995 to February 1998. The group consisted of 5 patients with spina bifida, 1 with sacral agenesis, 1 with classic bladder exstrophy and 1 with bladder dysfunction secondary to posterior urethral valves. Information was obtained via personal communication and review of the hospital records. RESULTS: Eight successful laparoscopic assisted procedures were performed, including bladder augmentation and an appendiceal Mitrofanoff procedure in 4 cases as well as tapered ileal Mitrofanoff and Malone antegrade continence enema procedures in 1, and bladder augmentation, appendiceal Mitrofanoff and antegrade continence enema procedure, gastrocystoplasty removal, ileal augmentation and an appendiceal Mitrofanoff procedure, and an antegrade continence enema procedure in 1 each. The laparoscopic component of these operations included extensive mobilization of the right colon in all patients and complete appendiceal harvesting in 2. Reconstruction was then completed through a Pfannenstiel incision in 4 patients, previous low midline scar in 2 and a small midline incision in 2. Drains were placed via existing trocar sites and open incisions were carried through other sites whenever possible. Continent stomas were matured through a trocar site in all 8 cases. Final cosmesis was excellent. Operative time was comparable to that of similar open procedures and intraoperative blood loss was minimal. CONCLUSIONS: Laparoscopy may be used as a successful adjunct in complex pediatric reconstructive procedures to minimize disfiguring and morbid upper abdominal incisions, and decrease the risk of future adhesions.

Laparoscopic visual field. Voice vs foot pedal interfaces for control of the AESOP robot.

BACKGROUND: In order for robotic devices to be introduced successfully into surgical practice, the development of transparent surgeon/machine interfaces is critical. METHODS: This study evaluated the standard foot pedal for the AESOP robot compared to a voice control interface. Speed, accuracy, learning curves, durability of learning at 2 weeks, and operator-interface failures were analyzed in an ex vivo model. RESULTS: Foot control was faster and had less operator-interface failures. Voice control was more accurate as measured by "pass points." The foot control learning curve reached a plateau at the third trial, while the voice control did not fully plateau. Durability of learning favored the foot control but was not significantly different. CONCLUSIONS: Currently, the voice control is more accurate and has the advantage of not requiring the surgeon to look away from the operative field. However, it is slower and may require more attention as an interface. As voice recognition software continues to advance, speed and transparency are anticipated to improve.

Laparoscopy for the acute abdomen in the postoperative urologic patient.

OBJECTIVES: Exploratory laparotomy offers the greatest diagnostic accuracy of intra-abdominal pathologic processes, but can be associated with significant morbidity. Laparoscopy provides diagnostic capabilities equivalent to that of open exploration, but with potentially less morbidity. We present 3 cases in which laparoscopy was used to diagnose and manage urologic patients with an acute abdomen in a postoperative period. METHODS: Three patients underwent laparoscopy between 1 and 14 days postoperatively for an acute abdomen (fever, elevated white blood cell count, and peritoneal signs). The initial procedures included a pubovaginal sling repair with fascia lata, endoscopic placement of a percutaneous gastrostomy tube, and a laparoscopic ureterolithotomy for a distal stone. RESULTS: In each of the 3 patients laparoscopy revealed misplacement or malfunction of a previously placed tube. In all cases, the patient was managed laparoscopically without the need for laparotomy. CONCLUSIONS: These cases demonstrate the feasibility of laparoscopy to provide diagnostic and therapeutic solutions to postoperative urologic patients presenting with an acute abdomen.

Percutaneous cystolithotomy after augmentation cystoplasty: comparison with open procedures.

Percutaneous procedures for the removal of calculi from reconstructed bladders have not been compared in a single institution with traditional open methods. The records of patients undergoing seven percutaneous and six open procedures for the removal of calculi from augmented bladders were reviewed. Operative time, hospitalization time, complications, stone burden, and recurrence were compared. All patients were stone-free at the end of either one or two procedures. Four of six patients in the percutaneous group and four of six patients in the open group had recurrent bladder calculi during average follow-up of 30 months. The average hospital stay was 1.1 days for patients undergoing percutaneous procedures and 3.7 days for those undergoing open cystolithotomy. Narcotic use was significantly lower in the percutaneous group. Percutaneous cystolithotomy is safe, effective, and currently the preferred method for removing stones from an augmented bladder.

Laparoscopic infrared imaging.

A system was developed to determine the potential role of infrared imaging as a tool for localizing anatomic structures and assessing tissue viability during laparoscopic surgical procedures. A camera system sensitive to emitted energy in the midinfrared range (3-5 micron) was incorporated into a two-channel visible laparoscope. Laparoscopic cholecystectomy, dissection of the ureter, and assessment of bowel perfusion were performed in a porcine model with the aid of this infrared imaging system. Inexperienced laparoscopists were asked to localize and differentiate structures before dissection using the visible system and then using the infrared system. Assessment of bowel perfusion was also conducted using each system. Infrared imaging proved to be useful in differentiating between blood vessels and other anatomic structures. Differentiation of the cystic duct and arteries and transperitoneal localization of the ureter were successful in all instances using the infrared system when use of the visible system had failed. This system also permitted assessment of bowel perfusion during laparoscopic occlusion of mesenteric vessels. These initial studies demonstrate that infrared imaging may improve the differentiation and localization of anatomic structures and allow assessment of physiologic parameters such as perfusion not previously attainable with visible laparoscopic techniques. It may thus potentially be a powerful adjunct to laparoscopic surgery.

Pseudotumor of the bladder: a late complication of inguinal herniorrhaphy.

Damage to the bladder during inguinal hernia repair is possible especially if the bladder or a bladder diverticulum is involved in the hernia sac. Unrecognized injury to the bladder can lead to late complications. We report a case of pseudotumor in a bladder diverticulum due to long-term retention of a misplaced suture. The literature on bladder injury after inguinal herniorrhaphy and on pseudotumor formation is briefly reviewed. It is important to be aware of a history of inguinal surgery and to obtain definitive histologic evidence of malignancy prior to making the diagnosis of bladder carcinoma. This will avoid unnecessary radical surgery, chemotherapy, or radiation therapy.