Laparoscopic radical nephrectomy in 100 patients: a single center experience from the United States.

BACKGROUND: The objective of the current study was to report a single-surgeon, single-center experience with 100 consecutive laparoscopic radical nephrectomies with intact specimen extraction, with the aim of evaluating the oncologic adequacy of the laparoscopic dissection from a technical standpoint and various parameters including the learning curve. METHODS: Of the 140 laparoscopic radical nephrectomies performed at the study institution since August 1997, the initial 100 are evaluated herein. To evaluate the technical oncologic adequacy, comparison was made with 40 contemporary open radical nephrectomy specimens with regard to detailed radiologic (computed tomography scan) and pathologic data. RESULTS: In the 100 patients studied (with a mean tumor size of 5.1 cm), the mean surgical time was 2.8 hours, the blood loss was 212 mL, the specimen weight was 554.3 g, and the hospital stay was 1.6 days. Complications occurred in 14 patients (14%) and were major in 3 (3%) and minor in 11 (11%). Two patients (2%) were converted to open surgery. There was no perioperative mortality. Over a mean follow-up of 16.1 months, there was no local or port site recurrence reported; 2 patients developed metastatic disease with 1 death occurring at 11 months. When evaluating the learning curve in the initial 50 versus the second 50 patients, a shorter surgical time (P = 0.02) appeared to be the only significant variable. On multivariate analyses, the only variables found to impact on surgical time were specimen weight (P < 0.001) and chronologic time period of surgery (P = 0.05). All laparoscopic specimens were extracted intact; surgical margins were negative for tumor in all 100 patients. All detailed radiologic and histopathologic parameters evaluated were nearly identical between the laparoscopic and open surgery groups. CONCLUSIONS: Laparoscopic radical nephrectomy with intact specimen extraction currently is a routine, effective, and efficacious treatment option for patients with T1-T3aN0M0 renal tumors. Although no long-term data were available as of last follow-up, the negative surgical margins achieved routinely in the current series provide encouraging surrogate evidence of the technical efficacy of laparoscopy from an oncologic standpoint. As such, at the study institution, laparoscopic radical nephrectomy with intact specimen extraction currently is the standard-of-care for patients with T1-3aN0M0 renal tumors measuring < or = 10-12 cm in size.

Robotic laparoscopic surgery: a comparison of the DA Vinci and Zeus systems.

OBJECTIVES: To evaluate two currently available robotic surgical systems in performing various urologic laparoscopic procedures in an acute porcine model. METHODS: Robotic laparoscopic surgery was performed in 14 swine. Data were compared between the da Vinci Robotic System and the Zeus Robotic System. RESULTS: During laparoscopic nephrectomy, the da Vinci System (n = 6) had a significantly shorter total operating room time (51.3 versus 71.6 minutes; P = 0.02) and actual surgical time (42.1 versus 61.4 minutes; P = 0.03) compared with the Zeus System (n = 5). However, the blood loss and adequacy of surgical dissection were comparable between the two groups. For laparoscopic adrenalectomy, the da Vinci System (n = 5) had a shorter actual surgical time (12.2 versus 26.0 minutes; P = 0.006) than did the Zeus System (n = 5). For laparoscopic pyeloplasty, the da Vinci System had a shorter total operating room time (61.4 versus 83.4 minutes; P = 0.10) and anastomotic time (44.7 versus 66.4 minutes; P = 0.11). During pyeloplasty anastomosis, the total number of suture bites per ureter was 13.0 for the da Vinci System (n = 6) and 10.8 for the Zeus System (n = 6). The complications included an adrenal parenchymal tear each during a da Vinci System-based left adrenalectomy and a Zeus System-based right adrenalectomy. An inferior vena caval tear during a Zeus System-based right adrenalectomy occurred in 1 case, which was suture-repaired telerobotically. CONCLUSIONS: Robotic laparoscopic procedures can be performed effectively using either the da Vinci or Zeus System. In this limited study, the learning curve and operative times were shorter and the intraoperative technical movements appeared inherently more intuitive with the da Vinci System. Additional clinical experience is necessary.

Laparoscopic renal cryoablation: impact on renal function and blood pressure.

OBJECTIVES: To evaluate the renal function and blood pressure outcomes after laparoscopic renal cryotherapy. Laparoscopic renal cryoablation is a developmental minimally invasive modality for the treatment of renal neoplasms. After cryotherapy, a segment of renal parenchyma is rendered ischemic/necrotic and left in situ. It is currently unknown whether this may trigger renin overproduction and thus renin-mediated hypertension. METHODS: Data are presented for 22 of 56 treated patients, each of whom completed a minimum follow-up of 6 months. The data were obtained from patient charts, phone interviews, and/or questionnaires. These results were statistically compared over time by paired t tests. RESULTS: The mean follow-up was 20.6 months. No significant differences were found between the preoperative and most recent postoperative serum creatinine (sCr) levels (1.13 and 0.91 mg/dL, respectively), systolic and diastolic blood pressure values (135.6 versus 131.2 mm Hg and 78 versus 72.7 mm Hg, respectively), or in the estimated creatinine clearance (P <0.05). The number or dose of antihypertensive medications did not change during the follow-up period for any patient. In 3 patients with a solitary kidney, the blood pressure and sCr values remained unchanged (mean preoperative sCr 1.43 mg/dL and mean postoperative sCr after a minimum of 6 months 1.33 mg/dL). CONCLUSIONS: Laparoscopic renal cryoablation did not have a deleterious impact on renal function or blood pressure during a mean follow-up of 20.6 months.

Laparoscopic intracorporeally constructed ileal conduit after porcine cystoprostatectomy.

PURPOSE: We present our technique of laparoscopic ileal conduit creation after cystoprostatectomy in a porcine model performed in a completely intracorporeal manner. METHODS AND METHODS: After developing the technique in 5 acute animals laparoscopic cystoprostatectomy with intracorporeally performed ileal conduit urinary diversion was performed in 10 surviving male pigs. A 5-port transperitoneal technique was used. All steps of the technique applied during open surgery were duplicated intracorporeally. Specifically cystectomy, isolation of an ileal conduit, restoration of bowel continuity and mucosa-to-mucosa stented bilateral ileoureteral anastomosis formation were performed by exclusively intracorporeal laparoscopic techniques. RESULTS: Surgery was successful in all 10 study animals without intraoperative or immediate postoperative complications. Blood loss was minimal and average operative time was 200 minutes. Stenosis of the end ileal stoma specifically at the skin level was noted in 6 animals. Three deaths occurred 2 to 3 weeks postoperatively. At sacrifice renal function was normal in all surviving animals. No ileo-ureteral anastomotic strictures were noted on pre-sacrifice radiography of the loop or at autopsy examination of the anastomotic sites. CONCLUSIONS: Laparoscopic ileal conduit urinary diversion after cystoprostatectomy may be performed completely intracorporeally in the porcine model. Clinical application of this technique is imminent.

Retroperitoneoscopic adrenalectomy: lateral approach.

Laparoscopy has become the essential surgical approach to the adrenal gland at many institutions, including ours. At the Cleveland Clinic, laparoscopic adrenalectomy for benign and malignant adrenal neoplasms can be performed by either the transperitoneal or the retroperitoneal approach. Herein, we present our technique of lateral retroperitoneal laparoscopic adrenalectomy.

Thoracoscopic transdiaphragmatic adrenalectomy: the initial experience.

PURPOSE: We introduce the technique of thoracoscopic transdiaphragmatic adrenalectomy. MATERIALS AND METHODS: Initially in 4 human cadavers bilateral thoracoscopic nephrectomy was performed to develop the technique of diaphragmatic incision, retroperitoneal control of renal artery and vein, circumferential mobilization of the kidney and adrenal gland, and suture repair of the diaphragm. Subsequently, 3 select patients underwent thoracoscopic transdiaphragmatic adrenalectomy (2 right side and 1 left side). All 3 patients had significant prior abdominal scarring after either partial or total radical nephrectomy, thereby precluding efficient transabdominal laparoscopic access to the adrenal gland. After double lumen endotracheal intubation, a 4 port transthoracic approach without pneumo-insufflation was performed with the patient in the prone position. The diaphragm was incised under real-time laparoscopic ultrasound guidance. The adrenal gland was visualized high in the retroperitoneum, the vasculature controlled, and the specimen entrapped and extracted intact through a thoracic port site. The diaphragm was suture repaired with freehand laparoscopic suturing and intracorporeal knot tying. A chest tube was inserted in the initial 2 patients. RESULTS: There were no intraoperative or postoperative complications. Operating time was 4.5, 6.5 and 2.5 hours, and blood loss was 150, 500 and 50 cc, respectively. Mean narcotic analgesic requirement was 27 mg. morphine sulfate equivalent. Hospital stay was 2 days for all 3 patients. Pathology revealed metastatic renal cell carcinoma in 2 patients and myelolipoma in 1. CONCLUSIONS: In select patients with significant concomitant intraperitoneal and retroperitoneal scarring from prior major abdominal or renal surgery laparoscopic adrenalectomy can be safely performed with the transthoracic transdiaphragmatic approach. We present our initial experience.

Laparoscopic renal autotransplantation.

BACKGROUND AND PURPOSE: Renal autotransplantation is an extensive open surgical operation consisting of two distinct procedures, live-donor nephrectomy and autotransplantation, and requiring two large skin incisions. Herein, we analyze the feasibility of performing the entire procedure laparoscopically. MATERIALS AND METHODS: Renal autotransplantation was performed entirely laparoscopically in six female farm pigs. Following a left donor nephrectomy, intracorporeal renal hypothermia was achieved by intra-arterial perfusion of ice-cold solution through a 4F balloon catheter. During autotransplantation, the renal vessels were anastomosed intracorporeally to the previously prepared ipsilateral common iliac vessels in an end-to-side fashion. Laparoscopic freehand suturing (5-0 Prolene) and knot-tying techniques were employed exclusively. A staged contralateral native nephrectomy was performed in five animals. Postoperative follow-up included serial creatinine measurements, intravenous urography, aortography, and renal histologic examination. RESULTS: The mean operating time was 6.2 hours (range 5.3-7.9 hours), the venous anastomosis time was 33 minutes (range 22-46 minutes), the arterial anastomosis time was 31 minutes (range 27-35 minutes), and the total iliac clamping time was 77 minutes (range 62-88 minutes). The total renal ischemia time was 68.7 minutes: warm ischemia 5.1 minutes, cold ischemia 33 minutes and rewarming 31 minutes. Serum creatinine concentrations remained stable: baseline 1.3 mg/dL, after autotransplantation 1.1 mg/dL, and after contralateral nephrectomy 1.6 mg/dL. Intravenous urography and aortography prior to euthanasia (N = 5) demonstrated prompt contrast uptake and excretion by the autotransplanted kidneys and patent arterial anastomoses, respectively. Histopathologic examination of the autograft demonstrated normal renal architecture. CONCLUSIONS: Renal autotransplantation can be performed utilizing laparoscopic techniques exclusively. This study may form the basis for performance of complex urologic vascular procedures laparoscopically.

Laparoscopic orthotopic ileal neobladder.

BACKGROUND AND PURPOSE: Orthotopic ileal neobladder is currently the preferred continent urinary diversion in suitable patients undergoing radical cystectomy for muscle-invasive bladder cancer. To our knowledge, presented herein is the initial report of laparoscopic orthotopic ileal neobladder following cystectomy that was performed completely intracorporeally in a porcine model. MATERIALS AND METHODS: The laparoscopic technique was developed in seven pigs. Subsequently, a long-term survival study was performed in 12 consecutive animals. Laparoscopic cystectomy was performed, preserving the urethral sphincter. An ileal segment of 35 cm (first three animals), 45 cm (next four), or 55 cm (final five animals) with adequate mesentery was isolated; and ileal continuity was restored intracorporeally by a stapled anastomosis. Ileal detubularization for construction of an ileal neobladder, urethroileal anastomosis, and bilateral stented ileoureteral anastomoses to a tubular Studer limb extension were all created completely intracorporeally using only laparoscopic free-hand suturing and knot-tying. Biochemical data (preoperative and serial postoperative hemoglobin, renal panel, blood gases), radiologic studies (intravenous urogram, retrograde pouchgram), functional measures (neobladder urodynamics, Whitaker pressure-flow study of both ureters), and microscopic evaluation of the neobladder and ureteroileal and urethroileal anastomotic sites were obtained to evaluate the long-term functional and anatomic outcome. RESULTS: Completely intracorporeal laparoscopic construction of an ileal orthotopic neobladder was successful in all 12 animals without intraoperative or early postoperative complications or open conversion. The mean operating time was 5.4 hours (range 4.5-6.5 hours), and the blood loss was minimal. All study pigs survived their predetermined follow-up period, ranging from 1 to 3 months. Late complications occurred in three animals: one port-site abscess and two cases of E. coli pyelonephritis and azotemia, leading to one death at 2 months. The mean serum creatinine concentrations were 1.33 mg/dL, 1.61 mg/dL, and 1.55 mg/dL at 1, 2, and 3 months, respectively. The mean neobladder capacity was 420 mL (range 250-700 mL) with pressures < or = 20 cm H2O (range 17-20 cm H2O). Pre-euthanasia Whitaker testing confirmed excellent drainage in all 24 ureters. No ileoureteral or ileourethral anastomotic strictures or leaks were noted on intravenous urography, retrograde pouchgram, or postmortem physical calibration of the anastomotic sites. Histologic examination confirmed excellent healing without obvious fibrosis. CONCLUSION: Laparoscopic construction of an orthotopic neobladder is feasible. The anatomic and functional outcome is excellent and comparable to that of open surgery. Clinical application is imminent.

Laparoscopic bilateral synchronous nephrectomy for autosomal dominant polycystic kidney disease: the initial experience.

PURPOSE: We report our experience with laparoscopic bilateral synchronous nephrectomy for giant symptomatic autosomal dominant polycystic kidney disease (ADPKD) and compare outcome data with open bilateral nephrectomy. MATERIALS AND METHODS: Since March 1998, 10 patients underwent bilateral synchronous laparoscopic nephrectomy for giant symptomatic ADPKD. A 3 port retroperitoneal laparoscopic approach was used to secure the renal hilum and mobilize the kidney. Intact specimen extraction was performed through a midline infraumbilical extraperitoneal incision. The patient was then repositioned for the contralateral retroperitoneoscopic nephrectomy, with the second specimen also delivered through the same infraumbilical incision. Data were retrospectively compared with 10 patients who had undergone bilateral synchronous open nephrectomy for ADPKD between 1981 and 1992. RESULTS: Patients in the laparoscopic and open groups were comparable in regard to age (53 versus 47 years, p = 0.54) and Anesthesiologist Society of America class (3 versus 3, p = 0.84) but patients in the laparoscopic group were significantly more obese (body mass index 35.9 versus 23.8, p = 0.02). For comparable total specimen weights (3 versus 3 kg, p = 0.69) surgical time was longer in the laparoscopic group (4.4 versus 3.8 hours, p = 0.007). However, the laparoscopic group was superior in regard to blood loss (150 versus 325 cc, p = 0.05), postoperative requirement of nasogastric tube (10% versus 100%, p = 0.0001), narcotic analgesics (34.2 versus 120.4 mg. morphine sulfate equivalent, p = 0.03) and hospital stay (1.5 versus 9 days, p = 0.004). Complications occurred in 5 patients (50%) in the laparoscopic group and 4 (40%) in the open group (p = 0.66). No laparoscopic case was converted to open surgery. CONCLUSIONS: Synchronous bilateral retroperitoneal laparoscopic nephrectomy for giant symptomatic adult polycystic kidney disease is feasible, safe and efficacious, and can be performed either before or after renal transplantation. Compared to open surgery, the laparoscopic approach results in significantly shorter hospital stay, decreased morbidity and quicker recovery. Laparoscopy is currently our technique of choice in this setting.

Laparoscopic renal cryoablation in 32 patients.

OBJECTIVES: Laparoscopic renal cryoablation is a developmental minimally invasive nephron-sparing treatment alternative for highly select patients with small renal tumors. We present our evolving experience with this procedure. METHODS: Thirty-two patients (34 tumors) with a mean tumor size of 2.3 cm on preoperative computed tomography underwent laparoscopic renal cryoablation. As dictated by the tumor location, cryoablation was performed by either the retroperitoneal (n = 22) or the transperitoneal (n = 10) laparoscopic approach using real-time ultrasound monitoring. A double freeze-thaw cycle was routinely performed. RESULTS: The mean surgical time was 2.9 hours, cryoablation time 15.1 minutes, and blood loss 66.8 mL. For a mean intraoperative ultrasonographic tumor size of 2 cm, the mean cryolesion size was 3.2 cm. The hospital stay was less than 23 hours in 22 (69%) of 32 patients. Sequential magnetic resonance imaging scans demonstrated a gradual contraction in the mean diameter of the cryolesions. Of the 20 patients who underwent a 1-year follow-up magnetic resonance imaging scan, the cryoablated tumor was no longer visible in 5. Of note, 23 patients have now undergone a 3 to 6-month follow-up computed tomography-directed biopsy of the cryoablated tumor site; the biopsy was negative for cancer in all 23 patients. No evidence of local or port-site recurrence was found during a mean follow-up of 16.2 months. CONCLUSIONS: Critical long-term data regarding laparoscopic renal cryoablation, a developmental technique, are awaited. However, our initial experience is cautiously optimistic. Despite its significant potential for false-negative results, it is encouraging that the follow-up computed tomography-directed needle biopsies at 3 to 6 months were negative for cancer in 23 of 23 patients.

Robotic remote laparoscopic nephrectomy and adrenalectomy: the initial experience.

PURPOSE: We evaluated the feasibility of performing laparoscopic nephrectomy and adrenalectomy exclusively by using robotic telepresent technology from a remote workstation and compared outcomes with those of conventional laparoscopy in an acute porcine model. MATERIALS AND METHODS: Five pigs underwent bilateral laparoscopic nephrectomy (robotic in 5 and conventional in 4) and adrenalectomy (robotic in 4 and conventional in 3). In the 9 robotic laparoscopic procedures all intraoperative manipulations were completely performed telerobotically from a remote workstation without any conventional laparoscopic assistance on site. Animals were sacrificed acutely. RESULTS: Robotic laparoscopic nephrectomy required significantly longer total operative (85.2 versus 38.5 minutes, p = 0.0009) and actual surgical (73.4 versus 27.5 minutes, p = 0.0002) time than conventional laparoscopy. However, blood loss and adequacy of surgical dissection were comparable in the 2 groups. Robotic laparoscopic adrenalectomy required longer total operative (51 versus 32.3 minutes, p = 0.13) and actual surgical (38.5 versus 18.7 minutes, p = 0.14) time than conventional laparoscopy. The solitary complication in this study was an inferior vena caval tear during robotic right adrenalectomy, which was adequately repaired by sutures telerobotically in a remote manner. CONCLUSIONS: To our knowledge we present the initial experience with remote telerobotic laparoscopic nephrectomy and adrenalectomy. Telepresent laparoscopic surgery is feasible.

Laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma: the Cleveland Clinic experience.

PURPOSE: We report our single institutional experience with retroperitoneal laparoscopic radical nephroureterectomy in patients with upper tract transitional cell carcinoma and compare results to those achieved by the open technique. MATERIALS AND METHODS: A total of 77 patients underwent radical nephroureterectomy for pathologically confirmed upper tract transitional cell carcinoma. Of these patients 42 underwent laparoscopic nephroureterectomy from September 1997 through January 2000 and 35 underwent open surgery. All specimens were extracted intact. Of the laparoscopic group the juxtavesical ureter and bladder cuff were excised by our novel transvesical needlescopic technique in 27 and radical nephrectomy was performed retroperitoneoscopically in all 42. Data were compared retrospectively with 35 patients undergoing open radical nephroureterectomy from February 1991 through December 1999. RESULTS: Laparoscopy was superior in regard to surgical time (3.7 versus 4.7 hours, p = 0.003), blood loss (242 versus 696 cc, p <0. 0001), specimen weight (559 versus 388 gm., p = 0.04), resumption of oral intake (1.6 versus 3.2 days, p = 0.0004), narcotic analgesia requirements (26 versus 228 mg., p <0.0001), hospital stay (2.3 versus 6.6 days, p <0.0001), normal activities (4.7 versus 8.2 weeks, p = 0.002) and convalescence (8 versus 14.1 weeks, p = 0.007). Complications occurred in 5 patients (12%) in the laparoscopic group, including open conversions in 2, and in 10 (29%) in the open group (p = 0.07). Followup was shorter in the laparoscopic group (11.1 versus 34.4 months, p <0.0001). The 2 groups were similar in regard to bladder recurrence (23% versus 37%, p = 0.42), local retroperitoneal or port site recurrence (0% versus 0%) and metastatic disease (8.6% versus 13%, p = 1.00). Mortality occurred in 2 patients (6%) in the laparoscopic group and 9 (30%) in the open group. Cancer specific survival (97% versus 87%) and crude survival (97% versus 94%) were similar between both groups (p = 0.59). CONCLUSIONS: In patients with upper tract transitional cell carcinoma who are candidates for radical nephroureterectomy the retroperitoneal laparoscopic approach satisfactorily duplicates established technical principles of traditional open oncological surgery, while significantly decreasing morbidity from this major procedure. Short-term oncological and survival data of the laparoscopic technique are comparable to open surgery. Although long-term followup data are not yet available, it appears that laparoscopic radical nephroureterectomy may supplant open surgery as the standard of care in patients with muscle invasive or high grade upper tract transitional cell carcinoma.

Needlescopic surgery for cryptorchidism: the initial series.

PURPOSE: The aim of this study is to report the initial experience with needlescopic surgery (2-mm optics and instrumentation exclusively) for the cryptorchid testicle. METHODS: Ten patients (age 8 months to 37 years) underwent 12 needlescopic procedures: orchiopexy (n = 8), orchiectomy (n = 2), and diagnostic exploration with attempted excision of testicular remnant (n = 2). Two patients underwent bilateral needlescopic orchiopexy. Needlescopic (2 mm) optics and instrumentation were used exclusively in the pediatric patients. RESULTS: All procedures were completed successfully by needlescopic techniques. Mean surgical time was 110 minutes (range, 60 to 180 minutes), and blood loss was 6 mL (range, 0 to 20 mL). There were no intraoperative complications. All procedures were performed on an outpatient basis. In all 8 orchidopexies, the testis was successfully brought to a scrotal position. CONCLUSIONS: Needlescopic techniques allow safe performance of various procedures for a cryptorchid testicle. The cosmetic result is excellent.

Laparoscopic and percutaneous radiofrequency ablation of the kidney: acute and chronic porcine study.

OBJECTIVES: The chronic effects of renal radiofrequency ablation are unknown. Herein, we investigate the anatomic and physiologic sequelae of laparoscopic and percutaneous renal radiofrequency ablation in acute and chronic porcine models. METHODS: Our study comprised two phases-an acute phase and a chronic phase. In the acute phase, bilateral laparoscopic renal radiofrequency ablation was performed in 6 animals (12 renal units), which were euthanized immediately after surgery. In the chronic study, bilateral percutaneous renal radiofrequency ablation was performed in 5 animals (10 renal units). One animal each was euthanized at postoperative day 3, 7, 14, 30, and 90. RESULTS: Ultrasound-monitored laparoscopic (n = 12) and percutaneous (n = 10) radiofrequency ablations of the lower pole of the kidney were technically successful in each instance. No intraoperative complications occurred. In the survival experiments, the radiolesions showed gradual spontaneous resorption and ultimate renal autoamputation, while maintaining pelvocalyceal integrity as confirmed by ex vivo retrograde ureteropyelogram. Serum creatinine and hematocrit remained stable in all survival animals. Postoperative complication occurred in 1 chronic animal with nonobstructive small bowel dilation at autopsy. CONCLUSIONS: Laparoscopic and percutaneous renal radiofrequency ablation are technically feasible. The anatomic and physiologic sequelae of renal radiosurgery are favorable. Improved techniques of real-time monitoring of the evolving renal radiolesion are necessary.

Survey of neuromuscular injuries to the patient and surgeon during urologic laparoscopic surgery.

OBJECTIVES: Laparoscopy may be complicated by neuromuscular injuries, both to the patient and to the surgeon. We used a survey to estimate the incidence of these injuries during urologic laparoscopic surgery, to assess risk factors for these injuries, and to determine preventive measures. METHODS: A survey of neuromuscular injuries associated with laparoscopy submitted to 18 institutions in the United States was completed by 18 attending urologists from 15 institutions. RESULTS: From among a total of 1651 procedures, there were 46 neuromuscular injuries in 45 patients (2.7%), including abdominal wall neuralgia (14), extremity sensory deficit (12), extremity motor deficit (8), clinical rhabdomyolysis (6), shoulder contusion (4), and back spasm (2). Neuromuscular injuries were twice as common with upper retroperitoneal as with pelvic laparoscopy (3. 1% versus 1.5%). Among patients with neuromuscular injuries, those with rhabdomyolysis were heavier (means 91 versus 80 kg) and underwent longer procedures (means 379 versus 300 minutes), and those with motor deficits were older (means 51 versus 42 years of age). Of the surgeons, 28% and 17% reported frequent neck and shoulder pain, respectively. CONCLUSIONS: Although not common, neuromuscular injuries during laparoscopy do contribute to morbidity. Abdominal wall neuralgias, injuries to peripheral nerves, and joint or back injuries likely occur no more frequently than during open surgery, but risk of rhabdomyolysis may be increased. Positioning in a partial rather than full flank position may reduce the incidence of some injuries. Measures to reduce neuromuscular strain on the surgeon during laparoscopy should be considered.

Laparoscopic radical cystoprostatectomy with ileal conduit performed completely intracorporeally: the initial 2 cases.

OBJECTIVES: To present the initial 2 patients who underwent laparoscopic radical cystoprostatectomy, bilateral pelvic lymphadenectomy, and ileal conduit urinary diversion, with the entire procedure performed exclusively by intracorporeal laparoscopic techniques. METHODS: Two male patients, 78 and 70 years old, with muscle-invasive, organ-confined, transitional cell carcinoma of the urinary bladder underwent the procedure. The entire procedure, including radical cystoprostatectomy, pelvic node dissection, isolation of the ileal loop, restoration of bowel continuity with stapled side-to-side ileoileal anastomosis, retroperitoneal transfer of the left ureter to the right side, and bilateral stented ileoureteral anastomoses were all performed exclusively by intracorporeal laparoscopic techniques. Free-hand laparoscopic suturing and in situ knot-tying techniques were used exclusively. RESULTS: The surgical time was 11.5 hours in the first patient and 10 hours in the second. The respective blood loss was 1200 mL and 1000 mL. In both patients, ambulation resumed on postoperative day 2, bowel sounds on day 3, and oral intake on day 4; the hospital stay was 6 days. Narcotic analgesia comprised 108.3 mg and 16.5 mg of morphine sulfate equivalent, respectively. Pathologic examination revealed pT4N0M0 (prostate) and pT2bN0M0 transitional cell carcinoma of the bladder with the surgical margins negative for cancer in both patients. No intraoperative or postoperative complications occurred in either patient. CONCLUSIONS: To our knowledge, this is the initial report of laparoscopic radical cystoprostatectomy with intracorporeal ileal conduit urinary diversion. We believe that with further experience and refinement in the operative technique, laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion may become an attractive treatment option for selected candidates with localized muscle-invasive bladder cancer.

Retroperitoneal laparoscopic radical nephrectomy: the Cleveland clinic experience.

PURPOSE: Laparoscopic radical nephrectomy is usually performed by the transperitoneal approach. At our institution the retroperitoneoscopic approach is preferred. We confirm the technical feasibility of retroperitoneoscopic radical nephrectomy, even for large specimens, and compare its results with open surgery in a contemporary cohort. MATERIALS AND METHODS: A total of 47 patients underwent 53 retroperitoneoscopic radical nephrectomies. Data from the most recent 34 laparoscopic cases were retrospectively compared with 34 contemporary cases treated with open radical nephrectomy. RESULTS: For the 53 retroperitoneoscopic radical nephrectomies mean tumor size was 4.6 cm. (range 2 to 12), surgical time was 2.9 hours (range 1.2 to 4.5) and blood loss was 128 cc. Mean specimen weight was 484 gm. (range 52 to 1,328), and concomitant adrenalectomy was performed in 72% of patients. Mean analgesic requirement was 31 mg. morphine sulfate equivalent. Average hospital stay was 1.6 days, with 68% of patients discharged from the hospital within 23 hours of the procedure. Minor complications occurred in 8 patients (17%) and major complications occurred in 2 (4%) who required conversion to open surgery. Various parameters, including patient age, body mass index, American Society of Anesthesiologists status, tumor size (5 versus 6.1 cm.), specimen weight (605 versus 638 gm.) and surgical time (3.1 versus 3.1 hours), were comparable between patients undergoing laparoscopic (34) and open (34) radical nephrectomy. However, laparoscopy resulted in decreased blood loss (p <0.001), hospital stay (p <0.001), analgesic requirements (p <0.001) and convalescence (p = 0.005). Complications occurred in 13% of patients in the laparoscopic group and 24% in the open group. CONCLUSIONS: Retroperitoneoscopy is a reliable, effective and, in our hands, the preferred technique of laparoscopic radical nephrectomy. At our institution retroperitoneoscopy has emerged as an attractive alternative to open radical nephrectomy in patients with T1-T2N0M0 renal tumors.

Laparoscopic aortorenal bypass.

BACKGROUND AND PURPOSE: Open surgical renovascular repair, although producing excellent results, confers significant operative morbidity. As a result, less morbid procedures such as percutaneous balloon angioplasty and stenting have gained increasing acceptance. Laparoscopic techniques have not previously been applied to renal revascularization. The aim of this study was to demonstrate the technical feasibility and the long-term clinical and pathologic outcomes of laparoscopic aorto-left renal artery bypass in a chronic porcine model. MATERIALS AND METHODS: Eight animals were used in the study. All laparoscopic suturing and knot-tying were performed intracorporeally using free-hand techniques. The following operative steps were employed: (1) aortic dissection and cross-clamping; (2) transection and refashioning of the left renal artery ostium; (3) in-situ renal hypothermia; (4) end-to-side aorto-left renal artery anastomosis; and (5) aortic unclamping. In situ renal hypothermia was achieved laparoscopically by infusion of ice-cold heparinized saline into the renal artery through a balloon catheter. RESULTS: All eight pigs underwent laparoscopic aortorenal bypass successfully. The median surgical time was 110 minutes, and the aortic cross-clamping time was 45.5 minutes. The median anastomotic time was 40 minutes, and the renal warm ischemia time was 9 minutes. The median estimated blood loss was 30 mL. An intraoperative complication of suture breakage leading to anastomotic hemorrhage occurred in one animal; the problem was corrected laparoscopically. Postoperatively, one animal died from pneumonia. The remaining seven animals experienced no postoperative complications and were euthanized, one each at postoperative day 0 and 1 and week 1, 2, 3, 4, and 6. The median preoperative and postoperative (at euthanasia) serum creatinine values (1.15 mg/dL v 1.2 mg/dL; P = 0.39) were similar. However, compared with preoperative peripheral renin activity (0.25 microg/L per hour), the postoperative peripheral renin activity was elevated (0.9 microg/L per hour; P = 0.047). Autopsy revealed a grossly normal left kidney, with Doppler confirmation of flow in the repaired renal artery in all seven animals. Ex vivo angiography confirmed a patent anastomosis. On histopathology examination, the early left renal parenchymal specimens revealed transient, mild acute tubular necrosis that resolved over sequential specimens without significant long-term sequelae. Histologic analysis of the aorto-left renal artery anastomotic site revealed gradual endothelialization with time. CONCLUSIONS: Laparoscopic aortorenal artery revascularization is technically feasible. Our chronic animal model has demonstrated durable success over a 6-week follow-up. This study represents the initial report in the literature.

Laparoscopic adrenalectomy for large-volume (> or = 5 cm) adrenal masses.

BACKGROUND AND PURPOSE: Laparoscopic adrenalectomy has emerged as the standard of care at many centers for small surgical adrenal masses. However, the role of laparoscopic adrenalectomy in the treatment of large adrenal masses has not been specifically addressed. Our aim was to evaluate the outcome of laparoscopic v open adrenalectomy for large-volume (> or =5 cm) adrenal masses and to compare laparoscopic adrenalectomy for large- and small-volume (<5 cm) masses. PATIENTS AND METHODS: Data from 14 patients with large adrenal masses undergoing laparoscopic adrenalectomy between February 1998 and March 1999 (Group I) were retrospectively compared with 14 contemporary large-volume open adrenalectomies between December 1992 and May 1998 (Group II) and 45 small-volume laparoscopic adrenalectomies between July 1997 and November 1998 (Group III). RESULTS: In Group I and Group II, the mean surgical time (205 min v 216 min) and blood loss (400 mL v 584 mL) were similar. Although the mean adrenal size was also comparable (8 cm v 7.8 cm), the specimen weight of the en bloc adrenal gland and periadrenal fat was greater in Group I (168 g v 106 g). The hospital stay was shorter in Group I (2.4 days v 7.7 days). Minor complications occurred in 21.4% of Group I and 50% of Group II patients. On comparing Group I and Group III (laparoscopic <5 cm), Group I had larger specimen weight (168 g v 51.4 g), longer surgical time (205 min v 158 min), greater blood loss (400 mL v 113 mL), longer hospital stay (2.4 days v 1.5 days), a higher complication rate (21.4% v 8.9%), and a higher incidence of open surgical conversion (14.3% v 2.2%). Over a mean follow-up of 9.9 months, no local or port-site recurrences have been noted in Group I. CONCLUSIONS: Laparoscopic adrenalectomy for large-volume adrenal masses is technically feasible and seems to replicate open surgical oncologic principles of achieving a wide-margin, en bloc excision of the adrenal gland and periadrenal fat. Successful laparoscopic resection is not impacted by the large size of the adrenal mass per se but rather by the presence of local invasion and poorly defined tissue planes that may be encountered in adrenal malignancy. As such, laparoscopic adrenalectomy for large masses should be attempted only by experienced laparoscopic surgeons and then with a low threshold for open conversion.

Laparoscopic ileal ureter.

PURPOSE: We describe the operative technique of laparoscopic ileal ureter replacement. MATERIALS AND METHODS: A transperitoneal 3-port approach was used. Ileovesical and pyeloileal anastomoses were performed with intracorporeal laparoscopic freehand suturing and knot tying techniques. RESULTS: Operating time was 8 hours and blood loss was 200 cc. Both anastomoses were immediately watertight. Hospital stay was 4 days and a cystogram at 14 days confirmed widely patent anastomoses without extravasation. CONCLUSIONS: Laparoscopic ileal ureter replacement satisfactorily duplicates established open surgical principles. The laparoscopic technique is efficient and technically straightforward.