Location and etiology of flexible and semirigid ureteroscope damage.

OBJECTIVES: To perform an analysis of currently available manufacturer data regarding the character of ureteroscope damage. The high costs associated with the repair of flexible and semirigid ureteroscopes are well documented. Increased knowledge of the etiology of ureteroscope damage should aid urologists in prolonging the lives of these delicate instruments. METHODS: We requested data from the four major ureteroscope manufacturers (ACMI, Olympus America, Karl Storz, and Richard Wolf) on the types, speculated causes, costs, and frequency of ureteroscope damage. The results were tabulated in a blinded fashion and analyzed for trends. We then formulated guidelines that could be applied by practicing urologists. RESULTS: For both flexible and semirigid ureteroscopes, the frequency of repair increased with decreasing ureteroscope diameter and increasing instrument length. The cost of the repair was generally greater for flexible ureteroscopes (mean 4597 dollars) than for semirigid ureteroscopes (mean 2437 dollars). The major causes of flexible ureteroscope damage were working channel damage from laser burn or instrument passage and extreme scope deflection with an indwelling instrument. The primary reasons for semirigid ureteroscope repair included overtorquing and improper handling in the operating room and during sterile processing. CONCLUSIONS: Urologists can minimize the repair costs of flexible and semirigid ureteroscopes by taking precautions to eliminate laser fiber-induced damage and by avoiding overdeflection. Improved storage and handling of these instruments is also necessary. Although small-diameter ureteroscopes are favorable because of their increased mobility and ease of passage, physician and staff awareness of their increased fragility is vital in maximizing the longevity of these commonly used instruments.

Simultaneous combined use of flexible ureteroscopy and percutaneous nephrolithotomy to reduce the number of access tracts in the management of complex renal calculi.

OBJECTIVE: To present early experience in managing complex renal calculi using a combined ureteroscopic and percutaneous approach, as complex and branched renal calculi often require multiple access tracts during percutaneous nephrolithotomy (PNL), and the combined use of flexible ureteroscopy and PNL has the potential to reduce the inherent morbidity of several tracts. PATIENTS AND METHODS: The study included seven patients (mean age 54 years) with multiple, branched, large-volume renal calculi suitable for management with PNL. Preoperative data, including patient demographics, stone location and stone surface area, were recorded. After informed consent, the patients underwent combined PNL and ureteroscopy in one session. Intraoperative data, including the location of PNL puncture sites, operative duration and complications, were analysed. Stone-free rates were determined by follow-up imaging at 3 months. RESULTS: All patients had either two or more stones in separate locations in the collecting system, or staghorn stones involving multiple calyces. The mean stone burden was 666 mm(2). All patients had only one percutaneous access tract. The mean operative duration was 142 min and the mean blood loss 79 mL. Two patients had small residual stones (< 3 mm), that required ureteroscopic intervention as they failed to pass spontaneously by 3 months after the initial combined procedure. The convalescence was similar to that in our current PNL practice; imaging showed that five of the patients were stone-free. CONCLUSIONS: Combined PNL and ureteroscopic management can effectively reduce the number of percutaneous access tracts which would otherwise be required for managing complex and branched renal calculi, as stones in an unfavourable location relative to the access tract can be relocated and fragmented within easy reach of the single nephrostomy tract. This manoeuvre reduces potential patient morbidity and blood loss but with no significant effect on stone-free rates and operative durations.

Laparoscopic heminephrectomy for tumor.

OBJECTIVES: To present our experience with laparoscopic heminephrectomy. We defined heminephrectomy as excision of 30% or more of the renal parenchyma. Laparoscopic partial nephrectomy has typically been performed for smaller, exophytic tumors. With growing experience, we have performed more extensive resections for larger tumors, when indicated. METHODS: Since August 1999, we have performed laparoscopic partial nephrectomy in more than 300 patients. Of these, 41 patients were deemed to have undergone laparoscopic heminephrectomy (group 1). A contemporary group of 41 consecutive patients who underwent laparoscopic partial nephrectomy (less than 30% resection) were retrospectively identified for comparison (group 2). RESULTS: The preoperative patient demographics were similar, except for a greater body mass index (P = 0.02) in group 1. Group 1 had larger tumors (3.7 cm versus 2.3 cm, P <0.001) that were more commonly centrally located (41% versus 9.8%, P = 0.001) and more deeply infiltrating (P <0.001) compared with group 2. Group 1 underwent larger parenchymal resections (P <0.001) and routine pelvicaliceal suture repair (P = 0.002). The warm ischemia time was longer in group 1 (39 versus 33 minutes, P = 0.02); however, the amount of blood loss (150 versus 100 mL, P = 0.28) and total operative time (220 versus 190 minutes, P = 0.09) were comparable between the groups. The analgesic requirements, hospital stay, overall complications, and postoperative serum creatinine were comparable between the groups. Histopathologic examination showed that all 82 surgical margins were negative. CONCLUSIONS: Laparoscopic heminephrectomy is an advanced procedure that can be performed efficaciously with equivalent outcomes to those of less substantial resections. To our knowledge, experience with laparoscopic heminephrectomy has not been previously described.

Ureteroscopic management of renal calculi in anomalous kidneys.

OBJECTIVES: To review our experience with ureteroscopy in treating patients with renal calculi in anomalous kidneys and to evaluate the efficacy of this approach. METHODS: Eight patients with renal calculi in anomalous kidneys who were managed by ureteroscopic procedures were identified. Demographic information, preoperative stone burden, operative information (ureteroscope size, lithotrite used, instruments used, duration of surgery, complications, stenting), follow-up imaging, and complications were obtained from the medical record. This information was analyzed to determine the most frequently used instruments and stone-free rates. RESULTS: Our cohort consisted of 4 patients with horseshoe kidneys (HSK) and 4 patients with pelvic kidneys (PK) (6 male, 2 female, mean age, 50.6 years). The average preoperative stone burden of the 11 treated calculi was 1.4 cm, with 5 stones located in the renal pelvis, 2 in the upper pole, and 4 in lower pole calyces. A 7.5F flexible ureteroscope, holmium laser lithotripsy, and nitinol baskets and graspers were used in all patients. Six patients had complete clearance of the stone on postoperative imaging (75% HSK, 75% PK), with 88% of patients asymptomatic after their procedure. No patients required additional surgical intervention. CONCLUSIONS: Flexible ureteroscopy with holmium laser lithotripsy and the use of nitinol baskets and graspers provides a reasonable alternative to shock wave lithotripsy in the management of patients harboring renal calculi in anomalous kidneys. In addition, ureteroscopy can be considered a primary option for managing select patients with symptomatic stones in PKs before a percutaneous surgical approach.

Hand-assisted laparoscopic heminephrectomy in horseshoe kidney.

BACKGROUND AND PURPOSE: Horseshoe kidneys are the most common renal fusion anomalies. In surgery on normal kidneys, the use of minimally invasive techniques has decreased morbidity and improved postoperative care. However, aberrant vasculature, abnormal kidney location, and the renal isthmus present technical challenges to the laparoscopic management of horseshoe kidneys. We describe a case of heminephrectomy using hand-assisted laparoscopic techniques. METHODS: A 35-year-old female patient with a horseshoe kidney was evaluated for recurrent nephrolithiasis and infections. Despite multiple previous percutaneous stone removal procedures, she continued to have symptomatic nephrolithiasis in the atrophic and obstructed right renal moiety. A transperitoneal hand-assisted laparoscopic heminephrectomy was performed on the right side. The aberrant vessels were identified and divided while the renal isthmus was divided using an endoscopic stapler. RESULTS: The operative time was 165 minutes, while the estimated blood loss was 200 mL. There were no intraoperative complications. Postoperative pain was minimal, and the hospital stay was 4 days. The patient remains asymptomatic 6 months after her partial nephrectomy, with stable renal function. CONCLUSION: Hand-assisted laparoscopic heminephrectomy provides a safe treatment option for patients with an atrophic, obstructed moiety in a horseshoe kidney.

Hand-assisted laparoscopic partial nephrectomy without hilar vascular clamping using a saline-cooled, high-density monopolar radiofrequency device.

BACKGROUND AND PURPOSE: Nephron-sparing surgery is now accepted as an alternative treatment option for small renal tumors. However, hemostasis during laparoscopic partial nephrectomy can be technically challenging, especially without hilar vascular clamping. The aim of our study was to evaluate the technique of hand-assisted laparoscopic partial nephrectomy using the TissueLink (TissueLink Medical, Dover, NH), a saline-cooled monopolar radiofrequency device, without hilar vascular clamping. PATIENTS AND METHODS: Using the hand-assisted laparoscopic approach, the kidney is mobilized transperitoneally, and the renal tumor with overlying perinephric fat is exposed. The tumor is excised with a 1-cm margin using a combination of the TissueLink device and endoscopic scissors. The tumor and a biopsy of the base of the tumor bed are sent for frozen-section examination. The bleeding vessels are controlled with digital compression and the TissueLink device. At the end of procedure, the tumor bed is covered with a hemostatic agent. Three female and four male patients ages 52 to 76 years (mean 66 years) were treated with this new device for incidental tumors detected during imaging studies (N = 6) or during work-up for gross hematuria (N = 1). Preoperative imaging studies included CT in six patients and MRI in three. The average tumor size was 2.2 cm (range 1.3-3 cm). Only peripheral tumors that did not approach the hilum or the collecting system were selected. RESULTS: All of the patients underwent a hand-assisted laparoscopic partial nephrectomy using the TissueLink device without hilar vascular clamping. There were no intraoperative complications or conversions to open surgery. The mean operative time was 175 minutes, with an estimated blood loss of 186 mL (range 100-300 mL). Histologic examination demonstrated renal-cell carcinoma in five cases, oncocytoma in one, and an angiomyolipoma in one. The dimensions of the normal tissue around the tumor ranged from 1 to 4 mm, and frozen-section analysis showed tumor-free margins in all cases. Postoperatively, all patients recovered well except one patient who developed transient atrial fibrillation, which was treated medically in the immediate postoperative period. All patients were discharged in good condition at an average of 3 days (range 2-6 days). CONCLUSION: Hand-assisted laparoscopic partial nephrectomy without vascular clamping using the TissueLink device is a safe and feasible technique for exclusion of small exophytic renal tissues.