Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction in an Incompletely Duplicated Collecting System in a Patient with a Horseshoe Kidney.

We present a case of UPJO associated with an incompletely duplicated collecting system in a horseshoe kidney that was successfully treated by laparoscopic pyeloplasty with concomitant pyelolithotomy. A 53-year-old man had three urological anomalies and urolithiasis. We performed a pyeloplasty and pyelolithotomy using a fully intracorporeal technique. Clinical and radiographic evaluation confirmed complete resolution of the patient's condition. To our knowledge, there have been no reported cases of UPJO in an incompletely duplicated collecting system with a horseshoe kidney in the same patient. We also provide convincing evidence that laparoscopic pyeloplasty is feasible in complex cases of renal anatomic anomalies.

Retrograde flexible ureteroscopy-assisted retroperitoneal laparoscopic ureteroureterostomy for refractory ureteral stricture: A case report.

INTRODUCTION: Laparoscopic ureteroureterostomy (UU) is a preferred and valid minimally invasive procedure for treatment of benign ureteral strictures. In some cases with chronic inflammation or after repeated endoscopic ureteral surgery, it is difficult to identify the location of a ureteral stricture. PRESENTATION OF CASE: We report a case of 48-year-old man with an impacted stone after laparoscopic partial nephrectomy. Although transurethral lithotripsy (TUL) was performed, the ureteral stricture did not improve by subsequent endoscopic ureteral Holmium laser incision and balloon dilation. DISCUSSION: To simultaneously identify the exact location of the constriction, we performed retroperitoneal laparoscopic ureteroureterostomy with intraoperative observations via super-slim flexible fiberoptic ureteroscopy retrograde. CONCLUSIONS: Accurate identification of the ureteral stricture via observation by laparoscopy and observation by ureteroscopy was feasible. In contrast to the use of a rigid ureteroscopy, flexible fiberoptic ureteroscopy did not require placing the patient in an unnatural position.

Laparoscopic repair of a ureteric sciatic hernia: report of a case.

Ureteric sciatic hernias are extremely rare. Here we report a case of a 78-year-old woman presented with colicky left abdominal pain. Computed tomography revealed a ureteric sciatic hernia, and drip infusion pyelography revealed dilated left ureter with herniation of the ureter into the sciatic foramen. The hernia was successfully repaired laparoscopically. We have described the diagnosis and management of the patient, followed by a review of the literature on sciatic hernias.

Relapse of scrotal calcinosis 7 years after primary excision.

Idiopathic scrotal calcinosis is a rare, benign condition characterized by progressive calcification of the scrotal skin. A 29-year-old man who had undergone primary surgical excision of idiopathic scrotal calcinosis 7 years previously presented with recurrence that he had first noticed 3 years after surgery. Multiple yellowish nodules were observed in the scrotal skin and were confirmed by computed tomography. He underwent repeat resection without any postoperative complications. Histological examination of the surgical specimens revealed diffusely calcified areas within and beneath the squamous epithelium, some of which were associated with epithelial cysts. Immunopathological stains for antibodies against carcinoembryonic antigen, epithelial membrane antigen, and gross cystic disease fluid protein-15 were negative. This is the first reported case of recurrence of scrotal calcinosis. One possible reason for the relapse is that there were remnant seeds of calcification after the primary surgery. This case demonstrates the importance of careful identification and resection of all calcified areas, and of counseling patients about the possibility of relapse after surgical treatment.

Comparisons of perioperative outcomes and costs between open and laparoscopic radical prostatectomy: a propensity-score matching analysis based on the Japanese Diagnosis Procedure Combination database.

We compared perioperative outcomes and costs between open and laparoscopic radical prostatectomy for prostate cancer. The Japanese Diagnosis Procedure Combination database, including cases from 2007 to 2010, was used by one-to-one propensity-score matching. The following items were compared: complication rate; homologous and autologous transfusion rate; first cystography day and cystography repeat rate; anesthesia time; postoperative length of stay; and costs. Multivariate analyses were carried out by including age, Charlson Comorbidity Index, T stage, hospital volume and hospital academic status as variables. As a result, among 15 616 open and 1997 laparoscopic radical prostatectomies, 1627 propensity-score matched pairs were generated. The laparoscopic approach showed a better overall complication rate (3.4% vs 5.0%), homologous transfusion rate (3.3% vs 9.2%), autologous transfusion rate (44.9% vs 79.3%), first cystography day (mean 6th vs 7th day), mean postoperative length of stay (mean 11 vs 13 days), and cost without surgery and anesthesia (mean $7965 vs $9235; all P < 0.001). Anesthesia time was longer (mean 345 vs 285 min) and total cost was higher (mean $14 980 vs $12 356) for the laparoscopic approach (both P < 0.001). The secondary cystography rates were comparable between the groups (18.3% vs 15.7%, P = 0.144). The multivariate analyses showed similar trends. In conclusion, these findings confirm several benefits of laparoscopy over open approach for radical prostatectomy.

Wide range and variation in minimally invasive surgery for renal malignancy in Japan: a population-based analysis.

BACKGROUND: Despite increasing interest in minimally invasive surgery, prevalence data are completely absent. Our objective was to analyze clinico-epidemiological variations of surgery for renal malignancy in Japan with emphasis on annual trends and regional gaps, and to analyze factors affecting choice of open versus minimally invasive surgery. METHODS: We identified patients who underwent open (n = 8646), laparoscopic (n = 5932), or minimum incision endoscopic surgery (MIES) (n = 381) nephrectomy for renal malignancy, using the Japanese Diagnosis Procedure Combination database, 2007-2010. Clinical and regional variations in these three approaches were determined, and the annual per-population incidence of nephrectomy was estimated. Multivariate logistic regression was used to analyze factors affecting choice of minimally invasive surgery (laparoscopy or MIES). RESULTS: The proportion of open nephrectomy decreased from 65.3 % in 2007 to 51.6 % in 2010. Laparoscopic nephrectomy accounted for 51.0 % of procedures for T1 tumors. The estimated incidence of nephrectomy in males and females was 14.3 and 6.1 per 100,000 person-years, respectively. Multivariate analysis showed that minimally invasive nephrectomy was more likely to be selected for patients in their 30-50s who had less comorbidity, better performance status, or lower TNM stage, in high-volume or academic hospitals, especially in western Japan. Hemodialysis use was a favorable factor. CONCLUSION: Despite differences between eastern and western Japan, minimally invasive surgery is becoming widespread throughout Japan, especially for patients with low operative risks and early-stage cancer who are hospitalized in high-volume institutes.

Regional, institutional and individual factors affecting selection of minimally invasive nephroureterectomy in Japan: a national database analysis.

OBJECTIVES: To reveal individual, institutional and regional factors affecting selection of minimally invasive nephroureterectomy in Japan. METHODS: The Japanese Diagnosis Procedure Combination database was queried to retrieve cases of nephroureterectomy for pelvic or ureter malignancies carried out between 2007 and 2010. A multivariate logistic regression analysis with variables including age, sex, pre-existing comorbidities, tumor location, tumor-nodes-metastasis classification, academic status of hospitals, hospital volume, geographic region and year of surgery was modeled to evaluate predictors of carrying out a minimally invasive (including laparoscopic and minimum incision endoscopic) nephroureterectomy. RESULTS: Overall, 3863 open (58.2%), 2635 laparoscopic (39.7%) and 139 minimum incision endoscopic nephroureterectomy (2.1%) cases from 713 hospitals were identified. The proportion of minimally invasive procedures increased from 35.7% to 48.6%. Minimally invasive nephroureterectomy was the most frequently carried out in the Kinki and Chugoku regions (50.9% and 50.4%, respectively) compared with the least in the Kanto region (31.3%). Multivariate analysis showed that lower Charlson Comorbidity Index, lower tumor-nodes-metastasis stage, academic hospitals, higher operative volume centers, western regions of Japan and later year were independently associated with the use of minimally invasive nephroureterectomy. Age, sex and tumor location were not significant factors. CONCLUSIONS: Despite regional and institutional variations, the proportion of minimally invasive nephroureterectomy has gradually increased in Japan. Minimally invasive nephroureterectomy is more likely to be carried out in patients with low tumor stage and low risk at higher volume academic hospitals. Our findings provide fundamental data for future health policies to foster nationwide healthcare uniformity.

[A clinical study of laparoscopic adrenalectomy for pheochromocytoma--analysis of clinical parameters influencing operative time and intraoperative systolic blood pressure].

PURPOSE: We retrospectively analyzed the preoperative clinical parameters which influence operative time and intraoperative maximum systolic blood pressure in patients undergoing laparoscopic adrenalectomy for pheochromocytoma. MATERIALS AND METHODS: Between January 1992 and September 2010, we performed 28 laparoscopic adrenalectomies for pheochromocytoma at Hamamatsu University School of Medicine. These 28 cases were characterized based on the following parameters: body mass index (BMI), tumor size, history of hypertension, preoperative blood pressure, serum concentration of catecholamine, and 24-h urinary excretion of catecholamine metabolite. We retrospectively analyzed whether or not these parameters influenced operative time or intraoperative maximum systolic blood pressure. RESULTS: All 28 cases of laparoscopic adrenalectomy were performed safely and without intraoperative complications and needed neither blood transfusion nor conversion to laparotomy. The median operative time was 203 minutes, and intraoperative hypertension (systolic blood pressure > 200 mmHg) occurred in 46% (13/28) of cases. Median day of discharge in all patients was post-operative day 5. Significant positive correlation was shown between tumor size and operative time and between intraoperative maximum systolic blood pressure and serum concentration of catecholamine or 24-h urinary excretion of catecholamine metabolite (p < 0.05). CONCLUSION: The lengthened operative time for large tumors and elevated intraoperative blood pressure for tumors with high preoperative catecholamine activity necessitate careful perioperative management in patients receiving laparoscopic adrenalectomy for pheochromocytoma.

Laparoscopic radical prostatectomy: transperitoneal anterior bladder approach versus transperitoneal pos-terior bladder approach / 中华泌尿外科杂志

Objective To compare perioperative parameters, as well as the oncological and func-tional results, for laparoscopic radical prostatectomy (LRP) performed via the posterior bladder and anterior bladder approaches. Methods The recorded pre-, peri-, and postoperative parameters and complications, and evaluated the oncological and functional results were collected and compared be-tween the posterior bladder approach (n=25) and the anterior bladder approach (n=34). Results There were no significant differences regarding the preoperative characteristics of the two groups. The mean blood loss, complications, positive surgical margins, and continence showed no significant differences between the 2 groups at 3 and 6 months postoperatively. The mean operation time was sig-nificantly shorter in anterior bladder approach group (174.2±58. 0 min) than in posterior bladder ap-proach group (224. 8±66.7 rain), (P<0. 01). Also, the postoperative recovery time until discharge was 5.9 d in anterior bladder approach group, which was significantly shorter than in posterior bladder approach group (7.5 d) (P<0.05). Conclusion The anterior bladder approach yields shorter oper-ation time and postoperative recovery period than posterior bladder approach for LRP.

Retrospective comparative study of 59 cases of laparoscopic radical prostatectomy: transperitoneal anterior versus transperitoneal posterior approach.

OBJECTIVE: We retrospectively compared perioperative parameters, as well as the oncological and functional results, for laparoscopic radical prostatectomy (LRP) carried out via the posterior and anterior approaches in our hospital. METHODS: We recorded pre-, peri-, and postoperative parameters and complications, and evaluated the oncological and functional results to compare the posterior approach (group 1, n = 25) with the anterior approach (group 2, n = 34). RESULTS: There were no significant differences regarding the preoperative characteristics of the two groups. The incidence of major complications, positive surgical margins, and continence at 3 and 6 months postoperatively showed no significant differences between the two groups. Although mean blood loss (including urine) was not significantly different, the mean prostatectomy time was significantly shorter in group 2 (174.21 +/- 57.97 min) than in group 1 (224.76 +/- 66.72 min) (P = 0.003 by Student's t-test). Also, the postoperative recovery period until discharge was 5.94 days in group 2, and was significantly shorter than in group 1 (7.48 days) (P = 0.02 by Student's t-test). CONCLUSIONS: This retrospective comparative study shows that the anterior approach yields similar, if not better results than the posterior approach for LRP.

Laparoscopic nephrectomy, ex vivo repair, and autotransplantation for a renal artery aneurysm: Report of a case.

A 57-year-old woman was hospitalized with a left renal artery aneurysm (RAA). The aneurysm measured 35 mm in diameter and was located at the renal artery bifurcation. We performed a laparoscopic nephrectomy using a retroperitoneal approach and performed an ex vivo repair of the renal artery. The reconstructed kidney was then autotransplanted at the left iliac fossa. The patient's postoperative course was uneventful. A laparoscopic nephrectomy and ex vivo repair are both considered to be effective for treating complex RAA.

Spontaneous rupture of the urinary bladder presenting as oliguric acute renal failure.

A 64-year-old female was admitted to hospital for acute abdominal pain with ascites. The patient had received postoperative pelvic irradiation for carcinoma of the uterine cervix 7 years previously. Serum creatinine (Scr) was elevated to 2.70 mg/dl, and urinary output was reduced to below 200 ml/day. Cystoscopy revealed a small perforation from the bladder diverticulum. Following transurethral catheterization, urinary output was promptly increased, and Scr was returned to 0.65 mg/dl 4 days later. This rare case suggested that spontaneous rupture of the urinary bladder following postoperative radiotherapy could occur very late with laboratory features of oliguric acute renal failure.

Transrectal high-intensity focused ultrasound in the treatment of localized prostate cancer: a multicenter study.

We report a multicenter trial with transrectal high-intensity focused ultrasound (HIFU) in the treatment of localized prostate cancer. A total of 72 consecutive patients with stage T1c-2NOM0 prostate cancer were treated using the Sonablate 500TM HIFU device (Focus Surgery, Indianapolis, USA). Biochemical recurrence was defined according to the criteria recommended by the American Society for Therapeutic Radiology and Oncology Consensus Panel. The median age and prostate specific antigen (PSA) level were 72 years and 8.10 ng/ml, respectively. The median follow-up period for all patients was 14.0 months. Biochemical disease-free survival rates in all patients at 1 and 2 years were 78% and 76%, respectively. Biochemical disease-free survival rates in patients with stage T1c, T2a and T2b groups at 2 years were 89, 67% and 40% (p = 0.0817). Biochemical disease-free survival rates in patients with Gleason scores of 2-4, 5-7 and 8-10 at 2 years were 88, 72% and 80% (p = 0.6539). Biochemical disease-free survival rates in patients with serum PSA of less than 10 ng/ml and 10-20 ng/ml were 75% and 78% (p = 0.6152). No viable tumor cells were noted in 68% of patients by postoperative prostate needle biopsy. Prostatic volume was decreased from 24.2 ml to 14.0 ml at 6 months after HIFU (p < 0.01). No statistically significant differences were noted in International Prostate Symptom Score, maximum urinary flow rate and quality of life analysis with Functional Assessment of Cancer Therapy. HIFU therapy appears to be minimally invasive, efficacious and safe for patients with localized prostate cancer with pretreatment PSA levels less than 20 ng/ml.

Laparoscopic adrenalectomy for primary and secondary malignant adrenal tumors.

Laparoscopic adrenalectomy is unanimously recognized as the gold standard for the treatment of adrenal tumors, but it is not indicated for tumors of any size when invasion of the surrounding tissues is clearly detected by preoperative imaging. Although laparoscopic adrenalectomy for metastatic adrenal malignancy is a feasible procedure, in the case of primary adrenal malignancy, it should be done very carefully. When laparoscopic surgery is performed for adrenal tumors >6 cm or for tumors that are considered potentially malignant after preoperative imaging or endocrine studies, the operation should be performed only by a highly skilled laparoscopic surgeon. It is also important to inform the patient and family that the tumors may be malignant and that conversion to open surgery could be necessary. The surgeon must create a sufficiently wide working space, remove the tumor and surrounding fat en bloc, and never grasp the tumor or adrenal tissue. The ultrasonically activated scalpel or ultrasonic endoaspirator should be carefully handled so that it does not touch the tumor surface because this will create a risk of tumor-cell dissemination. It also is essential not to persist unreasonably with laparoscopic procedures but to switch immediately to open surgery when laparoscopic surgery becomes difficult.

Laparoscopic adrenalectomy for large adrenal tumors.

BACKGROUND AND PURPOSE: Laparoscopic adrenalectomy remains a controversial procedure for large tumors. We examined the outcome and complications of laparoscopic adrenalectomy for such lesions. PATIENTS AND METHODS: A total of 178 patients underwent laparoscopic adrenalectomy, of whom 29 patients had large (>or =5 cm) tumors. Their mean age was 47.9 years (range 21-72 years), and the mean tumor size was 6.5 cm (range 5.0-11.0 cm). They were compared with patients whose adrenal tumors were <5 cm. RESULTS: The large-tumor group had a mean operating time of 176 +/- 48 minutes (range 84-278 minutes) and a mean blood loss of 136.6 mL (range 10-800 mL) and required a mean of 1.8 days before starting oral intake. None of these values is significantly different from the results in the control group (P > 0.05). The length of recovery was significantly longer in the large-tumor group (5.4 v 4.5 days; P < 0.05), but this was not true if a patient with a 23-day postoperative stay is excluded. The overall incidence of complications was 12% in the large-tumor group, which was not significantly different from that in the control group (P > 0.05). CONCLUSIONS: The operating time, blood loss, and incidence of complications after laparoscopic adrenalectomy did not differ between the patients with large and small adrenal tumors, indicating that experienced surgeons can safely and effectively use laparoscopy for larger tumors. However, it is necessary to consider carefully whether laparoscopic surgery is indicated for tumors that show infiltration on preoperative imaging or for patients who have undergone previous upper-retroperitoneal surgery.

Resistance index in benign prostatic hyperplasia using power Doppler imaging and clinical outcomes after transurethral vaporization of the prostate.

BACKGROUND: Using power Doppler ultrasonography (PDUS), we investigate the change of resistance index (RI) before and after transurethral vaporization of the prostate (TUVP) in benign prostatic hyperplasia (BPH) patients. METHODS: In all, 49 patients underwent transrectal PDUS before receiving TUVP, three were excluded because of cancer and three could not be followed up. The remaining 43 were enrolled in the present study. Patients were assessed before and 1, 3 and 6 months after surgery, giving a mean duration of follow-up of 9.1 months. International prostate symptom scores (IPSS), quality of life (QOL) scores, postvoiding residual urine volumes (PVR) and maximum urinary flow rates (Qmax) were evaluated and total prostatic volume (TPV) and RI were measured using PDUS. RESULTS: Resistance index ranged from 0.64 to 0.91. The postoperative parameters except for RI, such as TPV, PVR, IPSS and QOL scores improved significantly at the follow-up assessment after surgery. The elevated RI decreased significantly 1, 3 and 6 months after the treatment. Resistance index significantly decreased after TUVP and IPSS and other urodymamics parameters improved. CONCLUSIONS: The present study suggested that RI could evaluate the severity of BPH and the degree of intraprostatic pressure or bladder outlet obstruction.

Laparoscopic adrenalectomy.

Laparoscopic adrenalectomy is currently recognized as the gold standard for the treatment of adrenal tumors. In order to assess the current status of laparoscopic adrenalectomy, we reviewed the literature focusing on the indications and contraindications, surgical techniques, complications and new methods. We also reviewed the results separately for aldosteronoma, pheochromocytoma, Cushing's syndrome, and primary or metastatic adrenal cancer.Laparoscopic adrenalectomy is a safe and effective treatment for adrenal disorders, excluding primary adrenal cancer. There are no differences of the various operative parameters between the transperitoneal and retroperitoneal approaches, so the choice of approach should depend on the surgeon's preference or the patient's circumstances. It is important for the surgeon to remove the tumor and the surrounding fat en bloc, especially in the case of large or irregular tumors because of the potential for malignancy. The surgeon must also immediately switch to an open procedure if the laparoscopic operation becomes difficult.We conclude that use of laparoscopic adrenalectomy allows the performance of minimally invasive surgery with the advantages of more rapid recovery and a shorter hospital stay than open adrenalectomy.

Increased circulating levels of natriuretic peptides predict future cardiac event in patients with chronic hemodialysis.

BACKGROUND/AIMS: Cardiovascular events are the major determinant of the prognosis in patients with chronic hemodialysis. The present study was designed to investigate whether increased plasma levels of atrial or brain natriuretic peptides (ANP or BNP) predict future cardiac events in such patients. METHODS: Fifty-three patients undergoing chronic hemodialysis without clinical symptoms suggestive of cardiac disorders were enrolled and their blood was sampled for ANP and BNP measurements. Electrocardiograms demonstrated left ventricular hypertrophy in 28 patients but no other abnormal findings. We followed them up for 11.3 +/- 0.2 months. The endpoint was cardiac events. RESULTS: Cardiac events occurred in 13 patients (CE group). Both ANP and BNP levels were higher in CE group than in patients without cardiac events (ANP: 118 +/- 21 vs. 56 +/- 5 pg/ml, BNP: 769 +/- 204 vs. 193 +/- 25 pg/ml, respectively). Receiver operating characteristics curve revealed that the cut-off levels of ANP and BNP were 58 and 390 pg/ml, respectively. Using the Kaplan-Meier method, the incidence of cardiac events was significantly greater in patients with higher levels of ANP (50.0 vs. 0.0%) or BNP (72.7 vs. 11.9%) than in those with lower levels of the peptides. CONCLUSIONS: Elevated levels of ANP or BNP indicate an increased risk of cardiac events and these peptides are clinically useful to predict cardiac events in patients with hemodialysis.

Role of Doppler ultrasound and resistive index in benign prostatic hypertrophy.

BACKGROUND: The aim of the present study was to assess the resistive index in patients with benign prostatic hypertrophy (BPH) and the role of power Doppler ultrasonography. METHODS: From April 1996 to December 1997, a total of 214 men aged 48-86 years with symptoms of BPH were prospectively enrolled to participate in our study. All patients presented to our clinic with lower urinary tract symptoms. Transrectal ultrasonography was used to calculate the total prostate volume (TPV), transition zone (TZ) volume, transition zone index (TZI = TZ volume/TPV) and presumed circle area ratio (PCAR). Power Doppler imaging was used to identify the capsular and urethral arteries of the prostate and measure its resistive index (RI) value. RESULTS: The RI of capsular arteries significantly correlated with theTPV, TZ volume, TZI (r = 0.470; P < 0.0001) and PCAR (r = 0.334; P < 0.0001). Correlations were found between the RI of capsular arteries and the International Prostatic Symptom Score (IPSS) (r = 0.389; P < 0.0001), peak flow rate of uroflowmetry (r = -0.393; P < 0.0001). CONCLUSION: We demonstrated that an increase of the RI of capsular arteries correlated with increases in the TZI and PCAR in BPH. The lower IPSS and peak flow rate correlated with the high RI of capsular arteries; however, no correlation between the RI of urethral arteries and prostatic parameters was found. The findings suggested that the RI of capsular arteries may become the index for measuring lower urinary obstruction in the future.