Upper urinary tract laparoendoscopic single-site surgery based on a novel cost-effective reusable platform.

BACKGROUND AND PURPOSE: Several disposable platforms have been introduced for laparoendoscopic single-site (LESS) surgery. Besides technical issues, cost is one of the main limiting factors for their widespread use. We present our experience with LESS surgery for kidney pathologies using the first completely reusable LESS platform. PATIENTS AND METHODS: We performed LESS kidney procedures in 29 patients including nephrectomy (18), partial nephrectomy (3), pyeloplasty (4), and renal cyst ablation (4). All procedures were performed using a completely reusable single-port device (X-Cone) with a simplified combination of standard and prebent instruments. We obtained perioperative and demographic data including a visual analog pain scale (VAS); complications were recorded using Clavien grading. RESULTS: Mean patient age was 49.31 years. Conversion to standard laparoscopy was necessary in one and addition of a needlescopic instrument in four cases. No open conversion was necessary. Intra- and postoperative complications occurred in two (Clavien II) cases. Mean operative time was 110, 90, and 89 minutes, and hospital stay was 4.9, 3.1, and 3.6 days for nephrectomy, partial nephrectomy, and pyeloplasty, respectively. Mean VAS was 2.13, 1.67, and 1.5 while blood loss was 81.3 mL, 140 mL, and 17.5 mL, respectively. There were no positive resection margins. CONCLUSIONS: LESS with a completely reusable platform is feasible for different upper urinary tract procedures yielding favorable functional and cosmetic results. A simplified combination of standard straight instruments and a single prebent grasper facilitates handling and shortens the learning curve. Reusable materials significantly reduce cost and may help to further adopt LESS surgery in surgical practice.

Endoscopic inguinofemoral lymphadenectomy--extended follow-up.

BACKGROUND AND PURPOSE: Inguinofemoral lymphadenectomy (IFLA) is a standard procedure for cancer of the external genitalia. Open lymphadenectomy (O-IFLA) exhibits complication rates of more than 50%. We are demonstrating our extended experience with a modified endoscopic approach (E-IFLA) for groin lymphadenectomy. PATIENTS AND METHODS: Patients with nonpalpable as well as those with palpable nodes who had IFLA were identified. O-IFLA comprised both superficial and deep inguinal lymph node dissection. E-IFLA was performed using a three-trocar approach in the same field. We used a reduced CO2-pressure of <5 mm Hg. A suction drain was always placed. Perioperative data and postoperative outcomes were systematically assessed followed by statistical analysis. RESULTS: We performed 62 IFLAs in 42 patients. Twenty-eight procedures were completed endoscopically. Follow-up was 55.8 months (2-87 mos). Mean operative time for O-IFLA was 101.7 minutes (38-195 min), being shorter than for E-IFLA (136.3 min, 87-186 min), P<0.001. Both groups are comparable regarding the number of nodes (O-IFLA 7.2, 2-16 vs E-IFLA 7.1, 4-13) as well as with regard to the number of positive nodes (O-IFLA 1.8 vs E-IFLA 1.6). Secondary wound healing and leg edema were extremely rare events (1/28) after E-IFLA. The overall complication rate was 7.1%. Complications appeared in 55.3% of the O-IFLA-cases. There were no problems related to CO2 insufflation. Local recurrence rates were identical in both groups. CONCLUSIONS: O-IFLA and E-IFLA are efficient with respect to oncologic safety. E-IFLA is technically more challenging. E-IFLA can avoid secondary wound healing and lymphatic complications. E-IFLA is a safe procedure while a reduction of CO2 pressures optimizes the safety profile. Because cancer control rates remained equivalent during an extended follow-up, oncologic durability could be confirmed.

Single-stage dorsal inlay full-thickness genital skin grafts for hypospadias reoperations: extended follow up.

PURPOSE: To report our extended experience with single-stage genital skin graft urethroplasty for complex hypospadias reoperations. MATERIALS AND METHODS: Thirty-one patients with failed hypospadias surgery were included. The urethral plate had been removed or was scarred in all. After excision of fibrotic tissue a free full-thickness skin graft was quilted to the corpora cavernosa. The neourethra was then tubularized followed by glanuloplasty. Voiding cystograms, urethral ultrasound and flow measurements were performed in all. Outcome was considered a failure when postoperative instrumentation was needed. RESULTS: Follow up was 78.45 +/- 18.18 months. Shaft skin was used in 13 and internal prepuce in 18. Average graft length was 3.66 +/-1.56cm. Eighteen patients required glanuloplasty. Initial graft healing was successful in all. There was no postoperative infection involving the inlay. We did not note complications from the graft donor sites. Four patients underwent redo surgery yielding a complication rate of 12.9%. Urethral stricture of the proximal anastomosis was most frequent. CONCLUSIONS: This single-stage approach using dorsal inlay skin grafts is reliable, creating a substitute urethral plate in the long term. Complication rates are equivalent to those of staged strategies. This is a safe option for hypospadias reoperations if the urethral plate is compromised.

Anterior urethral reconstruction using the circular fasciocutaneous flap technique: long-term follow-up.

PURPOSE: The circular fasciocutaneous skin flap technique (FCF) yields excellent short-term results for complex anterior urethral reconstruction. We performed an observational retrospective and descriptive study to report our long-term experience. METHODS: A total of 36 adults with anterior urethral strictures (AUS) exceeding 3 cm underwent single-stage urethroplasty using the FCF. Exclusion criteria were: lichen sclerosus, absence of the urethral plate and hypospadias. All had a minimum follow-up of 7 years. Mean age was 49.7 years. Radiological work-up was supplemented by urethral ultrasound showing a mean stricture length of 5.9 cm. A circumferential island of distal penile skin was mobilized on a vascularized pedicle and used for urethral reconstruction. Tube repairs were not included. Outcome was considered a failure when post-operative instrumentation was needed. The Mann-Whitney U test was used for statistical analysis. RESULTS: Mean follow-up was 96.7 months (86-117). All received a ventral onlay repair secondary to stricturotomy. Complication rate was 8.3% (3/36): A flimsy stricture at the proximal anastomotic site occurred in 1 requiring optical urethrotomy. In 2 patients, glans dehiscence was noted. No penile skin necrosis was observed proximal to the flap-harvesting site. We did not observe neurovascular lower extremity complications. Long-term success rates exceeded 90%. CONCLUSIONS: FCF-urethroplasty yields excellent long-term results with no late stricture recurrence. All complications occurred early after surgery underlining the durability of pedicled genital skin flaps. Despite extensive stricture, disease complication rates and morbidity were low. In case of paucity of local skin or lichen scleroses, oral grafts are required for optimal treatment.

Long-term results after endoscopic VUR-treatment using dextranomer / hyaluronic acid copolymer - 5-year experience in a single-center.

BACKGROUND: A number of bulking agents have been used for the endoscopic correction of vesicoureteral reflux in children. We present our long-term results of endoscopic use of dextranomer/hyaluronic acid copolymer (Deflux(®)) for VUR treatment in children. PATIENTS AND METHODS: Between 2004 and 2008, 21 children underwent endoscopic subureteral injection of Deflux(®) in 30 ureters as an outpatient procedure. Twelve children had unilateral reflux (2 duplicated systems) and nine had bilateral reflux. Median age was 5-years (6-months to 14.9-years). Six weeks postoperatively, a voiding cystourethrogram was performed. This study examined the disappearance of VUR and urinary tract infection (UTI) in the long-term follow-up as well as QoL (questionnaire of the parents). RESULTS: No intra- or postoperative complications had been noticed. In 25 ureters (83%), VCUG showed no VUR 6-weeks postoperatively. Three children received a 2nd injection (two successful). After a median follow-up of 2.5 years, 27 ureters in 17 children (90%) had no urinary tract infection and VUR. The questionnaire results in regard to quality of life (QoL) were very good in the successfully treated children and the parents would choose the same treatment option again. CONCLUSION: Subureteral injection of Deflux(®) for children with VUR is an effective treatment option with a low complication rate.

Dorsal onlay skin graft urethroplasty in patients older than 65 years.

OBJECTIVES: Single-stage dorsal onlay graft urethroplasty is effective for anterior urethral reconstruction. Despite an aging population, the results of this technique in elderly patients have not yet been explicitly reported. We present our experience with dorsal onlay graft urethroplasty in this cohort. METHODS: We reviewed all urethroplasties performed on males older than 65 years with at least 6 months follow-up. All exhibited extensive anterior urethral strictures precluding anastomotic urethroplasty. Dorsal onlay skin graft urethroplasty was done after stricturotomy using either penile or groin skin grafts. The neourethra was then tubularized in a single stage. Pre- and postoperative urethrograms, urethral ultrasound, and flow measurements were performed in all. RESULTS: Forty-two men (mean age 69.25 years) underwent dorsal onlay urethroplasty. Mean graft length was 5.35 cm (range, 3-12). Penile skin was used in 29 and groin skin in 13. Average follow-up was 57.17 months (range, 29-82). Complications occurred in 4 (9.5%), including fistula formation and stricture recurrence. Final success rate was 90.5%. Compared with patients younger than 65 years, there were slightly more failures. Despite prolonged lithotomy position, we did not observe neurovascular lower extremity injuries. Perioperative complications were uncommon. CONCLUSIONS: Dorsal onlay skin graft urethroplasty can be reliably used in older men with extensive urethral strictures. Although recurrence rates seem to be slightly higher, urethroplasty is generally well tolerated in this cohort of patients. Given the favorable outcome of the dorsal onlay technique, urethral reconstruction should not be withheld solely on the basis of age. Regarding the lifelong benefits of repair, the increased complication rates appear negligible.