A prospective study of laparoscopic radical nephrectomy for T1 tumors--is transperitoneal, retroperitoneal or hand assisted the best approach?

PURPOSE: We designed a prospective, randomized clinical trial to compare 3 common approaches to laparoscopic radical nephrectomy, namely transperitoneal, retroperitoneal and hand assisted. MATERIALS AND METHODS: A total of 33 patients with a solid renal mass of 7 cm or less were prospectively enrolled in alternating fashion to a hand assisted procedure, a transperitoneal procedure with morcellation and a retroperitoneal procedure with intact specimen extraction. A single surgeon performed all operations. Preoperative, intraoperative and postoperative criteria were compared among the 3 techniques. RESULTS: A total of 11 patients underwent each type of procedure. There was no significant difference in age, American Society of Anesthesiologists class, body mass index or tumor size among the groups. Mean operative time was significantly lower using the hand assisted approach, whereas estimated blood loss was similar in all 3 groups. Incision size, hospital stay and time to normal daily activity were less using the transperitoneal approach. While not significant, there was a trend toward less narcotic use in the transperitoneal group. Hernia formation was seen with increased frequency in the hand assisted group. CONCLUSIONS: In our series the hand assisted approach had significantly shorter operative time than the transperitoneal or retroperitoneal approach but it had the greatest risk of hernia formation. The transperitoneal approach was associated with a significantly shorter hospital stay and the earliest resumption of normal activity.

Infectious response to E. coli: molecular and genetic pathways.

Urinary tract infections are most commonly caused by type 1-piliated Escherichia coli (UPEC) and result in urothelial apoptosis, local cytokine release and neutrophil infiltration. A human urothelial cell line was incubated with various E. coli isolates and was then characterized by flow cytometry. UPEC induced rapid urothelial apoptosis that was dependent upon interactions mediated by type 1 pili. Laboratory isolates expressing type 1 pili-induced approximately 50% less apoptosis. UPEC blocked activity of a NF-kappaB-dependent reporter in response to inflammatory stimuli by stabilizing IkappaBalpha and UPEC rapidly altered cellular signalling pathways. Finally, blocking NF-kappaB activity increased the level of the laboratory strain-induced apoptosis to the level of apoptosis induced by UPEC. These results suggest that UPEC blocks NF-kappaB and enhances type 1 pili-induced apoptosis as a component of the uropathogenic programme.

Retrieval of migrated ureteral stent by intussusception of ureteral balloon dilator tip.

A vexing complication of ureteral stent placement is inadvertent proximal migration. The retrieval of a migrated ureteral stent may be performed using a myriad of techniques but usually requires ureteroscopic extraction. We report a novel, time-efficient technique to capture and reposition a migrated ureteral stent without ureteroscopic manipulation.

Mast cell activation triggers a urothelial inflammatory response mediated by tumor necrosis factor-alpha.

PURPOSE: Mast cells have been implicated in bladder inflammation and pathogenesis. To determine if mast cell secretion products can modulate urothelial inflammatory responses we developed an in vitro model of mast cell-urothelial cell interactions. MATERIALS AND METHODS: Cultures of the immortalized urothelial cell line TEU-2 were incubated in the conditioned medium of mast cell cultures. The urothelial inflammatory response to mast cell secretion products was then determined by quantifying nuclear factor kappaB activity, the expression of endogenous nuclear factor kappaB dependent genes and the protein expression of inflammation markers. RESULTS: Conditioned medium from RBL-2H3 mast cells induced a 4-fold increase in TEU-2 nuclear factor kappaB activity that was independent of the activation state of the mast cells. In contrast, ribonuclease protection assays revealed that the nuclear factor kappaB dependent transcripts tumor necrosis factor-alpha (TNF-alpha), interleukin (IL) 8 and 1beta, and intracellular adhesion molecule 1 (ICAM-1) were induced by mast cell conditioned medium in a manner that strictly depended on mast cell activation (antigen challenge of IgE sensitized RBL-2H3 cells). The dependence on mast cell activation was confirmed by the observation that IL-8 secretion and ICAM-1 protein expression in TEU-2 cultures were induced only by conditioned medium of stimulated RBL-2H3 cells The induction of TEU-2 IL-8 secretion and ICAM-1 expression by mast cell conditioned medium could be blocked by an anti-TNF-alpha antibody or the cysteine protease inhibitor N-acetyl-leucinyl-leucinyl-norleucinal. CONCLUSIONS: Our data support the hypothesis that mast cells may participate in bladder inflammation. Furthermore, TNF-alpha acting via the nuclear factor kappaB signaling pathway may be a mediator of the urothelial response to mast cell secretion products.

Repair of a diaphragmatic injury during hand assisted laparoscopic nephrectomy using an onlay patch of polypropylene and polyglactin mesh.

PURPOSE: We describe a simple and time efficient technique for repairing a diaphragmatic injury occurring during right hand assisted laparoscopic radical nephrectomy. MATERIALS AND METHODS: A dual layer polypropylene and polyglactin mesh was created extracorporeally by sewing a 2 x 2 piece of polypropylene mesh to a 2 x 2 piece of polyglactin mesh with 4, 4-zero interrupted polyglactin sutures. This dual layer was then positioned manually over the diaphragmatic rent and secured with a laparoscopic stapling device. A 16Fr chest tube was placed at the conclusion of the procedure. RESULTS: Overall operative time was 3.5 hours with an estimated blood loss of 100 cc. Repair of the diaphragmatic injury extended operative time by 25 minutes. Extubation was done at the conclusion of the case and the chest tube was removed within 36 hours of the procedure. The patient was discharged home on postoperative day 3. At 14 months of followup the patient remained disease-free on radiography and without pulmonary or gastrointestinal sequelae. CONCLUSIONS: We describe a simple and time efficient technique for repairing diaphragmatic injury occurring during right hand assisted laparoscopy. This technique takes advantage of the manual and tactile sensation provided by the hand assistance device, provides a tension-free repair and avoids laparoscopic suturing.