Management of rectal injuries sustained during laparoscopic radical prostatectomy.

OBJECTIVES: To report on a treatment algorithm for the management of rectal injures. Rectal injuries during laparoscopic radical prostatectomy (LRP) are rare. In the first 200 cases of LRP performed at our institution, 2 (1%) rectal injuries occurred. Our experience prompted collaboration with our colorectal surgery colleagues to develop a treatment algorithm for the management of such injuries. METHODS: We report on the management of rectal injuries sustained during LRP at our institution. We describe the intraoperative laparoscopic repair of a rectal tear using a 2-layer interrupted closure with absorbable suture. The conservative, nonoperative, management of a rectourethral fistula in a patient who presented after LRP is also described. Collaboration with our colorectal surgery colleagues resulted in the formulation of a treatment algorithm for intraoperative and postoperative presentations of rectal injury during LRP. The algorithm is presented. RESULTS: Of the first 200 cases of LRP at our institution 2 (1%) were complicated by rectal injury. Injuries recognized intraoperatively should be managed laparoscopically if the operating surgeon is adept at intracorporeal suturing. Small rectourethral fistulas can be managed conservatively with urinary catheterization or diversion and antibiotics as needed. Rarely, rectal injuries sustained during LRP will require fecal diversion; injuries that fail to heal despite fecal diversion require operative repair. CONCLUSIONS: Rectal injuries incurred during LRP are rare but must be managed successfully to minimize morbidity. Rectal tears recognized intraoperatively can be managed laparoscopically. The development of a rectourethral fistula is a potential complication of LRP. Most fistulas can be managed conservatively with urinary catheterization or diversion. Rarely, rectal injuries that occur during LRP require fecal diversion or definitive operative repair.

IL-6 does not predict current urolithiasis in stone formers.

INTRODUCTION: Interleukin-6 (IL-6), an inflammatory marker, has previously been found to be elevated in the urine of patients with urolithiasis. Oxalate and other stone precursors have been shown to increase IL-6 production in proximal tubular epithelial cells in vitro. We examined whether urinary IL-6 could be used as a screening test to determine current urolithiasis in individuals who are known to form urinary stones. METHODS: Thirty-five adult patients with current urolithiasis demonstrated on imaging were enrolled in the study. Exclusion criteria included disease known to elevate IL-6. Each patient provided a pre-treatment urine specimen and one month after proven to be stone-free an additional urine specimen was obtained. The urinary IL-6/creatinine ratio was determined for both specimens and compared. RESULTS: Ten patients provided both specimens. The mean pre-operative urinary IL-6/creatinine ratio before the procedure was 1.63 pg/mL. The mean post procedure urinary IL-6/creatinine ratio after the patient was confirmed to be stone-free was 1.81 pg/mL. These were not significantly different (p=0.38). Preoperative urinary IL-6/creatinine ratio did not correlate to stone size (r=0.15) and no correlation was seen between time from treatment and stone free IL-6/creatinine ratio (r=0.48). CONCLUSION: Urinary IL-6 is not a good screening test for current urolithiasis in stone-forming individuals. It is elevated whether the stone is present or not.

Tubeless percutaneous nephrolithotomy with antegrade stent tether: clinical experience.

BACKGROUND AND PURPOSE: A limitation of tubeless percutaneous nephrolithotomy (PCNL) is the need for post-operative office cystoscopy to remove the ureteral stent. We developed a novel technique of intraoperative stent placement that allows removal via the flank. Herein, we report on our initial clinical experience. PATIENTS AND METHODS: Thirty consecutive patients (36 renal moieties) undergoing tubeless PCNL had ureteral stents placed at the end of the procedure with a stent tether exiting the flank incision. Patients were discharged home with the tether protected by a clear occlusive bandage. The stents were removed in the office between 3 and 12 days postoperatively by gently pulling on the tether. Patients were assessed for difficulty in removing the stent, leakage of urine from the flank, and any other postoperative complications. RESULTS: All stents could be removed from the flank using the tether. No urine leakage was noted in any patient, nor did any patient develop any complication related to stent placement or removal. Stents from several manufacturers were employed, with no difference noted. Patients reported no additional discomfort from the presence of the flank tether, and no significant pain was noted during stent removal. CONCLUSION: Utilization of the tether to remove the ureteral stent via the flank after tubeless PCNL is a feasible, safe, and cost-effective improvement on the standard tubeless PCNL technique. This modification obviates postoperative office cystoscopy, allowing easy removal of a stent.

Need for ancillary procedures among patients undergoing tubeless percutaneous renal surgery for nephrolithiasis.

PURPOSE: We routinely perform percutaneous nephrolithotomy (PCNL) without the use of nephrostomy tubes. We examined the need for secondary surgery for the treatment of residual stones in patients who underwent both tubeless surgery and PCNL with tube placement. PATIENTS AND METHODS: We retrospectively reviewed the charts of 180 patients who underwent 186 percutaneous nephrolithotomies. Among them, 125 patients had tubeless surgery, and 61 had nephrostomy tubes. We compared the need for ancillary surgical procedures for residual stone disease in the two groups. RESULTS: A total of 99 patients (79%) without tubes and 25 (41%) of those with tubes were stone free after surgery. A total of 45 ancillary procedures were performed for residual stone disease, with 15% of the tubeless and 43% of the patients with tubes requiring a second procedure. Extracorporeal shockwave lithotripsy (SWL) was the most common ancillary procedure. CONCLUSIONS: Patients who are eligible for tubeless PCNL are unlikely to need a secondary procedure, and residual stones can most often be treated with SWL. Patients who required nephrostomy tubes had more complicated disease and a greater need for subsequent surgery.

Randomized trial comparing modified tubeless percutaneous nephrolithotomy with tailed stent with percutaneous nephrostomy with small-bore tube.

BACKGROUND AND PURPOSE: Recent trials using smaller percutaneous catheters as well as "tubeless" percutaneous technique have attempted to reduce postoperative analgesia requirements and the morbidity of a traditional large-bore nephrostomy tube after percutaneous nephrolithotomy (PCNL). We performed a randomized trial comparing tubeless procedures and use of small catheters to elucidate any differences in perioperative parameters, postoperative discomfort, complications, convalescence, and CT scan findings. PATIENTS AND METHODS: Twenty-four consecutive patients underwent randomization into tubeless (using a tailed 6F double-J stent) and small tube (using an 8.2 pigtail nephrostomy tube) (N = 12 each). A CT scan of the abdomen and pelvis without contrast was obtained the morning of the first postoperative day. Morphine equivalents and a visual analog pain score, as well as questionnaires for convalescence at the postoperative check, postoperative day 1, time of tube removal (3-5 days), and 1-week follow-up were recorded. RESULTS: The mean pain scores and morphine requirements for the tubeless and small-tube groups at postoperative day 0, postoperative day 1, time of stent removal, and 10 days were not significantly different. Convalescence significantly favored stented patients. The CT findings were equivalent. Three patients had inadvertent dislodgment of their stents. CONCLUSIONS: Tubeless and small-bore procedures cause similar postoperative discomfort, with indwelling stents appearing to quicken return to normal activities. Tailed stents may not be appropriate for all patients.

Modification of tubeless percutaneous nephrolithotomy: anterograde stent with flank tether.

A limitation of tubeless percutaneous nephrolithotomy is the need for postoperative office cystoscopy for removal of the ureteral stent. We have developed a novel technique of intraoperative ureteral stent placement that allows for outpatient removal of the stent through the flank using the stent tether.

Laparoscopic urethrovesical anastomosis: a model to assess surgical competency.

PURPOSE: To create a model for the evaluation of resident competency and performance of laparoscopic skills in compliance with Accreditation Council for Graduate Medical Education (ACGME) outcome assessment guidelines for urology residency programs. MATERIALS AND METHODS: A model of laparoscopic interrupted urethrovesical anastomosis was developed using chicken skin from a local supermarket. Eight residents at various training levels utilized a simulator with a camera-operating assistant to practice placing interrupted stitches. The time necessary for completion of an anastomosis and the quality of the anastomosis were documented. RESULTS: The time required to recreate a simulated urethrovesical anastomosis by placing six interrupted stitches declined from an initial mean of 60.75 minutes to 20.5 minutes after each resident had performed 20 anastomoses each. The mean improvement was 39.5 minutes, with one postgraduate year-3 resident demonstrating an improvement of 50 minutes. CONCLUSION: This model can be used by ACGME-certified urology residency programs to assess the laparoscopic skills of residents.

Tubeless percutaneous renal surgery in obese patients.

OBJECTIVES: To assess the outcome and safety of tubeless percutaneous renal surgery in overweight and obese patients. METHODS: A single urologist performed tubeless percutaneous renal surgery on a total of 138 renal units in 133 patients from March 1996 to January 2003. The tubeless procedures consisted of either nephrolithotripsy or endopyelotomy. We analyzed the clinical data of a subset of these patients who were of considered normal weight (body mass index [BMI] 18.5 kg/m2 or greater but less than 25 kg/m2), overweight (BMI 25 kg/m2 or greater but less than 30 kg/m2), obese (BMI 30 kg/m2 or greater but less than 40 kg/m2), and morbidly obese (BMI 40 kg/m2 or greater). RESULTS: Of the 133 patients, 5 (3.8%) were considered morbidly obese, 28 (21.1%) were considered obese, 55 (41.4%) were considered overweight, and 45 (34%) were considered to be of normal weight. Of the 133 patients, 104 underwent percutaneous stone extraction and 29 underwent percutaneous antegrade endopyelotomy. Using unpaired t testing, BMI was compared with the transfusion rates, days of hospitalization, and stone-free outcome. The stone group did not demonstrate statistically significant relationships between BMI and transfusion rate, length of hospitalization, and stone-free outcome (P = 0.423, P = 0.105, and P = 0.127, respectively). A stone-free rate of 94.5% was achieved. In the endopyelotomy group, 29 patients were analyzed. Follow-up showed 24 patients (82.8%) had successful resolution of the ureteropelvic junction obstruction 1 year postoperatively. Two patients required readmission for gross hematuria and low hematocrit. One patient required selective angiographic embolization of a pseudoaneurysm. CONCLUSIONS: Tubeless percutaneous renal surgery is a safe and effective procedure in overweight, obese, and morbidly obese patients.

Use of fibrin glue in percutaneous nephrolithotomy.

OBJECTIVES: To report our experience with the use of fibrin glue during tubeless percutaneous nephrolithotomy. We addressed the safety of this approach and evaluated its use for any clinical benefit with respect to length of hospital stay, bleeding, analgesic usage, and urinary extravasation. METHODS: This was a retrospective review of 43 patients who underwent tubeless percutaneous nephrolithotomy. In 20 consecutive patients (one bilateral), percutaneous tracts were injected with 2 to 3 mL of Tissel Vapor Heated sealant at the conclusion of the procedure. The fibrin glue was instilled during simultaneous removal of the percutaneous sheath. These 20 patients were compared with a control group (23 consecutive patients) in which fibrin glue was not used. The length of hospitalization, hematocrit drop, analgesic use, stone burden, operative times, postoperative complications, and any noted computed tomography scan findings were compared. RESULTS: Postoperatively, the average length of hospital stay was less in the experimental than in the control group by 0.71 day (P <0.05). Differences in hematocrit drop between the experimental (6.8%) and control (5.6%) groups were not statistically significant. The total analgesic use was less in the experimental group, but the difference was not statistically significant. No statistical difference was found between the operative times for both groups. Postoperative fevers and wound seroma were noted in the experimental group. No abscesses or any significant changes along the percutaneous tracts were seen on postoperative computed tomography scans. In the control group, no procedure-related complications were noted. CONCLUSIONS: The use of fibrin glue is safe in percutaneous nephrolithotomy procedures and additional prospective randomized studies are needed to evaluate for any clinical benefit.

Laparoscopic linear cutting stapler failure.

OBJECTIVES: To characterize the frequency and nature of problems with linear cutting staplers to help prevent complications in the future. These devices are often used during laparoscopic urologic procedures. METHODS: We retrospectively reviewed the experience with laparoscopic linear cutting staplers at two institutions routinely performing urologic laparoscopy and analyzed the difficulties with any staplers. Data from the Food and Drug Administration Center for Devices and Radiological Health were also examined to determine the prevalence and types of reported problems. RESULTS: In performing approximately 460 laparoscopic cases, we encountered 5 problems (1%) with endovascular gastrointestinal anastomosis staplers. Fifty-five additional cases in 50 patients were documented in the Food and Drug Administration database. Of the 55 patients, 15 (27%) required open conversion to manage the problem, 8 (15%) received blood transfusions, and 2 (4%) died postoperatively. Twenty-two events occurred during 19 laparoscopic donor nephrectomies (35%) without associated graft dysfunction, damage, or loss. All phases of instrument use were subject to problems; however, abnormal firing of the stapler and improper staple formation were the most common and morbid aspects of device malfunction. CONCLUSIONS: Despite the general reliability of linear cutting staplers, difficulties were encountered in every step of use. Most situations were successfully managed by prompt identification and appropriate intracorporeal maneuvers. Nevertheless, significant morbidity may occur, and conversion to an open operation should be considered. Many potential problems can be avoided by surgeon and staff education, and one should be aware of the alternative methods of tissue ligation currently available.

Laparoscopic evaluation of indeterminate renal cysts: long-term follow-up.

PURPOSE: We present our long-term follow-up of patients who have undergone laparoscopic evaluation for their indeterminate renal cysts, specifically reporting those patients who were found to have cystic renal-cell carcinoma (RCC) and assessing the safety and efficacy of the procedure. PATIENTS AND METHODS: Fifty-seven patients with indeterminate renal cysts (28 Bosniak category II and 29 Bosniak category III) underwent laparoscopic evaluation between July 1993 and July 2000. A transperitoneal laparoscopic localization and aspiration of the cyst, cytologic analysis, and biopsy of the cyst wall and base were performed. A total of 11 patients were found to have cystic RCC. Patients with malignancy have been followed for a mean of 40 months (range 6-70 months), and five patients had 5 years or more of follow-up. RESULTS: Eleven patients (19% of the total) were found to have cystic RCC. Three of these patients had Bosniak category II cysts, and eight had category III cysts. All tumors were low grade (I or II), and the stages were T1-2, Nx-0, M0. There has been no evidence of laparoscopic port site or renal fossa tumor recurrence, local recurrence, or metastatic disease to date in these patients. There is no cancer-specific mortality. CONCLUSIONS: Long-term follow-up indicates that laparoscopic evaluation of indeterminate renal cysts is not associated with an increased risk of port site or retroperitoneal or peritoneal recurrence of RCC. It may save a patient from undergoing open surgery and should be considered as a diagnostic option for patients with indeterminate renal cysts.

Blind percutaneous renal access.

We describe a technique of blind percutaneous renal access when retrograde/intravenous imaging is not possible. We present the surgical technique, the patient population, and situations in which the technique is used. Following a review of 40 accesses, we concluded that this technique is safe, simple, and effective. It also allows the urologist to act autonomously in obtaining renal access.

Tubeless percutaneous renal surgery: review of first 112 patients.

OBJECTIVES: To assess the outcome and safety of the first 112 patients undergoing tubeless percutaneous renal surgery. METHODS: A total of 116 renal units in 112 patients underwent tubeless percutaneous renal surgery from December 1995 to November 2000 performed by a single urologist. The "tubeless" procedures consisted of nephrolithotripsy or endopyelotomy. An antegrade internal ureteral stent was placed during surgery, as was a Foley catheter for bladder drainage, in all patients. Nephrostomy tubes were not used in any patient. The incidence of complications, length of hospitalization, outcomes, transfusion requirements, stone burden, and stone-free rates were obtained by chart review. RESULTS: Of the 112 patients, 86 patients underwent percutaneous stone extraction and 26 patients underwent percutaneous antegrade endopyelotomy. In the group of patients undergoing percutaneous stone extraction, the mean stone burden was 3.30 cm(2). Patients stayed in the hospital an average of 1.25 days. A total of 5 patients required postoperative transfusions. One patient was found on readmission to have a pseudoaneurysm. A 93.0% stone-free rate was achieved. The correlations between transfusion rates, days of hospitalization, and outcome with stone burden were not statistically significant (P = 0.56, 0.78, and 0.18, respectively). For the endopyelotomy group, the mean length of hospitalization was 1.56 days. Only 1 patient required a transfusion, and 3 patients had postoperative complications. Of the 26 patients, 88.5% had a successful outcome from their endopyelotomy. CONCLUSIONS: Tubeless percutaneous renal surgery is a safe and effective procedure and can be performed in patients even with a moderate stone burden.

Radiation protection during percutaneous nephrolithotomy: a new urologic surgery radiation shield.

BACKGROUND AND PURPOSE: As endourology becomes an important part of the practice of urology, the use of fluoroscopic guidance has increased the exposure of urologists to the possibly deleterious effects of radiation. There is a need for a method of radiation protection for percutaneous nephrolithotomy (PCNL), as the exposure from radiation scatter may be significant, depending on the difficulty of establishing access. PATIENTS AND METHODS: We ascertained the effectiveness of a newly modified radiation shield during PCNL. Exposure readings were taken using a thermoluminescent dose monitor placed different distances from the radiation source during six PCNLs. We compared the exposure readings with and without the shield. RESULTS: The shield was able to reduce the radiation by an average of 96.1% at a distance of 25 cm and 71.2% at a distance of 50 cm from the source. CONCLUSION: The shield can be used as one step toward the goal of reducing surgeon radiation exposure. Other methods, such as dose-minimizing imaging protocols and adaptation of equipment optimized to reduce exposure, are also important measures in creating a safe environment for both the urologist and the patient.