Modified transurethral technique for the management of distal ureter during laparoscopic assisted nephroureterectomy.

INTRODUCTION: Laparoscopic assisted nephroureterectomy is a well established technique for managing the upper urinary tract urothelial cancer. However, management of the distal ureter remains a controversial issue. We describe a modified method of cystoscopic loop ligation and detachment of the distal ureter. TECHNICAL CONSIDERATION: We performed transperitoneal laparoscopic assisted nephroureterectomy in 13 patients. The lower end of the ureter was managed perurethrally using our modified technique. We circumscribed the ureteric orifice with a bladder cuff using a Collins knife. We ligated the ureteric stump via cystoscope to avoid urine spillage from the upper tract. We achieved the complete excision of the distal ureter with a bladder cuff in all cases with our modified technique. CONCLUSIONS: Our modified technique appears to be a simple, less invasive, and oncologically safe method to manage the distal ureter perurethrally.

Epididymal obstruction results in isolated sperm heads in post-vasectomy rats.

The aim of this study was to determine if, following vasectomy, epididymal obstruction resulted in changes in vasal stump fluid using a rat vasectomy model. One hundred and twenty-two mature male rats underwent bilateral surgical vasectomy and subsequent unilateral epididymal obstruction. Animals were randomly assigned to one of the five cohorts, which determined the time to kill and vasal fluid assessment. Numbers of whole sperm and sperm heads were compared between the obstructed and non-obstructed sides. Parametric analysis of microscopic vasal fluid findings was performed using a paired t-test. Whole sperm and sperm heads were detected bilaterally among the initial five cohorts. On the obstructed epididymis side, percentage of whole sperm dropped from 36.9% to less than 1% and sperm heads increased from 63.2 to 99.7% at 12 weeks post-obstruction (p < 0.05 at each time interval). On the unobstructed side, percentage of whole sperm rose from 66.3 to 89.5% and sperm heads dropped from 33.7 to 10.5% (p < 0.05 at each time interval). At 12 weeks, the difference between the obstructed and non-obstructed sides for both percentage and quantity of whole sperm and heads was significant with a p value of <0.001. In this rat model, following vasectomy and subsequent epididymal obstruction, testicular vasal stump fluid will contain progressively diminishing numbers of whole sperm and increases in the percentage and absolute numbers of sperm heads.

Does obesity influence the operative course or complications of robot-assisted laparoscopic prostatectomy.

OBJECTIVE: To determine if obesity is associated with prolonged surgery or more complications during and after surgery in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: Between December 2003 and September 2005 data were collected prospectively for all patients undergoing RALP. Obesity was defined as a body mass index of > or = 30 kg/m2. The duration of surgery was recorded, determining the duration of steps, including overall, robotic assistance, and vesico-urethral anastomosis. In all, 285 patients had RALP by one of two surgeons; 236 were classified as not obese and 49 as obese. RESULTS: The characteristics of the two groups were similar before and after RALP (mean age 60.7 vs 60.3 years, prostate-specific antigen level 7.9 vs 7.9 ng/mL, prostate weight 47.3 vs 45.3 g, length of stay 3.2 vs 3.5 days, and indwelling catheterization 8.3 vs 7.9 days). The mean duration of surgical steps was less for the non-obese than the obese group, with urethral dissection requiring 16 vs 19.3 min (P < 0.05), anastomotic time 30 vs 36 min (P < 0.01), and port closure 11 vs 14.5 min (P < 0.001), but the total duration of surgery, at 190 vs 205 min, was not significantly different (P = 0.07). In the non-obese group there were seven (3%) prolonged drain tube leaks, vs four (8%) in the obese group (P = 0.08). CONCLUSIONS: Obesity was associated with longer anastomotic times, but the overall duration was similar. Overall complication rates were not significantly different. The continuing follow-up will determine if obesity predisposes patients to greater long-term morbidity after RALP.

Laparoscopic and open surgical nephrectomy for xanthogranulomatous pyelonephritis.

BACKGROUND AND PURPOSE: Xanthogranulomatous pyelonephritis (XGP) is a severe, chronic renal-parenchymal infection. Nephrectomy is the treatment of choice. Because of the renal and perirenal inflammatory changes that commonly accompany XGP, the laparoscopic approach is difficult. We compared our experience with laparoscopic and open surgical nephrectomy for XGP. PATIENTS AND METHODS: A retrospective chart review of all adult nephrectomy specimens with the pathologic diagnosis of XGP between January 1997 and May 2003 was performed. Preoperative presentation, operative details, and postoperative recovery and complications were included in the data collection. RESULTS: Three patients approached laparoscopically and eight patients approached with open surgery were found to have XGP on pathologic analysis. The disease was suspected preoperatively in all patients. Among the laparoscopically treated patients, there was 1 (33%) who suffered major complications; this was the only patient who required conversion to open surgery. Among the open-surgical group, there were 2 (22%) major and 3 (33%) minor complications. Postoperative hospitalization was longer in the open-surgical group (mean 13.7 v 4.7 days), and when the case of open conversion was excluded, narcotic use was less in the laparoscopy group. CONCLUSIONS: The treatment of some XGP cases with laparoscopic nephrectomy is a possible, albeit challenging, option. The incidences of intraoperative and postoperative complications were roughly equivalent in the laparoscopic and open-surgery patients in our study. If completed, laparoscopy appears to be associated with decreased postoperative morbidity. However, this may represent selection bias, and larger, prospective studies may better define the suspected benefit.

Intraoperative local anesthesia decreases postoperative parenteral opioid requirements for transperitoneal laparoscopic renal and adrenal surgery: a randomized, double-blind, placebo controlled investigation.

PURPOSE: To determine if local anesthesia decreases discomfort following laparoscopic upper retroperitoneal surgery, we performed a randomized, double-blind, placebo controlled study in which the port sites and hand assist incision were infiltrated with bupivacaine or placebo prior to surgery. MATERIALS AND METHODS: A total of 72 patients undergoing transperitoneal laparoscopic renal or adrenal surgery were randomly assigned to the treatment (0.5% bupivacaine) or placebo (0.9% normal saline) arm. Port and hand assist port sites were infiltrated at the outset of the procedure. Postoperative pain and opioid use were measured at consistent intervals. RESULTS: A total of 37 individuals were treated with placebo (standard laparoscopy [SL] in 15 and hand assisted laparoscopy [HALS] in 22) and 35 were treated with bupivacaine (SL in 16 and HALS in 19). Mean parenteral morphine equivalents use for the placebo vs bupivacaine groups were 29.6 vs 20.0 mg at 12 hours, 50.2 vs 34.5 mg at 24 hours and 57.1 vs 36.6 mg for the total hospital stay (all p <0.05). Parenteral opioid use was decreased in the bupivacaine group in the SL and HALS subgroups with a significant effect at 12 hours in the latter subgroup. On multivariate ANOVA bupivacaine use but not SL vs HALS was associated with decreased parenteral opioid use at all time points (p <0.05). CONCLUSIONS: At the outset of transperitoneal laparoscopic urological surgery in the upper retroperitoneum, port site and other incision infiltration with long acting local anesthesia decreases postoperative parenteral opioid requirements compared with placebo controls. The effect was seen with SL and HALS and it was greater than any effect of SL vs HALS.

Helical computed tomography for identification of crossing vessels in ureteropelvic junction obstruction-comparison with operative findings.

OBJECTIVES: To evaluate the use of contrast-enhanced helical computed tomography (HCT) scanning with three-dimensional reconstructions as a possible identifier of crossing vessels in ureteropelvic junction (UPJ) obstruction. Endoscopic treatment of UPJ obstruction has a success rate that approaches 90%. These results drop to 40% in the presence of crossing vessels. Unrecognized crossing vessels can also result in significant hemorrhage during endopyelotomy. The presence of crossing vessels is, for many, an indication for open or laparoscopic UPJ repair. Therefore, accurate preoperative imaging is crucial for appropriate treatment planning. METHODS: Our study population consisted of 18 patients evaluated and treated for UPJ obstruction at the University of Michigan Health System. These patients underwent routine contrast-enhanced preoperative HCT scanning before UPJ repair. A prior history of failed endoscopic treatment, patient preference, and HCT findings of crossing vessels were indications for open or laparoscopic repair. The imaging findings were compared with open findings during laparoscopic or open pyeloplasty. RESULTS: An HCT finding of the presence of crossing vessels was a significant positive predictor, with a value of 100%. The sensitivity in this population was 91% and the specificity was 100%. No difference was noted between the detection of arterial or venous crossing vessels. The positive predictive value was 100%, and the negative predictive value was 88%. CONCLUSIONS: HCT is an accurate predictor of the presence of crossing vessels in UPJ obstruction. Because crossing vessels may have a profound impact on treatment outcome, HCT can serve as an effective, noninvasive, preoperative screening tool.