Sigmoid-urachal-cutaneous fistula in an adult male.

An infected urachal cyst is an uncommon finding in adults. We report the first case of a sigmoid-urachal-cutaneous fistula that resulted from rupture of an infected urachal cyst in an adult male. Definitive management consisted of resection of the urachus with a bladder cuff, along with removal of the affected bowel segments and bowel anastomosis.

Measuring the true success of laparoscopic pyeloplasty.

BACKGROUND AND PURPOSE: Laparoscopic pyeloplasty (LP) is a highly successful minimally invasive management option for ureteropelvic junction obstruction (UPJO) with success rates equaling or surpassing open repair. Definitions of success have varied greatly among reports of series in the literature. We propose that true success or failure be strictly defined by resolution of obstruction on objective physiologic testing (diuretic renography or Whitaker testing) and accordingly present our results. PATIENTS AND METHODS: We prospectively gathered data on all LP from December 2001 to November 2006. Ninety-two patients have matured to follow-up testing (> 3 months). Primary uncomplicated procedures were completed in 62/92 (67%) while secondary and/or complex repairs were performed in 30/92 (33%). Rigorous follow-up with physiologic testing was performed postoperatively. Patients with equivocal diuretic renal scans were evaluated with Whitaker pressure-flow studies. The subjective symptom score was assessed for our first 47 patients using a visual analog scale (VAS). Treatment in patients who lacked objective evidence of resolution of UPJO was considered a failure. RESULTS: The mean age of the cohort was 39 years (range 18-69 yrs). Average operating room time was 250 minutes (range 138-488 min), and estimated blood loss was 63 mL (range 10-500 mL). Average hospital length of stay was 1.2 days (range 1-6 d). Crossing vessels were identified in 47/92 (51%) patients. Overall mean follow-up was 13 months (range 2-54 months). There were no intraoperative complications and three perioperative complications. Overall, 85/92 (92%) patients were found to have resolution of UPJO on postoperative physiologic testing. The primary uncomplicated cohort success rate was 98%, while that for the secondary or complex repair cohort was 80%. The mean overall VAS pain score was 84%. CONCLUSION: Objective physiologic testing should be used as the measurement of true success after LP. A uniform definition of success will allow improved comparison of results with literature series and comparison with alternative management modalities.

Comparison of a novel one-step percutaneous nephrolithotomy sheath with a standard two-step device.

OBJECTIVES: Percutaneous nephrolithotomy (PCNL) is the treatment of choice for large renal calculi. The most widely used access sheath for PCNL involves two steps including placement of a high-pressure balloon catheter (HPBC) followed by advancement of a sheath over the balloon. A novel PCNL balloon/sheath combination (NSS) has been developed that allows for both dilation and sheath placement in a single step. The objective of this study was to compare the safety and efficacy of the NSS to the HPBC in a porcine model. METHODS: Six farm pigs underwent placement of a standard HPBC in one kidney and the NSS on the contralateral side. We obtained access in the upper pole in 2 animals, middle pole in 2 animals, and lower pole in 2 animals. We obtained data on insertion time, difficulty of insertion, estimated blood loss (EBL), ability to visualize the collecting system, and gross and histopathologic analysis. RESULTS: There was no statistical difference in degree of difficulty in placing the NSS (3 easy, 3 moderate) versus HPBC device (1 easy, 5 moderate; P = 0.07), estimated blood loss (P = 0.10), or the ability to visualize the collecting system (P = 0.32). There was a significantly shorter insertion time in the NSS group compared with the HPBC group (1:37 versus 2:26 minutes, P = 0.04). CONCLUSION: This study demonstrates that the NSS is safe and effective in the porcine model. Trials in patients are currently under way.

Laparoscopic management of large ureteral fibroepithelial polyp.

Fibroepithelial polyps of the ureter are rare benign mesothelial tumors. Most polyps are small; however, very rare large polyps have also been reported. Currently, most investigators encourage endoscopic management in these patients. Nevertheless, endoscopic resection can be difficult in patients with a long or large polypoid lesion. We describe our experience and laparoscopic technique for treatment of a symptomatic 42-year-old woman who presented with a 17-cm-long fibroepithelial polyp in the proximal ureter associated with ureteral obstruction. To our knowledge, this is the first reported case of laparoscopic management of a large ureteral fibroepithelial polyp.

A novel single step percutaneous access sheath: the initial human experience.

PURPOSE: A novel 1-step percutaneous access sheath NS has been developed that allows the insertion of a dilating balloon and renal access sheath in a single step. We present the initial human experience with this sheath. MATERIALS AND METHODS: We performed a retrospective chart and database review of the initial 30 consecutive patients undergoing percutaneous nephrostolithotomy using the NS. Data collected included patient demographics, operative and recovery parameters, and complications. RESULTS: Mean patient age was 50.4 years (range 11 to 81), mean body mass index was 31.63 kg/m(2) (range 17.1 to 65) and mean preoperative stone area was 6.23 cm(2) (range 1 to 14.6). Six and 3 patients had full and partial staghorn calculi, respectively. Access was achieved via the upper pole in 16 patients, middle pole in 7 and lower pole in 7. Mean operative time was 114.8 minutes (range 61 to 237). Mean estimated blood loss was 145.5 cc (range 10 to 500) and mean postoperative hospital stay was 4.89 days (range 2 to 14). A total of 23 patients (76.7%) had no residual calculi on postoperative computerized tomography, 5 (16.7%) had residual fragments 4 mm or less and 2 (6.7%) had residual stone fragments greater than 4 mm. There were no complications related to the NS. CONCLUSIONS: The NS is safe, easy to use and has potential advantages compared to currently available renal access sheaths.

Comparison of nonabsorbable polymer ligating and standard titanium clips with and without a vascular cuff.

PURPOSE: To compare the efficacy of nonabsorbable polymer ligating (NPL) and titanium clips applied with and without a 1-mm vascular cuff at physiologic and supraphysiologic pressures. MATERIALS AND METHODS: An in vitro equine-vessel model was created to test clip occlusion strength. Ten-millimeter NPL and standard Ti clips were applied to veins (10 mm) and arteries (10, 6, and 5 mm) with and without a 1-mm cuff and tested until they held a pressure of 300 mm Hg (veins) or 760 mm Hg (arteries) for 2 minutes or leaked. RESULTS: The NPL clip was statistically more secure on 10-mm veins with and without a cuff, 10-mm arteries with and without a cuff, and 6-mm arteries with a cuff than was the Ti clip. Leaving a 1-mm cuff resulted in a statistically higher leak point in all vessels tested except the 6-mm arteries secured with the Ti clip. CONCLUSIONS: The NPL clip was more secure than the Ti clip on larger arteries and veins. A 1-mm vascular cuff enhances the security of both NPL and Ti clips in vessels of all sizes. The NPL clip is secure and reliable in securing both arteries and veins.

Control of the renal artery and vein with the nonabsorbable polymer ligating clip in hand-assisted laparoscopic donor nephrectomy.

BACKGROUND: The large and variable size of the renal vein has prompted most surgeons to select linear stapling devices to secure the vein during laparoscopic donor nephrectomy. Although effective, these stapling devices have a potential for misfire. Use of the nonabsorbable polymer ligating (NPL) clip during laparoscopic donor nephrectomy provides increased graft vessel length compared with the stapling device, and the NPL clip has a locking mechanism which may increase security compared with standard titanium clips. The objective of this study was to evaluate the safety and efficacy of the NPL clip for control of the renal artery and vein during hand-assisted laparoscopic donor nephrectomy (HALDN). METHODS: A retrospective chart review of 50 consecutive HALDN patients was conducted where two parallel NPL clips were used to control both the renal artery and vein. Information collected included demographic data, operative and postoperative data, and complications. RESULTS: Mean donor age was 33.4 years and body mass index was 25.8 kg/m2. Mean operative time was 266.0 min, mean hospital stay was 3.2 days, and mean warm ischemia time was 123.3 seconds. There were no transfusions, open conversions, or complications related to use of the NPL clip. A US 16,300 dollars disposable cost savings was seen during this 1-year period alone. CONCLUSIONS: The NPL clip was 100% safe and effective in controlling the renal artery and vein during HALDN, allowed for additional vessel length, and resulted in a disposable cost savings of US 362 dollars per patient.

Hand-assisted laparoscopic partial nephrectomy in the porcine model using gelatin matrix hemostatic sealant without hilar occlusion.

BACKGROUND AND PURPOSE: Gelatin matrix hemostatic sealant (GMHS) has been used for hemostasis during partial nephrectomy with hilar clamping. The objective of this study was to determine the ability of GMHS to achieve hemostasis without hilar clamping in the porcine model. MATERIALS AND METHODS: In this feasibility study, eight farm pigs underwent a left-hand-assisted laparoscopic partial nephrectomy (HALPN). The lower fourth of the kidney was removed with cold scissors, and GMHS was applied laparoscopically. Samples were collected for measurement of serum hemoglobin (Hb) and creatinine (Cr) prior to surgery and at 4 and 30 days after HALPN. The kidneys were harvested at 30 days, and retrograde pyelograms and pathologic analysis were performed. RESULTS: Application of GMHS achieved complete hemostasis in all eight animals. The mean estimated blood loss was 40 mL, and the operating time was short (mean 92.5 minutes). In three kidneys, a significant collecting system opening was noted but not repaired. At harvest, there were no hematomas, infections, or urine leaks in any animals. In one animal, a 2-cm contained fluid collection was identified. There was no difference in the preoperative and harvest Hb (9.63 v 9.21 g/dL; P = 0.49), but there was a slight increase in Cr (1.21 v 1.46 mg/dL; P = 0.01) possibly because of the decreased renal mass after partial nephrectomy. CONCLUSION: Even without hilar occlusion, GMHS was 100% safe and effective in controlling bleeding after HALPN in the porcine model. Avoidance of hilar occlusion may reduce the risk associated with warm renal ischemia and the extra dissection required to isolate the hilum in preparation for clamping.

Simplified technique for laparoscopic extravesical ureteral reimplantation in the porcine model.

BACKGROUND AND PURPOSE: Laparoscopic intravesical and standard Lich-Gregoir repair have been reported but are technically challenging. Herein, we present our experience with a simplified laparoscopic reimplantation of the ureter to correct vesicoureteral reflux (VUR). MATERIALS AND METHODS: Bilateral VUR was created cystoscopically in six minipigs, as confirmed by a static cystogram 6 weeks later. The laparoscopic extravesical correction of VUR was performed utilizing a full-thickness cystotomy. The ureter was transposed inside the bladder, and a full-thickness bladder closure was performed. No attempt was made to cover the ureter with urothelium. No stents or catheters were utilized postoperatively. Three months after reimplantation, the animals were evaluated with serology, a static cystogram, an intravenous urogram (IVU), and gross pathologic and histopathologic examination. RESULTS: The postoperative cystograms confirmed no reflux in all the reimplanted ureters and residual grade 1 to 3 reflux in the non-reimplanted ureters. All pigs voided normally and were completely continent. Cystoscopic evaluation revealed complete epithelialization over the reimplanted ureter. One surgical complication occurred: the ureter was incorporated into the bladder closure and became obstructed. The IVU in all other pigs demonstrated patent ureters with prompt function. CONCLUSIONS: Laparoscopic reimplantation of the ureter utilizing this modified Lich-Gregoir approach corrected reflux in all animals. The full-thickness bladder incision and intravesical transposition of the ureter greatly simplifies the laparoscopic procedure. This laboratory experience encourages further clinical evaluation in the pediatric population with VUR.

Laparoscopic warm renal ischemia in the solitary porcine kidney model.

OBJECTIVES: To determine the effect of a laparoscopic approach on warm renal ischemia in the pig with a solitary kidney. Although the maximal safe duration for warm ischemia during open partial nephrectomy is commonly accepted to be 30 minutes, the maximal safe ischemic time during laparoscopic partial nephrectomy has not been previously determined. METHODS: Sixteen farm pigs underwent unilateral laparoscopic right nephrectomy. Two weeks later, the pigs underwent complete laparoscopic mobilization of the remaining left kidney and were randomized to complete hilar clamp times of 0, 30, 60, or 90 minutes. Serum creatinine was evaluated before right nephrectomy and at days 0, 2, 4, 7, 14, and 30 after renal ischemia during laparoscopy. All renal specimens were evaluated by an experienced nephropathologist in a blinded fashion. RESULTS: The serum creatinine remained stable at all points in the control and 30-minute ischemia groups. The serum creatinine level rose initially on days 2 and 4 in the 60-minute and 90-minute ischemia groups but returned to baseline by day 7. At harvest, no statistically significant difference was found among the groups in serum creatinine or histologic features. CONCLUSIONS: Renal ischemic times up to 90 minutes during laparoscopy were well tolerated by the solitary porcine kidney. Possible explanations for this finding include the protective effect of a solitary kidney and the potential protective effect of relative ischemic preconditioning provided by the pneumoperitoneum.

Cell Cycle Regulatory Proteins p27(kip), Cyclins Dl and E and Proliferative Activity in Oncocytic (Hurthle Cell) Lesions of the Thyroid.

Cyclins are prime cell-cycle regulators central to the control of cell proliferation in eukaryotic cells. The formation of cyclin/cyclin-dependent kinases (CDK) complexes activates the kinases and initiates a cascade of events, which directs cells through the cell cycle. CDK inhibitors (CDKIs) such as p27(kip1) inhibit cyclln-CDK complexes and function as negative regulators of the cell cycle. Previous studies have shown that p27(kip1) is decreased In malignant relative to benign thyroid tumors, but its role and Interaction with other cell cycle regulatory proteins have not been well established In oncocytic lesions of the thyroid. We studied the expression of p27(kip1), cyclins D1 and E, and Ki67 In 20 cases of oncocytic adenoma (AD). 6 cases of oncocytic carcinoma (CA). 8 cases of Hashimoto's thyroiditis (HT). and 9 cases of nodular goiter with oncocytic change (NG) by Immunohistochemlstry. In the latter two lesions only oncocytic cells were evaluated. The positive staining was stratified Into four groups. Statistical analysis was done using the Kruslcal-Wallis one-way analysis of variance test, and, when significant the Dunn multiple-comparisons procedure was used to determine pairwise differences. AllI 20 AD were p27(kip1) posItive, 10 were 4+, 2 were 3+, and the remaining 8 were 1+. In contrast all 6 CA showed 4+ p27(kip1) staining, of the 8 HT 2 were 4+, two 3+, three1+, and I was negative.All 9 NG were p27 positive, 7 showed 4+, one 3+, and one 1+ staining. On pairwise comparison differences in p27(kip1) staining between AD and CA and between HT and CA were statistically significant (p=0.0243 and p=0.0142, respectively). In all but one case Ki67 expression was either very low (<3%) or negative. No significant differences were seen in the expression of cyclin D1 or cyclin E among the groups observed. In conclusion, the increased p27(kip1) expression in malignant oncocytlc tumors relative to benign oncocytic lesions is unlike any other malignant progression reported in the thyroid and other organ systems in the body. This may reflect on the biologic nature of the oncocytic cells of the thyroid and the significance of this finding remains to be established. Proliferative activity as studied by Ki67 immunostalning was not helpful in distinguishing benign from malignant oncocytic tumors.