A simple, effective method to create laparoscopic renal protective hypothermia with cold saline surface irrigation: clinical application and assessment.

PURPOSE: We previously described the use of cold saline surface irrigation to achieve protective renal hypothermia in a laparoscopic partial nephrectomy porcine model. We now present our clinical application of this technique and characterization of the hypothermic effect during laparoscopic partial nephrectomy. MATERIALS AND METHODS: Seven patients underwent elective laparoscopic partial nephrectomy augmented with our hypothermia technique. Parenchymal temperature sensors were placed to confirm cooling efficacy and efficiency. After transperitoneal exposure of the kidney we performed temporary hilar vascular occlusion. Surface cooling with almost freezing normal saline was delivered with a laparoscopic suction/irrigation device. Tumor laparoscopic resection and renal reconstruction were completed. Outcome measures included intraoperative changes with hypothermia and postoperative estimated glomerular filtration rate changes. RESULTS: All patients successfully underwent laparoscopic partial nephrectomy without complications or evidence of residual disease. A protective renal parenchymal temperature of less than 20C was achieved at a mean application time of 8.3 minutes. The hypothermic window of 15C to 25C was maintained an average of 30.4 minutes. In 2 cases cooling was repeated and 4 minutes were required to lower the temperature below 20C. The overall mean core body temperature decrease was 1.28C. At a mean followup of 22.4 months the median preoperative, immediate postoperative and final estimated glomerular filtration rate was 75, 65 and 71 ml/minute/1.73 m(2), respectively. There was no evidence of disease recurrence on followup imaging. CONCLUSIONS: Our technique involving cold saline surface irrigation to achieve protective renal hypothermia is reproducible, and uses readily available laparoscopic instruments and equipment. This technique can be done simply and effectively, and may expand the use of laparoscopic partial nephrectomy.

Primary endoscopic management versus open revision of ureteroenteric anastomotic strictures after urinary diversion--single institution contemporary series.

PURPOSE: To review our institutional experience in the management of ureteroenteric strictures by primary endoscopic intervention or primary open revision. PATIENTS AND METHODS: Between January 2000 and December 2007, 28 patients with ureteroenteric strictures underwent endoscopic management (n = 21) or open revision (n = 7). Strictures were characterized with regard to length and side as well as time to failure between the two groups. Success was defined as symptomatic improvement and evidence of patency on follow-up radiologic imaging. RESULTS: Of all study patients, 78.6% were symptomatic on presentation. Endoscopic intervention (balloon dilation, electroincision, or holmium endoureterotomy) was successful in six patients for an overall success rate of 27% with a median follow-up of 21 months. Open revision was successful in 87.5% (7 of 8) patients for whom initial endoscopic surgery had failed. The success rate of primary open revision was 71.4% (5 of 7 patients) with a mean follow-up of 18.1 months. For the entire series, left-sided strictures were more common than right sided strictures; however, side and stricture length were not found to be significant (P > 0.05) with regard to patency. Functional renal imaging studies were performed in 42.9% of all study patients postoperatively. CONCLUSIONS: Endoscopic management continues to have success rates that remain lower than that of open revision. Left-sided strictures remain more common than right-sided strictures; however, side and stricture length were not found to be statistically significant in our series. The lack of consistent postoperative functional renal studies highlights the importance of diligent monitoring and warrants further study to develop a surveillance algorithm.

Toward image guided robotic surgery: system validation.

PURPOSE: Navigation for current robotic assisted surgical techniques is primarily accomplished through a stereo pair of laparoscopic camera images. These images provide standard optical visualization of the surface but provide no subsurface information. Image guidance methods allow the visualization of subsurface information to determine the current position in relationship to that of tracked tools. MATERIALS AND METHODS: A robotic image guided surgical system was designed and implemented based on our previous laboratory studies. A series of experiments using tissue mimicking phantoms with injected target lesions was performed. The surgeon was asked to resect "tumor" tissue with and without the augmentation of image guidance using the da Vinci robotic surgical system. Resections were performed and compared to an ideal resection based on the radius of the tumor measured from preoperative computerized tomography. A quantity called the resection ratio, that is the ratio of resected tissue compared to the ideal resection, was calculated for each of 13 trials and compared. RESULTS: The mean +/- SD resection ratio of procedures augmented with image guidance was smaller than that of procedures without image guidance (3.26 +/- 1.38 vs 9.01 +/- 1.81, p <0.01). Additionally, procedures using image guidance were shorter (average 8 vs 13 minutes). CONCLUSIONS: It was demonstrated that there is a benefit from the augmentation of laparoscopic video with updated preoperative images. Incorporating our image guided system into the da Vinci robotic system improved overall tissue resection, as measured by our metric. Adding image guidance to the da Vinci robotic surgery system may result in the potential for improvements such as the decreased removal of benign tissue while maintaining an appropriate surgical margin.

Laparoscopic nephrectomy for the management of renal medullary carcinoma in a child.

Renal medullary carcinoma is a lethal subtype of renal cancer that afflicts patients with sickle-cell hemoglobinopathies. Here we present the case of a 13-year-old boy with renal medullary carcinoma who is the first, to our knowledge, to be managed using a planned laparoscopic radical nephrectomy.

Safety and efficacy of synchronous percutaneous nephrostolithotomy and contralateral ureterorenoscopy for bilateral calculi.

Herein we describe the technique and review the medical records of 26 patients who underwent percutaneous nephrostolithotomy (PCNL) and simultaneous contralateral retrograde ureterorenoscopy (URS) for bilateral urolithiasis of discordant sizes at our institution. Preoperative factors, operative time, change in hemoglobin, change in serum creatinine, stone free, and efficacy rates after a single procedure were analyzed retrospectively. The total efficacy rate--defined as residual calculus of 4 mm or less--was 92.3%. A second look PCNL or URS was used to target any residual calculi; 5 of the 26 (19%) patients required further therapy following the initial intervention. All cases that required a second look were ultimately rendered stone-free. No preoperative factor was statistically significant with respect to treatment failures. In terms of complications, temporary, acute renal insufficiency occurred in 2 patients, (7.7%) and the duration was transient. Performing synchronous PCNL and contralateral retrograde URS is efficient, safe, and not more dramatically lengthy in terms of operative time or morbid in terms of complications when compared to a traditional unilateral percutaneous procedure. In this approach, management of bilateral urolithiasis in one operative procedure is practical and efficacious. The approach allows patients to return to normal activity within the same time period as those having a unilateral approach and to be free of stone without a need for a second, staged procedure.

Issue of prostate gland size, laparoscopic radical prostatectomy, and continence revisited.

OBJECTIVES: To evaluate the influence of prostate gland size on the perioperative, pathologic, and continence outcomes after laparoscopic radical prostatectomy (LRP). METHODS: 144 LRPs for which 18-month continence data were available were performed by a single surgeon, and were retrospectively reviewed. Patients were divided initially into two groups based on final prostate gland size: group 1 (weight less than 50 g) and group 2 (weight 50 g or more). Group 2 patients were stratified into group IIa (weight 50 to 70 g) and Group IIb (weight 70 g or more) to further examine the effect of gland size on continence. RESULTS: Larger glands had higher mean prostate-specific antigen (P <0.05) but among groups there were no significant differences in patient age, Gleason sum, pathological stage, operative time, intraoperative blood loss, or positive margin rate. We noted a significant difference in mean time to recovery of continence for patients with small glands versus large glands: group 1 (8.2 months), group 2 (9.9 months), group IIa (8.5 months), and group IIb (13.8 months) (P <0.05). CONCLUSIONS: Prostate gland size had no effect on perioperative outcomes. However, recovery of postoperative continence can be delayed in patients with large prostates.

Renal medullary carcinoma: the Bronx experience.

OBJECTIVES: Renal medullary carcinoma (RMC) is a devastating and extremely rare malignancy primarily afflicting young men with sickle cell trait. We present our clinical experience with 9 cases of RMC during a 10-year period and briefly review the published data. METHODS: A retrospective chart review of 9 cases of RMC during a 10-year period at our institutions was performed. The clinical patient characteristics, presentations, treatments, and outcomes were recorded. The radiographic images and pathologic specimens were reviewed. Applicable studies were selected from a Medline search. RESULTS: All 9 patients had sickle cell trait, the male/female ratio was 6:3, and the age range was 13 to 31 years. All the patients presented with flank pain, two thirds had hematuria, and 3 of the 9 patients presented with a palpable mass. Eight of the nine tumors were right sided, ranging from 4 to 12 cm in the greatest diameter. Of the 9 patients, 7 underwent radical nephrectomy. One patient was deemed to have unresectable disease by the operating surgeon, and one was given initial chemotherapy after biopsy of a metastatic lesion. The neoadjuvant therapies varied. Overall survival ranged from 4 to 16 months, with 2 patients still living at the last follow-up visit. CONCLUSIONS: Our urban setting likely explains our relatively large experience with this rare and extremely aggressive tumor. An early diagnosis is critical, and a high index of suspicion should be given to any individual with sickle cell trait and new-onset hematuria, especially in the setting of a right-sided mass. Prospective trials are needed for chemotherapy/immunotherapy, because surgical intervention alone is inadequate.

Case report: intrarenal arteriovenous fistula after ureteroscopic stone extraction with holmium laser lithotripsy.

A 79-year-old woman presented with gross hematuria 10 days after flexible ureteroscopic stone extraction with holmium laser lithotripsy. Work-up revealed a bleeding intrarenal arteriovenous fistula that was embolized. To our knowledge, this is the first report of this complication causing delayed hematuria after ureterorenoscopy.

Laparoscopic partial cystectomy for treatment of adenocarcinoma of the urachus.

The treatment of choice for urachal carcinoma has traditionally been an open approach, either by radical cystectomy or the more recently adopted bladder-sparing approach of extended partial cystectomy and umbilectomy. We report for the first time a laparoscopic technique for an extended partial cystectomy with en bloc umbilectomy for the management of urachal carcinoma in a 41-year-old man.

Laparoscopic nephrectomy for a nonfunctioning pelvic kidney in preparation for renal transplantation.

Pelvic kidneys pose a problem for any planned surgical intervention given their anomalous blood supply. Although minimally invasive approaches have been described for the management of benign conditions, only a handful of reports have described the use of laparoscopy for removal of ectopic or fused kidneys. We describe the laparoscopic removal of a symptomatic pelvic kidney in a patient before renal transplantation.