Cause-specific mortality following radical prostatectomy.

BACKGROUND: To evaluate cause-specific mortality following radical prostatectomy (RP) in a population cohort of US men adjusting for competing risks. METHODS: The Surveillance, Epidemiology and End Results (SEER) database was used to identify 120,392 men undergoing RP for clinically localized prostate cancer between 1988 and 2003. Cause-specific mortality data were extracted through 2006 and cumulative incidence was estimated using a competing risks approach. RESULTS: The stage distribution of the cancers was 32% local, 28% regional, 40% unknown, and 80% of tumors Gleason ≤ 7. Median follow-up was 7 years. The 15-year prostate cancer-specific mortality was 5.3% and the non-prostate cancer mortality was 30.6%. Stage, grade and race had minimal impact on non-prostate cancer mortality. At 15 years following surgery, mortality due to cardiovascular diseases was 11%, other cancers 9.1%, and other causes 10.5%. Among men ≥ 65 years, 15-year cancer-specific mortality was 6% and non-prostate cancer mortality was 40.8%. CONCLUSIONS: Following RP, death from cardiovascular diseases, other cancers, and other causes is far more common than death from prostate cancer. In men diagnosed with prostate cancer, significant efforts should be made to prevent, diagnose, and treat these diseases.

The dimensions and symmetry of the seminal vesicles.

The traditional anatomical description of the seminal vesicles is based on autopsy and imaging studies. Trans-peritoneal robotic-assisted laproscopic surgery, with its three-dimensional magnified view and miniature articulated working instruments, provides an opportunity to perform accurate dissections of the seminal vesicles even when extremely long and tortuous. We used specimens obtained by robotic-assisted laparoscopic radical prostatectomy (RLRP) for accurate anatomic assessment of the dimensions of the seminal vesicles. Digital photos of 78 specimens from men (mean age 59 ± 6.1 years) who underwent RLRP were analyzed using the Image Pro Plus software. Seminal vesicle dimensions were correlated with patients' age, weight, height, prostate weight, sexual function profile (SHIM) and symptom severity score of the lower urinary tract symptoms (IPSS). We found that the length of the seminal vesicles is highly variable (range of 8.5-94.6 mm). The average seminal vesicle length was 31 ± 10.3 mm and its average volume 7.1 ± 5.2 ml. The right seminal vesicle was significantly larger than the left in length, width and volume (P < 0.003). The seminal vesicles were found to be highly asymmetric with a mean difference of 17.8% in length and 24.9% in width between the sides. No correlation between seminal vesicle dimensions and any of the parameters tested was found. We concluded that the normal human seminal vesicles are characterized by marked (11-fold) variation in length and are asymmetric in most patients. The right seminal vesicle is significantly larger than the left. Seminal vesicle dimensions cannot be predicted from other morphometric or physiologic parameters.

Fifteen-year follow-up of transplantation of a cadaveric polycystic kidney: a case report.

INTRODUCTION: Kidneys from donors affected by autosomal-dominant polycystic kidney disease (ADPKD) are in general considered unsuitable for transplantation. To the best of our knowledge, only 12 cases of ADPKD transplanted renal units have been reported in the English literature; most have only short-term follow-up. METHODS: We provide a review of these patients and share our experience with an ADPKD patient who received a 21-year-old deceased donor ADPKD-affected renal transplant and has been closely followed for 15 years. Based on the current literature, this report is the longest follow-up of a ADPKD donor transplant. RESULTS: Over the 15-year follow-up period, there have been no complications related to the ADPKD-affected donor kidney, including three kidney transplant biopsies. The graft continues to function well with the serum creatinine currently 1.2 mg/dL. Serial axial imaging has demonstrated that the cystic disease has slowly progressed in the donor renal unit, with the largest cyst having only increasing from 1.2 to 2.9 cm in diameter. Metachronous, bilateral laparoscopic nephrectomies of the native kidneys were performed owing to intractable pain from cystic enlargement. CONCLUSIONS: Normal functioning deceased donor kidneys that show signs of early ADPKD should be considered acceptable for donation in select cases. These organs provide the recipient a safe, reasonable period of graft survival and have not been shown to cause adverse effects.

Bipolar electrocoagulation for clipless division of left renal vein branches during laparoscopic living donor nephrectomy.

We present our experience of using the bipolar electrocautery for division of the left renal vein branches in laparoscopic right living donor nephrectomy. This has been performed in 160 cases with no complications related to the technique. The absence of laparoscopic clips allows easier and safer placement of the endostaple.

Transplantation of a cadaveric polycystic kidney in a patient with autosomal dominant polycystic kidney disease: long-term outcome.

INTRODUCTION: Kidneys from donors affected by autosomal dominant polycystic kidney disease (ADPKD) were considered unusable for transplantation. To the best of our knowledge, seven cases worldwide have now been described in the English literature since 1967 suggesting such donor organs may be acceptable under certain conditions. Most of these reports have only short-term follow-up. METHODS: We provide a review of these patients and share our experience with an ADPKD patient who had a cadaveric ADPKD transplant and has been closely followed for 10 years. RESULTS: During the 10-year period, the patient had three transplant biopsies without complication. This creatinine is currently 1.2 mg/dL. Serial computed tomography imaging indicated that the cystic disease slowly progressed during this time period. He eventually developed intractable pain in his native left kidney and underwent a laparoscopic nephrectomy. CONCLUSIONS: Normal functioning cadaveric kidneys that show early signs of polycystic kidney disease should be considered acceptable for renal donation. These organs provide the recipient a safe, reasonable period of graft survival and have not been shown to cause adverse effects.

Laparoscopic management of retrovesical cystic disease: Washington University experience and review of the literature.

BACKGROUND AND PURPOSE: Recently, the laparoscopic approach to the management of seminal vesicle cysts has been described. This report outlines the Washington University experience and reviews the present literature to evaluate the results of the laparoscopic approach to the excision of retrovesical cysts of seminal vesicle and Müllerian origin. PATIENTS AND METHODS: The hospital and office records of three patients undergoing laparoscopic excision of seminal vesicle and Müllerian duct cyst disease between April 1993 and March 1999 were reviewed for the operative time, the estimated blood loss, total hospital stay, total analgesia required postoperatively, the time to resumption of oral intake, and the postoperative recovery. A literature search revealed two additional reports of laparoscopic management of cystic disease of the seminal vesicle, comprising only one and two patients. An additional review of the literature was performed to compare the laparoscopic procedure with the transvesical, transurethral, open transvesical, and open retrovesical approach for the management of the disease. RESULTS: For the three patients at Washington University, the operative time averaged 4 hours (range 1.8-6.1 hours), and the mean estimated blood loss was 150 mL (range 50-200 nL). The patients required a mean of 43 mg of morphine sulfate for postoperative pain control, had a mean hospital stay of 2.6 days, and resumed oral intake 5.8 hours postoperatively. In combination with the three other cases reported in the literature, the average operative time for laparoscopic retrovesical cyst excision was 2.9 hours, and the average hospital stay was 2.2 days. With an average follow-up of 17 months, all six patients had excellent resolution of their preoperative symptoms. There have been no major or minor complications or any need for further operative therapy. CONCLUSION: Laparoscopic excision of retrovesical cystic disease is an effective surgical procedure, associated with minimal postoperative morbidity, short hospitalization, and a rapid recovery for the patient.

Evaluation of prospective living renal donors for laparoscopic nephrectomy with multisection CT: the marriage of minimally invasive imaging with minimally invasive surgery.

Laparoscopic technique for excision of a kidney from a living donor has advantages over conventional open surgery, but operative visibility and surgical exposure are limited. Preoperative multisection computed tomography (CT) can provide necessary anatomic information in a minimally invasive procedure. A three-phase examination is suggested: (a) imaging from the top of the kidneys to the pubic symphysis with a section width of 2.5 mm and no contrast medium, (b) scanning of the kidneys and upper pelvis during the arterial phase of enhancement with a section width of 1.0 mm, and (c) scanning of the kidneys and upper retroperitoneum during the nephrographic phase of enhancement with a section width of 1.0 mm. Emphasis in this article is placed on analysis of the venous anatomy because most radiologists are unfamiliar with the anatomic variations. Conventional radiography of the abdomen and pelvis is performed after CT to evaluate the collecting system and ureters and to provide a lower total radiation dose than if CT were used. Of several postprocessing techniques that may be used, the authors prefer maximum intensity projection for arterial evaluation and multiplanar reformatting for venous evaluation.

Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi.

PURPOSE: We compared the efficacy of shock wave lithotripsy and ureteroscopy for treatment of distal ureteral calculi. MATERIALS AND METHODS: A total of 64 patients with solitary, radiopaque distal ureteral calculi 15 mm. or less in largest diameter were randomized to treatment with shock wave lithotripsy (32) using an HM3 lithotriptor (Dornier MedTech, Kennesaw, Georgia) or ureteroscopy (32). Patient and stone characteristics, treatment parameters, clinical outcomes, patient satisfaction and cost were assessed for each group. RESULTS: The 2 groups were comparable in regard to patient age, sex, body mass index, stone size, degree of hydronephrosis and time to treatment. Procedural and operating room times were statistically significantly shorter for the shock wave lithotripsy compared to the ureteroscopy group (34 and 72 versus 65 and 97 minutes, respectively). In addition, 94% of patients who underwent shock wave lithotripsy versus 75% who underwent ureteroscopy were discharged home the day of procedure. At a mean followup of 21 and 24 days for shock wave lithotripsy and ureteroscopy, respectively, 91% of patients in each group had undergone imaging with a plain abdominal radiograph, and all studies showed resolution of the target stone. Minor complications occurred in 9% and 25% of the shock wave lithotripsy and ureteroscopy groups, respectively (p value was not significant). No ureteral perforation or stricture occurred in the ureteroscopy group. Postoperative flank pain and dysuria were more severe in the ureteroscopy than shock wave lithotripsy group, although the differences were not statistically significant. Patient satisfaction was high, including 94% for shock wave lithotripsy and 87% for ureteroscopy (p value not significant). Cost favored ureteroscopy by $1,255 if outpatient treatment for both modalities was assumed. CONCLUSIONS: Ureteroscopy and shock wave lithotripsy were associated with high success and low complication rates. However, shock wave lithotripsy required significantly less operating time, was more often performed on an outpatient basis, and showed a trend towards less flank pain and dysuria, fewer complications and quicker convalescence. Patient satisfaction was uniformly high in both groups. Although ureteroscopy and shock wave lithotripsy are highly effective for treatment of distal ureteral stones, we believe that HM3 shock wave lithotripsy, albeit slightly more costly, is preferable to manipulation with ureteroscopy since it is equally efficacious, more efficient and less morbid.

Laparoscopic transverse hemicystectomy with ileocystoplasty in a porcine model.

BACKGROUND AND PURPOSE: The ideal replacement for bladder tissue is yet to be described, although multiple alternatives have been studied. Currently, enterocystoplasty, despite its limitations, is considered the gold standard for bladder augmentation. This study evaluated the feasibility, safety, and morbidity of laparoscopic ileocystoplasty in a large-animal model. MATERIALS AND METHODS: In eight minipigs, laparoscopy was performed using four ports. A segment of ileum was delivered through a 3-cm umbilical incision and detubularized and refashioned using standard open surgical technique. Laparoscopic hemicystectomy was then performed, followed by laparoscopic suturing of the ileal patch to the bladder. The bladder was drained with a Foley catheter, but no pelvic drain was placed. All animals were followed for for a minimum of 3 months. Preoperative and postoperative evaluation included measurement of bladder capacity, ultrasound imaging of the kidneys, blood counts, and serum electrolyte and creatinine measurements. Two of the animals were sacrificed at 3 months and one at 6 months, and the bladders were harvested. RESULTS: Eight animals underwent ileocystoplasty without intraoperative or postoperative complications. The average operating and anastomosis time was 250 minutes and 96 minutes, respectively. All animals had normal preoperative blood values that remained normal during follow-up. Bladder capacity decreased initially to 71% of the baseline volume and then increased to 83% and 117% at 3 and 6 months. One of three animals sacrificed was noted to have a right midureteral stricture. CONCLUSIONS: We developed a reliable laparoscopic technique for ileocystoplasty that may extend the advantages of laparoscopy, including better cosmesis and reduced risk of postoperative adhesions, to bladder augmentation.

Laparoscopic nephroureterectomy. A new standard for the surgical management of upper tract transitional cell cancer.

Laparoscopic nephroureterectomy for upper tract TCC still remains somewhat controversial. Unlike laparoscopic radical nephrectomy, which has become widely accepted, LNU is still in its earliest stages. Although there are obvious benefits for the patient who has LNU--less pulmonary complications, less postoperative discomfort, a shorter hospital stay, a better cosmetic result, and a brief convalescence--there are significant concerns. The longer operative time creates a negative financial and professional inducement to learn this technique. Operative times need to fall into the 4-hour range or less to make the procedure cost-effective. Analysis of the efficacy of laparoscopic nephroureterectomy as a curative treatment modality is important. In the short-run, LNU seems to provide similar results to open nephroureterectomy for upper TCC. Although concerns over port site seeding, bladder recurrence, and intraperitoneal seeding have been voiced, these problems have not occurred. The higher incidence of local recurrence noted in the authors' series, however, is of concern and remains an unsettled issue. Despite these local recurrences, the overall cancer survival for a given grade and stage of upper tract TCC seem to be similar to survivals recorded after open nephroureterectomy. Still, the number of LNU cases remains small, and follow-up is brief. These patients need to be monitored closely, with follow-up CT scans over the next decade. The authors believe that there are still several significant hurdles standing in the path of LNU before it can become a widely accepted procedure. Issues of cost, training, and long-term efficacy must be answered definitively. To obtain these types of data, it will be necessary to create a multi-institutional, cooperative study to obtain sufficient numbers of patients with a more than 5-year follow-up on which to base future recommendations.

Flow characteristics of 3 unique ureteral stents: investigation of a Poiseuille flow pattern.

PURPOSE: The pattern of flow in the stented ureter (intraluminal and/or extra luminal) has only been defined for the standard pigtail stent. No data are available on stent flow for any specialty stents. To our knowledge we present the first investigation characterizing the type of flow through a stent (Poiseuille versus nonPoiseuille flow). MATERIALS AND METHODS: Flow was measured in an unstented ureter, a standard 7Fr double pigtail stent and the 7/3Fr Tail stent, 7Fr Spirastent and 14/7Fr endopyelotomy stent using a previously developed stent flow model. In vitro pressure flow studies were also done in nonfenestrated 14/7Fr, Tail and standard 7Fr stents. These stents were infused at a constant flow rate of 2 to 10 ml. per minute with monitoring of the corresponding pressure gradients. Resistance to flow was determined for these stents using pressure flow plots and Poiseuille's law. RESULTS: In vivo the 7Fr pigtail, 14/7Fr endopyelotomy and 7/3Fr Tail stents had statistically similar flow rates. Flow through each of these stents exceeded the flow through an unstented ureter. The Spirastent had the least flow in all categories tested. There was no correlation of Poiseuille flow parameters measured in vitro for nonfenestrated stents with in vivo stent flow. CONCLUSIONS: In stented ureters fluid drains through and around the stent regardless of its design. The flow characteristics of these 3 specialty stents were not predictable according to lumen or stent size. In vitro Poiseuille's flow did not correlate with in vivo stent flow.

Laparoscopic versus open radical nephrectomy: a 9-year experience.

PURPOSE: The laparoscopic approach for renal cell carcinoma is slowly evolving. We report our experience with laparoscopic radical nephrectomy and compare it to a contemporary cohort of patients with renal cell carcinoma who underwent open radical nephrectomy. MATERIALS AND METHODS: From 1990 to 1999, 32 males and 28 females underwent 61 laparoscopic radical nephrectomies for suspicious renal cell carcinoma. Clinical data from a computerized database were reviewed and compared to a contemporary group of 33 patients who underwent open radical nephrectomy for renal cell carcinoma. RESULTS: Patients in the laparoscopic radical nephrectomy group had significantly reduced, estimated blood loss (172 versus 451 ml., p <0.001), hospital stay (3.4 versus 5.2 days, p <0.001), pain medication requirement (28.0 versus 78.3 mg., p <0.001) and quicker return to normal activity than patients in the open radical nephrectomy group (3.6 versus 8.1 weeks, p <0.001). The majority of laparoscopic specimens (65%) were morcellated. Operating time and cost were higher in the laparoscopic than the open nephrectomy group. Average followup was 25 months (range 3 to 73) for the laparoscopic and 27.5 months (range 7 to 90) for the open group. Renal cell carcinoma in 3 patients (8%) recurred in the laparoscopic group versus renal cell carcinoma in 3 (9%) in the open group. When stratified patients with tumors larger than 4 to 10 cm. experienced similar benefits and results as patients with tumors less than or equal to 4 cm. To date there have been no instances of trocar or intraperitoneal seeding in the laparoscopic radical nephrectomy group. CONCLUSIONS: Laparoscopic radical nephrectomy, although technically demanding, is a viable alternative for managing localized renal tumors up to 10 cm. It affords patients with renal tumors an improved postoperative course with less pain and a quicker recovery while providing similar efficacy at 2-year followup for patients with T1 and T2 tumors.

Flexible ureteroscopes: a single center evaluation of the durability and function of the new endoscopes smaller than 9Fr.

PURPOSE: Flexible ureteroscopes smaller than 9Fr are widely used in endourology. We systematically evaluated the functional durability of these instruments in the clinical setting. MATERIALS AND METHODS: We performed ureteronephroscopy 92 consecutive times in 84 patients at our hospital using a flexible Storz model 11274AA,double dagger Circon-ACMI model AUR-7, section sign Wolf model 7325.172 parallel and Olympus model URF/P3 ureteroscope paragraph sign. Preoperatively and postoperatively we evaluated all flexible ureteroscopes for luminosity, irrigant flow at 100 mm. Hg, number of broken image fibers and active deflection range. During the procedure a record was kept of the duration that the endoscope remained in the urinary tract, average irrigation pressure, method of insertion, various devices used within the working channel, need for lower pole access, and surgeon overall impression of visibility and maneuverability. RESULTS: The luminosity and irrigant flow of all endoscopes remained relatively unchanged during consecutive applications, while active deflection deteriorated 2% to 28%. Endoscopes were used for an average of 3 to 13 hours before they needed repair. The most fragile part of these instruments was the deflection unit. CONCLUSIONS: Small diameter flexible ureteroscopes are effective for diagnosing and treating upper urinary tract pathology but improved durability is required. Currently they represent a highly effective but high maintenance means of achieving retrograde access to the ureter and kidney with a need for repair after only 6 to 15 uses.

Laparoscopic augmentation cystoplasty with different biodegradable grafts in an animal model.

PURPOSE: Recently a variety of biodegradable organic materials have been used for bladder wall replacement. We sought to study the effectiveness of 4 different types of biodegradable materials for bladder augmentation using laparoscopic techniques. MATERIALS AND METHODS: Thirty one minipigs underwent successful transperitoneal laparoscopic partial cystectomy and subsequent closure (6 control) or patch augmentation (25): porcine bowel acellular tissue matrix (ATM) (6), bovine pericardium (BPC) (6), human placental membranes (HPM) (6) or porcine small intestinal submucosa (SIS) (7). An intracorporeal suturing technique with the EndoStitch device (U.S. Surgical, Norwalk, CT) and Lapra-Ty clips (Ethicon, Enodsurgery Inc. Cincinnati, OH) was used to anastomose the graft to the bladder wall. Postoperatively, a urethral catheter was left for one week. Bladders were evaluated by cystoscopy at 6 and 12 weeks and harvested at 12 weeks. RESULTS: Grafts remained in place in all groups except for the BPC group, where all grafts failed to incorporate. For the ATM and SIS groups, at 6 weeks, there was mucosal coverage of the grafts without evidence of encrustation. In the control group, at 12 weeks, the bladder capacity was 23% less than preoperatively. In the ATM, HPM and SIS groups, at 12 weeks, the bladder capacities were larger than preoperatively by 16%, 51% and 43% respectively; also the grafts had contracted to 70%, 65%, and 60% of their original sizes, respectively. Histologically, there was patchy epithelialization of ATM and SIS grafts with a mixture of squamoid and transitional cell epithelia. The graft persisted as a well-vascularized fibrous band in HPM, ATM, and SIS without evidence of significant inflammatory response. CONCLUSION: A laparoscopic technique for partial bladder wall replacement using a free graft is feasible. The biodegradable grafts of ATM, HPM and SIS are tolerated by host bladder and are associated with predominantly only mucosal regeneration at 12 weeks post-operatively.

Laparoscopic adrenalectomy for primary hyperaldosteronism during pregnancy.

Laparoscopic adrenalectomy was performed early in the second trimester of pregnancy in a woman with an aldosteronoma causing hypertension (254/154 mm Hg). The patient was later delivered of a healthy baby. With suitable precautions and timing, major laparoscopic surgery can be performed safely during pregnancy.

Clinical effectiveness of new stent design: randomized single-blind comparison of tail and double-pigtail stents.

BACKGROUND AND PURPOSE: Stent morbidity appears to be secondary to lower urinary tract irritation. In an effort to decrease stent morbidity, a "one size fits all" Tail stent (Microvasive [Boston Scientific] Natick, MA) was developed with a 7F proximal pigtail and 7F shaft which tapers to a lumenless straight 3F tail. PATIENTS AND METHODS: We randomized 60 patients in a single-blind fashion to a 7F tail stent or 7F double-pigtail Percuflex stent. Patients were evaluated at the time of stent removal and 2 weeks later with a standardized questionnaire assessing: irritative lower tract symptoms individually and on a total scale of 0 (no symptoms) to 30 (worst symptoms), obstructive lower tract symptoms (on a total scale of 0-20), and upper tract irritative symptoms (on a total scale of 0-10). RESULTS: Patient age, weight, and height were similar in the two groups. Complications, including fever, urinary tract infections, emergency room visits, and the need for antispasmodics and pain medication, also demonstrated no significant difference. At the time of stent removal, patients who received a tail stent had significantly less urinary frequency and a statistically significant (21%) decrease in overall irritative voiding symptoms (12.2 v 15.4; p = 0.048). Two weeks after stent removal, the total irritative voiding symptoms was markedly decreased in both groups (7.1 in the Tail v 5.3 in the double-pigtail group; p = 0.15). Obstructive bladder and flank symptoms were not significantly different in the two stent groups, either at the time of stent removal or at 2 weeks after removal. CONCLUSION: In this randomized, single-blind study, the 7F Tail stent produced significantly less irritative symptoms than did the standard 7F double-pigtail stent. Obstructive symptoms tended to be less with the new stent, while flank symptoms were similar.

Laparoscopic midsagittal hemicystectomy and replacement of bladder wall with small intestinal submucosa and reimplantation of ureter into graft.

BACKGROUND AND PURPOSE: A variety of biodegradable organic materials have been used for bladder wall replacement. In some instances, partial replacement has been done using laparoscopic reconstructive techniques. However, to date, this activity has been limited to small patches. Herein, we present the initial experience with laparoscopic sagittal hemicystectomy and the use of laparoscopic reconstructive techniques to replace half of the bladder with small-intestinal submucosa (SIS) and to reimplant the ureter into SIS. MATERIALS AND METHODS: Six female minipigs (20-25 kg) underwent transperitoneal laparoscopic sagittal hemicystectomy; the excised bladder wall was replaced with a 5 x 15-cm patch of SIS (Cook Biotechnology, Spencer, IN). The ipsilateral ureter was reimplanted through a small incision in the graft and secured with two sutures. Cystoscopy and cystometrograms were performed under general anesthesia preoperatively and at 6 and 12 weeks postoperatively. Tissues were harvested at 12 weeks. RESULTS: The procedure was successful in six animals (left three, right three). During cystoscopy at 12 weeks, the area of the graft was not distinguishable from normal mucosa. Cystometrograms revealed maintenance of volume and compliance, with volumes of 338, 343, and 369 mL and intravesical leak-point pressures of 37, 59, and 39 cm H2O at 0, 6, and 12 weeks, respectively. Antegrade ureterograms demonstrated extrinsic obstruction, minimal (two), moderate (three), or complete (one), at the ureterovesical junction. The kidney associated with the completely obstructed ureter was grossly hydronephrotic at sacrifice. Histologically, patchy epithelialization of the graft with a mixture of squamoid and mature transitional-cell epithelium was found. CONCLUSIONS: Laparoscopic hemicystectomy with replacement of the bladder wall and implantation of the ureter into the SIS graft is a feasible procedure. Clinical application awaits improvements in the method of ureteral reimplantation and longer follow-up to assess for ingrowth of muscle and nerve fibers.

Laparoscopic nephrectomy in patients with end-stage renal disease and autosomal dominant polycystic kidney disease.

Autosomal dominant polycystic kidney disease (ADPKD) is often characterized by end-stage renal disease (ESRD) and problems including pain, hematuria, and infection. Open nephrectomy is curative; however, the morbidity of the procedure is considerable. Between 1995 and 1998, 11 laparoscopic nephrectomies were performed on nine symptomatic patients (five men and four women) with ESRD and ADPKD. Two patients underwent a staged bilateral laparoscopic nephrectomy. All patients presented with abdominal or flank pain and an abdominal mass. Other clinical problems included hypertension in eight patients, urinary tract infections in two patients, and gross hematuria in one patient. Seven patients were receiving long-term dialysis treatment, and two patients had undergone prior renal transplantation. Patients were evaluated for preoperative and postoperative pain, analgesic use, hospital course, and convalescence. The overall average operative time was 6.3 hours, with an average estimated blood loss of 153 mL. Eight nephrectomy specimens were removed by morcellation, and three specimens were removed intact through a 7- to 12-cm incision. The average hospital stay was 3 days, and the average time to normal activity was 5 weeks. With a mean follow-up of 31 months, all nine patients reported elimination of their preoperative pain based on a pain analogue score. Six major and two minor complications occurred, including blood transfusion, a vena cavotomy, splenic cyanosis, pulmonary embolism, clotted arteriovenous fistula, and brachial plexus injury. Incisional hernias occurred in two of the three patients who underwent open removal. One patient noted improvement, and two patients noted resolution of their hypertension postoperatively. Laparoscopic nephrectomy in patients with ADPKD and ESRD offers an effective alternative to open nephrectomy to manage renal-related pain. This procedure provides the benefits of minimal intraoperative blood loss, minimal postoperative pain, brief hospital stay, and rapid convalescence.

Laparoscopic nephroureterectomy for upper tract transitional cell cancer: the Washington University experience.

PURPOSE: Laparoscopic nephroureterectomy has only recently been done to treat patients with upper tract transitional cell carcinoma. We retrospectively evaluated our experience with and long-term followup of laparoscopic nephroureterectomy, compared our results to those of contemporary series of open nephroureterectomy and reviewed the literature. MATERIALS AND METHODS: We reviewed the charts of and followed up by telephone 25 patients who underwent laparoscopic nephroureterectomy between May 1991 and June 1998, and 17 who underwent open nephroureterectomy between March 1990 and January 1997. Demographic, perioperative and followup data were compared. We performed a MEDLINE search and reviewed the literature on laparoscopic nephroureterectomy for upper tract transitional cell carcinoma. RESULTS: Laparoscopic nephroureterectomy required twice the operating time of open nephroureterectomy (7.7 versus 3.9 hours). However, patients who underwent the laparoscopic procedure had a 74% decrease in analgesia requirements (37 versus 144 mg. morphine sulfate equivalent), a 63% shorter hospital stay (3.6 versus 9.6 days) and a 72% more rapid convalescence (2.8 versus 10 weeks). Subsequent bladder transitional cell carcinoma and overall cancer specific survival were similar at a mean followup of 2 years. There was no sign of trocar site or peritoneal seeding after laparoscopic nephroureterectomy. CONCLUSIONS: Although laparoscopic nephroureterectomy is a longer operation, it has the same efficacy and is better tolerated by patients than open nephroureterectomy for upper tract transitional cell carcinoma. As operating time decreases due to surgeon experience and the recent development of hand assisted laparoscopy, laparoscopic nephroureterectomy may soon become the procedure of choice for the ablative management of upper tract transitional cell carcinoma.