Novel use of da Vinci Robotic Surgical System: removal of seminal vesicle cyst in previously dissected pelvis.

We report a novel use of the da Vinci Robotic Surgical System to remove a seminal vesicle cyst in a previously dissected pelvis.

Conservative management of a splenic injury related to percutaneous nephrostolithotomy.

INTRODUCTION: Injury to intraperitoneal organs is unusual during percutaneous renal surgery. We report a splenic injury during upper pole percutaneous renal access for nephrostolithotomy that was managed conservatively. METHODS: A 52-year-old male with left upper pole renal stones associated with a narrow upper pole infundibulum underwent upper pole renal access prior to percutaneous nephrostolithotomy (PCNL). The access was performed in the 10th to 11th intercostal space, and the patient underwent PCNL with stone clearance. Plain film radiography after percutaneous access and PCNL revealed no pneumothorax or hydrothorax. The patient was discharged on postoperative day one with the nephrostomy tube in place. RESULTS: On postoperative day 5, the patient was evaluated for persistent flank pain and bleeding from the nephrostomy tube. Computerized tomography revealed a transsplenic percutaneous renal access. The patient was admitted to the hospital, and the general surgery service was consulted. The patient was placed on strict bedrest. His hematocrit was within normal limits and remained stable. The nephrostomy tube was kept in place for 2 weeks. A pullback nephrostogram revealed no perirenal leak, and no evidence was present of acute bleeding. Follow-up computerized tomography on the same day revealed no evidence of acute bleeding. The patient was discharged without further complications and remains stone free at 1-year follow-up. CONCLUSIONS: A transsplenic renal access that was dilated and through which a successful left percutaneous nephrostolithotomy was performed is a highly unusual complication related to upper pole left renal access. We were able to manage this complication with conservative measures.

Hand-assisted laparoscopic removal of retroperitoneal liposarcoma.

Liposarcoma is known to be the most common soft-tissue sarcoma, and the treatment of retroperitoneal disease is surgical excision. We present a case of complete surgical removal with concomitant nephrectomy using a hand-assisted laparoscopic approach and provide a review of the published studies.

Computer-assisted laparoscopic pyeloplasty: University of Miami experience with the daVinci Surgical System.

PURPOSE: We report our experience with laparoscopic pyeloplasty using the daVinci surgical platform. PATIENTS AND METHODS: We routinely performed laparoscopic pyeloplasties prior to acquiring the daVinci system. We prospectively evaluated 26 computer-assisted laparoscopic pyeloplasties (CLP) performed since acquiring the device in March 2003. There were 15 male and 11 female patients with a mean age of 34.5 years, who underwent right-sided procedures in 11 cases and left-sided procedures in 15 cases. Four patients (15%) had secondary ureteropelvic junction obstruction. All procedures were performed through a transperitoneal approach over stents placed preoperatively. The operative time excluded the time needed for stent insertion. Radiographic objective success was defined as adequate cortical drainage (t (1/2) < or =15 minutes) and preserved or improved renal function on MAG-3 diuretic renography. RESULTS: A total of 23 dismembered pyeloplasties and 3 Y-V plasties were performed. In five patients, nephroscopy was performed for stone removal. The mean operative time and blood loss were 245 minutes and 69 mL, respectively. There were no intraoperative complications or open conversions. Three minor postoperative complications were noted. The mean length of hospital stay was 2 days (range 1-5 days). In 19 evaluable patients, at a median follow-up of 6 months (range 2-10 days), 15 (79%) had complete symptom resolution, while 3 (16%) had marked symptom improvement. The overall subjective improvement rate thus was 95%. The objective success rate based on our strict diuretic renography criteria was 100%. The overall clinical success rate was 95% (18/19). CONCLUSIONS: Robot-assisted laparoscopic pyeloplasty is a feasible alternative to laparoscopic or open pyeloplasty with excellent short-term subjective and objective success rates.

Prescrotal orchiopexy: an alternative surgical approach for the palpable undescended testis.

PURPOSE: Inguinal exploration has been a standard approach for the management of palpable undescended testis. We performed prescrotal orchiopexy in patients with palpable undescended testes at our institution and we report our results. MATERIALS AND METHODS: We reviewed the charts of patients with palpable undescended testes treated with prescrotal orchiopexy from 1999 to 2002. All children were referred to a university children's hospital and 1 of 2 surgeons performed the procedures. Examination using anesthesia was performed prior to any incision. If the testis was palpable and could be drawn close to the scrotum, prescrotal orchiopexy was performed. Retractile testes were excluded. RESULTS: During this period 291 patients underwent orchiopexy. Prescrotal orchiopexy was performed in 78 patients. Followup was 1 to 36 months (median 6). The overall success rate was 98.8% and the overall complication rate was 4.7%. At 7 months postoperatively 1 patient had a palpable retractile testicle. One patient had wound hematoma and another patient had wound cellulitis. At 31 months of followup 1 patient was considered to have a 25% decrease in testis size. All patients were without clinical evidence of hernia or hydrocele. CONCLUSIONS: Prescrotal orchiopexy is a successful procedure in select patients with a low complication rate. It has the advantage of a single, perfectly cosmetic incision. This approach should be considered an option when performing orchiopexy in a patient with a palpable, mobile undescended testis.

A new look at the medical management of infertility.

Effective therapies are available for the treatment of infertility owing to specific causes. Most hormonal imbalances can be readily identified and successfully treated. The treatment of men with unexplained idiopathic infertility remains difficult. The availability of a multitude of agents ranging from hormones to nutritional supplements emphasizes the fact that none are consistently effective. There is no good way to predict which patients will respond to a specific treatment. Idiopathic infertility may result from multiple discrete defects in sperm generation and maturation that are as yet unidentified. A better understanding of these defects will yield more effective treatment options and appropriate triage of patients to specific therapeutic regimens. Assisted reproductive techniques remain an option for patients with idiopathic male infertility; however, they are expensive and treat the female partner for a male problem. Multiple gestations and other complications are not infrequent. Initial management should be directed at improving the quality of semen to facilitate natural conception. Specific abnormalities should be corrected. If empiric pharmacologic therapy is to be used, treatment should last at least 3 to 6 months to incorporate a full 74-day spermatogenic cycle. The infertile couple should be advised of the inconsistent response to therapy and the low conception rate that may follow when compared with the results of ART. When empiric therapy is decided upon, antiestrogens may be used and are effective in a subset of patients. The authors prefer to use clomiphene citrate, 25 mg per day. The dose may be increased to 50 or 75 mg to raise testosterone levels to the upper normal range. Lack of a significant improvement in semen parameters or of a pregnancy after a 3- to 6-month treatment period may be an indication to proceed with ART.