Complete daVinci versus laparoscopic pyeloplasty: cost analysis.

BACKGROUND AND PURPOSE: Computer-assisted pyeloplasty with the daVinci system is an emerging technique to treat ureteropelvic junction (UPJ) obstruction. A relative cost analysis was performed assessing this technology in comparison with purely laparoscopic pyeloplasty. PATIENTS AND METHODS: Eight patients underwent computer-assisted (daVinci) dismembered pyeloplasty (CP) via a transperitoneal four-port approach. They were compared with 13 patients who underwent purely laparoscopic pyeloplasty (LP). All patients had a primary UPJ obstruction and were matched for age, sex, and body mass index. The cost of equipment and capital depreciation for both procedures, as well as assessment of room set-up time, takedown time, and personnel were analyzed. Surgeons and nursing staff for both groups were experienced in both laparoscopy and daVinci procedures. One- and two-way financial analysis was performed to assess relative costs. RESULTS: The mean set-up and takedown time was 71 minutes for CP and 49 minutes for LP. The mean length of stay was 2.3 days for CP and 2.5 days for LP. The mean operating room (OR) times for CP and LP were 176 and 210 minutes, respectively. There were no complications in either group. One-way cost analysis with an economic model showed that LP is more cost effective than CP at our hospital if LP OR time is <338 minutes. With adjustment to a volume of 500 daVinci cases/year, CP is still not as cost effective as LP. Two-way sensitivity analysis shows that in-room time must still be <130 minutes and yearly cases must be >500 to obtain cost equivalence for CP. CONCLUSIONS: Perioperative parameters for CP are encouraging. However, the costs are a clear disadvantage. In our hospital, it is more cost effective to teach and perform LP than to perform CP.

Laparoscopic retroperitoneal lymph node dissection: duplication of open technique.

Laparoscopic retroperitoneal lymph node dissection has been used to stage germ cell testicular cancer. Since its initial description, this minimally invasive procedure has evolved into a therapeutic operation that adheres to established strict oncologic principles. A modified template dissection that fully duplicates the open technique is now routinely performed at our institution. We describe and show in the accompanying video segments a laparoscopic modified template dissection.

Laparoscopic partial nephrectomy in patients with neoplasia in a solitary kidney.

OBJECTIVES: To assess the renal function and describe our operative experience with laparoscopic partial nephrectomy (LPN) in patients with solitary kidneys. METHODS: The medical records were analyzed to find patients with a solitary kidney and renal neoplasms who underwent LPN. Demographic, operative, pathologic, and follow-up data were obtained. RESULTS: Four patients were identified with solitary kidneys who had undergone LPN. The mean operative time was 251 minutes, mean warm ischemic time 15 minutes, mean estimated blood loss 395 mL, and mean hospitalization stay 3 days. The mean preoperative creatinine was 1.5 mg/dL and the mean peak creatinine 2.0 mg/dL. All patients returned to their baseline creatinine levels in the follow-up period. The final pathologic finding was Stage pT1 in 1, pT3a in 2, and angiomyolipoma in 1 patient. All surgical margins were negative. No cancer recurrence developed in the patients, with a mean follow-up of 17 months (range 3 to 35). CONCLUSIONS: LPN in patients with a solitary kidney is feasible and a reasonable treatment alternative to open partial nephrectomy.

Evaluation of water jet morcellation as an alternative to hand morcellation of renal tissue ablation during laparoscopic nephrectomy: an in vitro study.

OBJECTIVES: To evaluate the feasibility and safety of morcellation with a new prototype device that uses high-pressure water flow as a cutting/ablating tool and compare it with standard manual morcellation. METHODS: Ten porcine kidneys were morcellated with the new water jet device and ten with conventional manual morcellation. Morcellation in all cases was performed in commercially available entrapment bags. The two groups were evaluated for morcellation time, fragment size, and perforation rates (macroscopic and microscopic). RESULTS: The kidney size in both groups was similar. Morcellation was significantly (P <0.0001) faster in the water jet morcellator group than in the hand morcellation group (5.6 versus 11.9 minutes). The macroscopic evaluation after filling the entrapment bags with normal saline revealed 4 (40%) and 2 (20%) pinhole perforations in the water jet and hand morcellation groups, respectively. The microscopic evaluation revealed an 80% perforation rate in the water jet group and a 20% rate in the hand morcellator group. The size of the resulting fragments in the water jet group was not available, because the morcellated kidney was transformed in a semiliquid form. Therefore, cytology evaluation of the tissue was not possible. CONCLUSIONS: Water jet technology can be used to morcellate renal porcine tissue effectively. It is faster, but the problems of safety and histologic evaluation must be solved before this promising technology can be used in a clinical setting.