Laparoscopic radical cystectomy: initial experience using the single-incision triangulated umbilical surgery (SITUS) technique.

INTRODUCTION: As could be demonstrated for simple and radical nephrectomy, single-incision triangulated umbilical surgery (SITUS) is an interesting alternative to laparoscopic single-site surgery. We present our initial experience with the SITUS technique in radical cystectomy. MATERIALS AND METHODS: Between September 2010 and September 2011, eight patients underwent SITUS radical cystectomy (SITUS Cx), pelvic lymph node dissection and extracorporeal urinary diversion. A cutaneous ureterostomy was performed in three, an ileum conduit in one and an ileal neobladder in four patients. Data were collected prospectively, including patients' characteristics, intraoperative parameters, pathological stage and postoperative outcome. RESULTS: Mean age of the patients was 67 years and the mean body mass index 24 kg/m(2). SITUS Cx was successfully completed in all patients without conversion to conventional laparoscopic or open surgery. Mean surgical time was 434 min and mean estimated blood loss 643 ml. No major intra- or postoperative surgical complications occurred. All patients recovered quickly reporting low postoperative pain levels. Mean hospital stay was 16 (7-24 days). Histopathological evaluation revealed a mean of 16 (6-33) retrieved lymph nodes and no positive margins. CONCLUSION: In the present experience, SITUS Cx proved to be feasible with surgical outcome comparable to conventional techniques. Because SITUS Cx combines the advantages of traditional laparoscopy (straight instruments and triangulation) with those of single-port surgery (superior cosmesis and minimal invasiveness), it presents an attractive alternative to other minimally invasive techniques.

Waterjet hydrodissection: first experiences and short-term outcomes of a novel approach to bladder tumor resection.

INTRODUCTION: TURB is the standard approach to bladder tumors but suffers from several disadvantages. Waterjet hydrodissection is a new technology for removing superficial tumors in the GI tract promising to preserve the histological structures of biopsy specimens with favorable long-term results as recent studies have shown. The aim of this study was to show the feasibility and applicability of waterjet hydrodissection for removing papillary superficial bladder tumors. MATERIALS AND METHODS: In five patients diagnosed with superficial papillary bladder tumor, transurethral submucosal dissection was conducted using the T-type I-Jet HybridKnife (Erbe, Tuebingen). The resection edges were labeled by means of electrical coagulation with the HybridKnife. Subsequently, a submucosal fluid cushion specific to the tissue layer was formed by the waterjet implementation function of the HybridKnife, thereby elevating the tumorous tissue. The tumor was endoscopically extracted with a retrieval bag. Biopsy specimens of the tumor edges and base were subsequently collected. RESULTS: All tumors could be resected en bloc, and the lamina propria was intact in all specimens, allowing the pathologist to distinguish between superficial and invasive tumors. Pathological analysis confirmed R0 resection in all samples. CONCLUSION: These initial results prove the feasibility of waterjet hydrodissection for removing bladder tumors. In contrast to conventional TURB, this new technique allows the pathologist to assess the entire lamina propria and the resection edges due to the en-bloc resection and to determine invasiveness as well as R0 versus R1 resection. These first results are promising, long-term oncological follow-up, and prospective randomized surveys investigating the recurrence rate have to be evaluated.

[Minimally invasive percutaneous treatment of lower pole stones with a diameter of 8 to 15 millimeters]. / Die minimalinvasive perkutane Behandlung kleiner unterer Kelchsteine mit einem Durchmesser von 8 bis 15 Millimeter.

PURPOSE: The optimal treatment options for lower pole stones with a diameter below 15 mm are controversially discussed. Extracorporeal shock wave lithotripsy (ESWL) is non-invasive but is hampered by low stone-free rates and a significant retreatment rate. Flexible ureterorenoscopy (URS) has been demonstrated to have high stone-free rates but the treatment costs - consisting of OR time, repair costs and expenditure for laser fibers, guide wires and stone baskets - as well as low stone-free rates with increasing stone size render this procedure highly expensive. Minimally invasive percutaneous litholapaxy (MIP) has shown low morbidity and high efficacy in the treatment of nephrolithiasis. The goal of this study was to investigate the efficacy and -safety of MIP for the treatment of small lower pole stones. PATIENTS AND METHOD: The charts of 29 patients who were treated with MIP were reviewed and clinical data like OR time, drop in haemoglobin, complication rate, stone-free rate and duration of hospital stay were collected. RESULTS: 28 of 29 patients were primarily stone-free; one had to undergo additional flexible URS to become stone-free. All procedures were undertaken with only one access, no severe complications occurred; none of the patients had to be transfused. CONCLUSIONS: The MIP concept has a low complication rate and has been shown to be safe and effective in previous studies. We demonstrate that the feasibility and efficacy justify the percutaneous approach also for small lower pole stones.

[Minimally invasive percutaneous nephrolitholapaxy (MIP)]. / Minimal-invasive perkutane Nephrolitholapaxie (MIP).

Minimally invasive percutaneous nephrolithopaxy (MIP) was developed to combine the excellent stone-free rates of the conventional percutaneous nephrolithopaxy (PCNL) technique with the low morbidity of the miniaturized PCNL (Mini-Perc) and, at the same time, achieve a high level of patient comfort. The procedure is characterized not only by the diameter of the miniaturized 18-Fr Amplatz sheath that was adopted from the Mini-Perc but also by the following features: ultrasound-guided puncture of the kidney; single-step dilatation of the access tract; ballistic lithotripsy; a low-pressure irrigation system together with stone retraction by irrigation with a specially designed nephroscope sheath, for the so-called vacuum cleaner effect; and a sealed and tubeless access tract with primary closure of the channel independent of hemorrhage and without a second-look procedure.The results of the first 57 patients demonstrate primary stone-free rates of 92.9% with operating times averaging 62 (25-123) min. Severe complications, such as sepsis or bleeding requiring blood transfusion, did not occur. The high and predictable stone-free rate and a low morbidity comparable to that of ureteroscopy and extracorporeal shock-wave lithotripsy make MIP an attractive option for patients and urologists. The "vacuum cleaner effect" with quick removal of stone fragments reduces operating time and prevents new stone formation by avoiding residual fragments. The direct and primary closure of the access tract increases patient comfort and is justified by the reintervention rate of less than 8% in the presented cohort.The lack of a need for second-look nephroscopies, the vacuum cleaner effect, improved patient comfort without nephrostomy tubes, as well as surgery times comparable to that of traditional PCNL demonstrate a consequent evolution of the Mini-Perc. MIP therefore represents a promising and future-oriented module in modern stone therapy.

[Use of a gelatine-thrombin matrix for closure of the access tract without a nephrostomy tube in minimally invasive percutaneous nephrolitholapaxy]. / Die Verwendung von Gelatine-Thrombin-Matrix zum Verschluss des Arbeitskanals bei der nephrostomielosen minimal-invasiven perkutanen Nephrolitholapaxie.

BACKGROUND: The spectrum of percutaneous stone treatment was significantly widened following the introduction of the miniaturized percutaneous nephrolitholapaxy. At the end of the procedure usually a nephrostomy tube was placed to avoid urine paravasation and prolonged bleeding. In this work the tube-less mini-PCNL with direct closure of the access tract was compared to traditional mini-PCNL with placement of the nephrostomy tube. PATIENTS AND METHODS: Twenty consecutive patients undergoing mini-PCNL with placement of a nephrostomy tube at the end of the procedure were compared to 20 consecutive patients with direct closure of the access tracts following percutaneous stone removal. Clinical data like decrease in Hb, complications, need for analgesics and duration of hospital stay were compared. RESULTS: Both groups underwent the procedure without complications. There was no need for blood transfusions. The difference in total analgetic dose was not statistically significant; however, patients in the nephrostomy group needed analgetics for a longer period of time. There was no difference in duration of hospital stay (3.2 days in the tube-less group versus 3.4 days in the nephrostomy group). The primary stone-free rate was higher in the group with direct closure of the access tract (95 versus 85%). CONCLUSIONS: Closure of the percutaneous access following mini-PCNL with a gelatine-thrombin-haemostatic sealant is a safe alternative to the commonly used nephrostomy tube and can help to reduce postoperative pain and patient discomfort.