Management of ureteral stricture disease during laparoscopic ureteroneocystostomy.

BACKGROUND AND PURPOSE: Laparoscopic surgery has many applications in urology. The surgical management of obliterative ureteral stricture disease using laparoscopy has not been widely reported. We recently implemented this technique in an adult patient with an obliterative ureteral stricture. METHODS: A transperitoneal refluxing right ureteral reimplantation was performed using the Endostitch device. Placement of the new ureteral orifice in the bladder was monitored by simultaneous cystoscopy and laparoscopy. The anastomosis was performed without tension, torsion, or angulation and was stented for 4 weeks. RESULTS: The operative time was 233 minutes. The blood loss was minimal. There were no intraoperative complications, and the postoperative hospital course was uneventful. CONCLUSION: Laparoscopic ureteral reimplantation is a safe and feasible technique. Cystoscopic determination of the neoureteral orifice is helpful. The Endostitch device is a useful adjunct in this procedure.

Retroperitoneoscopic radiofrequency ablation of a solid renal mass.

PURPOSE: To report a new technique for radiofrequency (RF) ablation of a solid renal mass. PATIENT AND METHODS: An 83-year-old man with a history of chronic renal insufficiency was found to have solid mass in the right kidney. Retroperitoneoscopic localization of the renal mass was accomplished using intraoperative ultrasonography. The lesion was treated with a 14-gauge RITA Starburst XL probe (Rita Medical Systems, Inc., Mountain View, CA). RESULTS: The total treatment time included two cycles of 5.5 minutes. There were no intraoperative complications. Tissue desiccation was noted during treatment. A CT scan 48 hours after ablation showed a decrease in the density of the lesion suggestive of coagulation necrosis. The postoperative hospital course was uneventful. CONCLUSION: The retroperitoneal laparoscopic technique is a feasible approach to performing RF ablation of a solid renal mass. It facilitates direct insertion of the RF probe, allows viewing and avoidance of adjacent structures such as bowel, and permits better staging by enabling biopsy of perirenal fatty tissue.

Does laparoscopic ureterolithotomy replace shock-wave lithotripsy or ureteroscopy for ureteral stones?

Ureteral stones are a major cause of morbidity and anxiety among urologic patients. Before the 1980s, ureteral stones were managed by open ureterolithotomy. Since then, second- and third-generation shock-wave lithotriptors, small-caliber ureteroscopes, and laparoscopic procedures have evolved as options for the treatment of ureteral calculi. Each technique is highly effective when implemented for the appropriate indication. Stone size, location, composition, and surgeon's and patient's preferences each play a major role in the decision-making process. Currently, ureteroscopy and shock-wave lithotripsy are regarded by many as the first-line treatment modalities for the management of ureteral stones, and the exact role of laparoscopic ureterolithotomy remains poorly defined. The present review addresses the most recent literature, and highlights the advantages and disadvantages of each surgical option.

Laparoscopic ureteral reconstruction with small intestinal submucosa.

PURPOSE: To evaluate the feasibility of laparoscopic ureteral reconstruction with small intestinal submucosa (SIS) in the pig ureter. MATERIALS AND METHODS: Eight female pigs weighing between 25 and 30 kg were enrolled. After anesthesia was administered, a double-pigtail stent was inserted, the animals were moved to a lateral decubitus position, pneumoperitoneum was established, and three 10-mm ports were positioned. The ureter was opened longitudinally for 7 cm, and two thirds of the periphery of the upper third of the left ureter was excised. The SIS was anastomosed to the upper and distal ureteral segments with chromic 4-0 sutures. The double-pigtail stent was removed 6 weeks after the initial procedure, and retrograde pyelography was performed a week later to confirm the viability of the pelvicaliceal system. RESULTS: The average duration of the procedures was 210 minutes (range 125-250 minutes). All animals survived the entire follow-up period of 7 weeks. Retrograde pyelography revealed a patent ureteral lumen, and no obstructive phenomena were observed. Histologically, the SIS-regenerated ureteral segments were remarkably similar to normal porcine ureters and were indistinguishable from neighboring tissue. CONCLUSION: Laparoscopic ureteral reconstruction with SIS proved to be effective and technically feasible. The SIS seems to be an effective biodegradable scaffold, facilitating regeneration of host tissue.

Management of malignant extrinsic compression of the ureter by simultaneous placement of two ipsilateral ureteral stents.

BACKGROUND AND PURPOSE: Extrinsic ureteral obstruction caused by various malignancies often necessitates urinary diversion. The use of single ureteral stents as a form of urinary diversion results in a high failure rate, while the use of two ipsilateral stents has shown promising results. We report our experience using the latter technique. PATIENTS AND METHODS: Between 1996 and 2001, four male and three female patients with a mean age of 65 years (range 37-95 years) who had extrinsic compression of the ureters underwent single stent management to relieve obstruction. Ureteral obstruction was secondary to prostate cancer (N = 3), cervical cancer (2), non-Hodgkin's lymphoma (1), and transitional-cell cancer of the bladder and ureter (1). After failure of such management, two 7F stents or a combination of 8F/6F double-J ureteral stents were placed. The stents were changed every 4 to 6 months. Follow-up included serial renal ultrasound scans and serum creatinine measurements. RESULTS: Ureteral stricture length ranged from 2 to 4 cm. Insertion of two double-J ureteral stents in a single ureter was successful in all cases. During the mean follow-up of 16 months (range 1-38 months), the ureteral stents were tolerated by all patients, without significant discomfort. Marked improvement of hydronephrosis and alleviation of flank pain was noted in all patients. Three patients have died at 1 to 3 months. Renal function improved, with a mean decline in the serum creatinine concentration from 3.2 mg/dL to 1.48 mg/dL in the five patients tested. CONCLUSION: Simultaneous placement of two double-J ureteral stents for the management of ureteral obstruction secondary to a malignancy is a safe and effective technique.

Laparoscopic antegrade continence enema in situ appendix procedure for refractory constipation and overflow fecal incontinence in children with spina bifida.

PURPOSE: The antegrade continence enema procedure allows patients with neurogenic bowel to administer large volume enemas through a right lower quadrant stoma to flush the colon every other day. This procedure results in freedom from refractory constipation and diapers required by unexpected episodes of overflow fecal incontinence. We present a simplified laparoscopic technique using in situ appendix. MATERIALS AND METHODS: A total of 6 male and 10 female children with a mean age of 12 years (range 4 to 21) and neurogenic bowel secondary to myelomeningocele underwent the antegrade continence enema in situ appendix procedure. The procedure was done with laparoscopic assistance, and associated with other bladder and bladder outlet reconstructive surgery in 5 patients. In 3 patients, a purely laparoscopic antegrade continence enema in situ appendix procedure was performed. The appendix and cecum were mobilized, and the tip of the appendix was anastomosed directly to the skin of the right lower quadrant through 1 of the 5 mm. lower quadrant port sites. The continence mechanism is simply a function of the appendix length and the mucosal coaptation of the appendiceal lumen. A 6Fr silicone Foley catheter is used to stent the mucocutaneous anastomosis. Concomitant procedures included ileocystoplasty, ileovesicostomy, sigmoidovesicostomy or ureterovesicostomy, and/or pubovaginal sling done through a low Pfannenstiel incision after laparoscopic mobilization of the appendix and cecum. RESULTS: The 3 patients treated with the laparoscopic antegrade continence enema procedure ate the day of surgery and were discharged home the next morning. Constipation and fecal incontinence resolved in all cases. All antegrade continence enema stomas were catheterized easily with a 6 or 8Fr feeding tube and were continent. Complications in the 8 laparoscopic and laparoscopic assisted cases included stomal stenosis requiring dilation in the office and obstructive volvulus associated with malrotation requiring segmental resection. Patient mothers in particular were gratified by this procedure at a mean followup of 11/2 years. CONCLUSIONS: The simplified antegrade continence enema in situ appendix procedure works well for refractory constipation and overflow fecal incontinence in children with neurogenic bowel secondary to spina bifida. Coaptation of the appendiceal lumen and use of small catheters allow for persistent continence without a formal surgically constructed valve mechanism. The combined antegrade continence enema and either ileovesicostomy or sigmoidovesicostomy continent urinary diversion procedures allow children to control bowel and bladder evacuation programs. A laparoscopic approach is reasonable particularly in cases requiring no other procedures.