Informed consent in endoscopic sinus surgery: the patient perspective

OBJECTIVES

To understand patient expectations during the informed consent process for functional endoscopic sinus surgery (FESS).

STUDY DESIGN

Multi-institutional, cross-sectional survey design.

METHODS

Anonymous surveys were administered to patients in two tertiary academic centers with a chief complaint relating to "allergy and sinus" problems. Patients completed an eight-item questionnaire that assessed both the nature and the level of risks that they wished to be informed of prior to FESS.

RESULTS

Three hundred eighty-nine surveys were returned. Sixty-nine percent of patients wished to be informed of complications that occur as infrequently as 1 in 100 cases, regardless of severity. Ninety percent of patients wanted to know of a risk that occurred as frequently as 1 in 10 cases. Patients also reported whether or not they wished to be told in detail about specific complications during the informed consent process, regardless of their infrequency. Affirmative responses were as follows: 83% for cerebrospinal fluid leak and orbital injury, 81% for infection, 76% for revision surgery, 74% for impairment of smell, 73% for bleeding and myocardial infarction, 72% for cerebrovascular accident, and 58% for scarring.

CONCLUSIONS

Patients wanted to be informed about severe FESS complications at a higher rate than physicians previously surveyed, even if the incidence is low. This study, combined with our previous examination of the physicians' perspective, highlights that there may be a discrepancy between what the physician and the patient believe are priority topics during the informed consent process.

Inflammatory myofibroblastic tumor of the larynx in a 2-year-old male

Inflammatory myofibroblastic tumor (IMT) is an uncommon neoplasm that is usually located in the lung in the pediatric population. These tumors contain a variety of cell types with the myofibroblast being dominant. When located in the upper airway, IMTs tend to be less aggressive, but have the potential for local invasion and recurrence. We present an unusual case of IMT in the pediatric larynx and review the medical literature describing the common locations, diagnosis, etiology, histology, and treatment of this tumor. The mainstay of treatment is complete surgical excision. Careful and frequent follow-up including frequent fiberoptic laryngoscopy and CT scans are recommended to evaluate for recurrence. More aggressive resection may be necessary if multiple recurrences occur.

Oral lactoferrin inhibits growth of established tumors and potentiates conventional chemotherapy

In this work, we investigated the anticancer activity of orally administered recombinant human lactoferrin (rhLF) alone and in combination with chemotherapy in tumor-bearing mice. rhLF inhibited the growth of squamous cell carcinoma (O12) tumors in T cell-immunocompromised nu/nu mice by 80% when administered at 1,000 mg/kg (2.9 g/m2) by oral gavage twice daily for 8 days (p < 0.001). Similar activity was observed in syngeneic, immunocompetent BALB/c mice, where orally administered rhLF (1,000 mg/kg, 2.9 g/m2 once daily) halted the growth of mammary adenocarcinoma TUBO. Oral rhLF (200 mg/kg, 0.57 g/m2) was also used alone and in combination with cis-platinum (5 mg/kg) to treat head-and-neck squamous cell carcinoma in a syngeneic murine model. Monotherapy with oral rhLF or cis-platinum caused 61% or 66% tumor growth inhibition over placebo, respectively. Mice receiving both therapies showed 79% growth inhibition, a statistically significant improvement over each drug alone. We then demonstrated that administration of oral rhLF (300 mg/kg, 0.86 g/m2) to tumor-bearing or naive mice resulted in (i) significantly increased production of IL-18 in the intestinal tract, (ii) systemic NK cell activation and (iii) circulating CD8+ T-cell expansion. These data suggest that oral rhLF is an immunomodulatory agent active against cancer as a single agent and in combination chemotherapy, exerting its systemic effect through stimulation of IL-18 and other cytokines in the gut enterocytes. rhLF has been administered orally to 211 people without a single serious drug-related adverse event. Thus, rhLF shows promise as a safe and well-tolerated novel immunomodulatory anticancer agent.

Lactoferrin Inhibits Growth of Malignant Tumors of the Head and Neck

Lactoferrin, a naturally occurring glycoprotein found in breast milk, has previously been shown to have antimicrobial properties and recently has been demonstrated to inhibit malignant tumor growth, presumably through immunomodulation. We hypothesized that intratumoral injection of human and murine recombinant lactoferrin would decrease the growth of malignant tumors in vivo. Using an orthotopic murine model for both squamous cell carcinoma and fibrosarcoma of the floor of the mouth, we administered lactoferrin directly into the tumors using variable dosing strategies. Additionally, we performed in vitro experiments to assess whether the effects of lactoferrin are due to direct cytotoxicity. Our results revealed growth inhibition of 50% (p=0.03)and 54% (p=0.01) as compared with controls for both human and murine tumor cells in immunodeficient and immunocompetent mice, respectively. There was a more dramatic effect in immunocompetent models which may identify immunomodulation as an important mechanism of action for lactoferrin. Support for immunomodulation as a possible mechanism was the lack of any difference between controls and the experimental groups in vitro. Lactoferrin proved effective in reducing malignant tumor growth in a murine model. These properties offer hope for its use as a primary or adjuvant chemotherapeutic agent. Further investigation focused on mechanism and delivery is needed.

Surface modification to improve in vitro attachment and proliferation of human urinary tract cells

OBJECTIVE

To evaluate the attachment and proliferation of cultured human urinary tract cells to culture plates surface-modified by photochemical immobilization of extracellular matrix (ECM) proteins.

MATERIALS AND METHODS

Human uroepithelial (UEC) and smooth muscle (SMC) cells were harvested from ureter and expanded in culture; 24-well culture plates surface-modified by photochemical covalent immobilization of ECM proteins were then seeded with UEC or SMC. To characterize cellular attachment, cells were incubated on surface-modified plates for 30 and 90 min. For proliferation assays the cells were incubated for 3-12 days. Standard tissue culture plates with no surface modification and sham-modified plates served as controls. Differential attachment and proliferation on the various surfaces were assessed using analysis of variance with Fisher's posthoc test for multiple comparisons.

RESULTS

Attachment at 30 and 90 min of both UEC and SMC on plates surface-modified with ECM proteins was significantly greater than in control plates. Surface-modification with collagen resulted in significantly greater cellular attachment than with either laminin or fibronectin. UEC proliferation was also significantly greater than in control plates by surface-modification with collagen and fibronectin, but not with laminin. SMC proliferation was significantly better after surface modification than on sham- modified plates, but was no better than standard plates.

CONCLUSIONS

Covalent photochemical immobilization of ECM proteins to potential growth surfaces enhances the attachment of cultured UEC and SMC and the proliferation of UEC. This technique might be useful in modifying surface properties of synthetic polymer-based materials in a controlled and defined manner, giving them the capacity to promote and sustain the growth of urinary tract cells. This may lead to development of alternative methods of tissue engineering in the urinary tract.

Informed consent in functional endoscopic sinus surgery

OBJECTIVES

Functional endoscopic sinus surgery (FESS) is one of the more common procedures performed by otolaryngologists. Before performing FESS, surgeons are obligated to discuss the procedure and its risks through the process of informed patient consent. The study identifies current practices in informed consent for FESS and formulates guidelines for informed consent for FESS.

STUDY DESIGN

Survey.

METHODS

Surveys were sent to 1000 American Academy of Otolaryngology-Head and Neck Surgery members in the United States. Surveys inquired about current informed consent practices related to FESS.

RESULTS

Three hundred forty-six surveys were returned. Nearly 60% of respondents thought that 1% incidence of a complication warrants a discussion with patients. The percentage of respondents who discuss specific risks were as follows: bleeding, 96.7%; infection, 84.8%; cerebrospinal fluid leak, 99.1%; orbital injury, 96.7%; smell changes, 40.2%; cerebrovascular accident, 17.9%; myocardial infarction, 81%; and death, 28.0%.

CONCLUSIONS

The study suggests that there is variability in specific informed consent practices for FESS among otolaryngologists. It also suggests that the incidence or severity of a complication does not necessarily correlate with whether or not it is mentioned during the informed consent process. The authors think that practicing otolaryngologists may be able to use this information to improve their consent practices.

Flexible ureteroscopy in conjunction with in situ lithotripsy for lower pole calculi

OBJECTIVES

To demonstrate the efficacy and safety of ureteroscopy as a compromise in treating small and intermediate-size lower pole calculi. The optimal management of lower pole calculi remains controversial. Shock wave lithotripsy is associated with minimal morbidity but with suboptimal stone clearance rates. Conversely, percutaneous nephrostolithotomy has greater morbidity but stone-free rates greater than 90% regardless of size.

METHODS

Seventy-two patients underwent ureteroscopy for lower pole calculi 2 cm or less (mean 8.7 mm) during a 3-year period. To minimize confounding, 11 patients with additional calculi at other ipsilateral renal sites and 1 patient with large (2.4 cm each) bilateral calculi were excluded. Two patients with bilateral lower pole calculi and four who required a second procedure were included in the analysis. Thus, the final cohort consisted of 60 patients who underwent 66 procedures.

RESULTS

Of patients with follow-up longer than 1 month, 79% were stone free after a single procedure, and this improved to 88% after a second procedure in 4 patients. All 7 patients with follow-up less than 1 month had a reduction in stone burden after successful fragmentation. Overall, 8 patients required an auxiliary procedure. No intraoperative complications, and 7 (11%) postoperative complications occurred.

CONCLUSIONS

Ureteroscopy for lower pole calculi is associated with minimal morbidity and stone-free rates comparable to shock wave lithotripsy for smaller stones. The greatest utility of ureteroscopy is in the management of intermediate-size calculi, for which it has substantially higher stone-free rates and lower repeated treatment rates than does shock wave lithotripsy.

A canine model to assess the biochemical stress response to laparoscopic and open surgery

PURPOSE

To develop an animal model to assess the stress response to open and laparoscopic surgery. Such a model would allow objective physiologic assessment of the putative benefits of laparoscopy and provide a framework in which to compare modifications in operative and anesthetic technique that might decrease the stress of surgery.

MATERIALS AND METHODS

Mongrel dogs underwent laparoscopic (N = 12) or open surgical (N = 12) left nephrectomy. In 11 control animals, after induction of anesthesia and line placement, the animal underwent either no intervention (open surgery sham; N = 6) or pneumoperitoneum only (laparoscopic sham; N = 5). Serum glucose and cortisol were measured preoperatively, at skin closure, and at 4, 8, and 24 hours postoperatively. Values at each time point were compared in the laparoscopic and open surgical nephrectomy groups and in each of the two nephrectomy groups and their respective shams.

RESULTS

Compared with baseline, there was a sharp rise in serum cortisol at the time of skin closure, with a gradual decline to baseline values by 24 hours, in all experimental animals. Significantly lower serum cortisol concentrations were seen at 4 and 8 hours postoperatively in the laparoscopic group than in the open surgery group. Cortisol was significantly higher in the open group than in the sham-open group at all time points, whereas cortisol was greater in the laparoscopic group than in the pneumoperitoneum-only group only at the 4-hour time point. No differences were seen in serum glucose between groups.

CONCLUSIONS

The serum cortisol concentration appears to be a good measure of surgical stress in the canine model. The rapid decline in serum cortisol after laparoscopy compared with open surgery may indicate a lesser degree, or quicker resolution, of surgical stress in the former. Furthermore, the similarity in cortisol curves between laparoscopy and pneumoperitoneum only suggests that surgical stress in laparoscopic surgery may be attributable mainly to the effects of pneumoperitoneum.

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.

Comparison of outcomes of ureteroscopy for ureteral calculi located above and below the pelvic brim

OBJECTIVES

To compare the safety and efficacy of ureteroscopy performed for proximal and distal ureteral calculi in a contemporary cohort. Ureteroscopy has been used most often for distal ureteral calculi. However, advances in endoscopic equipment have facilitated access to the proximal urinary tract and have broadened the indications for ureteroscopy.

METHODS

One hundred ninety-one patients underwent rigid and/or flexible ureteroscopy for ureteral calculi at the University of Michigan between January 1, 1997 and September 30, 1999. Only 7 patients with either bilateral calculi or steinstrasse were excluded. The final cohort consisted of 184 patients who underwent ureteroscopy for distal stones (n = 103) or middle/upper ureteral stones (n = 81).

RESULTS

Bivariate analyses of pretreatment and perioperative characteristics were used to assess the sample population. The initial success rate for the distal and proximal ureteral calculi was 96% and 78%, respectively (P = 0.0008). After a "second-look" procedure in 4 and 7 patients with distal and proximal calculi, respectively, the success rate improved to 99% and 88%, respectively (P = 0.004). No differences were noted between groups regarding the intraoperative (P = 0.51) or postoperative (P = 0.85) complication rates. Multivariate logistic regression analysis confirmed that larger stone size (odds ratio 1.2, P = 0.0006) and proximal ureteral location (odds ratio 4.8, P = 0.01) are independent predictors of treatment failure.

CONCLUSIONS

Ureteroscopic management of proximal and distal ureteral calculi is highly successful, and the difference in success rates has narrowed substantially. Currently, no greater risk is conferred to the patient for endoscopy of more proximal ureteral calculi.

IL (interleukin)-1alpha promotes nuclear factor-kappaB and AP-1-induced IL-8 expression, cell survival, and proliferation in head and neck squamous cell carcinomas

Interleukin 1alpha (IL-1alpha) is an important regulatory cytokine, the release of which after an injury can induce activation of transcription factors nuclear factor (NF)kappaB and activator protein (AP-1), which promote expression of genes involved in cell survival, proliferation, and angiogenesis. IL-1alpha is expressed autonomously by head and neck squamous cell carcinomas (HNSCCs) and a variety of other cancers, raising the possibility that IL-1alpha may serve as an autocrine factor that stimulates the activation of prosurvival transcription factors and target genes in cancer. In this study, we examined the role of IL-1alpha in the activation of NFkappaB and AP-1, the expression of proangiogenic cytokine IL-8, and in the survival and proliferation of HNSCC cell lines. HNSCCs were found to secrete and respond to functional IL-1alpha, in that culture supernatant from a high IL-1alpha-secreting line, UM-SCC-11B, could induce secretion of cytokine IL-8 by a low IL-1alpha-secreting line, UM-SCC-9; and the induction of IL-8 secretion could be blocked by the anti-IL-1alpha-neutralizing antibody or the IL-1 receptor antagonist (IL-1RA). Furthermore, IL-1alpha could induce the expression of IL-8 through an autocrine mechanism, in that transfection of UM-SCC-9 cells with a plasmid encoding IL-1alpha resulted in the increased coexpression of IL-1alpha and IL-8; whereas transfection with a plasmid encoding IL-1RA lacking the secretory leader sequence led to the decreased coexpression of IL-1alpha and IL-8. IL-1alpha was found to induce coexpression of IL-8 through the activation of NFkappaB and AP-1, in that mutation of the NFkappaB site within the IL-8 promoter abolished autocrine- and recombinant IL-1alpha-induced IL-8 reporter gene activity, whereas mutation in AP-1 partially decreased IL-8 reporter gene activity in UM-SCC-9 cells. Intracellular expression of IL-1RA decreased NFkappaB reporter gene activity, indicating that endogenously expressed IL-1alpha contributes to constitutive NFkappaB activation in this HNSCC line. Expression of IL-1alpha affected survival of UM-SCC-9, inasmuch as transfection of cells with plasmid encoding IL-1alpha or IL-1RA led to the increased or decreased survival of cells cotransfected with a beta-galactosidase reporter gene, respectively. IL-1alpha was also found to promote the increased growth of UM-SCC-9 cells in vitro. We demonstrate that exogenous and endogenous IL-1alpha contributes to the transcriptional activation of NFkappaB and AP-1, to the expression of IL-8, and to cell survival and the growth of HNSCC in vitro.

Comparison of shockwave lithotripsy outcomes in patients receiving sufentanil or lidocaine spinal anesthesia

PURPOSE

To determine whether the use of intrathecal sufentanil, which allows the patient to move during shockwave lithostripsy (SWL), affects treatment outcomes and operative and recovery times compared with standard lidocaine spinal anesthesia.

PATIENTS AND METHODS

We retrospectively studied a series of 62 SWL procedures performed on an unmodified Dornier HM3 lithotripter. The mean calculus size was 10.7 mm. There were 46 renal calculi, 13 ureteral calculi, and 4 patients with calculi in both locations. Of the 63 procedures, 25 were performed using intrathecal sufentanil alone, and 37 were performed with intrathecal lidocaine with or without additional agents. We compared treatment outcomes, as well as treatment time, fluoroscopy time, postanesthesia care unit (PACU) time, time to voiding, and time to ambulation.

RESULTS

Sufentanil use was associated with a significantly higher rate of successful treatment, defined as residual fragments absent or <4 mm on follow-up imaging, compared with lodocaine: 68% v. 40% (p = 0.0394). There was no significant difference between the groups in treatment time or fluoroscopy time. Use of sufentanil was associated with significantly shorter PACU time, time to ambulation, and time to voiding postoperatively. These differences persisted when men and women were analyzed separately, although the differences were less significant in women.

CONCLUSIONS

The use of intrathecal sufentanil for anesthesia during SWL does not adversely affect treatment outcome; it is, in fact, associated with better outcomes. The advantages of this agent in shortening recovery times and in easing patient transfer into the HM3 gantry argue for increasing its use.

Indications, technique, and results of laparoscopic pelvic lymphadenectomy

Despite considerable clinical research, there is still controversy about the optimal management of the pelvic lymph nodes in men with prostate cancer. This article reviews the creation and application of selection criteria for laparoscopic pelvic lymphadenectomy and describes the various techniques.

Laparascopic partial nephrectomy

The role of laparoscopy in urologic surgery has greatly increased over the past decade as has the popularity of elective nephron-sparing surgery. The emergence of these trends in conjunction with improvements in equipment and expertise has led to the increasing application of laparoscopic partial nephrectomy. Initially, this modality was applied in patients with benign diseases, such as chronic pyelonephritis and calculus disease with associated atrophy. Concerns of tumor spillage and local-regional control precluded the application of the laparoscopic modality to small, indeterminate renal masses. However, increasing experience with the technique and advances in intraoperative imaging have prompted its use in removing small renal masses. Herein, we describe the indications for laparoscopic partial nephrectomy, the two approaches (transperitoneal and extraperitoneal) to gain access to the kidney, current options to assist in controlling intraoperative hemorrhage, a comprehensive assessment of the results for benign and malignant resections, and an examination of the similarities and contrasts between open and laparoscopic techniques.

Routine placement of ureteral stents is unnecessary after ureteroscopy for urinary calculi

OBJECTIVES

To report a matched comparison of patients with and without stenting after ureteroscopy for calculi, including middle or proximal ureteral and renal calculi. The elimination of routine stenting after ureteroscopy would prevent stent pain, minimize the need for re-instrumentation, and reduce costs-as long as efficacy and safety are not diminished.

METHODS

Of 318 patients who underwent ureteroscopy, 81 (25%) did not have a ureteral stent placed. Of those, 51 were suitable for analysis and included patients with distal ureteral (n = 22), middle or proximal ureteral (n = 11), and renal calculi (n = 18). This cohort was matched to a stented group by stone size and location.

RESULTS

The preoperative characteristics of the groups were similar. A stone-free rate of 86% and 94% was achieved in the stented and nonstented groups, respectively (P = 0.32). Complications in the nonstented group were less frequent (flank pain in 3 and postoperative nausea in 1) than in the stented group (hospital visits for flank pain in 12, persistent nausea and vomiting in 1, sepsis in 1, perinephric hematoma in 1, and urinary retention in 1) (total of 4 versus 16, P = 0.025).

CONCLUSIONS

Ureteroscopy for distal ureteral stones without ureteral stent placement has been previously described. Our experience expands to include the elimination of stent placement after ureteroscopy for middle or proximal ureteral (22%) and renal (35%) calculi. Our data suggest that after ureteroscopies with short operative times and minimal ureteral trauma, ureteral stents may not be necessary, even if proximal ureteral or renal ureteroscopy has been performed.

Functional effects of unilateral laser papillectomy in the pig

OBJECTIVES

To evaluate the use of endoscopic laser papillectomy in a multi-papillary animal model to unilaterally impair concentrating ability and increase the urinary flow rate.

METHODS

Domestic pigs underwent unilateral retrograde flexible nephroscopy. With a holmium:yttrium-aluminum-garnet laser, varying numbers of papillae were ablated. Four weeks after the procedure, renal function studies were performed during hydropenia and after hydration, the animals were killed, and the kidneys were examined histologically.

RESULTS

The urine flow rate per 100 mL creatinine clearance was significantly increased in the papillectomized kidney compared with the control kidney during hydropenia (1.50 versus 0.94, P <0.01). The papillectomized kidneys were unable to concentrate the urine as well as the control kidneys during both hydropenia (urine osmolarity 430 versus 534 mOsm/L, P <0.01) and after hydration (329 versus 362 mOsm/L, P = 0.02). The free water reabsorption per 100 mL creatinine clearance was impaired in the papillectomized kidneys compared with the control kidneys (0.48 versus 1.00, P = 0.02) after hydration. A significant correlation existed between the percentage of papillae ablated and the difference in osmolarity between the operated and control kidneys (r(2) = 0.50, P = 0.015). Histologic examination demonstrated transitional re-epithelialization with moderate collecting duct dilation and medullary fibrosis underlying the ablated papillae early in the series; however, the histologic features normalized and the creatinine clearance was less impaired with a more proficient technique later in the series.

CONCLUSIONS

Endoscopic laser papillectomy results in increased urine flow and impaired urinary concentrating ability. This surgical technique should be investigated further for its role in the prevention of nephrolithiasis.

Comparison of 2-octyl cyanoacrylate adhesive, fibrin glue, and suturing for wound closure in the porcine urinary tract

OBJECTIVES

To evaluate 2-octyl cyanoacrylate glue (OCG) for wound closure in the urinary tract and compare the ability of OCG, fibrin glue (FG), and suture to withstand physiologic and supraphysiologic stress, because the use of tissue adhesives such as OCG or FG might simplify laparoscopic surgery.

METHODS

Female domestic pigs (n = 22) underwent a 7.5-cm cystotomy. Of these, 8 had closure with OCG and 8 with FG (6 open and 2 laparoscopic in each group). The controls were closed with suture (n = 4) or not at all (n = 2). Postoperative catheter drainage was not used. At 2 days or 4 weeks postoperatively, the bladders were filled with saline to 200 mm Hg pressure and the cystotomy scars inspected for leakage. The excised scars were also examined histologically.

RESULTS

The 2 OCG and 2 FG pigs tested on postoperative day 2 leaked at less than 200 mm Hg. None of the 6 OCG pigs tested at 4 weeks leaked at less than 200 mm Hg, including the 2 closed laparoscopically. Of the 6 FG pigs intended for study at 4 weeks, 3 (including the 2 closed laparoscopically) died from a massive urine leak, 1 tested at 4 weeks leaked, and 2 did not leak. Thus, 4 of 6 FG pigs leaked by 4 weeks compared with none in the OCG group (P = 0.06). The histologic examination was similar in the two groups.

CONCLUSIONS

Preliminary results suggest that OCG provides enough strength to hold together a large bladder wound. In the same model, FG did not consistently provide adequate closure.

Laparoscopic access with a visualizing trocar

Although useful in most situations, there are several inherent disadvantages of the standard laparoscopic access techniques of Veress needle insertion and Hasson-type cannula placement. Veress needle placement may be hazardous in patients at high risk for intraabdominal adhesions and difficult in patients who are obese. The usual alternative, the Hasson-type cannula, often does not provide a good gas seal. As another option, the use of a visualizing trocar (OPTIVIEW) has proven to be effective in the initial experience at the University of Michigan. The inner trocar of the visualizing trocar is hollow except for a clear plastic conical tip with two external ridges. The trocar-cannula assembly is passed through tissue layers to enter the operative space under direct vision from a 10-mm zero-degree laparoscope placed into the trocar. Results suggest that this technique is an excellent alternative to Veress needle placement when laparoscopic access is likely to be hazardous or difficult.

Hand-assisted laparoscopic nephrectomy: technical considerations

PURPOSE

Laparoscopic nephrectomy can be technically difficult and associated with lengthy operative times because of the limitations imposed by working with long instruments rotating about a fixed site on the abdominal wall, and without direct manual contact with the tissue. Hand-assisted laparoscopy is an option that addresses these problems. Herein we report our initial technique for hand-assisted laparoscopic nephrectomy.

TECHNIQUE

After obtaining pneumoperitoneum and placing a 12-mm cannula lateral to the rectus muscle, a 7- to 8-cm incision is made in the upper midline. A commercially available wound protector and occlusive sleeve are inserted. Once an arm strap has been secured, the surgeon can operate with one hand in the abdomen while maintaining pneumoperitoneum. Using instruments placed through one or two additional laparoscopic ports, the nephrectomy is completed and the specimen is removed through the upper midline incision. Our continued experience with 10 hand-assisted laparoscopic nephrectomies to date has been favorable.

CONCLUSION

Hand-assisted laparoscopic nephrectomy may facilitate the laparoscopic management of demanding pathologies, such as severely inflamed kidneys and larger tumors. It is particularly advantageous when intact specimens are required. Although more experience is required to define the role of hand-assisted urologic laparoscopy, we are encouraged by our initial technique and results.

Fragment of a catheter as a foreign body in the kidney

Foreign bodies in the kidney are unusual. A review of the literature disclosed few reports of renal foreign body from nontraumatic causes. In this article, we report a case of gross hematuria due to iatrogenic foreign body in the kidney from ureteral endoscopy. The catheter fragment eluded diagnosis for 18 months until it was discovered and retrieved by means of a flexible ureteroscope. To our knowledge, this is the first report of this complication and presentation following endoscopic manipulation of the upper ureteral tract.