High-grade transitional cell carcinoma and melanosis of urinary bladder: case report and review of the literature

Melanosis of the urinary bladder is a rare entity. It is generally regarded as a benign condition, but it is sometimes associated with primary malignant melanoma of the urinary bladder. It has never been reported to be connected with transitional cell carcinoma. We present a case of a woman with melanosis of the bladder who a year later developed high grade transitional cell bladder carcinoma.

Pure natural orifice transluminal endoscopic surgery (NOTES) nephrectomy using standard laparoscopic instruments in the porcine model

PURPOSE

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an emerging technology that uses endoscopic instruments passed into the peritoneal cavity through hollow viscera to perform surgical procedures without the use of abdominal incisions. There are, however, limitations regarding the equipment available to simulate traditional surgery. The aim of this study was to determine the feasibility of a pure NOTES nephrectomy by using standard laparoscopic instruments through a modified transvaginal trocar.

MATERIALS AND METHODS

One 40-kg female swine underwent transgastric peritoneoscopy. Transgastric endoscopic visualization guided the introduction of a second transvaginal endoscope through a novel laparoscopic trocar/endoscopic overtube device. The retroflexed transgastric endoscope provided triangulated visualization as standard endoscopic instruments provided retraction, which allowed dissection of the kidney with standard laparoscopic instruments through our modified transvaginal trocar device. Each renal hilum, artery, vein, and ureter was dissected and divided with a transvaginal laparoscopic stapler.

RESULTS

Transgastric and transvaginal NOTES accesses were easily achieved, and bilateral nephrectomies were performed. Completion of peritoneoscopy revealed complete hemostasis and identification of ligated ureters and hilar vessels. Total operative time was 40 and 20 minutes for the right and left kidney, respectively. One kidney was captured with a laparoscopic retrieval sac and removed intact through the vaginal defect.

CONCLUSIONS

Pure NOTES nephrectomies are technically feasible in the porcine model by using standard laparoscopic instruments. Survival studies are necessary to determine the long-term complications and physiologic implications of NOTES nephrectomy. The development of innovative NOTES access trocars may allow for an increased armamentarium of NOTES instruments.

Single access site laparoscopic radical nephrectomy: initial clinical experience

PURPOSE

We present the initial clinical experience with single access site (SAS) laparoscopic radical nephrectomy.

MATERIALS AND METHODS

An 86-year-old woman presented with an 8-cm central-enhancing right renal lesion. The patient elected to undergo a laparoscopic radical nephrectomy. A 7-cm paramedian incision was made just lateral to the left rectus muscle and cranial to the umbilicus. A GelPort was inserted into the incision. Three trocars (12 mm, 10 mm, and 5 mm) were placed through the access port, and only standard laparoscopic instruments were used. The kidney was mobilized in the standard fashion. Controlling the renal artery with nonabsorbable polymer clips and the renal vein with a stapling device, the specimen was manipulated into a laparoscopic retrieval bag and removed intact. Hemostasis was confirmed, the GelPort was removed, and the 7-cm incision was closed.

RESULTS

The procedure was completed in 96 minutes without complications. Blood loss was estimated to be 10 mL. Postoperatively, the patient was treated with intermittent intravenous and oral analgesics. She was discharged on postoperative day 2 and tolerated a regular diet.

CONCLUSION

This represents the initial report of an SAS laparoscopic radical nephrectomy, with intact specimen extraction. Using standard laparoscopic instrumentation, the procedure was performed safely and effectively, with minimal blood loss, and short hospitalization. Additional evaluation and development of this type of approach and instrumentation may allow for further expansion of SAS laparoscopic surgery in the future.

Renal radiosurgery: initial clinical experience with histological evaluation

The purpose of this study was to determine whether radiosurgical technology can be safely applied to renal tumors. Patients received radiosurgical treatment of renal lesions. At 8 weeks after radiosurgical treatment, patients underwent a partial or radical nephrectomy and histologic evaluation. The patients received a radiation dose of 4 Gy per fraction for 4 fractions. Patients were followed, and radiation-induced toxicities were noted. Three patients were treated for a minimum of 1 year of follow-up. All patients completed the treatments, tolerating each of the 4 fractions with no adverse events. No acute toxicities or changes in renal function were noted. None of the patients had any evidence of acute radiation injury or toxicity noted at the time of surgery or within the subsequent 12 months after the radiosurgical treatment. The last patient treated was found to have a cavity with no microscopic evidence of viable tumor after radiosurgical treatment; pathology was consistent with necrotic renal cell carcinoma, papillary type. The other 2 tumors demonstrated pathologic evidence of viable renal cell carcinoma (grade I and grade II). Tumor size remained relatively unchanged for 8 weeks after the radiosurgical treatment in all patients. The authors are extremely encouraged and cautiously optimistic with the initial results. Radiosurgery for renal tumors appears to be safe at this initial dose level.

Rapid Communication: Transvaginal Single-Port NOTES Nephrectomy: Initial Laboratory Experience

BACKGROUND AND PURPOSE

Natural orifice translumenal endoscopic surgery (NOTES) using purpose-built equipment has never been applied to urologic surgery. Herein, we present our initial experience with a trans-vaginal single-port NOTES nephrectomy.

METHODS AND RESULTS

An acute experiment was performed in a female farm pig. A single 12-mm trocar was placed in the midline and the TransPort Multi-Lumen Operating Platform (USGI Medical, San Clemente, CA) was passed transvaginally. This flexible device has four working channels and can be locked into position, thereby creating a rigid multitasking platform that allows two-handed tissue manipulation. Dissection was performed using an endoscopic needle knife and a tissue grasper for retraction. Via the 12-mm port, the renal artery and vein were taken separately with a vascular EndoGIA and standard laparoscopic titanium clips, respectively. The kidney was placed in a 10-mm EndoPouch retriever and removed intact via the vagina. The total operative time was 300 minutes.

CONCLUSION

Transvaginal NOTES nephrectomy can be accomplished in a porcine model. Additional testing on survival animals is necessary to validate this approach.

Retrograde endopyelotomy: a comparative study of hot-wire balloon and ureteroscopic laser

PURPOSE

This study compared the immediate and long-term results and complications of hot-wire balloon endopyelotomy and ureteroscopic holmium laser endopyelotomy.

PATIENTS AND METHODS

Between March 1994 and January 2002, 64 patients with a primary (N = 52) or secondary (N = 12) ureteropelvic junction obstruction underwent retrograde endopyelotomy using either a fluoroscopically guided hot-wire balloon incision (N = 27) or a ureteroscopically guided, direct-vision holmium laser incision (N = 37). This study group included 46 women and 18 men aged 13 to 79 years (mean 38.9 years). The indications and contraindications to a retrograde approach were identical in each group and included documented functionally significant evidence of obstruction, no upper-tract stones, obstruction <2 cm, and no radiographic evidence of entanglement of crossing vessels at the ureteropelvic junction. Immediate and long-term outcomes were obtained from a prospective registry, with success defined as resolution of symptoms and radiographic relief of obstruction as determined by follow-up with intravenous urography, diuretic renography, or both. Follow-up ranged from 39 to 133 months (mean 75.6 months).

RESULTS

Length of hospital stay, indwelling stent duration, and long-term success rates (77.8% v 74.2% in the hot-wire balloon and holmium-laser group, respectively) were equivalent. However, two patients in the hot-wire balloon group developed bleeding necessitating transfusion and selective embolization of lower-pole vessels. No patient in the ureteroscopic group suffered a major complication.

CONCLUSIONS

These two alternatives for retrograde endopyelotomy provide comparable success rates for similarly selected patients. However, because significant hemorrhagic complications developed with greater frequency in those treated with the hot-wire balloon, our preference is for a ureteroscopic approach, as it allows direct visual control of the incision and thus, a lower risk of significant bleeding.

Shock-wave lithotripsy of renal stones situated adjacent to electronic nerve stimulators

Shock-wave lithotripsy is commonly employed for the treatment of nephrolithiasis in the pediatric patient population. This report describes such treatment of a patient with electronic nerve stimulators that were located in close proximity to bilateral renal pelvic stones. Precautions and considerations of shock-wave lithotripsy in this context are discussed.

LAPAROSCOPIC TRANSUTERINE FETAL VESICOSTOMY: A FEASIBILITY STUDY

PURPOSE

We evaluate the feasibility of applying minimally invasive techniques for fetal vesicostomy. We also evaluate whether transuterine fetal vesicostomy can be performed laparoscopically.

MATERIALS AND METHODS

A total of 25 pregnant ewes were time dated at approximately 90 days of gestation. With the animals under general anesthesia a low open abdominal incision was made and the uterus was brought out through the incision. With a 14 gauge needle the amniotic sac was filled with 1 to 2 l warm glycine. Three to 4, 5/12 blunt tip balloon trocars were placed in the uterus. Using laparoscopic techniques, a low transverse incision was made in the fetal abdomen, the bladder was opened at the dome and 2 running sutures were placed approximating the fetal abdominal wall to the edge of the fetal bladder. The trocar sites in the uterus were closed, and the maternal abdominal incision was closed.

RESULTS

Of the 25 pregnant ewes the technique was developed in the initial 15. In the subsequent 10 animals the complete procedure was accomplished successfully. Following these 10 procedures 5 abortions occurred on postoperative day 2, and there was 1 intrauterine fetal demise. Three fetuses were alive and delivered by cesarean section on postoperative days 10, 30 and 31. In the first fetus in which we used an interrupted suture for the vesicostomy a large hernia was noted at the vesicostomy site. The other 2 fetuses had a patent, well healed vesicostomy and were alive at cesarean section delivery on postoperative days 10 and 31. The last fetus was allowed to deliver at term by standard vaginal delivery. The fetus was alive and well, and the vesicostomy had strictured down to a pinhole in size, which was not unexpected as it was not an obstructed model.

CONCLUSIONS

Although technically challenging, transuterine laparoscopic fetal vesicostomy is technically feasible in the ewe model. Continued evaluation of this technique should include intensive fetal monitoring and the use of tocolytics to decrease the incidence of spontaneous abortion.

Laparoscopic radical nephrectomy: incorporating advantages of hand assisted and standard laparoscopy

PURPOSE

We present an approach to laparoscopic radical nephrectomy and intact specimen extraction, which incorporates hand assisted and standard laparoscopic techniques.

MATERIALS AND METHODS

A refined approach to laparoscopic radical nephrectomy is described and our experience is reviewed. A low, muscle splitting Gibson incision is made just lateral to the rectus muscle and the hand port is inserted. A trocar is placed through the hand port and pneumoperitoneum is established. With the laparoscope in the hand port trocar 2 additional trocars are placed under direct vision. The laparoscope is then repositioned through the middle trocar and standard laparoscopic instruments are used through the other 2 trocars including the one in the hand port. If at any time during the procedure the surgeon believes the hand would be useful or needed, the trocar is removed from the hand port and the hand is inserted.

RESULTS

This approach has been applied to 7 patients. Mean estimated blood loss was 200 cc (range 50 to 300) and mean operative time was 276.7 minutes (range 247 to 360). Mean specimen weight was 767 gm. (range 538 to 1,170). Pathologically 6 specimens were renal cell carcinoma (grades 2 to 4) and 1 was oncocytoma. Mean length of hospital stay was 3.71 days (range 2 to 7). There were no major complications.

CONCLUSIONS

We believe that this approach enables the surgeon to incorporate the advantages of the hand assisted and standard laparoscopic approaches.

Laparoscopic ureterocalicostomy: a feasibility study

PURPOSE

Ureterocalicostomy is occasionally indicated for reconstruction of recurrent, recalcitrant ureteropelvic junction obstruction associated with postoperative fibrosis and a relatively inaccessible renal pelvis. We investigated the feasibility of performing laparoscopic ureterocalicostomy in a survival porcine model. Anatomical, histological and chronic functional outcomes were evaluated.

MATERIALS AND METHODS

Laparoscopic ureterocalicostomy was performed in 10 survival female swine. A ureteropelvic junction obstruction model was created by laparoscopic ligation of a 2 to 3 cm. segment of upper ureter. After an interval of complete ureteropelvic junction obstruction laparoscopic ureterocalicostomy was performed in a manner duplicating the steps of conventional open surgery. After transverse amputation of the lower renal pole end-to-end anastomosis of the proximal ureter to the inferior calix was formed by laparoscopic freehand suturing and knot-tying techniques.

RESULTS

Mean ureter stricture length was 2.2 cm. (range 1.7 to 3.1). Mean duration of obstruction before laparoscopic ureterocalicostomy was 6.3 days (range 2 to 18). Mean operative time for laparoscopic ureterocalicostomy was 165.3 minutes (range 105 to 240). Mean estimated blood loss was 145 cc (range 25 to 400). Mean stent duration in 6 pigs was 8.7 days (range 7 to 11). Excretory urograms demonstrated immediate function with symmetrical and unobstructed drainage in all operated renal units. At 4 to 8 weeks of followup no urine leaks were noted and histological examination documented complete urothelial healing without fibrosis or scar formation.

CONCLUSIONS

Laparoscopic ureterocalicostomy is technically feasible in the porcine model and it effectively duplicates the established principles of open surgery. Our technique further extends the application of laparoscopic surgery for difficult ureteropelvic junction obstruction.

Evaluation of preoperative ProstaScint scans in the prediction of nodal disease

Diagnostic methods are limited for detecting microscopic soft tissue metastases in patients with prostate cancer. Previous studies using (111)Indium Capromab Pendetide (ProstaScint scan) analyzed patients with extensive localized tumor (prostate specific antigen (PSA) >20 ng/ml) not optimal for surgical therapy. We evaluated the role of the ProstaScint trade mark scan in a preoperative population to provide histological documentation and to assess its utility in a surgical population. A total of 22 preoperative patients, underwent a ProstaScint scan. The mean preoperative PSA was 16.0 ng/ml (range 3.9-33 ng/ml). The mean Gleason score at biopsy was 6.9 (range 6-9). Each patient underwent a radical retropubic prostatectomy and bilateral pelvic lymph node dissection, which included resection of both obturator and common iliac lymph nodes. Histologic analysis of the resected lymph nodes provided the standard of comparison with the ProstaScint scan. The results of the scan and pathology for all 22 patients were compared with the bilateral obturator and iliac nodes, creating 88 data points. Nine areas (10%) were positive on the scan. One of these (11%) was a true positive while the other eight (89%) were false positives. Seventy-nine areas (90%) were negative on scan results. Of these, five areas (6%) were false negatives and 74 areas (94%) were true negatives. The scan yielded a sensitivity of 17%, specificity of 90%, negative predictive value (NPV) of 94% and a positive predictive value (PPV) of 11%. The high false positive rate and low PPV of ProstaScint scans overestimates metastatic lymph nodes disease, and is not useful when used preoperatively.

Initial evaluation of Cyberknife technology for extracorporeal renal tissue ablation

OBJECTIVES

To determine whether Cyberknife technology can be applied to renal tissue safely and effectively. The goal was to achieve the high efficacy of a surgical treatment, with the low morbidity of a noninvasive intervention.

METHODS

The Cyberknife is a frameless, image-guided radiosurgical device. This innovative extracorporeal treatment combines a linear accelerator mounted on a highly maneuverable robotic arm. The Cyberknife is unique in that it divides the high-dose radiation necessary to ablate the lesion completely into up to 1200 beams. Each one of these beams of radiation has a significantly reduced dose. Therefore, the individual dose of each beam is essentially benign to the pathway and surrounding tissue. However, at the focal point of these beams, the dose is additive, and the desired ablative dose is attained. Predetermined "lesions" in 16 kidneys were treated in vivo in the porcine model. Complete treatment was accomplished in one session per animal, with no complications. Gross and histologic evaluations were completed at 4, 6, or 8 weeks.

RESULTS

The degree of radiation changes correlated with longer treatment intervals. After 8 weeks, the lesions showed complete fibrosis. The zones of complete fibrosis were characterized by dense, paucicellular connective tissue completely devoid of all normal kidney elements, including tubules and glomeruli.

CONCLUSIONS

This initial preclinical evaluation of the Cyberknife for extracorporeal renal tissue ablation appears to be very promising and demonstrated its ability to ablate a targeted area precisely and completely with relative sparing of the surrounding tissue. This innovative technology introduces an exciting approach as a potential treatment option of renal masses in the future.

Laparoscopic excision of suspected extra-adrenal pheochromocytoma located in the mesenteric root

A 35-year-old woman presented with symptoms consistent with pheochromocytoma. Biochemical evaluation was equivocal. An MRI scan demonstrated an extra-adrenal high-intensity lesion on a T2-weighted sequence, which supported the suspicion of an extra-adrenal pheochromocytoma. Laparoscopically discovered to be located in the root of the small bowel mesentery, the 5-cm mass was excised along with a segment of small bowel. Pathology examination demonstrated fibromatosis, a benign lesion.