Almost totally tubeless percutaneous nephrolithotomy: further evolution of the technique

BACKGROUND AND OBJECTIVES

There is renewed interest in the concept of foregoing placement of the postoperative nephrostomy tube (PNT) after percutaneous nephrolithotomy (PCNL) with the intent of reducing postoperative discomfort and hospital stay. We have omitted the PNT and placed an internal ureteral stent or externalized ureteral catheter after PCNL in selected patients. We reviewed our experience in order to assess the efficacy and safety of this practice.

PATIENTS AND METHODS

Primary PCNL was performed in 26 renal units in 21 patients (5 bilateral PCNL, 4 of which were simultaneous) by one surgeon at the University of Michigan and the Ann Arbor Veterans Affairs Medical Center. A postoperative nephrostomy tube was placed if the stone burden was >3 cm, more than one access site was used, the renal anatomy was obstructive, significant bleeding or perforation was noted, or a second look was required.

RESULTS

No PNT was placed in 10 renal units in 8 patients (no-PNT group). In six no-PNT kidneys, internal ureteral stents were used, and in four, externalized ureteral stents were placed for 1 to 2 days. The mean stone size in the PNT and no-PNT patients was 3.0 and 1.8 cm, respectively. Of the 16 kidneys in the PNT group, 4 were initially eligible for omission of PNT, but a PNT was placed because of bleeding or other access-related problem. All patients were rendered stone free except for three (one PNT and two no-PNT) patients, who each had a fragment < or =4 mm. Omission of PNT placement resulted in decreased mean length of stay (2.3 days in the no-PNT group v 3.6 days in the PNT group). There were four complications, all managed with delayed stenting (one in a no-PNT patient and the remaining three in the PNT group).

CONCLUSION

Omission of PNT placement in selected patients may reduce morbidity without compromising efficacy and safety, but further study is needed.

Renal malacoplakia

We present a well-documented case of biopsy-proven renal malacoplakia with an excellent response to oral fluoroquinolone therapy.

Pneumoperitoneum does not potentiate the nephrotoxicity of aminoglycosides in rats

OBJECTIVES

Pneumoperitoneum is associated with transient renal dysfunction. To our knowledge, the safety of administering nephrotoxins such as aminoglycosides during pneumoperitoneum has not been studied. Our hypothesis was that pneumoperitoneum potentiates the nephrotoxicity of aminoglycosides.

METHODS

From 29 rats we obtained preprocedure 24-hour urine collections. In the pneumoperitoneum group (n = 7), carbon dioxide was insufflated intra-abdominally at 15 mm Hg pressure for 2 hours. In the gentamicin group (n = 7), 10 mg/kg gentamicin was administered intravenously. In the combined pneumoperitoneum/gentamicin group (n = 8), the same dose of gentamicin was administered 10 minutes before pneumoperitoneum. Sham rats (n = 7) received anesthesia only. Urine was collected for the 24 hours after the procedure, and 1 week later blood for creatinine determination and final 24-hour urine collections were obtained. All urine samples were assayed for creatinine and N-acetyl-beta-glucosaminidase (NAG).

RESULTS

Only the gentamicin and combined pneumoperitoneum/gentamicin groups presented day 1 values for NAG excretion that were significantly greater than same day sham or paired preprocedure values; the rest of the urinary creatinine and NAG day 1 levels and all the day 7 levels were not significantly different from same day sham or paired preprocedure levels. Day 7 serum creatinine and creatinine clearance did not differ significantly among the groups.

CONCLUSIONS

We found that intravenous gentamicin transiently increased urinary excretion of NAG in rats, which resolved within 1 week. Pneumoperitoneum for 2 hours at 15 mm Hg did not increase urinary NAG, either alone or in gentamicin-treated rats. Moreover, our data are sufficient to refute with 95% certainty the possibility that gentamicin plus pneumoperitoneum decreases creatinine clearance more than approximately 60%. These results do not support the hypothesis that pneumoperitoneum potentiates the nephrotoxicity of aminoglycosides.

Laparoscopic adrenal cyst resection

Two patients with left adrenal cysts underwent laparoscopic resection. In one case an adrenal origin of the cyst was suspected. In the other case the cyst was thought to be renal in origin. Both patients were female, ages 16 and 40 years. Operative time was 150 and 160 minutes. Blood loss was 50 and 30 mL. One patient received 14 mg of morphine and 60 mg of ketorolac. The other patient did not require any parenteral analgesics. Hospital stay was 1 day for both patients. Return to normal activity occurred at 15 and 7 days postoperatively, respectively. Histology in both cases revealed benign adrenal cysts. Our experience supports the laparoscopic approach for resection of adrenal cysts.

Long-term outcome of caliceal diverticula following percutaneous endosurgical management

PURPOSE

We review the morbidity and long-term outcome of percutaneous caliceal diverticulectomy and associated stone extraction.

MATERIALS AND METHODS

Percutaneous caliceal diverticulectomy was performed in 19 women and 11 men (age range 20 to 58 years), of whom 26 had stones (all 15 mm. or less). The diverticula were located throughout the kidney, including the upper (11 patients), middle (15) and lower (4) calices. Percutaneous caliceal diverticulectomy included 28 direct and 2 indirect accesses (1 via a previously placed nephrostomy tract and 1 due to stones in other areas of the kidney). In all cases the stone was removed and the diverticular neck was incised or dilated. Fulguration of the diverticular walls was performed in 22 cases. Transdiverticular percutaneous renal and ureteral drainage was maintained from 2 to 7 days until a nephrostogram demonstrated no extravasation.

RESULTS

The average operating room time and hospital stay were 171 minutes (range 75 to 330) and 4.1 days (range 2 to 7), respectively. Major complications occurred in 6.6% of the cases, requiring 1 blood transfusion and 1 chest tube placement, and minor complications occurred in 13.4%. There was no mortality. Followup for more than 1 year was available in 27 patients. Stone-free rate was 93% with obliteration of the diverticulum in 76% of patients. Overall, 85% of patients are asymptomatic at average followup of 3.5 years (range 1 to 7.3).

CONCLUSIONS

Direct percutaneous endosurgical management provides a safe, efficacious and durable means of treating stone bearing caliceal diverticula, regardless of stone size or location of the diverticulum.

Hand-assisted laparoscopic live donor nephrectomy

Minimally invasive live donor nephrectomy has been described using both standard laparoscopic dissection and "gasless" endoscopically assisted techniques. We report another method, hand-assisted laparoscopic live donor nephrectomy, which uses an occlusive sleeve to maintain pneumoperitoneum. The procedure is performed under excellent laparoscopic visualization in a generous operative field, and is facilitated substantially by manual assistance, which takes advantage throughout the procedure of the incision that is necessary for intact organ removal. The results of our first procedure are encouraging.

Management of intraoperatively diagnosed colonic injury during percutaneous nephrostolithotomy

Colonic injury associated with percutaneous nephrostolithotomy is an unusual event. Significant and morbid sequelae can be avoided through careful evaluation and management, which is facilitated by intraoperative diagnosis. Factors predisposing to colonic injury during percutaneous nephrostolithotomy include a lower caliceal access site, lateral origin of the percutaneous puncture, left-sided kidney, female patient, advancing patient age, and thin body habitus of the patient. Principles of management include inspection of the percutaneous nephrostolithotomy tract for colonic injury whenever the tract is inspected for bleeding, high index of suspicion for colonic injury when a patient develops unexplained signs or symptoms of inflammation or infection postoperatively, and prompt, assured drainage of both the colon and urinary collecting system.

Hand assisted laparoscopic nephrectomy: comparison to standard laparoscopic nephrectomy

PURPOSE

We report our initial experience with hand assisted laparoscopic nephrectomy, and compare it to our results of standard laparoscopic nephrectomy.

MATERIALS AND METHODS

The results of 21 hand assisted and standard laparoscopic nephrectomies (15 simple and 4 radical nephrectomies, and 2 nephroureterectomies) were reviewed. Hand assisted laparoscopic nephrectomy was performed with a hand placed intra-abdominally using the Pneumo Sleeve,* in addition to standard laparoscopic instruments manipulated through laparoscopic ports. Standard laparoscopic nephrectomy was performed using laparoscopic instruments alone. Perioperative data were recorded and questionnaires, including visual analog pain scales, were administered prospectively to 17 of 21 cases.

RESULTS

The average operative time for 13 hand assisted laparoscopic nephrectomies was 240 minutes, which was significantly less than the 325-minute average for 8 standard laparoscopic nephrectomies (p = 0.04). Major complications tended to be more frequent in the standard group (38 versus 8%, p = 0.10). Hospital stay, return to normal activity and corrected 2-week abdominal/flank pain score in the hand assisted group (3.1 days, 14 days and 0.8, respectively) were not significantly different from the standard group (3.0 days, 10 days and 0.2, respectively).

CONCLUSIONS

Compared to standard laparoscopic techniques, hand assistance appears to facilitate the operative speed and safety of laparoscopic nephrectomy without sacrificing the benefits of minimally invasive surgery. Hand assistance may make laparoscopic nephrectomy more appealing to urologists without advanced laparoscopic experience, may facilitate the laparoscopic management of demanding pathological conditions and is particularly useful when intact specimens are required. Hand assistance, by improving manipulative ability and tactile sense, is helpful for select cases of laparoscopic nephrectomy.

Laparoscopy for the treatment of positional renal pain

OBJECTIVES

The differential diagnosis of renal pain is extensive. When the pain is altered by a change in position, two relatively uncommon etiologies, nephroptosis and ovarian vein syndrome, should be considered. We present an algorithm for the evaluation of positional renal pain and demonstrate the effectiveness of its treatment by laparoscopic surgery.

METHODS

Laparoscopic technique was used to resect the offending ovarian vein in a case of ovarian vein syndrome and to fix the kidney in position for a case of symptomatic nephroptosis. A review of the evaluation and management of these entities is presented.

RESULTS

The patient with nephroptosis and the patient with ovarian vein syndrome were both discharged on postoperative day 2, had complete relief of pain, and suffered no long-term complications.

CONCLUSIONS

Nephroptosis and ovarian vein syndrome should be considered in the differential diagnosis of renal pain altered by change in position. Laparoscopy is an excellent approach for repair of these conditions because it is safe, effective, and causes minimal morbidity.

Evaluation and management of solid and cystic renal masses

PURPOSE

With the increasing detection of incidental renal lesions, the evaluation and management of solid and cystic renal masses are assuming greater importance in urological practice. A review of the techniques for evaluation and management is presented, with an emphasis on new and evolving procedures, along with recommendations for their selective use.

MATERIAL AND METHODS

A MEDLINE computerized reference search and manual bibliographic review were performed to find pertinent peer reviewed articles published since 1985. Meeting abstracts were considered if they provided unique information.

RESULTS

The primary means of evaluating renal masses is radiography (mainly ultrasonography and computerized tomography), although minimally invasive techniques such as percutaneous biopsy and laparoscopy are useful in selected situations. Nephron sparing surgery, minimally invasive surgery, alternative energy sources and other new techniques are being increasingly applied to the management of solid and cystic renal masses.

CONCLUSIONS

Simple renal cysts can be defined ultrasonographically but more complicated masses require computerized tomography, other imaging modalities or rarely biopsy. Currently, minimally invasive techniques are commonly applied only to assist in the diagnosis of selected renal lesions and to treat benign simple cysts. The treatment of choice of solid renal masses remains open surgical radical nephrectomy and partial nephrectomy but alternative techniques will likely have a more significant role in the near future.

Postsurgical changes in the testis: a diagnostic dilemma

Postsurgical changes in the testicle following epididymal surgery may mimic neoplastic transformation on ultrasound evaluation. We report a case in which postoperative ultrasound findings following epididymectomy, which in retrospect were consistent with tubular ectasia of the rete testis, resulted in unnecessary testicular biopsy and orchiectomy.

Retrospective analysis of the effect of crossing vessels on successful retrograde endopyelotomy outcomes using spiral computerized tomography angiography

PURPOSE

Using spiral computerized tomography (CT) angiography, we sought to evaluate the incidence of a crossing vessel in a group of adults with primary ureteropelvic junction obstruction who had previously undergone successful retrograde endopyelotomy.

MATERIALS AND METHODS

A total of 16 patients who had undergone successful Acucise balloon incision endopyelotomy for ureteropelvic junction obstruction, all with followup greater than 2 years, underwent a spiral CT angiogram with intravenous contrast material to identify those with a crossing vessel. Contrast enhanced CT was performed with dual phase technique on a Somatom-Plus-S CT scanner using prototype software. After 180-degree linear interpolation of the projection data, transaxial images of the affected kidney were reconstructed. In addition, at the time of the study all patients completed analog followup pain scales and quality of life assessment questionnaires.

RESULTS

Among the 16 patients 6 (38%) had anterior or posterior crossing vessels based on spiral CT angiography. No patient had both types. By analog pain scale patients had 80% mean improvement in pain (range 63 to 100).

CONCLUSIONS

In our series nearly 40% of patients with anterior or posterior crossing vessels had a long-term (greater than 2 years) successful outcome with retrograde endopyelotomy. Endopyelotomy continues to be our initial mode of therapy among adults with primary ureteropelvic junction obstruction. In our opinion the adverse influence of the crossing vessel is not sufficient to justify the added expense of preoperative angiography, spinal CT or endoluminal ultrasound.

Long-term results of endoureterotomy for benign ureteral and ureteroenteric strictures

PURPOSE

We reviewed the results of endoureterotomy for benign ureteral and ureteroenteric strictures to determine efficacy and factors associated with a successful outcome.

MATERIALS AND METHODS

Followup was available for 69 patients undergoing 77 endoureterotomies. Success was defined as symptomatic improvement and radiographic resolution of obstruction. Kaplan-Meier survival curves were constructed and data were analyzed with a Cox proportional hazards model.

RESULTS

None of 9 procedures in patients with the ipsilateral kidney contributing less than 25% of total renal function was successful. Among the 38 remaining benign ureteral stricture treatments with ipsilateral function 25% or greater with a median followup of 28.4 months among successful cases the 3-year success rate was 80%. No procedure failed beyond 11 months and there were 25 patients at risk beyond this point. Among the 30 remaining ureteroenteric stricture treatments with ipsilateral function 25% or greater the success rates at 1, 2 and 3 years were 73, 51 and 32%, respectively. Failures were noted during the first 36 months but none occurred later and 5 patients were at risk beyond this point. Overall, complete or tight strictures were less successfully treated. A nonischemic etiology, a stent 12F or greater and injection of triamcinolone into the bed of the incised stricture were associated with better outcome for strictures longer than 1 cm.

CONCLUSIONS

Endoureterotomy of benign ureteral strictures is associated with an excellent outcome (80% success at 3 years). Endoscopic treatment of ureteroenteric strictures is less successful but still offers a reasonable first step (32% 3-year success rate). For all strictures failure is likely if ipsilateral renal function is poor. For strictures longer than 1 cm. use of a stent 12F or greater and injection of triamcinolone appear to be beneficial.

Pleomorphic adenoma of the parotid

Pleomorphic adenoma of the parotid is the most common tumor of salivary gland origin, accounting for 60 to 70 percent of all benign salivary gland tumors. This lesion usually presents as a slow-growing painless mass inferior to the pinna of the ear. The diagnosis is based on clinical presentation, magnetic resonance imaging or computed tomography, and fine-needle aspiration biopsy. The treatment is wide excision in which the entire capsule is removed but the facial nerve is spared. Proper diagnosis and treatment are necessary to prevent the complications of tumor recurrence and malignant transformation. Carcinoma expleomorphic adenoma arises in longstanding tumors and has a five-year recurrence rate of 75 percent.

Comparison of fibrin glue, laser weld, and mechanical suturing device for the laparoscopic closure of ureterotomy in a porcine model

PURPOSE

We evaluated fibrin glue, laser welding, and a mechanical suturing device (Endo-Stitch) as alternatives to standard laparoscopic suturing with a free needle.

METHODS

In 14 pigs, 22 linear proximal ureterotomies were closed laparoscopically with one of 4 different methods: fibrin glue, laser welding, Endo-Stitch suture placement (4-0 polyglactin), and free-needle suture placement (4-0 polyglactin). The ureterotomy was left open in 6 ureters. Acute leakage was tested by instillation of methylene blue. After 12 weeks, the ureters were assessed with radiography, ex-vivo pressure-flow studies, bursting pressures, and histology.

RESULTS

All alternative closure techniques were more rapid than free-needle suturing, and less frequently allowed acute leakage. Closure with fibrin glue yielded significantly higher flow rates than control, whereas the other closure techniques yielded flow rates similar to that of unclosed ureters. All alternative closure methods demonstrated histological evidence of healing that were superior to free-needle suturing. In multifactorial analysis, leakage at the ureterotomy site was the factor most significantly associated with subsequent poor ex-vivo flow characteristics.

CONCLUSIONS

All of the alternative laparoscopic ureteral closure methods compared favorably with standard free-needle suturing. Fibrin glue produced better radiographic findings, flow characteristics, and histology, suggesting that it currently has the most promise as an alternative or adjunct to laparoscopic suturing. Development of alternative laparoscopic techniques is ongoing, however, and thus the current state-of-the-art techniques used in this study may well be supplanted by other technologies in the future.

Use of nephrostomy drape for nonendoscopic procedures

The use of a nephrostomy drape for perineal prostatectomy and laparoscopic renal/ureteral surgery is illustrated. Draping is simplified, fixation sites for cords are present, and a large pocket for instruments and drainage is provided. The nephrostomy drape is recommended for use during operations performed on nonhorizontal surfaces, or when several instruments attached by cords are used.

Preoperative assessment of ureteropelvic junction obstruction with endoluminal sonography and helical CT

OBJECTIVE

Our objective was to compare the value of endoluminal sonography with the value of helical CT in the preoperative assessment of crossing vessels in patients with ureteropelvic junction (UPJ) obstruction.

SUBJECTS AND METHODS

Thirteen patients with UPJ obstruction underwent contrast-enhanced helical CT with multiplanar reformations and endoluminal sonography. Imaging preceded surgery for UPJ repair. On imaging, vessels were considered significant if greater than or equal to 2 mm in diameter and within 1 cm of the UPJ.

RESULTS

Three patients had no crossing vessels revealed by either study. On sonography, another patient had a vessel revealed with a diameter that varied between 1.3 and 2.2 mm; on CT no correlate was detected. The remaining nine patients had vessels revealed by both techniques. On CT, four patients had two vessels revealed and five patients had single vessels revealed for a total of 13 vessels revealed by CT. On sonography, five patients had two vessels revealed and five patients had single vessels revealed. Thus, 15 vessels were revealed by sonography. Both arteries and veins were revealed anterior, posterior, and medial to the UPJ; no lateral vessels were seen. Four patients underwent laparoscopy, during which the absence, presence, and location of vessels were found to correlate with sonography and helical CT.

CONCLUSION

Endoluminal sonography and helical CT were similar in revealing crossing vessels in patients with UPJ obstruction.