Laparoscopy in urology

Laparoscopic assisted dismembered pyeloplasty versus open pyeloplasty in UPJO with poorly function kidney in pediatrics

BACKGROUND

The management of UPJO with poor function kidney, less than 10%, has been the subject of debate for more than a decade. Some authors have recommended nephrectomy, while others favor renal salvage (pyeloplasty). We report our experience with laparoscopic assisted pyeloplasty in pediatric patients with poorly functioning kidneys in comparison with an open approach.

MATERIALS AND METHODS

A retrospective study was conducted to review 65 patients who were diagnosed with hydronephrosis and had impaired renal function due to UPJO. The study was conducted in the pediatric surgery departments of Al-Azhar University Hospital and Fattouma Bourguiba University Hospital of Monastir over a period of 20 years. Limited to pediatric patients with UPJO with ≥ Grade III hydronephrosis, antero-posterior pelvic diameter ≥ 20 mm, as well as a renal function equal to or less than 10%, was corrected by laparoscopic assisted or open pyeloplasty.

RESULTS

There were 40 cases in group A who underwent laparoscopic assisted pyeloplasty, and 25 cases in group B who underwent open pyeloplasty. There were no complications or difficulties during the operation. The mean operative time in group A was 90 ± 12 min, while in group B, it was 120 ± 11 min. The renal assessment parameters significantly improved in both groups. In group A, the mean split renal function was 7.9 ± 1.3% and increased to 22.2 ± 6.3%. In group B, the mean split renal function was 8.1 ± 1.1% and increased to 24.2 ± 5.1%. However, the differences between both groups in terms of pre-operative and post-operative renal functions were statistically insignificant.

CONCLUSION

Laparoscopic assisted pyeloplasty is an effective treatment for patients with poorly functioning kidneys, especially those with less than 10% function. While this surgical procedure requires shorter operative times, it yields functional outcomes that are comparable to open approach.

Complications of urologic laparoscopic surgery: a center surgeon's experience involving 601 procedures including the learning curve

When indications for laparoscopy were expanded to include a variety of urologic diseases, this increased the importance of prevention of complications, especially during the surgeons' learning curve period. Therefore, we evaluated the complications of urologic laparoscopic surgery in the course of one surgeon's experience including the learning curve after completing his long-term fellowship program. From December 2004 to August 2010, a total of 601 urologic laparoscopic surgical procedures were performed by a single surgeon who had finished a 9-month fellowship program at an experienced center. The intra- and postoperative complications of these cases were documented and graded according to the modified Clavien classification system, and then compared with the first and second 3-year periods. Of these 601 laparoscopic procedures, 47 complications occurred in 38 patients, resulting in a total complication rate of 7.8%. Conversion to open surgery occurred in four (0.6%) patients. Clavien grades I and II accounted for minor complications and occurred in 36 (5.9%) patients, whereas grades III, IV, and V accounted for major complications, which occurred in 11 (1.8%) patients. The annual complication rates formed a plateau in the 3rd year. Complication rates were significantly lower in the second 3-year period compared with the first 3 years (p<0.05). Despite the well-organized training program and transferability, surgeons must practice caution in the early years until they become more experienced. In spite of the presence of experienced laparoscopic surgeons, the surgical team needs time to gain experience. These factors cause complication rates to form a plateau in terms of time and experience.

Kidney safety during surgical pneumoperitoneum: an experimental study in rats

BACKGROUND

Elevations of intraabdominal pressure during laparoscopic procedures may lead to oliguria or anuria in mammals. Despite this, previous research has not been able to confirm an associated kidney injury. This study aimed to investigate the occurrence of an early kidney lesion secondary to surgical pneumoperitoneum in a rat model using the expression of neutrophil gelatinase-associated lipocalin (N-GAL) as a biomarker for early kidney injury.

METHODS

In this study, 20 male Sprague-Dawley rats under general anesthesia and mechanically ventilated were allocated to one of five experimental time-dependent groups: group 1 (1-h control), group 2 (1-h pneumoperitoneum), group 3 (2-h control), group 4 (2-h pneumoperitoneum), and group 5 (positive kidney injury group induced by intravenous administration of cisplatin 7.5 mg/kg). To evaluate the renal expression of N-GAL 24 h after the procedure, all the rats underwent a 2-h urine output evaluation as well as laparotomy and bilateral nephrectomy performed sequentially to investigate the presence of renal injury using immunofluorescence qualification and western blotting.

RESULTS

Urine output was reduced and N-GAL expression was increased in the animals from the cisplatin group. The animals undergoing 1- or 2-h pneumoperitoneum displayed urine output and N-GAL expression similar to that of the animals from the matching control groups.

CONCLUSIONS

Under the experimental conditions of this study, the animals with normal preoperative renal function did not show any type of acute kidney injury associated with the presence of a stabilized surgical pneumoperitoneum.

Experience with laparoscopy-assisted retroperitoneal pyeloplasty in children

PURPOSE

To describe a laparoscopy-assisted retroperitoneal pyeloplasty (LARP) and results of initial experience.

METHODS

Port placement used by Farhat in retroperitoneal-assisted laparoscopic pyeloplasty was modified for better cosmetic results. Surgery was done using 2-cm incision for 5-mm camera port and two 3-mm working ports. Dissection was done anterior to the kidney. The ureteropelvic junction was brought out through the 2-cm trocar site and the pyeloplasty was performed extracorporeally. Between January 2004 and February 2008, a total of 39 kidneys in 38 children with mean age of 4.1 months underwent LARP. The operative time, hospital stay, functional outcome and follow-up renogram studies were reviewed.

RESULTS

The mean operative time was 147 min. 2-cm incision was extended in one patient with malrotated kidney. There was improvement in function in 37 (95%) with no failure. The mean split renal function, preoperative and at follow-up were 35.7 and 44.2%, respectively (P = 0.000). The mean glomerular filtration rate (ml/min), preoperative and at follow-up were 27.4 and 39.1%, respectively (P = 0.000). Mean follow-up period was 24 months.

CONCLUSION

LARP is safe in treating UPJ obstruction in infants. It is recommended especially in small babies where laparoscopic pyeloplasty is difficult.

Major urological oncological surgeries can be performed using minimally invasive robotic or laparoscopic methods with similar early perioperative outcomes compared to conventional open methods

Robotic and laparoscopic surgical methods (RLM) are increasingly being used for urological oncological procedures. We compared the outcomes in a cohort of patients undergoing procedures by either RLM or open methods (OM) at a single institution. The data on 279 consecutive patients undergoing major urological oncological procedures from September 2000 to June 2005 was entered into a Microsoft Access database and queried. Continuous variables were compared using the Wilcoxon rank sum test and categorical variables were compared using Fisher's exact test. P values were compared to a significance level of 0.05. Of the 279 patients who underwent urological oncological surgeries, OM and RLM were used in 139 (49.8%) and 140 (50.2%) of patients, respectively. Numbers of perioperative mortalities and morbidities were not statistically different in the OM group versus the RLM group. Primary urological oncological surgeries can be performed without significantly increased perioperative complications by RLM compared to OM.

Radical cystectomy with ileal conduit diversion: early prospective evaluation of the impact of robotic assistance

OBJECTIVE

To compare the performance of radical cystectomy with ileal conduit diversion by standard methods with that using the assistance of the daVinci robotic system (Intuitive Surgical, Sunnyvale, CA, USA).

PATIENTS AND METHODS

From November 2003 to August 2005, we performed 30 radical cystectomies with ileal conduit urinary diversions on patients with bladder cancer. Seven patients (one woman) had a cystectomy with the daVinci system and 23 (nine women) had a standard cystectomy. Data were collected prospectively, including estimated blood loss (EBL), transfusion requirement, operative duration, hospital stay and body mass index (BMI), and compared.

RESULTS

The mean EBL and transfusion requirements for standard and daVinci-assisted cases was 1109 and 479 mL (P = 0.002) and 2.7 and 1.6 units (P = 0.14), respectively. Four of seven patients received a transfusion in the robotic group, and 20 of 23 in the standard group (P = 0.084). The mean operative duration was 638 and 507 min (P = 0.005) for the daVinci and standard group, respectively, with respective mean hospital stays of 11 and 13 days (P = 0.52). There was no difference in patient BMI between the groups (P = 0.22).

CONCLUSION

The daVinci-assisted cystectomy appears to offer some advantages over standard cystectomy. Larger randomized studies are needed to confirm these findings.

Retroperitoneal-Assisted Laparoscopic Pyeloplasty in Children: Initial Experience

PURPOSE

To demonstrate a novel application of laparoscopy to assist in the correction of ureteropelvic junction (UPJ) obstruction.

PATIENTS AND METHODS

A retroperitoneal space is created, and the UPJ is identified and dissected from the surrounding tissue with a 1 x 10-mm 0 degrees telescope and 2 x 5-mm endoscopic instruments. Using a 5-0 Prolene stay suture, the UPJ is brought up through the 10-mm trocar site to the skin level, and the pyeloplasty is performed ex vivo over a double-J stent with loop magnification. Between July 2002 and March 2003, nine male and two female patients with UPJ obstruction underwent a pyeloplasty using this retroperitoneal-assisted laparoscopic pyeloplasty (RALP). The operative time, hospital stay, pain management, and follow-up radiologic studies were reviewed.

RESULTS

In nine patients, RALP (bilateral in one patient) was performed (nine on the left side and one on the right). In the remaining two patients, mobilization of the UPJ was inadequate, and open conversion was performed. The average RALP operative time was 160 minutes (range 121-193 minutes). Postoperative pain management was optimal using oral codeine in eight patients, while one patient (RALP and pyelolithotomy) received parenteral analgesic postoperatively. The average length of stay in the hospital was 2 days (range 1-3 days). Follow-up (5-14 months) radiologic studies after stent removal showed improvement in the hydronephrosis in all except one patient. Furosemide renal scan at 3 to 6 months postoperatively was done in all patients and showed no obstruction.

CONCLUSION

We consider RALP as the technique of choice for surgeons who want to increase their reconstructive laparoscopic skills. It provides an additional technique when skilled laparoscopists are faced with technically difficult pyeloplasties.

Early experience with laparoscopic cryoablation in patients with small renal tumors and severe comorbidities

PURPOSE

To present our preliminary experience with laparoscopic renal cryoablation in patients with small renal tumors and severe comorbidities.

PATIENTS AND METHODS

Eight patients with a mean age of 75.6 years (range 68-82 years) who had small (mean 2.6+/-0.7-cm; range 1.4-3.8-cm) peripheral renal cortical lesions and significant comorbidities underwent laparoscopic cryoablation with a 3-mm cryoprobe. None of the patients was considered a good candidate for extirpative surgery. Tumors were biopsied prior to cryoablation. Intraoperative laparoscopic ultrasonography was utilized to confirm the tumor and to monitor the biopsy and the cryoablation process.

RESULTS

Most patients had right-sided tumors, although there were no significant differences in the approach or outcome on this basis. Seven patients had intraoperative biopsies, and in all cases, good tissue samples were obtained. There were no intraoperative or postoperative complications. The average blood loss was 102.5+/-123.3 mL, and the mean operative time was 120+/-27.8 minutes. The mean hospital stay was 2.9+/-1.6 days. Postoperative imaging demonstrated defects consistent with ablation of the affected area; however, a residual nonenhancing mass defect usually was demonstrated.

CONCLUSION

Laparoscopic cryoablation appears to be safe for the treatment of solid or complex renal masses in elderly patients with severe comorbidities. Further studies are necessary to determine the long-term efficacy before this modality can be considered an acceptable curative treatment for small renal cortical tumors.

Critical care and the urologic patient

Changing concepts of disease management, expanding indications for invasive therapy to elderly patients, together with technologic advances have changed the management of various urologic diseases. Although minimally invasive surgery may have reduced the need for ICU care, we are faced with new and unique treatment problems.