RETROPERITONEOSCOPY: EXPERIENCE WITH 200 CASES

Retroperitoneoscopic nephrectomy/heminephrectomy in children planned, performed, and managed by supervised senior pediatric surgical trainees

INTRODUCTION

Retroperitoneoscopic nephrectomy (R-neph) is still not generally favored by pediatric surgeons for various reasons, including lack of experience of retroperitoneal anatomy compared with pediatric urologists, concern about long operative times, and related complications.

MATERIALS AND METHODS

We compared nephrectomies/heminephrectomies planned, performed, and managed by five senior pediatric surgical trainees (SPST) under the supervision of a board-certified pediatric surgeon (BCPS) (A.Y.) using four-trocar retroperitoneoscopy (R-neph) (n=11) with conventional open nephrectomy and heminephrectomy (O-neph) (n=20) performed by 4 BCPS.

RESULTS

O-neph comprised 14 nephrectomies and 6 upper pole nephrectomies; R-neph comprised 9 total nephrectomies and 2 upper pole nephrectomies. Mean age and mean weight at nephrectomy were not statistically different. Mean operating time (MOT) was 137 (range, 85-290) minutes in O-neph versus 197 (116-341) minutes in R-neph. MOT for the first 5 R-neph cases was 249 minutes versus 153 minutes for the last 6 cases. Mean blood loss was 17 (range, 1-55) mL in O-neph versus 10.3 (2-40) mL in R-neph. One R-neph case required conversion to O-neph. There were no transfusions and no intraoperative complications. Two partial heminephrectomy patients (one O-neph and one R-neph) developed transient urinoma postoperatively that resolved conservatively. Mean duration of postoperative bed rest was 1.0 day in O-neph versus 0.6 days in R-neph. Differences in mean postoperative fentanyl requirement (O-neph, 21.5 [10-40] μg/kg; R-neph, 4.1 [0-20] μg/kg) and duration of nonsteroidal anti-inflammatory suppository usage (O-neph, 2.3 [0-5] days; R-neph, 0.9 [0-2] days) were significant (both P<.05). Full oral feeding was resumed after a mean of 1.6 (1-2) days in O neph and 1.2 (1-2) days in R-neph.

CONCLUSIONS

R-neph was safely performed by SPST, and results were comparable to those with O-neph performed by BCPS.

Evaluation of ureteral stent placement after retroperitoneal laparoscopic ureterolithotomy for upper ureteral stone: randomized controlled study

PURPOSE

To determine the necessity of ureteral stent placement after retroperitoneal laparoscopic ureterolithotomy (RLU) for upper ureteral stones more than 1 cm.

PATIENTS AND METHODS

Between May 2006 and May 2009, 104 RLUs were performed as primary management of large upper ureteral stones. The patients were randomly divided into two groups: In group 1 (52 patients), RLU was performed without stent placement afterward, and in group 2 (52 patients), the stent was placed after RLU. The mean stone size was 16.8 cm in group 1 and 18.2 cm in group 2. The stent in group 2 was placed cystoscopically.

RESULTS

All procedures were performed successfully. The mean operative time was 48 minutes in group 1 vs. 65 minutes in group 2. The mean drainage time was 4.1 days in group 1 vs. 2.3 days in group 2. All the patients were followed up for a period of 6 months with no recorded cases of residual stone or ureteral stricture.

CONCLUSION

RLU for large upper ureteral stones could be considered as a primary line for treatment as regards the economic status in developing countries. Laparoscopic ureterolithotomy (LU) without stent placement for upper ureteral stones is safe, cost effective, has less operative time, and needs no auxiliary procedures when compared with the use of stent placement after LU, which adds costs and discomfort for the patient.

Complications of urologic laparoscopic surgery: a single institute experience of 1017 procedures

PURPOSE

We evaluated complications of urologic laparoscopic surgery at our institution.

PATIENTS AND METHODS

From December 1991 to January 2009, 1017 urologic laparoscopic surgical procedures were performed in Kansai Medical University, including 277 radical prostatectomies, 13 donor nephrectomies, 74 partial nephrectomies, 158 radical nephrectomies, 55 pyeloplasties, 97 nephrouretectomies, 54 simple nephrectomies, 128 adrenalectomies, 34 varicocelectomies, and 127 other procedures. Medical records of each procedure were retrospectively evaluated. The difficulty of each procedure was classified according to the European Scoring System (ESS). Intraoperative and postoperative complications were graded according to the Satava and Clavien classifications, respectively.

RESULTS

Among the 1017 laparoscopic procedures, 148 complications occurred in 123 patients, resulting in a total complication rate of 14.6%. Conversion to open surgery occurred in 20 (1.9%) patients. Nephrouretectomy had the highest incidence of complications at 23.7%, which was significantly higher than that of other procedures classified as "difficult" group, according to the ESS (P < 0.05). Clavien grades I and II accounted for 73.8% of all the postoperative complications. We experienced one fatality that was caused by air embolism.

CONCLUSION

We evaluated the complications of each procedure using the ESS for classification of technical difficulty. Based on the results of our retrospective study, nephrouretectomy should be upgraded as "very difficult" group according to the ESS. Appropriate grading by technical difficulty is beneficial for the prevention of complications from laparoscopic surgery.

Experience and learning curve of retroperitoneal laparoscopic ureterolithotomy for upper ureteral calculi

PURPOSE

To summarize our experience and evaluate the learning curve of retroperitoneal laparoscopic ureterolithotomy of the upper ureter.

PATIENTS AND METHODS

Between May 2004 and May 2007, 40 patients underwent retroperitoneal laparoscopic ureterolithotomy of the upper ureter. We divided the first and last 20 patients into group I and group II. There was no statistical difference in stone size between groups. Operative time and complications were measured as a basis for the assessment of the learning curve.

RESULTS

In group I, the complication rate was 15% (3/20), including two patients whose procedure was converted to open surgery because of intraoperative bleeding, and one patient who experienced urine leakage because of a displaced Double-J ureteral stent. In group II, no postoperative complications occurred, while the mean operative time was significantly shorter compared with the earlier operations (65 vs 120 min).

CONCLUSION

Retroperitoneal laparoscopic ureterolithotomy is safe and effective for large or impacted stones of the upper ureter. It is associated with a short learning curve in the setting of an active laparoscopic practice for selected patients.

Outcome of retroperitoneoscopic nephrectomy for benign nonfunctioning kidney: a single-center experience

OBJECTIVE

To analyze the feasibility and outcome of retroperitoneoscopic nephrectomy for benign nonfunctioning kidneys and compare it with open simple nephrectomy.

MATERIALS AND METHODS

From January 1998 to December 2006, 505 retroperitoneoscopic nephrectomies were performed. In the same time period, 112 open nephrectomies were also performed. In the retroperitoneoscopic group, the mean age was 39 years (range 15-74 years); 204 (40.4%) were men and 301 (59.6%) were women. Forty in this group had a history of surgery. Thirty-six patients had a pyonephrotic kidney; 33 of these patients had undergone percutaneous nephrostomy preoperatively. The cause of the nonfunctioning kidney was ureteropelvic junction obstruction in 198 patients, calculus disease in 193 patients, genitourinary tuberculosis in 48 patients, renal dysplasia in 19 patients, anomalous kidney in 20 patients, and renovascular hypertension in 16 patients. In 11 patients, there were other causes for the nonfunctioning kidney.

RESULTS

Retroperitoneoscopic nephrectomy was performed in 476 (94.2%) patients. Conversion to open nephrectomy was necessary in 25 patients. The mean operative time was 85 minutes (range 45-240 min) in the retroperitoneoscopic group and 70 minutes (range 35-120 min) in the open group. The mean blood loss was 110 mL (range 30-600 mL) in the retroperitoneoscopic group and 170 mL (range 70-500 mL) in the open group. Four (0.8%) patients in the retroperitoneoscopic group needed a blood transfusion, whereas 5 (4.5%) patients in the open group had a blood transfusion. The hospital stay in the retroperitoneoscopic group was 3 days (range 1-7 d) and was 5 days (range 3-12 d) in the open group.

CONCLUSIONS

Retroperitoneoscopic nephrectomy, although technically challenging, is becoming a gold standard for patients with nonfunctioning kidneys caused by benign conditions.

Comparison of Intraoperative Parameters and Perioperative Complications of Retroperitoneal and Transperitoneal Approaches to Laparoscopic Partial Nephrectomy: Support for a Retroperitoneal Approach in Selected Patients

BACKGROUND AND PURPOSE

Retroperitoneal laparoscopy (RP) may have some intrinsic advantages over transperitoneal laparoscopy (TP) in certain patients undergoing partial nephrectomy. We reviewed our experience with RP and TP partial nephrectomy to identify differences in intraoperative and postoperative parameters.

PATIENTS AND METHODS

The records of 72 patients (45 TP, 27 RP) undergoing laparoscopic partial nephrectomy without hand assistance between January 2003 and August 2005 were reviewed. The two groups were similar demographically; tumors were smaller in RP patients (2.1 v 2.7 cm; P = 0.03), and the RP approach was used more frequently on right kidneys (70.4% v 37.8%; P = 0.01).

RESULTS

The operative time (mean 160 v 192 minutes; P = 0.008) and length of stay (LOS; median 1.0 days [range 1-10 days] v 2.0 days [range 1-64 days]; P = 0.001) were shorter in RP patients. Rates of collecting system entry (22% v 38%), positive-margin rate (0% v 6.7%; P = 0.29), and complications (19% v 22%; P = 0.77) were similar in RP and TP patients. Hemorrhage was the most common complication in both groups. Bowel-related complications occurred in three TP patients, but in no RP patients. Overall, the median estimated blood loss (EBL) was lower in RP patients (100 mL [range 25-3500 mL] v 225 mL [range 25-1900 mL]; P = 0.06). Among patients with complications, EBL was similar in both groups (median 325 mL [50-1500 mL] v 200 mL [50-3500 mL] for RP and TP; P = 0.86).

CONCLUSIONS

The RP approach reduces operative time, LOS, and some types of complications without compromising the quality of tumor resection. Complications in the retroperitoneal space are not associated with higher EBL. Anatomic considerations and surgeon experience may improve outcomes.

Laparoscopic retroperitoneal nephrectomy for giant hydronephrosis: when simple nephrectomy isn't simple

BACKGROUND AND PURPOSE

Retroperitoneoscopic nephrectomy (RN) for giant hydronephrosis (GH) is regarded as a more challenging procedure than RN for small nonfunctioning kidneys (SNFK). We describe specific technical modifications to facilitate surgery in the GH group and compare outcomes in the two groups.

PATIENTS AND METHODS

Data were collected in a prospective fashion on all patients undergoing upper urinary-tract laparoscopy at a single institution. Eleven patients (eight women, three men; mean age 41 years) underwent RN for GH. The etiologies were congenital ureteropelvic junction obstruction in 10 and obstruction secondary to endometriosis in 1. Technical modifications to facilitate surgery included initial fingerplasty, balloon dissection in two directions, initial intact dissection, subsequent pelvic puncture and aspiration, and extracorporeal retraction if required. The results were compared with those of a matched group of 19 patients who had RN for SNFK.

RESULTS

All procedures were completed without open conversion. In the GH group, the mean operating time was 126 minutes (range 65-240 minutes) and the estimated blood loss 101 mL (range 5-450 mL). No patient required transfusion, and the mean length of the hospital stay was 2.9 days (range 1.5-6 days). In the group undergoing RN for SNFK, the mean operating time was 116 minutes (range 55-270 minutes), the estimated blood loss 46 mL (range 5-400 mL), and the mean length of stay 2.8 days (range 1-5 days). In the GH group, the estimated blood loss was significantly greater (P = 0.042), and the operative time was longer, although this difference did not reach statistical significance.

CONCLUSION

An RN for GH is not as simple as laparoscopic simple nephrectomy for other benign lesions. Operative duration and blood loss are greater. Technical modifications have been vital to our success with this procedure.

LigaSure in Laparoscopic Transperitoneal Heminephroureterectomy in Children: A Comparative Study

BACKGROUND

This study was conducted to evaluate the feasibility of using the LigaSure vessel sealing system (Valleylab, Boulder, CO) in laparoscopic transperitoneal vs. open retroperitoneal heminephroureterectomy in children.

MATERIALS AND METHODS

Seven consecutive patients with impaired renal duplex systems underwent laparoscopic heminephroureterectomies using LigaSure between April 2003 and April 2005. The operative time, complications, and hospital stay were analyzed prospectively. The data of 7 consecutive patients who had undergone open retroperitoneal heminephroureterectomy from 2001 to 2003 were analyzed for comparison purposes. The mean ages, underlying disease, and location of the affected kidney pole were not significantly different between these groups.

RESULTS

There were no intraoperative complications during laparoscopic heminephroureterectomy and all procedures were completed laparoscopically. The mean operative time of 144 minutes (range, 90-210 minutes) for laparoscopic heminephroureterectomy was somewhat longer than in open heminephroureterectomy-mean time 110 minutes (range, 60-165 minutes) (P = 0.5). Complications of open retroperitoneal heminephroureterectomy included bleeding of the surface of the remaining kidney pole in one patient, requiring extensive hemostatic suturing. Postoperative recovery was uneventful in all laparoscopic procedures, whereas intermittent retention of urine was noticed in one patient undergoing the open procedure.

CONCLUSION

Laparoscopic heminephroureterectomy using LigaSure is feasible in children and has a similar operative time compared to conventional heminephroureterectomy.

Retroperitoneoscopic ureterolithotomy for the treatment of ureteral calculi

INTRODUCTION

Most upper or middle ureteral stones are treated with shock wave lithotripsy or endoscopic techniques. In rare cases the ureteral stones are treated with open surgery after failure of first-line treatments. Retroperitoneoscopy is a minimally invasive alternative to open surgery.

PATIENTS AND METHODS

Between May 1995 and January 2001, twenty-one patients underwent retroperitoneoscopic ureterolithotomy. The stones in upper and middle ureter were large and impacted (5 patients) or not fragmented after shock wave lithotripsy (16 patients). A balloon dissector was placed and infiltrated with 800 ml air in the retroperitoneal space. Three 10-mm trocars were used. The pressure was kept at 15 mm Hg by carbon dioxide insufflation. The stones were extracted from the ureter using a laparoscopic stylet.

RESULTS

The stones in 17 patients were successfully removed in a median operating time of 105 (min-max 45-190) min. Urine extravasation in all cases and pnomoscrotum in 2 cases were observed as postoperative complications. The median hospital stay was 6 (min-max 3-22) days with minimal analgesic requirement.

CONCLUSION

Retroperitoneoscopic ureterolithotomy is a useful and effective alternative treatment technique to open surgery when first-line treatments have failed or are unlikely to be effective.

Retroperitoneoscopic Nephrectomy v Classic Lumbotomy for Pyonephrosis

PURPOSE

To describe our experience and operative technique for retroperitoneoscopic nephrectomy for pyonephrosis and to compare the results with those of open surgery.

PATIENTS AND METHODS

Since October 1998, 23 successful retroperitoneoscopic nephrectomies for pyonephrosis were performed in our institution (Group A). These patients were compared with 23 patients, matched by age, sex, and body weight, who underwent classic lumbotomy for pyonephrosis (Group B). The two groups were compared in terms of operative time, blood loss, hospital stay, wound complications, and time of return to previous occupation.

RESULTS

All the features studied except operative time were significantly different in favor of laparoscopy.

CONCLUSION

Although technically difficult, retroperitoneoscopic nephrectomy for pyonephrosis is feasible. The extraperitoneal approach allows direct access to the renal hilum and helps avoid spillage of pus into the peritoneum.

Retroperitoneoscopic Living-Donor Nephrectomy: First Clinical Experiences in 19 Operations

The wish for a minimally invasive procedure is one of the utmost demands by all persons undergoing living-donor nephrectomies. The retroperitoneoscopic access for this procedure has proven to be a safe, minimally invasive, and efficient approach accompanied by early mobilization and a fast return to general daily activities. The incidence of complications during and after this technically demanding operation is comparable to that of other approaches. Because of the direct anatomic approach, retroperitoneoscopic living-donor nephrectomy has become the preferred access at our institution for both donors and surgeons.

Retroperitoneoscopic Nephropexy for Symptomatic Nephroptosis

PURPOSE

Recently, laparoscopic nephropexy has been performed using a transperitoneal approach. We evaluated the efficacy of a retroperitoneoscopic technique for symptomatic nephroptosis.

PATIENTS AND METHODS

Three men and two women with right nephroptosis underwent retroperitoneal laparoscopic nephropexy. Their symptoms were right flank pain, gross hematuria, or both. The mean body mass index was 18.7. Surgery consisted of complete dissection of the kidney, after which three sutures were placed between the renal capsule at the posterior lateral edge and the psoas or quadratus lumborum muscle. Silk sutures were used in all five patients.

RESULTS

Retroperitoneoscopic nephropexy was successful with no intraoperative complications. The mean operative time was 167 minutes, and the mean estimated blood loss was <10 mL in all five patients. The mean convalescence period was 19.6 days. A postoperative urogram with the patients both supine and erect revealed an improvement in renal function, decreased displacement of the kidney (less than one vertebral body), or both. All patients were satisfied with the clinical outcome during an average of 18 months of follow-up.

CONCLUSIONS

Retroperitoneoscopic nephropexy is feasible for patients with symptomatic nephroptosis. We recommend nonabsorbable materials such as silk for fixation of the kidney to the psoas or quadratus lumborum muscle.

Retroperitoneoscopic adrenal surgery with reusable instruments

BACKGROUND AND PURPOSE

Retroperitoneoscopic surgery has proven advantages over open surgery in terms of cosmesis, reduced postoperative pain, hospital stay, and early return to work. This is particularly true for surgery of the adrenal gland that otherwise entails a large surgical incision. One of the drawbacks of this surgery is the additional cost attributable to the disposable instruments. We present our cost-reductive retroperitoneoscopic techniques to tackle a variety of adrenal pathologies.

PATIENTS AND METHODS

Beginning March 1995, 17 patients underwent cost-reductive retroperitoneoscopic adrenal surgery for various indications including 12 pheochromocytomas, 3 myelolipomas, 2 adrenal cortical adenomas, and two adrenal cysts. Two patients underwent simultaneous bilateral procedures for pheochromocytoma. A cost-reductive technique using minimal disposable equipment was employed.

RESULTS

The procedure was completed in 18 of 19 cases (94%). One patient undergoing an adrenalectomy for pheochromocytoma was converted to open surgery because of nonprogress of the dissection. The largest tumor removed measured 10 cm. The mean operative time was 133 minutes, the average blood loss 169 mL, NSAID doses 3.56, and hospital stay 4.6 days. There were two major and two minor complications with no deaths.

CONCLUSIONS

Cost-reductive retroperitoneoscopy is a feasible option for the management of a variety of adrenal pathologies. It should be considered a difficult procedure and be undertaken only by surgeons proficient in laparoscopy.

Mini-access for retroperitoneal laparoscopy

The purpose of this study was to establish the feasibility of primary mini-access to the retroperitoneal space to perform certain retroperitoneoscopic procedures in which an enlarged port is not required for extraction of the specimen. Mini-laparoscopy or needlescopic laparoscopy has been performed in the past via the transperitoneal route, but this has not yet been reported for a retroperitoneoscopic procedure. Through a 5-mm primary access and 3- or 5-mm secondary ports, retroperitoneoscopic surgery was performed in seven adults for ureterolithotomy, renal biopsy, simple nephrectomy, nephropexy, cyst decortication, or drainage of a subphrenic abscess. The access technique used was a mini-version of a previously described percutaneous access technique with some modifications. The retroperitoneoscopic procedure was successful in all seven patients, and no complications developed. The operative time, blood loss, analgesic intake, and length of hospital stay were comparable with those of a standard retroperitoneoscopic procedure. However, the cosmetic results were better. Mini-retroperitoneoscopy is feasible and is a better alternative for patients in whom the whole procedure can be performed through 5-mm or smaller ports.

Renal chemoembolization with mitomycin c/Ethibloc: pharmacokinetics and efficacy in an animal model

BACKGROUND AND PURPOSE

Arterial embolization can be an alternative treatment for kidney malignancy. We investigated the efficacy of renal embolization with a combination of an occlusive agent (Ethibloc) and the cytotoxic substance mitomycin C (MMC) in an animal model.

MATERIALS AND METHODS

In 32 rats with implanted Yoshida sarcoma, nephrectomy was carried out 15, 30, 60, or 90 minutes after chemoembolization (1 mg v 2 mg of MMC/mL of Ethibloc) or chemoperfusion (1 mg of MMC/mL of NaCl) of the tumor-bearing kidney. The MMC tissue concentration was measured in the kidney specimens. Six dogs also underwent chemoembolization or chemoperfusion with monitoring of MMC serum concentration at the same intervals. We compared the survival time of rats with Yoshida sarcoma after chemoembolization (N = 15), chemoperfusion (N = 18), embolization (N = 18), nephrectomy (N = 21), and no treatment (N = 25).

RESULTS

The MMC tissue concentration in the rat model was much higher after chemoembolization than after chemoperfusion for at least 1.5 hours. The MMC serum concentration in the dogs showed a high initial peak (0.6 mg/L) after chemoperfusion, then dropped quickly to the same level seen 30 minutes after chemoembolization with 1 mg of MMC/mL of Ethibloc (0.15 mg/L). The MMC serum concentration following chemoembolization with 2 mg of MMC/mL of Ethibloc stayed higher (0.3-0.25 mg/L) for 60 minutes. The survival rates after nephrectomy were equal to those after chemoembolization (80% survival after 30 days), with poorer survival being seen after embolization (75%) and chemoperfusion (70%). In the control group, all rats were dead at the 27th day.

CONCLUSION

Chemoembolization produces persistently high tissue concentrations of MMC and avoids toxic peak serum levels. It improves the efficacy of organ ablative vasoocclusion in renal malignancies.

Evaluation of laparoscopic retroperitoneal surgery in urinary stone disease

PURPOSE

To assess the safety and effectiveness of laparoscopic retroperitoneal surgery and attempt to define its role in the management of urolithiasis.

PATIENTS AND METHODS

Laparoscopic retroperitoneal surgery (LRS) was undertaken in 72 male and 42 female patients with calculous disease from March 1994 to April 2000 for variety of indications that otherwise would have made them candidates for conventional open surgery. Some of these patients were subjected to retroperitoneoscopic ureterolithotomy (RPUL) (40 patients) and retroperitoneoscopic pyelolithomy (RPPL) (7 patients). Retroperitoneoscopic nephrectomy (RPN) and nephroureterectomy (RPNUT) for a nonfunctioning renal unit secondary to renal and or ureteral calculi was done in 53 and 14 patients, respectively. Most of the procedures were performed with three 10-mm ports. In some cases, an additional 5-mm port was used.

RESULTS

The procedure was successful in 75%, 71%, 90.5%, and 86% of cases subjected to RPUL, RPPL, RPN, and RPNUT, respectively. The mean operating time for RPUL was 106.3 minutes and for RPPL was 108.2 minutes, whereas it was 99.7 minutes for RPN and 147 minutes for RPNUT of nonfunctioning kidneys secondary to calculous disease. The major complications encountered were colon injury in one patient with calculous pyonephrosis who had dense adhesions and injury to the external iliac artery in another patient having RPUL. The mean blood loss was 69.8, 127.2, 135.6, and 206.5 mL, respectively, for RPUL, RPPL, RPN, and RPNUT. The average hospital ranged from 3 to 4 days.

CONCLUSIONS

Laparoscopic retroperitoneal surgery has a definite role in the management of patients requiring open surgery for calculous disease. It is safe and feasible in spite of the dense adhesions that are frequently encountered in such patients. Often, previous attempts at treatment with shockwave lithotripsy or endourologic procedures also lead to inflammation and adhesions, making surgery difficult. However, these problems can be dealt with by LRS with good results.

Laparoscopic nephropexy

Although there has long been debate about the existence of nephroptosis, contemporary radiologic and biochemical studies confirm its existence. Both percutaneous and laparoscopic operations are available for fixing the kidney, with high early success rates. Objective documentation of the diagnosis is mandatory. Further studies with validated quality-of-life and pain questionnaires are needed to determine the long-term success of nephropexy.

Retroperitoneoscopic and laparoscopic suturing: tips and strategies for improving efficiency

BACKGROUND

The difficulties of minimally invasive reconstructive surgery, laparoscopically or retroperitoneoscopically, are caused by spatial limitation and fixed trocar positions and, therefore, restricted movement and handling of the instruments. In addition to a standardization of the technique, continual training, and improved instrument technologies, optimization of the geometry of reconstructive surgery, such as angles and distances between the working ports or the camera and needle position, are imperative to providing an optimal clinical performance.

MATERIALS AND METHODS

After designing a standardized suturing technique and conducting an experimental analysis of the geometric factors important in reconstructive surgery, we transferred these results to our clinical setting. A series of 116 reconstructive laparoscopic and retroperitoneoscopic procedures (nephropexy, pyeloplasty, bladder neck suspension, and radical prostatectomy) were analyzed according to the technical realization and quality of reconstruction. Trocar and table positions were adjusted according to our preliminary results, as were the position of the instruments and camera.

RESULTS

The trocar and instrument positions are critical for the clinical outcome of reconstructive surgery. Continual training in a standardized suturing technique, together with the clinical application of the important geometric rules, can reduce surgery time by 50%. The time required for suturing single knots could be decreased even more: as much as 75%, thus ensuring efficient and safe reconstructive surgery.

CONCLUSION

Reconstructive procedures such as pyeloplasty or radical prostatectomy can be standardized and performed in an acceptable amount of time with adequate quality when adhering to a standardized technique and the important geometric rules. Improved performance in terms of time and quality will increase the acceptance of these procedures, which can help to solve the problem associated with a low total number of indications for laparoscopy and retroperitoneoscopy.

Pediatric retroperitoneoscopic nephrectomy

The endoscopic retroperitoneal (retroperitoneoscopic) approach to extirpative intervention for benign renal disease is increasingly popular. We describe several modifications of this approach, including the use of prone positioning and 2-mm instruments, that may improve the safety and efficacy of the technique in children. These modifications provide unobstructed views of the kidney and renal hilum and facilitate dissection in a small working space.

Laparoscopic nephrectomy for nonfunctioning tuberculous kidney

BACKGROUND AND PURPOSE

Although laparoscopic nephrectomy for benign renal disease has been widely accepted, use of the operation for tubercular pyelonephritic kidney is relatively contraindicated because of difficulties in dissecting the dense fibrotic adhesions and the risk of spillage of caseous materials with subsequent dissemination of the disease. However, with the accumulation of experience, laparoscopic surgery is expanding its applications. In this study, we tried to evaluate the efficacy and safety of the laparoscopic nephrectomy for renal tuberculosis.

PATIENTS AND METHODS

At three centers, 13 laparoscopic nephrectomies were performed between April 1996 and March 1999. The patients consisted of eight men and five women with a mean age of 44.8 years (range 37-51 years). All patients had known renal tuberculosis with a nonfunctioning kidney and underwent nephrectomy after at least 3 months of chemotherapy with four antituberculous drugs. Nine patients underwent the transperitoneal approach and four patients, the retroperitoneal approach. The follow-up was from 2 to 35 months with a mean of 15.8 months.

RESULTS

Kidneys were removed laparoscopically in 12 patients (92%). The mean operative time was 268 minutes (range 190-500 minutes), and the mean estimated blood loss was 227 mL. Although there had been some difficulties releasing the adhesions, no significant intraoperative and postoperative complications were observed. Conversion to open surgery was needed in only one patient. The mean hospital stay was 4 days, and the patients returned to normal activity within 10 days. Neither local recurrence nor distant dissemination of the disease was observed during the follow-up period.

CONCLUSION

Laparoscopic nephrectomy for renal tuberculosis was safe and effective with minor complications. Therefore, tuberculosis should not be a contraindication to a laparoscopic approach.