Retrograde placement of ureteral stent and ureteropelvic anastomosis with two running sutures in transperitoneal laparoscopic pyeloplasty: Tips of success in our learning curve

Purpose: We report our experience of transperitoneal laparoscopic dismembered pyeloplasties describing our step-by-step surgical technique, and we retrospectively analyze the impact on operative times of technical modifications that were introduced during the learning curve. Patients and Methods: From November 2002 to May 2008, 84 consecutive patients with ureteropelvic junction (UPJ) obstruction were selected for laparoscopic pyeloplasty (LP). The main steps of the surgical procedure are described. In the initial 14 patients who underwent LP, we performed intraoperative antegrade stenting, and we configured the ureteropelvic anastomosis with interrupted sutures; in the 25 following patients, anastomosis was performed with running sutures. In the latest 45 patients, the ureteral stent was positioned retrograde, and ureteropelvic anastomosis was performed with two running sutures. We evaluated the impact of technical modifications on the operative times, dividing patients into three groups (group A, first 14 patients; group B, following 25 patients; and group C, last 45 patients). Median operative times of each group were compared with the Student t test. Results: No major complications ccurred, while postoperative urinary leakage was seen in three patients at bladder catheter removal (two in group A and one in group B). Mean operative blood loss was 70mL, and mean hospital stay was 1.6 days. Median operative time was 115min (range 110-125min) for group A, 100min (range 95-115min) for group B, and 85min (range 65-95min) for group C; differences between operative times of groups A and B and between groups B and C were statistically ignificant (both P<0.001). At a median follow-up of 38 months, recurrent symptoms developed in three patients. Overall, the success rate of the procedure was 96.5%. Conclusion: In a retrospective analysis of our series, the retrograde placement of the ureteral stent and the ureteropelvic anastomosis with two running sutures seemed to be tips of success in reducing operative times. © 2009 Mary Ann Liebert, Inc

Superselective embolization as first step of laparoscopic partial nephrectomy

OBJECTIVES Laparoscopic partial nephrectomy is currently very hard to perform because of the great difficulty in obtaining renal parenchymal hemostasis during tumor excision and the consequent high risk of bleeding. The aim of this study was to propose a method to decrease the risk of bleeding, consisting of the superselective embolization of tumor vessels before performing the laparoscopic partial nephrectomy. METHODS Fifty patients with small, solitary, enhancing, predominantly exophytic renal tumors underwent a superselective radiographically guided embolization of tumor vessels. An average of 6 hours after embolization, the patients underwent partial laparoscopic nephrectomy, with transperitoneal access and three trocars placed, under balanced general anesthesia. The mean operative time was measured, as was the mean estimated blood loss. RESULTS The mean operative time was 90 minutes, the mean estimated blood loss was 200 mL, and the average hospital stay was 6 days. Complications were reported in only 2 patients. The final pathologic evaluation confirmed the diagnosis of renal cell carcinoma in 43 cases. The median follow-up was I I months and, to date, the examinations have revealed no recurrences in any of the cases. CONCLUSIONS Superselective embolization is a valid option for laparoscopic partial nephrectomy. The procedure does not require any regional vascular control or clamping, reduces the estimated blood loss, and reduces the operative time

Simplified Indiana pouch with multiple teniamyotomies

Objectives. To describe a retrospective review of a single-institution, single-surgeon (M.G.) experience with 44 simplified Indiana pouch with multiple teniamyotomies without detubularization and reconfiguration. Methods. From April 1999 to May 2003, 44 patients underwent radical cystectomy and continent urinary diversion with a simplified Indiana pouch technique using teniamyotomies without detubularization and reconfiguration. The tenia was sectioned across the whole width and deepened as far as the submucosal layer, with 2 to 3 cm between each teniamyotomy. The efferent tract of the reservoir was prepared using the appendix. If it was unsuitable, an ileum invagination nipple fixed in the ileocecal valve was constructed. Results. The mean follow-up was 3 years (range 1 to 5). Continence was excellent for 40 patients (91%); in 4 patients (9%), daytime incontinence was reported. The urodynamic studies showed an average pressure at 350 mL of capacity of 19.6 cm H2O (range 15.1 to 25.5). The average pressure at maximal capacity (400 to 600 mL) was 32.3 cm H2O (range 28.5 to 35). Long-term complications occurred in 15 patients (34%), with a mean onset of 13.4 months postoperatively. Conclusions. Our experience showed that a modified Indiana pouch with multiple teniamyotomies has a good capacity with low internal pressure and good continence. Thus, even with the comparable results of other continent pouch models, our modified Indiana pouch is a valid alternative because of its simplicity to perform