Laparoscopic Transperitoneal Pyeloplasty

Laparoscopic pyeloplasty is a first-line option for the management of ureteropelvic junction obstruction. It has a greater success rate than endopyelotomy and is associated with a shorter and less intense convalescence than open surgical pyeloplasty. The technique is well established and reproducible, although the procedure is more difficult in certain situations, such as after a previous pyeloplasty. Because laparoscopic suturing is needed, it is considered an advanced laparoscopic procedure. Suturing devices can facilitate suturing, but they are not optimal for all repairs. This article and the accompanying video summarize the preoperative, intraoperative, and postoperative considerations for laparoscopic pyeloplasty.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90443/1/end-2E2010-2E0605.pd

Convenient Creation and Use of Suturing Supplies for Laparoscopic Partial Nephrectomy

Abstract The closure of the renal defect is the most challenging part of laparoscopic partial nephrectomy when suturing is required. The author presents a method of creating and using suturing material for laparoscopic partial nephrectomy that has been developed over several hundred cases at the author's institution. These techniques can be used to simplify the task of suturing during laparoscopic partial nephrectomy.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78109/1/end.2009.0006.pd

The Alternative to Laparoendoscopic Single-Site Surgery: Small Strategic Laparoscopic Incision Placement (SLIP) Nephrectomy Improves Cosmesis Without Technical Restrictions

Background: The latest attempt to improve the cosmesis of laparoscopic surgery is laparoendoscopic single-site surgery (LESS). We present our initial experience with an alternative procedure with similar cosmetic benefit but without technical limitations. Methods: Small strategic laparoscopic incision placement (SLIP) nephrectomy is performed transperitoneally, generally using three 5-mm ports (one in the umbilicus) and one 12-mm port placed below the pubic hairline, such that only two 5-mm scars are visible without close inspection. We assessed our first 21 procedures, which included all but five of the standard transperitoneal nephrectomies by a single surgeon from June 2008 through July 2009. These were matched 1:2 (exactly by gender and American Society of Anesthesiology score, and then closest in age and body mass index) from 96 patients undergoing similar standard transperitoneal laparoscopic procedures from 2005 through 2008. Results: The SLIP and control groups were well matched, with mean age and body mass index differing by only 3.6 years and 1.1, respectively. Of the SLIP patients, 34% were obese or morbidly obese, and a trainee was the primary surgeon in 81% of cases. Mean operative time was 23 minutes longer in the SLIP cases. There was no difference between groups in estimated blood loss, complication rate, or convalescence. Conclusions: Like LESS, SLIP nephrectomy provides improved cosmesis. Unlike LESS, it is only slightly more difficult to perform than standard laparoscopic nephrectomy and can be performed in technically challenging cases (obesity, large specimen, etc). Similar to the literature on LESS, there is no convalescence benefit to SLIP nephrectomy; the advantage over standard laparoscopy is purely cosmetic.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90438/1/end-2E2010-2E0340.pd

Failure of Percutaneous Endoscopic Resection of a Renal Cystic Nephroma on Longer-Term Follow-Up

In 2005 we reported in this journal the treatment of cystic nephroma, a rare but presumed benign renal tumor, with percutaneous resection. Initial follow-up confirmed removal of the intra-pelvic portion of the cystic nephroma and persistence of the unresected intra-parenchymal portion. Surveillance with computed tomography revealed gradual regrowth of the mass, ultimately resulting in a size greater than that at the time of initial resection. Laparoscopic radical nephrectomy without adrenalectomy revealed benign cystic nephroma.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63237/1/end.2007.0441.pd

Single-Setting Bilateral Hand-Assisted Laparoscopic Partial Nephrectomy

Abstract Purpose: To assess the feasibility and safety of single-setting bilateral hand-assisted laparoscopic partial nephrectomy. Materials and Methods: Between August 2003 and June 2004, we performed single-setting bilateral laparoscopic partial nephrectomies on three patients. A hand-assisted approach was used, employing the same hand-assistance incision for both sides. Renal hilar clamping was not required, as the depth of penetration of all six tumors was only 0 to 4mm (mean, 1.8mm). The tumor diameters ranged from 1.8 to 3.8cm (mean, 2.4cm). Results: All operations were performed successfully, with no conversion to open surgery. Excision was performed with bipolar forceps, and final hemostasis was obtained with an argon beam coagulator (Valleylab, Boulder, CO) and Floseal (Baxter, Deerfield, IL), without suturing. The mean estimated blood loss was 208mL. The mean operative time was 246 minutes, which included repositioning. There were no intraoperative complications, and the postoperative course was uneventful in all patients except for a hospital stay of 5 days in one patient owing to transient ileus. Pathology revealed a benign lesion on one side and renal cell carcinoma on the other side in two patients, and bilateral leiomyomas in one patient. All margins of resection were negative, and neither of the two patients with cancer has had recurrence at a mean follow-up of 51 months. Among all three patients, the mean preoperative serum creatinine was 0.9mg/dL, and the average level at a mean of 35 months postoperatively was 1.0mg/dL. Conclusion: Single-setting bilateral hand-assisted laparoscopic partial nephrectomies can be safely and effectively performed on patients with bilateral small exophytic kidney tumors. We do not recommend this technique if both kidneys require temporary hilar occlusion, but it can be considered if only one kidney requires hilar occlusion.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78122/1/end.2008.0549.pd

Ex-Vivo Ureteroscopy at the Time of Live Donor Nephrectomy

Background and Purpose: Potential transplant renal allograft recipients exceed the number of donors. Our institution now considers patients with small, unilateral, nonobstructing, incidental renal calculi for possible renal donation. We adopted ex-vivo ureteroscopy (ExURS) to render these kidneys stone free at the time of renal transplantation. We examined the safety and efficacy of ExURS. Patients and Methods: After confirming a lack of significant metabolic defects on 24-hour urinalysis, 23 patients with small nonobstructing unilateral nephrolithiasis detected on preoperative CT angiography underwent donor nephrectomy. Immediately after cold perfusion, ExURS was performed with ice cold saline irrigation. Retrospective review was performed. Results: Pyeloscopy was successfully performed in all 23 patients. A total of 28 calculi, mean largest diameter 3.9-mm (range 3-6-mm), were visualized in 19 kidneys. Basket extraction and holmium laser lithotripsy was performed in 12 and 6 kidneys, respectively. Treatment rendered 17/19 stone-containing kidneys stone free with a mean treatment time of 6.2 minutes (3-10-min). There were no intraoperative complications. Median serum creatinine level of recipients at 1 month and 1 year were 1.4+/-1.8-mg/dL and 1.3+/-0.6-mg/dL, respectively. At a median follow-up of 63+/-47.2 months, there were no transplant urinary calculi among the recipients. Conclusions: ExURS safely renders live donor kidney allografts stone free with low risk of recurrence. When used appropriately, ExURS could safely increase the number of potential kidney donors and minimize the risk of adverse stone events.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90444/1/end-2E2010-2E0627.pd

Nephron-Sparing Diagnosis and Management of Renal Keratinizing Desquamative Squamous Metaplasia

Background and Purpose: Keratinizing desquamative squamous metaplasia (KDSM) of the upper urinary tract is a rare condition for which there is no defined management plan. A condition historically treated with extirpative surgery, conservative management would be preferable, because this is almost certainly a benign condition. We report the favorable clinical course of two cases of renal KDSM diagnosed and managed with a nephron-sparing approach, relying on ureteroscopy and serial imaging. Patients and Methods: Retrospective chart review was performed to obtain history, physical examination results, radiographic imaging, and diagnostic procedures. Results: Both patients were referred to our institution for evaluation of complex cystic renal masses. Both reported passing flaky material in their urine. Flexible ureteroscopy revealed waxy sediment in the collecting system, which broke up easily with manipulation and proved to be squamous keratin debris on cytologic and histologic examination. In 1 patient, we obtained a percutaneous needle biopsy as well, which revealed benign keratinizing squamous epithelium. All findings were consistent with KDSM. Each patient has since been followed conservatively with CT. In 1 case, there has been slight growth of the mass but no worrisome changes after 42 months. In the other case, there were several new renal collecting system filling defects on CT 17 months after diagnosis. Another ureteroscopy revealed the same findings as the original, with the addition of keratin debris draining out of the lesion into the rest of the kidney. Conclusions: Our two cases of KDSM confirm the feasibility of nephron-sparing management using a combination of diagnostic ureteroscopy and imaging surveillance. The duration of follow-up without adverse events suggests that the finding of renal KDSM is not necessarily an indication for extirpative surgery, and that conservative management is an appropriate option.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78150/1/end.2008.0501.pd

Laparoscopic and Open Surgical Nephrectomy for Xanthogranulomatous Pyelonephritis

Background and Purpose: Xanthogranulomatous pyelonephritis (XGP) is a severe, chronic renal-parenchymal infection. Nephrectomy is the treatment of choice. Because of the renal and perirenal inflammatory changes that commonly accompany XGP, the laparoscopic approach is difficult. We compared our experience with laparoscopic and open surgical nephrectomy for XGP. Patients and Methods: A retrospective chart review of all adult nephrectomy specimens with the pathologic diagnosis of XGP between January 1997 and May 2003 was performed. Preoperative presentation, operative details, and postoperative recovery and complications were included in the data collection. Results: Three patients approached laparoscopically and eight patients approached with open surgery were found to have XGP on pathologic analysis. The disease was suspected preoperatively in all patients. Among the laparoscopically treated patients, there was 1 (33%) who suffered major complications; this was the only patient who required conversion to open surgery. Among the open-surgical group, there were 2 (22%) major and 3 (33%) minor complications. Postoperative hospitalization was longer in the open-surgical group (mean 13.7 v 4.7 days), and when the case of open conversion was excluded, narcotic use was less in the laparoscopy group. Conclusions: The treatment of some XGP cases with laparoscopic nephrectomy is a possible, albeit challenging, option. The incidences of intraoperative and postoperative complications were roughly equivalent in the laparoscopic and open-surgery patients in our study. If completed, laparoscopy appears to be associated with decreased postoperative morbidity. However, this may represent selection bias, and larger, prospective studies may better define the suspected benefit.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63141/1/end.2005.19.813.pd

Comparison of Neuromuscular Injuries to the Surgeon during Hand-Assisted and Standard Laparoscopic Urologic Surgery

Background and Purpose: Hand-assisted procedures have assumed a greater role in the practice of many laparoscopists. We surveyed major laparoscopy program directors to compare the incidence and location of neuromuscular injury to the surgeon during hand-assisted laparoscopic (HAL) and standard laparoscopic (SL) surgery. Materials and Methods: A questionnaire on neuromuscular injuries was e-mailed to 42 laparoscopic program directors. Respondents were instructed to report only injuries or pain associated with laparoscopic surgery when they were the primary responsible surgeon and not during open or endoscopic procedures. Results: Surveys were returned from 23 attending laparoscopic surgeons and 2 laparoscopic fellows. Surgeons reported an average of 3.9 HAL and 6.3 SL cases per month as the primary surgeon. The HAL was completed with the GelPort, LapDisk, Omniport, or a combination of devices 55%, 22%, 5%, and 14%, respectively, of the time. Comparing HAL with SL, there was significantly more hand/wrist, forearm, and shoulder pain/injuries associated with HAL (P < 0.004). There was significantly more neck pain associated with SL than HAL (P < 0.003), but no significant difference in lower-back pain (P = 0.40). Comparing the two most commonly used hand-assist devices (GelPort and LapDisk), the LapDisk demonstrated significantly more hand/wrist pain or injury (P = 0.001). Conclusion: Hand-assisted laparoscopy is associated with more frequent neuromuscular strain to the upper extremity than SL, but SL surgeons experience more neck pain or injury. Surgeon discomfort is also dependent on the type of hand-assist device. The long-term consequences of physical strain on the laparoscopic surgeon are unknown currently, but measures to minimize neuromuscular strain should be considered.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63117/1/end.2005.19.377.pd