Ali Panah

Simultaneous Anterograde and Retrograde Endourologic Access: “The Barts Technique”

We present our technique for achieving simultaneous anterograde and retrograde endourologic access to manage complex and demanding cases.

Laparoscopic cranial plication in pelviureteral junction obstruction by aberrant lower pole artery.

BACKGROUND AND PURPOSE The standard management for pelviureteral junction (PUJ) obstruction is a laparoscopic dismembered pyeloplasty. We present the initial results of our experience of laparoscopic cranial transposition of lower-pole crossing vessels in the management of adult PUJ obstruction where crossing vessels were identified. PATIENTS AND METHODS All patients during the last 2 years who presented with PUJ obstruction caused by crossing lower-pole vessels underwent a laparoscopic transposition of the artery to a more cranial position and, in fact, plicated within the renal pelvis well above the PUJ to reduce the size of the baggy renal pelvis. Patients were followed up postoperatively with mercaptoacetyl triglycine renography as well as clinical symptom review at 3 months, 6 months, and then yearly. RESULTS Seven patients have undergone this procedure so far. The mean follow-up period at present is 14 months (range 8-22 months). All patients had a nonobstructive renogram curve at 3 months and 6 months. One patient has had renography at 22 months, which still shows a nonobstructive drainage pattern. All patients have had a resolution of their pain and urinary tract infections. The mean operative time, including the retrograde study and Double-J stent insertion was 121 minutes (range 110-131 min) with a mean blood loss of 30 mL. The mean hospital stay was 2 days. There were no complications. CONCLUSIONS Although currently the number of patients is small and follow-up is short, this procedure appears to be effective in relieving both symptoms and obstruction in patients with lower-pole crossing vessels. Other benefits include shorter operative time, less blood loss, as well as no risk of anastomotic stricture and urine leak when compared with a dismembered pyeloplasty. The Double-J stent can be removed within a few days (typically 5 in our hands) or even shorter where logistically feasible. This reduces stent-related complications.

A technique to flush out renal stone fragments during percutaneous nephrolithotomy.

There are a number of graspers and baskets to snare and remove stones during percutaneous nephrolithotomy (PCNL). These instrumental techniques can, however, cause inadvertent trauma to the renal mucosa and can be time consuming. Increasingly, these graspers and baskets are disposable, which also has financial implications. We use a simple technique to flush out fragments from the kidney during PCNL. Once fragments have been identified as a size that can pass through the Amplatz sheath, a cut nasogastric tube is inserted through the sheath--if possible next to or behind the fragments. It is repeatedly moved forward and backward in a jerking motion while saline is instilled under some pressure to create some turbulence. This results in the mechanical flushing out of stone fragments. We have found this to be a safe, effective, and reliable technique of stone extraction during PCNL.

Insertion of a Ureteric Memokath Stent through a Prostatic Memokath Stent Using Extracorporeal Needles Placed on the Skin to Mark and Measure the Ureteric Stricture in a Patient with Prostate Cancer

Background: Patients with prostate cancer can often have simultaneous upper and lower urinary tract pathologies. If the patient is elderly and unfit for any major surgery, treat-ment options are limited. Thermo-expandable shape-memory nickel-titanium alloy stents (MemokathTM) offer a minimally invasive solution in such cases and are available for long-term use in both, ureter strictures and prostatic outflow obstruction in patients deemed high risk for transurethral or open surgery. Surgical Technique: We present how we man-aged to exchange in a retrograde fashion a double J ureteric stent for a ureteric Memokath 051TM using metallic needle placed externally over the skin to mark the stricture in an elderly patient unfit for any invasive procedure in whom for the same reason we had previously inserted a prostate Memokath 028TM. This technique allows safe and efficient access to the upper urinary tract without removing the previously sited prostatic Memokath stent. Conclusion: In patients with a prostate stent, this technique allows safe access to the upper urinary tract to exchange a double J stent to a permanent Memokath stent without displacing or requiring re-insertion of a new prostate stent. This has cost and time saving implications as well as reducing patient morbidity and hospital visits due to regular stent exchange. The use of extracorporeal needles placed on the skin to mark and measure the length of the stricture is both an efficient and accurate way of placing the sheath through which a ureteric Memokath 051TM stent can be placed across the stricture.

A Ureteric Suspension Suture: An Invaluable Aid during Upper Tract Laparoscopic Surgery

Background: One of the keys to performing successful laparoscopic surgery is good retraction and exposure of the operating field without too many instruments in a limited working space ‘getting in each others way’. Methods: We describe a very useful technique for retracting the ureter using a temporary suture inserted through the abdominal wall to aid dissection and mobilization of the ureter and kidney in procedures such as laparoscopic pyeloplasty and nephrectomy. Results: This suspension suture greatly helps with mobilization of the ureter and if placed close to the pelviureteric junction it also helps hilar as well as dissection of the posterior part of the kidney. We have had no complications with this technique. Conclusion: Although this technique is not new, to our knowledge it is not widely used or known about. We wish to highlight this simple yet very effective technique as laparoscopic surgeons may find it extremely useful for a variety of procedures.