Andrei Nadu

EARLY REMOVAL OF THE CATHETER AFTER LAPAROSCOPIC RADICAL PROSTATECTOMY

PURPOSEnWe prospectively tested the safety of routine removal of the catheter as early as 2 to 4 days after laparoscopic radical prostatectomy.nnnMATERIALS AND METHODSnBetween March 1998 and March 2001, 228 patients underwent laparoscopic radical prostatectomy for clinically organ confined prostate cancer. The last 113 consecutive patients were included in a prospective study according to gravitational cystography performed 2 to 4 days postoperatively. If no leak was seen the catheter was removed. If a leak was apparent the catheter was left indwelling for another 6 days and cystography was repeated.nnnRESULTSnCystography 2 to 4 days postoperatively showed an anastomosis without a leak in 96 (84.9%) patients who subsequently had the catheters removed. There were 28 patients who had the catheter removed on postoperative day 2, 28 day 3 and 40 day 4. In 17 (15.1%) patients an anastomotic leak was observed, and the catheter was not removed at that time. Of the 96 patients in whom the catheter was removed early 10 (10.4%) had urinary retention that necessitated re-catheterization. This procedure was performed without the need for cystoscopy. After the catheter was removed all patients were able to void 24 hours later. Median followup was 7 months (range 1 to 15) and showed continence rates greater than 93%. No anastomotic stricture, pelvic abscess or urinoma developed in any patient.nnnCONCLUSIONSnPatients who undergo laparoscopic radical prostatectomy can have the catheter safely removed 2 to 4 days postoperatively without a higher risk of incontinence, stricture or leak related problems.

CLINICAL EFFICACY OF SILDENAFIL IN PATIENTS ON CHRONIC DIALYSIS

PURPOSEnWe evaluate the clinical efficacy of sildenafil citrate for patients who are on chronic dialysis and who have concomitant erectile dysfunction.nnnMATERIALS AND METHODSnA total of 35 men (mean age 60.7 years) on dialysis and with erectile dysfunction of various etiologies were administered 25 to 100 mg sildenafil for at least 6 months. The International Index of Erectile Function questionnaire (IIEF), a global assessment question and partner satisfaction question were used to evaluate sildenafil efficacy. Patients also reported any adverse events that occurred during treatment.nnnRESULTSnTreatment was effective for 28 of the 35 (80%) patients according to the results of the IIEF and global assessment questions. Partner satisfaction correlated with the IIEF overall response (0.79) and global assessment question results (0.86). No correlation was found between sildenafil failure and patient age, the etiology of erectile dysfunction, duration of erectile dysfunction, prior treatments, testosterone and prolactin blood levels, and the duration and etiology of renal failure. Of the 35 patients sildenafil was stopped due to intolerable headaches in 3 and because of lack of efficacy in 7.nnnCONCLUSIONSnSildenafil is an effective and safe treatment for erectile dysfunction in most patients on chronic dialysis.

Prospective patient-reported continence after laparoscopic radical prostatectomy

OBJECTIVESnTo perform a prospective study using confidential patient-completed questionnaires about their urinary habits before and after laparoscopic radical prostatectomy. Published reports on urinary continence after radical prostatectomy vary depending on the definitions of urinary continence and methods of data collection.nnnMETHODSnFrom May 1998 to February 2000, 228 men underwent laparoscopic radical prostatectomy for clinically localized prostate cancer. The patients were given questionnaires before surgery and at 1, 3, 6, and 12 months postoperatively.nnnRESULTSnBefore surgery, no patient reported incontinence. At 1, 3, 6, and 12 months postoperatively, perfect diurnal urinary control (no pads, no leakage at all) was reported in 9.9%, 28.6%, 57.4%, and 56.8% of patients, respectively. No pads were used in 18.8%, 58.4%, 68.9%, and 78.4% at 1, 3, 6, and 12 months, respectively. No patient reported use of more than 1 pad daily at 6 months of follow-up.nnnCONCLUSIONSnContinence after laparoscopic radical prostatectomy is comparable to the results after traditional radical retropubic prostatectomy. Ongoing use of the laparoscopic route for treating clinically localized prostate cancer is warranted.

Simple model for training in the laparoscopic vesicourethral running anastomosis

PURPOSEnTo create a simple model for training in the complex technique of laparoscopic vesicourethral anastomosis after radical prostatectomy.nnnMATERIALS AND METHODSnA model simulating the performance of a laparoscopic running urethrovesical anastomosis was fashioned using skin of a supermarket chicken set in a laparoscopic training box. A circular continuous anastomosis was performed, following exactly the technique we use in vivo for performing a vesicourethral anastomosis after laparoscopic radical prostatectomy. Details regarding the use of the right or the left needle holder, needle positioning, precise stitch position, and use of forehand or backhand stitch were strictly respected in order to reproduce the continuous stitch currently done in vivo in our department. The learning curve was analyzed in terms of the time necessary to perform the task and the quality of the anastomosis.nnnRESULTSnThe model was created and used by the junior authors during their year of fellowship in advanced laparoscopic urology. The authors had no previous experience with hands-on laparoscopic suturing but have assisted in a great number of laparoscopic radical prostatectomies. The time required for performing the anastomosis on the model declined from 75 minutes initially to 20 minutes after the trainees had performed 20 anastomoses each. After this training, it was possible to create a watertight running laparoscopic vesicourethral anastomosis in patients in a mean time of 40 minutes (range 30-55 minutes).nnnCONCLUSIONnThis simple model allows the trainee in laparoscopic urology to acquire the skills necessary to perform a laparoscopic vesicourethral anastomosis, one of the most complex steps in laparoscopic radical prostatectomy, as well as to develop dexterity and facility in laparoscopic manipulation of needles, sutures, and fragile tissues.

Laparoscopic treatment for ureteropelvic junction obstruction

OBJECTIVESnTo assess retrospectively the subjective and objective outcomes achieved after laparoscopic treatment for ureteropelvic junction obstruction at our institutions.nnnMETHODSnBetween August 1999 and July 2001, 19 patients (11 women and 8 men), with a mean age of 31.2 years (range 17 to 67), underwent laparoscopic treatment for ureteropelvic junction obstruction. Of these, 17 patients were eligible for postoperative analysis. Nine of these patients had a history of prior surgical intervention on the affected side. The patients were subjectively assessed by an analog pain scale performed before and at least 6 months after surgery. Preoperatively, patients had a diuretic renal scan to confirm the presence of obstruction. Helical computed tomography was also performed preoperatively to assess for the presence of crossing vessels. The renal scan was repeated at least 12 weeks after surgery to document the relief of obstruction objectively.nnnRESULTSnHelical computed tomography correctly predicted the presence of crossing vessels in 12 patients (63%). The Anderson-Hynes and Fenger pyeloplasty techniques were performed in 16 and 2 patients, respectively. In 1 patient, a small crossing vein over the ureteropelvic junction was identified and divided without complications. The average operative time was 240 minutes (range 128 to 470). The blood loss was minimal, and no open conversions were required. The mean hospital stay was 2.9 days (range 2 to 7). Two postoperative complications occurred (11.7%). The average subjective follow-up was 14.4 months (range 6 to 27), and the average objective follow-up was 7.8 months (range 3 to 12). Of 17 assessable patients, 16 (94%) had subjective and objective success (postoperative improvement in analog pain score and half-life of radiotracer washout). The average split renal function improved from 34.1% to 38.5% (P <0.01).nnnCONCLUSIONSnOn the basis of our data, laparoscopic pyeloplasty has a similar success rate compared with the traditional open approach and better results than other minimally invasive techniques. Longer follow-up and further experience are needed to validate these data.

Clinical significance of gross hematuria and its evaluation in patients receiving anticoagulant and aspirin treatment

OBJECTIVESnTo investigate the results of evaluations in patients presenting with gross hematuria while receiving anticoagulant or aspirin treatment and to compare the source of bleeding in these respective groups.nnnMETHODSnWe retrospectively studied all patients admitted because of gross hematuria while receiving warfarin or aspirin treatment between 1990 and 1998. The degree of anticoagulation was evaluated in patients taking anticoagulation medication. Almost all patients were evaluated by cystoscopy and either excretory urography or ultrasound.nnnRESULTSnPatients taking warfarin had a normal evaluation almost twice as often as those taking aspirin: 38% versus 22%, respectively. The leading pathologic findings in both groups were a bleeding benign prostate and a tumor in the urinary tract, in similar proportions. Overall, a tumor was diagnosed in one quarter of patients, and other treatable pathologic findings were diagnosed about half the time. In the 11 patients receiving excessive anticoagulation medication, two tumors were found (18%). Hemorrhagic cystitis was diagnosed in 12 patients. All 12 were taking aspirin.nnnCONCLUSIONSnA normal evaluation was more prevalent in the warfarin group. A tumor was diagnosed in about one quarter of the patients. The prevalence of hemorrhagic cystitis in patients taking aspirin may point to a specific bleeding diathesis in the urothelium of these patients. In light of these findings, a full evaluation is warranted in patients receiving aspirin or warfarin therapy, and the presence of excessive anticoagulation should not impede a full evaluation.

Pediatric transperitoneal laparoscopic partial nephrectomy: comparison with an age-matched group undergoing open surgery

We have retrospectively evaluated the effectiveness of laparoscopic transperitoneal partial nephrectomy (LTPN) in children in comparison to an age-matched group of children who underwent open partial nephrectomy (OPN) in terms of safety, operative time, narcotic requirements and the length of hospitalization. All patients were divided into two groups. The first group of 10 children with a mean age of 3.6xa0±xa01.3xa0years (meanxa0±xa0SEM) who underwent LTPN compared with an age and gender matched second group of 10 children with a mean age of 3.9xa0±xa01.4xa0years who underwent OPN (Pxa0=xa00.9119). In the first group, 5 upper poles and 5 lower poles partial nephrectomies were performed while in the second group 6 upper moieties and 4 lower moieties partial nephrectomies were performed, respectively. There was a single complication in each group. Intraoperative injury to the unaffected ureter was recognized during LTPN and required conversion to the open surgery in the beginning of learning curve and persistent urinary leakage from collecting system of the remnant pole in the OPN group, which resolved spontaneously. There was no difference in length of surgery and the intraoperative narcotic requirements (Pxa0=xa00.8182, 0.7638, respectively). However, postoperative narcotic requirements were significantly lower in the first group 0.56xa0±xa00.29xa0mg/kg compared to the second group 2.13xa0±xa00.3xa0mg/kg, Pxa0=xa00.0019. LTPN patients had significantly shorter hospitalization 2.7xa0±xa00.29xa0days compared with the OPN group 5.1xa0±xa00.64xa0days, Pxa0=xa00.0039. Similar findings were also found in the subgroup of patients younger than 2xa0years. Median follow up in each group was 28 and 36xa0months, respectively. Our data show that LTPN is a safe and effective minimally invasive procedure at every age. It has an equivalent operative time, shorter hospitalization and lower postoperative narcotic requirements compared to the open approach.

Are indications for prostatectomy in octogenarians the same as for younger men

Prostatectomy for benign hypertrophy of the prostate is usually performed to alleviate lower urinary tract symptoms (LUTS). We assessed indications for and risks of prostatectomy in men 80 years of age and compared them to those for younger men in order to determine whether indications for prostatectomy in octogenarians are different than these for younger men. Medical records of 171 men comprised of 84 patients >80 years of age (mean 84.4) and 87 patients <65 years of age (mean 60.6) who underwent prostatectomy for benign prostate hypertrophy were reviewed. Data regarding indications for surgery, American Society of Anesthesiologists system grade, anesthesia and surgery performed, duration of hospitalization and intrahospital postoperative complications were obtained. The respective indications for surgery in the very elderly and younger patients were: urinary retention with indwelling catheter in 46 (55%) and 34 (39%) (p < 0.04), LUTS in 32 (38%) and 52 (59%) (p < 0.005), and gross hematuria in 6 (7%) and 1 (1.2%). Transurethral prostatectomy was performed in 47 elderly patients (56%) and in 30 young patients (34.5%). The other patients in each group underwent open (suprapubic prostatectomy) surgery. The overall complication rate was significantly higher in the elderly group (39% vs 22%, p < 0.05), with major complications occurring only in this group. Indications for surgery were different for octogenarians than for younger men. Morbidity and mortality rates were significantly higher among the elderly men. Age appears to be an independent risk factor for complications associated with prostatectomy.

Is Postoperative Arteriovenous Fistula Still a Concern After En Bloc Stapling of the Renal Hilum During Laparoscopic Nephrectomy

PURPOSEnTo report our experience with en bloc stapling of the renal hilum during laparoscopic nephrectomy (LN) and nephroureterectomy and to compare it with separate stapling performed during the same period at the same institution.nnnPATIENTS AND METHODSnWe conducted a retrospective review of 125 laparoscopic nephrectomies and nephroureterectomies performed between November 2003 and September 2006 for benign and malignant conditions. The main outcome was assessment of complications, with special emphasis on postoperative arteriovenous fistula. Secondary outcomes included operative blood loss and operative time. Statistical analysis was performed using two-sided parametric, nonparametric, or categorical tests as appropriate. Statistical significance was set at P < or = 0.05.nnnRESULTSnThe transperitoneal approach and 2.5 mM vascular titanium clips were used in all cases. En bloc stapling (group 1) was performed in 65 patients and individual stapling (group 2) in 60. There was a significantly higher proportion of right-side surgeries in group 1 than in group 2 (51 vs 25%, P = 0.05). Overall complications were 31% vs 32%, P = 0.91; mean operative time (confidence interval [CI]) 130 (95% 119, 141) vs 125 min (95% 115, 136), P = 0.3; and mean operative blood loss (CI) 100 (95% 39, 160) vs 135 mL (95% 76, 193), P = 0.33 did not differ for groups 1 and 2, respectively. After a median follow-up (interquartile range) of 25 (24.7) vs 30 (30.0) months, P = 0.14, no cases of arteriovenous fistula were detected.nnnCONCLUSIONSnEn bloc stapling of the renal hilum is as safe and effective as individual stapling. Arteriovenous fistula after LN does not seem to be a concern with the use of modern inorganic titanium staplers.

Laparoscopic retroperitoneal nephrectomy for Aspergillus-infected polycystic kidney.

BACKGROUND AND PURPOSEnThe management of polycystic kidney disease is mostly restricted to conservative measures. However, nephrectomy may be indicated in particular cases, especially when there are infective complications. To decrease the morbidity of the procedure, the laparoscopic approach has become appealing. We present a laparoscopic retroperitoneal approach to complicated polycystic kidney disease in a high-risk patient. CASERESPORT: We performed right retroperitoneal laparoscopic nephrectomy in a 39-year-old man who had autosomal polycystic kidney disease and had undergone heart transplantation. The immunosuppressed patient presented with severe flank pain, generalized signs of infection, and acute renal insufficiency. With the patient in the right lateral decubitus position, the retroperitoneal space was entered by the open technique, and the posterior pararenal space was developed with finger dissection. Five trocars were used. After the renal vessels had been secured and divided, the cysts were successively punctured, gradually shrinking the operative specimen. The kidney was placed in an Endo-catch and removed after morcellation, with no need to enlarge the 2-cm lumbotomy. The operating time was 80 minutes, and the hospital stay was 4 days. Histologic examination revealed a polycystic kidney with Aspergillus infection.nnnCONCLUSIONnThe laparoscopic approach is a less-invasive option for removing a polycystic kidney when nephrectomy is indicated. The retroperitoneal route has the advantage of minimizing infection risks because of the absence of peritoneal opening.