Andrew J. Portis

LAPAROSCOPIC VERSUS OPEN RADICAL NEPHRECTOMY: A 9-YEAR EXPERIENCE

PURPOSE The laparoscopic approach for renal cell carcinoma is slowly evolving. We report our experience with laparoscopic radical nephrectomy and compare it to a contemporary cohort of patients with renal cell carcinoma who underwent open radical nephrectomy. MATERIALS AND METHODS From 1990 to 1999, 32 males and 28 females underwent 61 laparoscopic radical nephrectomies for suspicious renal cell carcinoma. Clinical data from a computerized database were reviewed and compared to a contemporary group of 33 patients who underwent open radical nephrectomy for renal cell carcinoma. RESULTS Patients in the laparoscopic radical nephrectomy group had significantly reduced, estimated blood loss (172 versus 451 ml., p <0.001), hospital stay (3.4 versus 5.2 days, p <0.001), pain medication requirement (28.0 versus 78.3 mg., p <0.001) and quicker return to normal activity than patients in the open radical nephrectomy group (3.6 versus 8.1 weeks, p <0.001). The majority of laparoscopic specimens (65%) were morcellated. Operating time and cost were higher in the laparoscopic than the open nephrectomy group. Average followup was 25 months (range 3 to 73) for the laparoscopic and 27.5 months (range 7 to 90) for the open group. Renal cell carcinoma in 3 patients (8%) recurred in the laparoscopic group versus renal cell carcinoma in 3 (9%) in the open group. When stratified patients with tumors larger than 4 to 10 cm. experienced similar benefits and results as patients with tumors less than or equal to 4 cm. To date there have been no instances of trocar or intraperitoneal seeding in the laparoscopic radical nephrectomy group. CONCLUSIONS Laparoscopic radical nephrectomy, although technically demanding, is a viable alternative for managing localized renal tumors up to 10 cm. It affords patients with renal tumors an improved postoperative course with less pain and a quicker recovery while providing similar efficacy at 2-year followup for patients with T1 and T2 tumors.

LONG-TERM FOLLOWUP AFTER LAPAROSCOPIC RADICAL NEPHRECTOMY

PURPOSE Laparoscopic radical nephrectomy has been shown to be less morbid than traditional open radical nephrectomy. The long-term oncological effectiveness of laparoscopic radical nephrectomy remains to be established. MATERIALS AND METHODS At 3 centers patients undergoing laparoscopic radical nephrectomy before November 1, 1996 with pathologically confirmed renal cell carcinoma were identified. A representative group of patients undergoing open radical nephrectomy for clinical T1, T2 lesions was also identified. Staging, operative details and postoperative course were reviewed. Followup consisted of review of clinical, laboratory and radiological records. Kaplan-Meier analysis was performed. RESULTS The study included 64 patients treated with laparoscopic and 69 treated with open radical nephrectomy with respective average ages of 60.6 and 61.3 years at surgery. On preoperative imaging open lesions were larger (6.2 cm., range 2.5 to 15) than laparoscopic radical nephrectomy lesions (4.3 cm., range 2 to 10, p <0.001). Pathology reports revealed no difference in specimen weight (425 and 495 gm., p = 0.146) or average Fuhrman grade (1.88 and 1.78, p = 0.476) between laparoscopic and open radical nephrectomy, respectively. Median followup was 54 months (range 0 to 94) for laparoscopic and 69 months (range 8 to 114) for open radical nephrectomy. Kaplan-Meier analysis with log rank comparison revealed 5-year recurrence-free survival of 92% and 91% for laparoscopic and open radical nephrectomy, respectively (p = 0.583). At 5 years cancer specific survival was 98% and 92% (p = 0.124), and nonspecific survival was 81% and 89% (p = 0.260) for laparoscopic and open radical nephrectomy, respectively. CONCLUSIONS Laparoscopic radical nephrectomy confers long-term oncological effectiveness equivalent to traditional open radical nephrectomy.

Laparoscopic nephrectomy in patients with end-stage renal disease and autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is often characterized by end-stage renal disease (ESRD) and problems including pain, hematuria, and infection. Open nephrectomy is curative; however, the morbidity of the procedure is considerable. Between 1995 and 1998, 11 laparoscopic nephrectomies were performed on nine symptomatic patients (five men and four women) with ESRD and ADPKD. Two patients underwent a staged bilateral laparoscopic nephrectomy. All patients presented with abdominal or flank pain and an abdominal mass. Other clinical problems included hypertension in eight patients, urinary tract infections in two patients, and gross hematuria in one patient. Seven patients were receiving long-term dialysis treatment, and two patients had undergone prior renal transplantation. Patients were evaluated for preoperative and postoperative pain, analgesic use, hospital course, and convalescence. The overall average operative time was 6.3 hours, with an average estimated blood loss of 153 mL. Eight nephrectomy specimens were removed by morcellation, and three specimens were removed intact through a 7- to 12-cm incision. The average hospital stay was 3 days, and the average time to normal activity was 5 weeks. With a mean follow-up of 31 months, all nine patients reported elimination of their preoperative pain based on a pain analogue score. Six major and two minor complications occurred, including blood transfusion, a vena cavotomy, splenic cyanosis, pulmonary embolism, clotted arteriovenous fistula, and brachial plexus injury. Incisional hernias occurred in two of the three patients who underwent open removal. One patient noted improvement, and two patients noted resolution of their hypertension postoperatively. Laparoscopic nephrectomy in patients with ADPKD and ESRD offers an effective alternative to open nephrectomy to manage renal-related pain. This procedure provides the benefits of minimal intraoperative blood loss, minimal postoperative pain, brief hospital stay, and rapid convalescence.

Ureteroscopic Laser Lithotripsy for Upper Urinary Tract Calculi With Active Fragment Extraction and Computerized Tomography Followup

PURPOSE Management of fragments generated by ureteroscopic laser lithotripsy remains controversial. In this study we explored the impact of active fragment extraction after ureteroscopic laser lithotripsy on stone clearance. MATERIALS AND METHODS A total of 69 patients with 3 or less upper urinary tract calculi (5 to 15 mm) demonstrated on preoperative CT were prospectively evaluated. Stones were translocated to a dependent upper pole calix where laser lithotripsy was performed. An attempt was made to clear all fragments using tipless stone baskets. One month after surgery stone clearance was evaluated exclusively with noncontrast spiral CT. RESULTS In 58 patients undergoing surgery on protocol, average stone burden was 9.4 +/- 3.4 mm and was significantly smaller in 44 patients with stones in a solitary location (8.5 +/- 2.9 mm) than in 14 patients with stones in multiple locations (12.3 +/- 3.2 mm, p <0.001). Primary stone location was categorized as renal nonlower pole (in 16), renal lower pole (in 19) and proximal ureter (in 23). Average operative time (43.7 +/- 18.4 minutes) was unaffected by stone location or multiplicity after controlling for stone size (p >0.05). Stone clearance rates were not affected by stone location or multiplicity, with overall success rates of 54%, 84% and 95% at fragment thresholds of 0, 2 and 4 mm, respectively (p >0.05). CONCLUSIONS Ureteroscopic laser lithotripsy with active fragment extraction was time efficient and highly effective. Sensitive postoperative imaging reveals the challenge of achieving a true stone-free state. We were unable to demonstrate an impact of stone location on stone-free rates.

Matched pair analysis of shock wave lithotripsy effectiveness for comparison of lithotriptors

PURPOSE In an effort to streamline a comparison of the effectiveness of a new lithotriptor with the standard HM3 lithotriptor (Dornier Medical Systems, Inc., Marietta, Georgia) we used a matched pair analysis design. A matched design often provides more efficient estimates (smaller variances) than an unmatched design given the same sample size. MATERIALS AND METHODS Patients with solitary renal or ureteral calculi treated on a LithoTron shock wave lithotriptor (HealthTronics, Marietta, Georgia) between October 1999 and February 2000 with a minimum followup of 3 months were identified. Evaluable patients treated with the LithoTron were matched using 5 parameters to a data base of patients treated with an unmodified HM3 shock wave lithotriptor between October 1997 and February 2000. Matching criteria consisted of calculus side, calculus location (1 of 7 categories), maximum stone diameter (+/-2 mm.), minimum stone diameter (+/-2 mm.) and patient body mass index (BMI +/-6). When more than 1 match was suitable, matching was directed by random numbers. Following matching, clinical charts and radiographic reports were evaluated for stone clearance and post-shock wave lithotripsy interventions. Stone treatment success was defined as residual fragments less than 2 mm. without need for further intervention. RESULTS A total of 94 potentially evaluable patients treated with the LithoTron were identified and 38 matched pairs were created. Average maximum stone diameter, minimum stone diameter, and BMI were 9.6 and 9.9 mm., 6.7 and 6.8 mm. and 29.3 and 28.9 kg./m. for HM3 and LithoTron cases, respectively. All calculi were radiopaque and consisted of mixed calcium oxalate monohydrate (19 and 13), calcium oxalate dihydrate (1 and 1) or calcium phosphate (2 and 2) in the HM3 and LithoTron groups, respectively. Patients were not specifically matched on stone composition because of incomplete availability. Overall intervention-free, stone treatment success rate was 79% for the HM3 and 58% for the LithoTron. OR for failure of LithoTron versus HM3 treatment was 3.004 (McNemar test p = 0.08). There were 16 discordant pairs. In 4 cases LithoTron was successful and HM3 failed, and in 12 cases LithoTron failed and HM3 was successful. Subgroup analysis revealed a trend for LithoTron treatment failure for lower pole calculi, calculi 10 mm. or greater and BMI of 30 kg./m. or greater. CONCLUSIONS In this initial evaluation the HM3, despite a relatively small study sample size, appeared to provide superior clinical results to the LithoTron (p = 0.08). The use of matched pair analysis using a large cohort of patients treated with the HM3 for retrospective matching may allow for accurate determination of the effectiveness of new lithotripsy technology with a relatively small clinical study group.

Is the laparoscopic approach justified in patients with xanthogranulomatous pyelonephritis

OBJECTIVES Xanthogranulomatous pyelonephritis (XGP) is an atypical form of chronic renal infection. The treatment of choice is open nephrectomy, which is challenging, given the extent of the disease and the not uncommon involvement of the renal hilum and contiguous structures. We compared our experience with laparoscopic nephrectomy for histologically confirmed XGP with the open approach. METHODS Review of all nephrectomy specimens at Washington University School of Medicine from July 1990 to March 1998 disclosed 9 patients with a pathologic diagnosis of unilateral XGP, of whom 5 patients underwent laparoscopic nephrectomy and 4 underwent open nephrectomy. XGP was suspected preoperatively in 56% of the patients. RESULTS For the laparoscopic group, the average operating room time was 360 minutes, average blood loss was 260 mL, and complications occurred in 60% of patients (1 conversion to open, 1 ileus, 1 pulmonary embolus). For the open group, the average operating room time was 154 minutes, average blood loss was 438 mL, and there were no complications. Both groups were similar regarding time to oral intake, analgesia requirement, hospital stay, and time to complete recovery. CONCLUSIONS Our early experience demonstrates that the benefits of laparoscopic nephrectomy, at present, do not extend to patients with XGP. Conventional open surgery is quicker, associated with fewer complications, and results in a similar use of analgesics, hospital stay, and recovery time.

LAPAROSCOPIC AUGMENTATION CYSTOPLASTY WITH DIFFERENT BIODEGRADABLE GRAFTS IN AN ANIMAL MODEL

PURPOSE Recently a variety of biodegradable organic materials have been used for bladder wall replacement. We sought to study the effectiveness of 4 different types of biodegradable materials for bladder augmentation using laparoscopic techniques. MATERIALS AND METHODS Thirty one minipigs underwent successful transperitoneal laparoscopic partial cystectomy and subsequent closure (6 control) or patch augmentation (25): porcine bowel acellular tissue matrix (ATM) (6), bovine pericardium (BPC) (6), human placental membranes (HPM) (6) or porcine small intestinal submucosa (SIS) (7). An intracorporeal suturing technique with the EndoStitch device (U.S. Surgical, Norwalk, CT) and Lapra-Ty clips (Ethicon, Enodsurgery Inc. Cincinnati, OH) was used to anastomose the graft to the bladder wall. Postoperatively, a urethral catheter was left for one week. Bladders were evaluated by cystoscopy at 6 and 12 weeks and harvested at 12 weeks. RESULTS Grafts remained in place in all groups except for the BPC group, where all grafts failed to incorporate. For the ATM and SIS groups, at 6 weeks, there was mucosal coverage of the grafts without evidence of encrustation. In the control group, at 12 weeks, the bladder capacity was 23% less than preoperatively. In the ATM, HPM and SIS groups, at 12 weeks, the bladder capacities were larger than preoperatively by 16%, 51% and 43% respectively; also the grafts had contracted to 70%, 65%, and 60% of their original sizes, respectively. Histologically, there was patchy epithelialization of ATM and SIS grafts with a mixture of squamoid and transitional cell epithelia. The graft persisted as a well-vascularized fibrous band in HPM, ATM, and SIS without evidence of significant inflammatory response. CONCLUSION A laparoscopic technique for partial bladder wall replacement using a free graft is feasible. The biodegradable grafts of ATM, HPM and SIS are tolerated by host bladder and are associated with predominantly only mucosal regeneration at 12 weeks post-operatively.

Laparoscopic Radical/Total Nephrectomy: A Decade of Progress

The first laparoscopic radical/total nephrectomy for a renal tumor was performed in June 1990. Since that time, the procedure has evolved as numerous surgeons have contributed novel strategies and technical advances. The state of the art is reviewed, including transperitoneal laparoscopic and hand-assisted techniques, as well as the retroperitoneal approach. Operative and postoperative data are reviewed with the goal of determining four factors: the efficacy, efficiency, morbidity, and cost of the procedure. Within the limits of available follow-up for this novel procedure, it appears to be as effective as open surgery in rendering the patient tumor free. Although it clearly is a less painful and less disabling procedure than open surgery, our understanding of the efficiency of the laparoscopic procedure remains in flux. The operative times for laparoscopic radical/total nephrectomy are approaching those of traditional open radical nephrectomy, although intraoperative costs remain higher and thus must be balanced against decreased hospitalization and convalescence.

Intraoperative Fragment Detection During Percutaneous Nephrolithotomy: Evaluation of High Magnification Rotational Fluoroscopy Combined With Aggressive Nephroscopy

PURPOSE Percutaneous nephrolithotomy effectively treats large volume renal calculi but relies on postoperative imaging to judge success. We evaluated the effectiveness of maximizing intraoperative imaging through combined high resolution fluoroscopy and flexible nephroscopy. MATERIALS AND METHODS Percutaneous nephrolithotomy was performed cooperatively with a radiologist in an interventional radiology suite equipped with a ceiling mounted, high resolution C-arm. Aggressive rigid and flexible nephroscopy was performed. At the conclusion patients were prospectively classified as radiologically and/or endoscopically stone-free. Postoperative noncontrast CT allowed fragment classification as stone-free, 2 mm or less, 2 to 4 mm and greater than 4 mm. RESULTS The average stone dimension +/- SEM was 579 +/- 77 mm(2) in 25 consecutive renal units. CT demonstrated that 15 renal units (60%) were stone-free after the primary procedure, while 2 (8%), 5 (20%) and 3 (12%) had fragments 2 or less, 2 to 4 and greater than 4 mm, respectively. Of 21 renal units considered endoscopically and fluoroscopically stone-free postoperative CT demonstrated that 6 had residual fragments, of which all were less than 4 mm. All 4 renal units not considered radiologically and endoscopically stone-free had fragments on CT. Intraoperative fluoroscopy after nephroscopy demonstrated fragments in 36% of renal units, of which after further nephroscopy 78% were stone-free on CT. The sensitivity of intraoperative imaging with reference to the gold standard of postoperative CT was 40%, 38% and 100% at thresholds of 0, 2 and 4 mm, respectively. Specificity was 100%, 94% and 95%, respectively. CONCLUSIONS Flexible nephroscopy combined with high magnification rotational fluoroscopy allows sensitive and specific intraoperative detection of residual fragments, enabling immediate removal or the planning of necessary second look nephroscopy.

LAPAROSCOPIC BLADDER NECK SUSPENSION FAILS THE TEST OF TIME

PURPOSE Initial reports on laparoscopic bladder neck suspension have suggested success rates similar to those of traditional bladder neck suspension. We compare long-term success rates of laparoscopic and transvaginal Raz bladder neck suspension. MATERIALS AND METHODS A total of 100 patients with anatomical stress urinary incontinence underwent extraperitoneal laparoscopic bladder neck suspension with securing of the endopelvic fascia to Coopers ligament (58, laparoscopy group) or transvaginal Raz bladder neck suspension (42, transvaginal group). Patients were evaluated by chart review and telephone questionnaire to determine whether they had urinary incontinence. RESULTS The 2 groups were similar in terms of age, mean body mass index, preoperative bladder capacity and post-void residual. Mean followup was 45 months (range 14 to 71) in 50 laparoscopy group (86%) and 59 months (range 35 to 72) in 29 transvaginal group (70%) patients. Only 15 of 50 laparoscopy group (30%) and 10 of 29 transvaginal group (35%) patients were completely continent at followup. There was no statistically significant difference in the success rates for the 2 groups. Mean time to failure for both groups was 18 to 24 months. CONCLUSIONS With long-term followup laparoscopic bladder neck suspension demonstrated poor success rates similar to other minimally invasive surgical therapies for stress urinary incontinence. Any new surgical technique for treatment of stress urinary incontinence should have a mean followup of more than 2 years to determine true clinical efficacy.