Brian D. Seifman

NEPHRON SPARING SURGERY FOR SUSPECTED MALIGNANCY: OPEN SURGERY COMPARED TO LAPAROSCOPY WITH SELECTIVE USE OF HAND ASSISTANCE

PURPOSE Laparoscopic nephron sparing surgery has been reported rarely, likely due to technical difficulty when using only laparoscopic instrumentation. Hand assisted techniques may facilitate the procedure in select cases while maintaining the benefits of minimally invasive surgery. We prospectively compared the laparoscopic with selective hand assistance and open surgical approaches to nephron sparing surgery for suspected malignancy. MATERIALS AND METHODS We compared our initial 10 laparoscopic nephron sparing procedures for suspected malignancy, including 8 with hand assistance, in 9 patients (11 tumors) with 11 consecutive open surgical procedures for similar indications. Standard laparoscopic technique was used in cases of an exophytic mass with shallow penetration into the parenchyma. Otherwise hand assistance was used. Recovery data were obtained prospectively using self-administered questionnaires. RESULTS Although mean operative time was 24% greater in the laparoscopic group, recovery was more favorable than in the open surgical group, as evidenced by 62% less parenteral narcotic use, 43% shorter hospital stay, 64% more rapid return to normal nonstrenuous activity, and improved pain and physical health scores 2 and 6 weeks postoperatively. In each group mean lesion diameter was 2.4 cm., 8 of 11 neoplasms were malignant and no margins were positive for malignancy. There were no conversions to open surgery and no major complications in the laparoscopic group. CONCLUSIONS Laparoscopic nephron sparing surgery appears to have an advantage over open surgery in terms of patient recovery. Facilitation by hand assistance may make laparoscopic nephron sparing surgery a more widely available, minimally invasive alternative to open surgery for small, favorably located renal tumors.

Transperitoneal Laparoscopy into the Previously Operated Abdomen: Effect on Operative Time, Length of Stay and Complications

PURPOSE We evaluated the effect of previous abdominal surgery on perioperative outcomes in patients undergoing a renal/adrenal laparoscopic procedure via a transperitoneal approach. MATERIALS AND METHODS Renal/adrenal laparoscopic procedures via a transperitoneal approach were assessed. Medical records were reviewed to obtain operative and perioperative data. RESULTS Of the 190 patients 76 (40%) had previously undergone abdominal surgery. Patients with versus without an earlier abdominal operation had a longer mean hospital stay (3.8 versus 2.6 days, p = 0.002) but not longer median operative room time (median 220 versus 210 minutes, p >0.05). Operative and major complication rates were greater in patients with previous operations (16% versus 4%, p = 0.009 and 16% versus 5%, p = 0.022, respectively). Access and total complication rates were not altered (4% versus 2% and 33% versus 24%, respectively, p >0.1). An upper midline scar/ipsilateral upper quadrant scar was associated with a greater access complication rate (12% versus 0%, p = 0.029) but not a higher operative complication rate (21% versus 13%, p = 0.502). Multiple logistic regression confirmed that previous abdominal surgery was the only factor associated with operative complications. CONCLUSIONS Previous open abdominal operation increased the risk of operative and major complications, which most likely resulted in increased length of stay. The location of the scar impacted the access complication rate. Patients who have undergone previous open surgical procedures should be counseled on the greater risk of complications if the transperitoneal route is elected. Alternatively a retroperitoneal approach may be used.

Use Of Absorbable Cyanoacrylate Glue To Repair An Open Cystotomy

PURPOSE A biodegradable cyanoacrylate glue was tested for its ability to close bladder injuries in an established porcine model. Inflammation and encrustation associated with this glue were examined in a rabbit model. MATERIALS AND METHODS Four domestic pigs underwent transverse cystotomy, which was closed with absorbable cyanoacrylate glue. Four weeks later the bladder was distended with normal saline to evaluate the repair. A total of 45 rabbits underwent cystotomy, which was closed with polyglactin suture, absorbable cyanoacrylate glue or nonabsorbable 2-octyl cyanoacrylate glue. The bladder was harvested at 4 or 12 weeks to evaluate inflammation, microcalcification and encrustation. RESULTS All 4 pig bladders tolerated a pressure of 200 mm. Hg 4 weeks after closure. In the rabbit bladders there was no difference in inflammation in the groups at 4 and 12 weeks. The absorbable glue and suture groups had less microcalcification than the 2-octyl cyanoacrylate glue group at 4 and 12 weeks (p = 0.01 and 0.02, respectively). Encrustation was less in the suture and absorbable glue groups than in the 2-octyl cyanoacrylate glue group at 4 and 12 weeks (p = 0.004 and 0.02, respectively). CONCLUSIONS An experimental absorbable cyanoacrylate glue has the strength to seal a large cystotomy. The inflammatory response to absorbable glue is similar to that to suture at 12 weeks. Absorbable glue does not promote calcification. These properties may make it a suitable material for replacing or augmenting suture in the urinary tract.

Functional effects of unilateral laser papillectomy in the pig.

OBJECTIVES To evaluate the use of endoscopic laser papillectomy in a multi-papillary animal model to unilaterally impair concentrating ability and increase the urinary flow rate. METHODS Domestic pigs underwent unilateral retrograde flexible nephroscopy. With a holmium:yttrium-aluminum-garnet laser, varying numbers of papillae were ablated. Four weeks after the procedure, renal function studies were performed during hydropenia and after hydration, the animals were killed, and the kidneys were examined histologically. RESULTS The urine flow rate per 100 mL creatinine clearance was significantly increased in the papillectomized kidney compared with the control kidney during hydropenia (1.50 versus 0.94, P <0.01). The papillectomized kidneys were unable to concentrate the urine as well as the control kidneys during both hydropenia (urine osmolarity 430 versus 534 mOsm/L, P <0.01) and after hydration (329 versus 362 mOsm/L, P = 0.02). The free water reabsorption per 100 mL creatinine clearance was impaired in the papillectomized kidneys compared with the control kidneys (0.48 versus 1.00, P = 0.02) after hydration. A significant correlation existed between the percentage of papillae ablated and the difference in osmolarity between the operated and control kidneys (r(2) = 0.50, P = 0.015). Histologic examination demonstrated transitional re-epithelialization with moderate collecting duct dilation and medullary fibrosis underlying the ablated papillae early in the series; however, the histologic features normalized and the creatinine clearance was less impaired with a more proficient technique later in the series. CONCLUSIONS Endoscopic laser papillectomy results in increased urine flow and impaired urinary concentrating ability. This surgical technique should be investigated further for its role in the prevention of nephrolithiasis.

Use of bowel in laparoscopic urology.

Minimally invasive urology is a rapidly expanding field. What once was thought technically impossible is now becoming a reality, especially with the advent of intracorporeal stapling and automated suturing devices. Laparoscopic assistance and pure laparoscopy improve convalescence and cosmesis in comparison with open surgical procedures. Minimally invasive continent urinary stomas, ACE procedures, bladder augmentation, urinary diversion, and urinary undiversion have all been described in clinical practice. Continent urinary diversions and ileal bladder augmentations are being developed. Eventually, even the most challenging urologic procedures will be performed in a minimally invasive manner.

PD14-03 POST-ACUTE CARE AS A DRIVER OF EPISODE COST VARIATION FOR AMBULATORY STONE SURGERY

INTRODUCTION AND OBJECTIVES: Because many postacute care (PAC) services, including emergency department (ED) visits, after ambulatory stone surgery are potentially avoidable, they are coming under payer scrutiny. In this context, we analyzed claims data to describe variation in total episode costs for ambulatory stone surgery across a diverse set of hospitals, examining PAC as a driver of this variation. METHODS: We used Medicare and private insurer claims to identify patients who underwent ambulatory stone surgery (ureteroscopy or shockwave lithotripsy) at hospitals in Michigan (20122015) from the Michigan Value Collaborative. We defined surgical episodes that extended from the surgery date through 30 days postdischarge and totaled costs for all relevant services during this window. We then categorized component payments to the hospital for the index surgery, as well as those for professional services, subsequent hospitalizations, and PAC. Finally, after aggregating across episodes within a year by hospital, we placed hospitals into quartiles based on their mean total costs and compared component payments at highversus low-cost hospitals. RESULTS: In total, we identified 7,807 patients who underwent ambulatory stone surgery at 69 hospitals in Michigan. The mean total cost for hospitals was

FIBRIN GLUE V SUTURED BOLSTER: LESSONS LEARNED DURING 100 LAPAROSCOPIC PARTIAL NEPHRECTOMIES

9,538 (

Identifying Patients Who are Suitable for Stentless Ureteroscopy Following Treatment of Urolithiasis

13,044 and

Clinical Skills Acquisition for Hand-Assisted Laparoscopic Donor Nephrectomy

9,037 for episodes associated with and without an ED visit after surgery, respectively) and ranged from

Laparoscopic nephron-sparing surgery for a renal mass: 1-year minimum follow-up.

7,317 to