Chad R. Tracy

Lower Extremity Neuropathies After Robot-Assisted Laparoscopic Prostatectomy on a Split-Leg Table

BACKGROUND AND PURPOSE Lower extremity neuropathies from prolonged lithotomy positioning have been well documented. When we initiated our robot-assisted laparoscopic prostatectomy (RALP) program in December 2002, we chose to use the split-leg table that allows patient support in a more anatomic position, hypothesizing that this would reduce risk of neurologic compression injuries. We report our incidence of lower extremity neuropathies associated with RALP using split-leg positioning and review patient and surgical variables associated with this complication. PATIENTS AND METHODS We retrospectively reviewed records of 377 patients who underwent RALP using a split-leg table. Patient data including height, weight, body mass index, age, and smoking status; surgical variables such as surgeon operative experience and intraoperative times were also assessed. Intraoperative time was defined as anesthesia induction to anesthesia emergence to more accurately measure total time patients spent in the split-leg position. RESULTS Of 377 patients, lower extremity neuropathies developed in 5 (1.3%) in the immediate postoperative period. Of all variables examined, only increased intraoperative time was identified as a potential risk factor for the development of this complication (496.2 ± 34.8 min vs 366.3 ± 96.1 min, P<0.001). Overall mean operative time for all patients was 368.0 ± 96.6 minutes. Three of the five patients had symptoms suggestive of a femoral mononeuropathy. CONCLUSIONS Intraoperative time as defined in our study is a significant risk factor for development of postoperative neuropathy. We also found that split-leg positioning appears to put the femoral nerve at risk for injury, instead of the common peroneal nerve as has been previously reported from prolonged lithotomy positioning.

Laparoendoscopic single-site surgery in urology: where have we been and where are we heading?

One-port, single-incision laparoscopy is part of the natural development of minimally invasive surgery. Refinement and modification of laparoscopic instrumentation has resulted in a substantial increase in the use of laparoendoscopic single-site surgery (LESS) in urology over the past 2 years. Since the initial report of single-port nephrectomy in 2007, urologists have successfully performed various procedures with LESS, including partial nephrectomy, pyeloplasty, orchiectomy, orchiopexy, ureterolithotomy, sacrocolpopexy, renal biopsy, renal cryotherapy, and adrenalectomy. Further advancements in technology, such as magnetic anchoring and guidance systems, and robotic instrumentation, may allow broader application of this emerging surgical technique. Future research is required to determine the intraoperative and postoperative benefits of LESS in comparison with standard laparoscopy.

Durable oncologic outcomes after radiofrequency ablation: experience from treating 243 small renal masses over 7.5 years.

Long‐term oncologic outcomes for renal thermal ablation are limited. The authors of this report present their experience with radiofrequency ablation (RFA) therapy for 243 small renal masses (SRMs) over the past 7.5 years.

Perioperative Outcomes in Patients Undergoing Conventional Laparoscopic Versus Laparoendoscopic Single-site Pyeloplasty

OBJECTIVES To compare the outcomes of laparoendoscopic single-site (LESS) surgery with conventional laparoscopic pyeloplasty (CLP) before LESS can be widely accepted. LESS surgery is a novel technique for performing laparoscopic pyeloplasty through a single incision. METHODS Fourteen patients undergoing less pyeloplasty were matched 2:1 with regard to age and side of surgery to a previous cohort of 28 patients who underwent CLP. All patients underwent surgery for symptomatic ureteropelvic junction obstruction and/or delayed urinary excretion based on functional imaging. Intracorporeal suturing was aided through a 5-mm instrument placed in the eventual drain site. RESULTS No difference was observed between the LESS and CLP cohorts in regard to preoperative characteristics. Postoperatively, no difference was noted between LESS and CLP cases in regard to length of stay (77 vs 74 hours; P = .69), morphine equivalents required (34 vs 38; P = .93), minor postoperative complications (14.3% vs 14.3%; P = 1.0), or major postoperative complications (21.4% vs 10%; P = .18). Median operative times (207 vs 237.5 minutes; P <.001) and median estimated blood loss (30 vs 72.5 mL; P = .002) were lower in patients undergoing LESS. Detailed follow-up imaging revealed a success rate of 96% for CLP at 14.6 months (86% follow-up) and 100% for LESS at 6.8 months (71% follow-up). CONCLUSIONS Although LESS pyeloplasty is feasible, all measured perioperative outcomes are similar to CLP. Further studies are needed to better define the appropriate role of LESS surgery in urology.

Where do we really stand with LESS and NOTES

Matthew T. Gettman *, Wesley M. White, Monish Aron, Riccardo Autorino, Tim Averch, Geoffrey Box, Jeffrey A. Cadeddu, David Canes, Edward Cherullo, Mihir M. Desai, Igor Frank, Indebir S. Gill, Mantu Gupta, Georges-Pascal Haber, Mitchell R. Humphreys, Brian H. Irwin, Jihad H. Kaouk, Louis R. Kavoussi, Jaime Landman, Evangelos N. Liatsikos, Estevao Lima, Lee E. Ponsky, Abhay Rane, Maria Ribal, Robert Rabenhalt, Pradeep Rao, Lee Richstone, Mark D. Sawyer, Rene Sotelo, Jens-Uwe Stolzenburg, Chad R. Tracy, Robert J. Stein; Endourological Society NOTES and LESS Working Group; European Society of Urotechnology NOTES and LESS Working Group E U RO P E AN URO LOGY 5 9 ( 2 0 1 1 ) 2 3 1 – 2 3 4

Patient-reported body image and cosmesis outcomes following kidney surgery: Comparison of laparoendoscopic single-site, laparoscopic, and open surgery

BACKGROUND Laparoendoscopic single-site surgery (LESS) is reported to result in superior cosmesis versus alternative surgical approaches, based solely on surgeon assessment or anecdotal evidence. OBJECTIVE Evaluate patient-reported body image and cosmesis outcomes following kidney surgery. DESIGN, SETTING, AND PARTICIPANTS We conducted a prospective and retrospective observational cohort study involving patients who underwent kidney surgery (n=114) via LESS (n=35), laparoscopic (n=52), or open (n=27) approaches. Cosmesis was evaluated using a comprehensive survey administered ≥3 mo postoperatively. MEASUREMENTS Survey components were a body image questionnaire (BIQ) consisting of body image and cosmesis subscales, a photo-series questionnaire (PSQ) assessing scar preferences after knowledge of scar outcomes for alternative surgical approaches, and query of preference for future surgical approach using a trade-off method. Body image, cosmesis, and PSQ scales ranged from 5 to 20, 3 to 24, and 1 to 10, respectively. RESULTS AND LIMITATIONS Median BIQ component scores did not significantly differ across surgical approaches. Median ratings for the LESS, laparoscopy, and open scar photographs were 8, 5, and 5, respectively (p=0.0001). Before viewing photographs, median self-scar ratings for LESS, laparoscopy, and open approaches were 9, 5, and 6.5, respectively (p=0.02); after photographs, ratings were 9, 7, and 7, respectively (p=0.008). Assuming equivalent surgical risk among the approaches, overall preference for future LESS, laparoscopy, or open surgery was 39%, 33%, or 4%, respectively. As theoretical risk of LESS was raised, preference for LESS decreased, whereas preference for laparoscopy and open surgery increased. Study limitations are a nonrandomized design and the use of a nonvalidated scale. CONCLUSIONS Urologic patients favor LESS cosmesis outcomes over those for laparoscopy or open surgery. Considering the superior scar satisfaction among LESS patients, who were younger and more likely to be undergoing surgery for benign disease, we infer that this demographic most values the cosmetic advantages of LESS.

Irreversible electroporation (IRE): a novel method for renal tissue ablation

What’s known on the subject? and What does the study add?

Utility of the RENAL nephrometry scoring system in the real world: predicting surgeon operative preference and complication risk

Study Type – Prognosis (individual cohort)

Update on the medical management of stone disease.

Purpose of review Recurrent nephrolithiasis is a burden to the individual patient as well as the healthcare system. A lack of new medications for treatment of stone disease and continued poor compliance with drug therapy has led to a growing interest in dietary manipulation and novel therapies aimed at preventing recurrent stone formation. Recent findings Despite initial enthusiasm for lemonade therapy, recent metabolic studies suggest that beverages with a high potassium citrate content, rather than citric acid, may be more effective in reducing stone risk because of the alkali load and citraturic response. In addition, there is increasing epidemiologic and metabolic evidence that obesity and dietary excess, including fructose-rich and purine-rich foods, are associated with increased stone risk. Finally, alternative measures for reducing urinary risk factors, such as probiotics, show promise in reducing urinary oxalate and may be effective in the treatment of primary and enteric hyperoxaluria or even idiopathic calcium oxalate nephrolithiasis. Although changes in urinary stone risk factors may reduce the need for surgical treatment of stone disease, the best management for recurrent nephrolithiasis is likely a combination of surgical and medical therapy. Summary Dietary measures and novel probiotic therapy are promising adjuncts for preventing recurrent nephrolithiasis.

Importance of cosmesis to patients undergoing renal surgery: a comparison of laparoendoscopic single-site (LESS), laparoscopic and open surgery

Study Type – Therapy (case series)