Chien Hui Ou

Hand Assisted Retroperitoneoscopic Nephroureterectomy With the Patient Spread-Eagled: An Approach Through a Completely Supine Position

PURPOSE We evaluated the feasibility of hand assisted retroperitoneoscopic nephroureterectomy for transitional cell carcinoma of the upper urinary tract with the patient completely supine (spread-eagled). MATERIALS AND METHODS From October 2006 to January 2008 hand assisted retroperitoneoscopic nephroureterectomy with open bladder cuff excision was performed in 32 patients with upper tract transitional cell carcinoma. The patient was placed supine with the legs extended and abducted at 45 to 60 degrees, and the arms stretched out to the sides in the spread-eagle position. The patient was secured to the operation table with 3-inch tapes to permit lateral table tilt. The operation was completed via a 7 or 8 cm Gibson incision plus 2 laparoscopic ports. RESULTS All procedures were successful. The mean time needed for hand assisted retroperitoneoscopic nephroureterectomy and bladder cuff resection was 137.6 minutes. Mean estimated blood loss was 200 ml. Simultaneous transurethral endoscopic procedures were performed in 8 patients. Time to oral intake was 2.1 days and time to ambulation was 2.0 days. No specific complication was related to the position. All patients recovered to normal daily activity uneventfully. CONCLUSIONS Hand assisted retroperitoneoscopic nephroureterectomy with the patient completely supine is feasible and safe. The completely supine position has several advantages, including ease of patient positioning and the ability to perform simultaneous endoscopic procedures. It not only decreases the time and cost of changing position, but also avoids potential risks associated with the lateral decubitus position. Bowel interference with the visual field and mechanical bowel injury are not a concern using this approach.

Validation and simplification of Fournier's gangrene severity index

To validate the predictive value of Fourniers Gangrene Severity Index in patients with Fournier gangrene and to facilitate patient mortality risk‐stratification by simplifying the Fourniers Gangrene Severity Index.

Complete Urinary Tract Exenteration for a Dialysis Patient With Urothelial Cancer: Lower Midline and Extraperitoneal Approach in a Supine Position

OBJECTIVES To report a novel technique of extraperitoneal complete urinary tract exenteration (CUTE) for dialysis patients with multifocal urothelial cancer via a lower midline approach in a supine position (the spread-eagle position [SEP]). MATERIALS AND METHODS From October 2006 to May 2009, extraperitoneal CUTE was performed in 10 dialysis patients with multifocal urothelial cancer. Patients were placed supine with both legs extended and abducted at 45 to 60 degrees and both arms stretched out to the sides (SEP). CUTE involves simultaneous bilateral hand-assisted retroperitoneoscopic nephroureterectomy (HARN) and cystectomy or cystoprostatectomy. Bilateral HARN was completed via a 7- to 8-cm lower midline incision and 4 laparoscopic ports (2 on each side). Infraumbilical incision was extended to 12 cm and then extraperitoneal cystectomy was performed under direct vision using standard open surgical techniques. RESULTS All procedures were successful. The mean operation time of extraperitoneal CUTE was 328 minutes. The time to oral intake was 2.6 days and to ambulation was 4.6 days. The mean parenteral narcotic requirement (morphine) was 43.6 mg (range, 12-88.6). No patient had recurrent transitional cell carcinoma at a mean follow-up of 29.8 months. CONCLUSIONS Extraperitoneal CUTE via a lower midline incision in a completely supine position is feasible and safe. This technique has the benefit of easy supine positioning, eliminates the need for interprocedural repositioning, avoids bowel interference of the visual field, and reduces the risk of possible mechanical bowel injury of a retroperitoneal approach. This approach is a rational option when CUTE is considered.

Impact of Earlier Ureteral Ligation on Intravesical Recurrence during Hand-Assisted Retroperitoneoscopic Nephroureterectomy

Objective: To determine the impact of earlier ureteral ligation (EUL) during hand-assisted retroperitoneoscopic nephroureterectomy (HARN) for primary renal pelvis urothelial cancer. Methods: We retrospectively reviewed 240 patients with upper urinary tract urothelial cancer who underwent HARN. Only patients with primary renal pelvis urothelial cancer and complete follow-up with a minimum of 1 year after HARN were enrolled into our study. We defined EUL as ligating the ureter prior to pneumoretroperitoneum and mobilizing the kidney during the surgery. Of these 61 patients, 31 (who composed the study group) underwent EUL, while 30 serving as controls were without ureteral ligation during the surgery. We analyzed intravesical recurrence utilizing log rank testing to assess the significance between the two groups. Results: Clinical parameters were similar between the two groups. The median follow-up after HARN was 39.7 months (range 12-96). There was no significant difference in the rate of intravesical recurrence and cancer-specific survival. However, patients without ligation of the ureter had shorter time to first bladder tumor recurrence (11.7 ± 9.1 months vs. 26.4 ± 19.1 months, p = 0.03). Conclusion: EUL during HARN for primary renal urothelial cancer did not affect intravesical recurrence rate or cancer-specific survival.

Retroperitoneoscopic Hand-Assisted Nephroureterectomy Using a Homemade Device

PURPOSE To carry out hand-assisted retroperitoneoscopic nephroureterectomy (HARN) and open bladder cuff excision using a homemade hand-assist device. PATIENTS AND METHODS Twenty-four consecutive patients with upper tract transitional cell carcinoma received HARN and open bladder cuff excisions. The procedures were carried out using a homemade hand-assist device comprising a medium-sized Alexis wound retractor and surgical gloves. The Alexis wound retractor was positioned through a 7-8-cm Gibson incision ready for use. The surgeon inserted the double-gloved, nondominant hand into the retroperitoneal space via the wound retractor. During the procedure, the cuff of the surgeons outer surgical glove was turned outside-in and snapped onto the external ring of the Alexis wound retractor to prevent carbon dioxide gas leakage. We successfully created pneumoretroperitoneum by insufflating with carbon dioxide at 15 mm Hg. The procedure was carried out through the 7-8-cm Gibson incision and two additional laparoscopic ports. RESULTS All procedures were performed without complication. The mean estimated blood loss was 81 mL. The mean operation time was 103 minutes. Morphine (mean, 17.6 mg) was administered for pain relief for 1-3 days following surgery. The mean time for recommencing oral intake was 1.5 days, and that to ambulation was 2.0 days. There were no wound complications related to the homemade hand-assist device. CONCLUSIONS Preliminary results show that carrying out HARN using a homemade hand-assist device is safe and feasible. Our homemade hand-assist device offers a cost reduction for the HARN procedure over using commercially available devices.

A muscle-sparing modified Gibson incision for hand-assisted retroperitoneoscopic nephroureterectomy and bladder cuff excision--an approach through a window behind the rectus abdominis muscle.

OBJECTIVE To report our technique using a modified muscle-sparing Gibson incision for hand-assisted retroperitoneoscopic nephroureterectomy (HARN) and open bladder cuff excision. MATERIALS AND METHODS Thirty-four patients with upper tract transitional cell carcinoma received HARN and open bladder cuff excision using the modified muscle-sparing Gibson incision-an approach through a window behind the rectus abdominis muscle with the patient in a supine position with the legs extended and abducted at 45-60° with the surgeon standing between the legs of the patient. The window behind the rectus muscle was identified with ease. HARN and open bladder cuff excision were performed uneventfully using this incision. Mean estimated blood loss was 119 mL. Mean operation time was 139 minutes. Morphine was required for pain relief for 1-3 days (mean 16.5 mg). Mean time to oral intake was 1.5 days and to ambulation was 2.1 days. No lower abdominal bulge was found during a 15.4-month follow-up. CONCLUSION This modified muscle-sparing Gibson incision for retroperitoneal hand-assisted laparoscopic nephrectomy has the benefit of easier retroperitoneal approach of the Gibson incision. Iliohypogastric nerves can be spared under direct vision. By merely retracting and not incising or splitting the rectus abdominis muscle, this incision may decrease wound-related morbidity. This window could be an important portal for hand-assisted laparoscopic surgeries.

Bilateral Hand-assisted Retroperitoneoscopic Nephroureterectomy (HARN) in the Spread-eagle Position for Dialysis Patients—Low Midline HARN in a Completely Supine Position

OBJECTIVES To evaluate the feasibility of hand-assisted bilateral retroperitoneoscopic nephroureterectomy (HARN) in a completely supine position (spread-eagle position [SEP]) for dialysis patients with bilateral upper urinary tract tumors. METHODS From October 2006 to May 2009, bilateral HARN with open bladder cuff excisions were performed in 13 dialysis patients with upper urinary tract tumors. The patient was placed supine with both legs extended and abducted at 45-60 degrees and both arms stretched out to the sides in a SEP. The operation was completed via a 7- to 8-cm lower midline incision and 4 laparoscopic ports (2 on each side). RESULTS All procedures were successful. The mean operation time of bilateral HARN and open bladder cuff resection was 215 minutes, and the mean estimated blood loss was 216 mL. The time to oral intake was 2.5 days and to ambulation was 4.3 days. All patients recovered uneventfully to normal daily activity. No specific complication was related to the position. CONCLUSIONS Bilateral HARN in a completely supine, SEP position is feasible and safe. SEP has several advantages, including ease in patient positioning, and the feasibility to perform simultaneous bilateral nephroureterectomy without repositioning of the patient. It also avoids potential risks associated with the lateral decubitus position. Bowel interference of the visual field and mechanical bowel injury are not concerns in this approach. Our experience shows that a completely supine position is not only possible but also advantageous to bilateral HARN.

Partial Nephrectomy Without Renal Ischemia Using an Electromagnetic Thermal Surgery System in a Porcine Model

OBJECTIVE To test the feasibility of partial nephrectomy using needle arrays under alternating current (AC) electromagnetic field without renal artery clamping. METHODS We performed an experimental study for partial nephrectomy without renal artery clamping in a porcine model, comparing a new thermal surgery system consisting of an AC electromagnetic field generator and stainless steel needle arrays (using 10 pigs) vs an ultrasonic Harmonic Scalpel (on 8 pigs). Two cm of the upper pole of the kidneys were resected, and then the feasibility, operation time, blood loss, biochemical parameters, pathology, and complications were observed for 14 days. RESULTS There was no difference by weight in the mean percentage of kidney removed between the 2 groups (8.1 ± 3.4% vs 12.7 ± 5.5%). The estimated blood loss for the partial nephrectomy with electromagnetic thermal surgery system was significantly less compared to the ultrasonic Harmonic Scalpel (53.0 ± 73.0 vs 188.8 ± 49.3 mL). Transection time was shorter with the electromagnetic thermal surgery system (10 vs 12 minutes). Bleeding from the cut surface after partial nephrectomy was noted in 2 pigs (electromagnetic surgery group) and 8 pigs (control group); all the bleeding was controlled with additional monopolar electrocoagulation and sutures. No urinoma was identified in either group when a second laparotomy was performed 2 weeks later. CONCLUSION Our study of a partial nephrectomy in a porcine model demonstrates that the heat generated by the electromagnetic thermal surgery system is sufficient to coagulate renal parenchyma and to seal off the blood vessels without pedicle clamping.

Consequences of Peritoneal Tears During Hand-assisted Retroperitoneoscopic Nephroureterectomy

OBJECTIVE To evaluate the possible effects of peritoneal tears during hand-assisted retroperitoneoscopic nephroureterectomy (HARN). MATERIALS AND METHODS Between October 2003 and June 2008, HARN and open bladder cuff excision were performed in 110 patients, 20 of whom had peritoneal tears during the operation. Our policy is not to close the peritoneal defect. We compared the intraoperative and postoperative criteria among the peritoneum-preserved or peritoneum-violated group to evaluate the impacts of peritoneal tears during and after HARN. RESULTS All procedures were successful except 2 open conversions in cases without peritoneal tears because of vascular injuries. There was no significant difference in age, American Society of Anesthesiologists class, or body mass index between the 2 groups. Both groups were similar in terms of total operative time (166 vs 137 minutes, P = .06), estimated blood loss (196 vs 268 mL, P = .51), hospital stay (9.1 vs 12.1 days, P = .41), and postoperative analgesia requirements (28.6 vs 28.5 mg morphine equivalent, P = .51). Compared with the peritoneum-preserved group, peritoneal violation during HARN was associated with a heavier specimen weight (308 vs 193 g, P = .01), and 1 patient in the violation group developed small bowel obstruction 3 weeks after the surgery. CONCLUSIONS Most peritoneal tears during HARN may be safely managed without peritoneal closure. Bowel obstruction from internal herniation is rare but is too significant to be ignored. To prevent this morbidity, peritoneal tears of a selected size need either repair or enlargement.

AB136. Successful penile replantation following penile self-amputation: case report and literature review

Objective Penile amputation is an uncommon injury resulting from self-mutilation, felonious assault, or accidental trauma. Although it is uncommon and rarely fatal, penile amputation is a challenging injury for Urologist to treat. Many factors should be taken into consideration of proper treatment. In this kind of patients, the mental and physical conditions are usually complicated. Rapid stabilization is very important to afford the appropriate time and specialization for surgical success. Currently, many reconstructive techniques provide an excellent outcome for penile replantation. We reported a case of soft palate squamous cell carcinoma under palliative chemotherapy who amputated his penis at the base with a sharp blade due to severe depression. Methods A 66-year-old man with soft palate squamous cell carcinoma, pT2N0M0, post surgery and local recurrence, was under palliative chemotherapy now. Two days before this emergent episode, he was just admitted due to dyspnea and electrolytes imbalance. He decided to discharge against advice before completing the treatment. After lunch, he locked himself in the bathroom and used kitchen knife to mutilate his penis. He was brought to our emergency department by his family. A clinical examination found a bloody and destroyed penis. One small piece of penile appendage was connected with actively bleeding penile stump by one side of prepuce. The exploratory surgery showed a complete transection of corpus cavernosum, corpus spongiosum, and urethra. A 14-French silicon catheter was threaded through the glans and aligned with the proximal urethra. We began with interrupted 4-0 Vicryl sutures in a 360-degree fashion to connect urethra. Interrupted 4-0 Vicryl sutures were placed from ventral side of the tunica albuginea of the corpus spongiosum. Till the dorsal aspect of amputated penis, we carefully applied tension-free, interrupted 4-0 Vicryl sutures to reapproximate the tunica albuginea of the corpus cavernosum. A pressure dressing was placed around the anastomosis wound. After surgery, the patient was taken daily wound care. Results Penile amputation is a rare urologic emergency. The actual incidence of penile amputation is rare. The first documented case of macroscopic penile replantation was reported in 1929 by Ehric. Since then, there have been gradual rise of traumatic penile amputation with 87% of cases reported associated with an underlying psychotic disorder. A review of the literature revealed at least 30 cases of penile auto-amputation with successful replantation since 1970. Treatment of penile amputation includes three basic forms: surgical replantation of the amputated penis, tailoring of the remaining penile stump, or total phallic replacement. Many factors will lead to positive final results: the degree of injury, type of injury, duration of warm ischemia, the equipment used, and experience of the operative team. Most outcomes reported till now were acceptable. Conclusions Penile amputation is an extremely rare urology emergency. We reported that a macrosurgical technique without microsurgical venous repair is able to restore normal urinary function in a case with penile amputation and complete urethra injury and partial corpus spongiosum injury.