Christopher S. Ng

RETROPERITONEOSCOPIC SURGERY IS NOT ASSOCIATED WITH INCREASED CARBON DIOXIDE ABSORPTION

PURPOSE Previous studies have suggested that retroperitoneal laparoscopy is associated with greater carbon dioxide absorption and related postoperative morbidity, such as subcutaneous emphysema and pneumothorax. We prospectively compared the effects of carbon dioxide absorption during transperitoneal and retroperitoneal laparoscopic renal and adrenal surgery at our institution. MATERIALS AND METHODS Data were collected prospectively on 51 patients who underwent laparoscopic renal (26) or adrenal (25) surgery via the transperitoneal (18) or retroperitoneal (33) approach from September 1997 to February 1998. RESULTS There was no significant difference in carbon dioxide elimination in patients who underwent transperitoneal laparoscopy compared to retroperitoneoscopy at any interval. Subcutaneous emphysema occurred in 12.5% of the transperitoneal and 45% of the retroperitoneal group (p = 0.09). Patients with subcutaneous emphysema had greater carbon dioxide elimination during the first 2.5 hours of insufflation compared to those without subcutaneous emphysema and, thereafter, carbon dioxide elimination decreased to baseline. CONCLUSIONS In contrast to previous reports our prospective nonrandomized study suggests that retroperitoneoscopy is not associated with greater carbon dioxide absorption compared to transperitoneal laparoscopy. Patients with subcutaneous emphysema exhibited only transient increases in carbon dioxide absorption above control levels.

Laparoscopic management of caliceal diverticular calculi.

PURPOSE We describe laparoscopic techniques for the definitive management of symptomatic caliceal diverticular stone disease. MATERIALS AND METHODS Five patients underwent retroperitoneoscopic management of a symptomatic, stone bearing caliceal diverticulum. Techniques for intraoperative localization of the stone bearing diverticulum included retrograde injection of indigo carmine, fluoroscopy and/or laparoscopic ultrasound. In 2 cases the patent neck of the diverticulum was sutured via laparoscopy. RESULTS Complete stone clearance and obliteration of the diverticular cavity was achieved in all cases without any open conversion. Mean operative time was 133.8 minutes. Mean estimated blood loss was less than 50 cc in 4 cases and 150 cc in 1. Mean hospital stay was 36 hours. There were no laparoscopic or postoperative complications. CONCLUSIONS The laparoscopic approach to symptomatic caliceal diverticula represents an effective and minimally invasive modality for complete clearance of the stone burden and definitive management of the anatomical abnormality. However, patient selection is paramount. We reserve the laparoscopic approach for symptomatic caliceal diverticula with thin overlying renal parenchyma, or for anterior lesions inaccessible to or unsuccessfully managed by endourological techniques. A decision tree algorithm for managing symptomatic caliceal diverticular calculi is proposed.

The Hem-o-Lok Clip Is Safe for Laparoscopic Nephrectomy : A Multi-institutional Review

OBJECTIVES To evaluate the safety and reliability of the Hem-o-lok clips for the control of the renal artery during laparoscopic nephrectomies. METHODS Our multi-institutional working group compiled a retrospective review of all laparoscopic nephrectomies (radical nephrectomy, simple nephrectomy, nephroureterectomy, and donor nephrectomy) performed by surgeons in our group. For each procedure, we used Hem-o-lok clips to control the renal artery and in some cases the renal vein. The number of Hem-o-lok clip failures (defined as intraoperative or postoperative clip dislodgement necessitating reoperation) was recorded. RESULTS Between October 2001 and June 2006, 9 institutions with laparoscopic trained urologists performed 1695 laparoscopic nephrectomies (radical nephrectomy, N = 899; simple nephrectomy, N = 112; nephroureterectomy, N = 198; donor nephrectomy, N = 486). Follow-up was a minimum of 6 months from the time of surgery. For each case, we used Hem-o-lock clips to control the renal artery. The renal vein was controlled with Hem-o-lok clips in 68 cases (radical nephrectomy, N = 54; simple nephrectomy, N = 3; nephroureterectomy, N = 5; donor nephrectomy, N = 6). Number of clips placed on the patient side of the renal artery was most often 2, occasionally 3. Number of clips placed on the patient side of the renal vein was most often 2 and rarely 3. All cases used the large (L-purple) clip on the artery, and most cases of renal vein used the extra-large (XL- gold) clip on the vein. No clips failed. CONCLUSIONS Based on this large retrospective review, properly applied Hem-o-lock clips for vascular control during renal procedures may provide a safe option.

Degradation of NF-κB in T Cells by Gangliosides Expressed on Renal Cell Carcinomas

T cells from cancer patients are often functionally impaired, which imposes a barrier to effective immunotherapy. Most pronounced are the alterations characterizing tumor-infiltrating T cells, which in renal cell carcinomas includes defective NF-κB activation and a heightened sensitivity to apoptosis. Coculture experiments revealed that renal tumor cell lines induced a time-dependent decrease in RelA(p65) and p50 protein levels within both Jurkat T cells and peripheral blood T lymphocytes that coincided with the onset of apoptosis. The degradation of RelA/p50 is critical for SK-RC-45-induced apoptosis because overexpression of RelA in Jurkat cells protects against cell death. The loss of RelA/p50 coincided with a decrease in expression of the NF-κB regulated antiapoptotic protein Bcl-xL at both the protein and mRNA level. The disappearance of RelA/p50 protein was mediated by a caspase-dependent pathway because pretreatment of T lymphocytes with a pan caspase inhibitor before coculture with SK-RC-45 blocked RelA and p50 degradation. SK-RC-45 gangliosides appear to mediate this degradative pathway, as blocking ganglioside synthesis in SK-RC-45 cells with the glucosylceramide synthase inhibitor, PPPP, protected T cells from tumor cell-induced RelA degradation and apoptosis. The ability of the Bcl-2 transgene to protect Jurkat cells from RelA degradation, caspase activation, and apoptosis implicates the mitochondria in these SK-RC-45 ganglioside-mediated effects.

Management of failed primary intervention for ureteropelvic junction obstruction: 12-year, single-center experience

OBJECTIVES To compare contemporary endourologic and open surgical management of failed primary intervention for ureteropelvic junction obstruction, specifically in regard to immediate and long-term results and complications. METHODS Since 1989, 48 patients have undergone management of failed primary intervention for ureteropelvic junction obstruction. Of these, 42 patients (21 females and 21 males; age range 16 to 68 years, mean age 34.9) underwent follow-up evaluations. These 42 patients constitute the present study group. The mode of secondary intervention was determined by individual upper tract anatomy, concurrent medical conditions, and informed patient preference. Secondary intervention included open operative repair (n = 20) or percutaneous (n = 11), ureteroscopic (n = 5), or retrograde cautery wire balloon (n = 6) endopyelotomy. Success was defined as symptomatic relief and improved calicectasis on radiographic evaluation at latest follow-up. RESULTS Follow-up ranged from 6 to 148 months (mean 47.7). Endourologic intervention was associated with a mean hospital stay of 2.3 nights and a complication rate of 13.6%. The long-term success rate of these endoscopic approaches was 59.1% overall, including a 71.4% success rate after a failed open operative procedure and a 37.5% success rate after a failed endourologic procedure. In contrast, open operative salvage was associated with a mean stay of 4.3 nights and a 15% complication rate. The success of open operative salvage was 95% overall, including 94.1% after failed endourologic intervention and 100% after failed open operative intervention. CONCLUSIONS Endourologic intervention for failed primary management of ureteropelvic junction obstruction is associated with a short hospital stay and low rate of complications. Such intervention provides acceptable success rates in the setting of prior failed open operative intervention. However, when endourologic salvage was used for prior failed endourologic intervention, the success rates were limited. This suggests that intrinsic factors such as crossing vessels or periureteral fibrosis may play a role in limiting the utility of such procedures in this setting. In contrast, open operative salvage after any prior failed intervention for ureteropelvic junction obstruction provides excellent functional results without any increase in morbidity, with, in this contemporary series, an acceptably short hospital stay. These data should help urologists and patients make well-informed treatment decisions.

Rhabdomyolysis after laparoscopic donor nephrectomy

Rhabdomyolysis is a postoperative complication that may result in acute renal failure owing to excessive myoglobinuria. After uncomplicated laparoscopic left transperitoneal donor nephrectomy, a 32-year-old man developed anuric acute renal failure secondary to postoperative rhabdomyolysis that required intermittent hemodialysis for 2 weeks. The presumed risk factors in this case were the patients high body mass index, intraoperative flank position with flexion, a solitary kidney, and the duration of surgery. Our current surgical technique has been modified to drop the kidney bridge early, immediately after visualization of the hilum.

Incidence of concomitant procedures for pelvic organ prolapse and reconstruction in women who undergo surgery for stress urinary incontinence

OBJECTIVES To determine the incidence of concomitant procedures performed for pelvic organ prolapse or vaginal reconstruction at the time of surgery for stress urinary incontinence in contemporary practice. METHODS We recorded all concomitant procedures for pelvic organ prolapse or vaginal reconstruction in 264 women who underwent surgery for stress urinary incontinence at our institution from January 1995 to August 1997. RESULTS Of 264 women, 111 (42%) had at least one concomitant procedure performed for pelvic organ prolapse or vaginal reconstruction, including 87 cystocele repairs, 31 rectocele repairs, 8 sacrospinous fixations, 5 enterocele repairs, 5 abdominal sacrocolpopexies, 4 perineoplasties, 3 urethral diverticulectomies, and 1 vaginal hysterectomy. Furthermore, 9% of patients had two or more procedures. CONCLUSIONS We found that women who undergo surgery for stress urinary incontinence have a high incidence (42%) of associated pelvic organ prolapse requiring surgical repair. These additional repairs contribute to the overall success of surgery and should not be overlooked.

Extracorporeal Shockwave Lithotripsy

Since its first scientific and clinical descriptions by Chaussy more than 20 years ago, extracorporeal Shockwave lithotripsy (SWL) has truly revolutionized the urologic management of stone disease and remains the sole noninvasive surgical treatment modality for urinary tract calculi (1–3). During the 1980s, the explosion of clinical experience with SWL was joined by that of other emerging“endo-urologic” modalities, such as percutaneous nephrolithotomy and ureteroscopy. As these technologies have continued to improve over the last decade, the relative roles of each endo-urologic approach have likewise continued to evolve. As is often the case, more controversies have been raised than have been settled as a result. This chapter details the contemporary role of SWL in the surgical management of urinary tract calculi and addresses areas of debate with its use.

Detection of live circulating tumor cells by a class of near-infrared heptamethine carbocyanine dyes in patients with localized and metastatic prostate cancer.

Tumor cells are inherently heterogeneous and often exhibit diminished adhesion, resulting in the shedding of tumor cells into the circulation to form circulating tumor cells (CTCs). A fraction of these are live CTCs with potential of metastatic colonization whereas others are at various stages of apoptosis making them likely to be less relevant to understanding the disease. Isolation and characterization of live CTCs may augment information yielded by standard enumeration to help physicians to more accurately establish diagnosis, choose therapy, monitor response, and provide prognosis. We previously reported on a group of near-infrared (NIR) heptamethine carbocyanine dyes that are specifically and actively transported into live cancer cells. In this study, this viable tumor cell-specific behavior was utilized to detect live CTCs in prostate cancer patients. Peripheral blood mononuclear cells (PBMCs) from 40 patients with localized prostate cancer together with 5 patients with metastatic disease were stained with IR-783, the prototype heptamethine cyanine dye. Stained cells were subjected to flow cytometric analysis to identify live (NIR+) CTCs from the pool of total CTCs, which were identified by EpCAM staining. In patients with localized tumor, live CTC counts corresponded with total CTC numbers. Higher live CTC counts were seen in patients with larger tumors and those with more aggressive pathologic features including positive margins and/or lymph node invasion. Even higher CTC numbers (live and total) were detected in patients with metastatic disease. Live CTC counts declined when patients were receiving effective treatments, and conversely the counts tended to rise at the time of disease progression. Our study demonstrates the feasibility of applying of this staining technique to identify live CTCs, creating an opportunity for further molecular interrogation of a more biologically relevant CTC population.

Laparoscopic upper pole partial nephrectomy with concomitant en bloc adrenalectomy

Abstract Objectives To report our experience with laparoscopic partial nephrectomy for renal tumor with concomitant adrenalectomy. An upper pole renal tumor may contiguously involve the adrenal gland, requiring concomitant adrenalectomy. Although commonly performed in the setting of laparoscopic radical nephrectomy, concomitant adrenalectomy has not been described during laparoscopic partial nephrectomy. Methods Four patients with an upper pole renal tumor and suspected adrenal involvement underwent laparoscopic partial nephrectomy with concomitant ipsilateral adrenalectomy. Preoperative three-dimensional computed tomography revealed the renal tumor to be closely abutting the adrenal gland in 3 patients and a 4-cm adrenal mass in 1 patient. The mean renal tumor size was 3.2 cm (range 1.4 to 6.6). To maintain oncologic principles, our transperitoneal laparoscopic technique excises the adrenal gland en bloc with the renal tumor. As such, adrenalectomy is performed first, followed by partial nephrectomy, incorporating hilar control, tumor excision, and sutured renal reconstruction. Results All four procedures were performed without open conversion or intraoperative complications. The mean renal warm ischemia time was 36 minutes, estimated blood loss 169 mL, total operating time 3.9 hours, and hospital stay 3.2 days. One patient developed a transient urinary leak postoperatively. Pathologic examination of the renal tumor revealed renal cell carcinoma (n = 1), dystrophic calcification with ectopic bone formation (n = 1), adult mesoblastic nephroma (n = 1), and subcapsular heterotopic adrenal cortex with cyst (n = 1), all with negative surgical margins. Pathologic examination of the adrenal gland revealed adenoma in 1 case and a normal adrenal gland without malignant involvement in 3 cases. All patients were disease free at last follow-up (mean 6.2 months, range 2 to 12). Conclusions In patients with an upper pole renal tumor and radiologically suspected adrenal involvement, laparoscopic partial nephrectomy with concomitant adrenalectomy can be performed efficaciously respecting oncologic principles.