Erdal Erturk

Robotic Extraperitoneal Radical Prostatectomy: An Alternative Approach

PURPOSE Laparoscopic radical prostatectomy with or without a robot has been increasingly performed worldwide, primarily using a transperitoneal approach. We report our experience with daVinci(R) robot assisted extraperitoneal laparoscopic radical prostatectomy. MATERIALS AND METHODS A total of 325 patients underwent robot assisted extraperitoneal laparoscopic radical prostatectomy for clinically localized prostate cancer at our center during a 2-year period. Perioperative data, and oncological and functional results were prospectively recorded. RESULTS Perioperative demographics included mean age, PSA and Gleason score, which were 60 years (range 42 to 76), 6.6 ng/ml (range 0.6 to 26) and 6 (range 5 to 9), respectively. Preoperative clinical stage was 81%, 16% and 3% for T1c, T2a and T2b, respectively. Average total operative time was 130 minutes (range 80 to 480). Intraoperative data included a mean blood loss of 196 cc with no open conversions. Bilateral, unilateral and nonnerve sparing prostatectomy was performed in 70%, 24% and 6% of patients, respectively. Of the patients 96% were discharged home within 8 to 23 hours of surgery. Pathological stage was pT2a, pT2b, pT3a and pT3b in 18%, 63%, 14% and 5% of all radical prostatectomy specimens, respectively, with an overall positive surgical margin rate of 13%. Two of 92 patients had positive nodal disease after lymph node dissection. Continence and erectile function were measured. CONCLUSIONS The extraperitoneal approach offers the advantages of improved dexterity and visualization of the robot, while avoiding the abdominal cavity and potential associated morbidity. As surgeons gain more experience with this new technology, the extraperitoneal approach simulating the standard open retropubic technique is likely to gain popularity.

Robot‐assisted vs pure laparoscopic radical prostatectomy: are there any differences?

To compare our experience of pure laparoscopic radical prostatectomy (LRP) with robot‐assisted radical prostatectomy (RAP).

Extracorporeal Shock Wave Lithotripsy for Distal Ureteral Stones

A retrospective analysis of distal ureteral calculi treated by extracorporeal shock wave lithotripsy (ESWL*) as the primary mode of therapy was performed. Using the Dornier HM3 unit 312 patients underwent a total of 326 ESWL procedures. Several pretreatment procedures, including placement of ureteral catheters were used to help with stone localization. Early fragmentation and 3-month stone-free rates were analyzed. Of the patients 81% were stone-free at 3 months. We reviewed 27 failures, revealing a higher incidence of impacted stones and stones greater than 1 cm. Complications were few and minor. ESWL is a safe and effective treatment option for distal ureteral calculi.

Near Infrared Fluorescence Imaging After Intravenous Indocyanine Green: Initial Clinical Experience With Open Partial Nephrectomy for Renal Cortical Tumors

OBJECTIVE To evaluate the safety of near infrared fluorescence (NIRF) of intravenously injected indocyanine green (ICG) during open partial nephrectomy, and to demonstrate the feasibility of this technology to identify the renal vasculature and distinguish renal cortical tumors from normal parenchyma. METHODS Patients undergoing open partial nephrectomy provided written informed consent for inclusion in this institutional review board-approved study. Perirenal fat was removed to allow visualization of the renal parenchyma and lesions to be excised. The patients received intravenous injections of ICG, and NIRF imaging was performed using the SPY system. Intraoperative NIRF video images were evaluated for differentiation of tumor from normal parenchyma and for renal vasculature identification. RESULTS A total of 15 patients underwent 16 open partial nephrectomies. The mean cold ischemia time was 26.6 minutes (range 20-33). All 14 malignant lesions were afluorescent or hypofluorescent compared with the surrounding normal renal parenchyma. NIRF imaging of intravenously injected ICG clearly identified the renal hilar vessels and guided selective arterial clamping in 3 patients. No adverse reactions to ICG were noted, and all surgical margins were negative on final pathologic examination. CONCLUSION The intravenous use of ICG combined with NIRF is safe during open renal surgery. This technology allows the surgeon to distinguish renal cortical tumors from normal tissue and highlights the renal vasculature, with the potential to maximize oncologic control and nephron sparing during open partial nephrectomy. Additional study is needed to determine whether this imaging technique will help improve the outcomes during open partial nephrectomy.

Impact of Ureteral Stent Diameter on Symptoms and Tolerability

BACKGROUND AND PURPOSE Indwelling double-pigtail ureteral stents are frequently associated with debilitating symptoms. A randomized study was performed to evaluate the effect of stent diameter (4.7F v. 6F) on symptoms and tolerability. PATIENTS AND METHODS Between February and October 2000, 46 consecutive patients undergoing ureteroscopy for stone disease were randomly assigned to receive either a 4.7F (group I) or a 6F (group II) ureteral stent following the procedure. The patients were asked to leave their stents in place for minimum of 7 days. Pain and irritative urinary symptoms in the two groups were compared according to a scale ranging from 0 (none) to 5 (severe). The two groups were also compared for stone size and location, rigid v. flexible ureteroscopy, anesthesia, stent migration, and ureteral dilation. RESULTS There were no differences between the groups in terms of pain (P = 0.28) or irritative symptoms (P = 0.37). There was a tendency for stents in group I to migrate distally and dislodge more often than those in group II (32% v 10%). CONCLUSIONS When stent insertion following ureteroscopy is deemed necessary, a minimum diameter of 6F is recommended.

Operator Experience and Adequate Anesthesia Improve Treatment Outcome with Third-Generation Lithotripters

PURPOSE To characterize the effect of operator experience and type of anesthesia on treatment outcome when switching from the Dornier HM3 to the third-generation Dornier U/50 lithotripter. PATIENTS AND METHODS A population of 370 consecutive patients treated by 15 urologists was divided into two groups. Group I (N = 225) included patients treated during the initial 3 months with our new lithotripter. Group II (N = 145) included patients treated during the last 3 months. Changes were made during the intervening 6 months in focusing technique, anesthesia type, coupling technique, and shockwave delivery. Information was collected regarding success of stone treatment (defined as complete clearance of stone or fragments < 3 mm at 1 month). RESULTS There were no differences between the two groups with regard to age, sex, fluoroscopic time or maximal shockwave intensity used. Group I had a slightly higher percentage of upper ureteral stones (20% v 13%); however, the difference was not significant. Upper ureteral stones in Group II were on average significantly larger (9.4 mm v 7.3 mm; P = 0.003). Intravenous sedation was used frequently in Group I (111 patients; 49%) and not at all in Group II. General anesthesia was used more frequently in Group II than in group I (34% v 24%; P < 0.02). Spinal anesthesia also was utilized more frequently in Group II patients (66% v 28%; P < 0.0001). Overall, general or regional anesthesia was received by 100% of the patients in Group II but only 52% of the patients in group I. The success rate of stone treatment was much better for Group II than for Group I (78% v 51%; P < 0.0001). CONCLUSION The transition from a Dornier HM3 lithotripter to a third-generation lithotripter can be difficult, but if adequate anesthesia is given to minimize patient movement and balloon pressures are optimized, stone targeting can be accurate and similar stone clearance rates can be obtained.

TREATMENT OF TRANSPLANT URETERAL STENOSIS WITH ENDOURETEROTOMY

PURPOSE The safety and efficacy of treating renal transplant ureteral stenosis with the Acucise endoureterotomy catheter are described. MATERIALS AND METHODS We treated 4 women and 3 men 31 to 63 years old (mean age 45) with Acucise endoureterotomy for distal (6) and proximal (1) ureteral stenosis. Diagnosis was based on increasing serum creatinine and hydronephrosis on ultrasound, and confirmed by antegrade nephrostogram. One patient had recurrence and, therefore, 8 procedures were performed. Mean followup was 13 months (range 7 to 21). RESULTS Technical success was 100%. One patient had a recurrent stricture and was successfully re-treated. Of the patients 3 had chronic rejection and renal failure, and 4 had stable renal function. All ureters remain patent to date. CONCLUSIONS Treatment of short ureteral stenosis with Acucise endoureterotomy in a renal transplant is safe and effective. Furthermore, it can be performed in an ambulatory setting with minimal morbidity. This procedure should be considered as the initial approach for distal ureteral stenosis in the transplanted kidney.

Comparison of the Ti-knot Device and Hem-o-lok Clips with Other Devices Commonly Used for Laparoscopic Renal-Artery Ligation

BACKGROUND AND PURPOSE New devices such as the Ti-knot and Hem-o-lok clips have been developed for laparoscopic surgical applications. We compared the effectiveness of Ti-knot TK5 (LSI Solutions), Hem-o-lok MLK clips (Weck Closure), Ligaclip 5-mm titanium clips (Ethicon), and Endopath vascular staples (35 mm long, 12.3 mm wide) (Ethicon). MATERIALS AND METHODS Renal artery segments from 5 to 6 mm in diameter were harvested from fresh porcine kidneys. One end of the vessel was intubated with a 25-gauge ball-tipped needle and fastened with two silk ties. The other end was occluded with one of the test devices. Saline was infused into each arterial segment at 3 mL/min with the maximum pump pressure at 800 mm Hg. The maximum pressure with leakage was recorded. Each of the five test devices was tested eight times on a rotating basis. Saline infusion was stopped when the maximum pump pressure was reached or when leakage was observed. RESULTS All Ti-knot devices, Hem-o-lok clips, titanium metal clips, and standard hand ties tolerated pressures >800 mm Hg with no leakage, but 4 of the 8 vascular staple lines (50%) leaked before this maximum pump pressure was reached. For those that leaked, the mean leak pressure was 273 mm Hg (range 237-322 mm Hg). CONCLUSIONS All devices tested are capable of occluding renal arteries under physiologic conditions. Ti-knot devices and Hem-o-lok clips occluded renal arteries to pressures that exceeded 800 mm Hg. They are equivalent to hand ties under supraphysiologic conditions.

Outcome of patients with vesicoureteral reflux after renal transplantation: the effect of pretransplantation surgery on posttransplant urinary tract infections

OBJECTIVES We evaluated the relation of vesicoureteral reflux, pretransplant nephrectomy, and prior ureteral reimplant with respect to posttransplant urinary tract infection and graft survival. METHODS From 1984 to 1995, 820 renal transplants were performed. Thirty-six (4%) patients had documented vesicoureteral reflux. The patients were divided into three groups: Group I, N = 10 (28%) underwent ureteral reimplantation prior to transplantation; Group II, N = 8 (22%) had bilateral nephrectomy prior to transplantation; and Group III, N = 18 (50%) had persistent reflux at the time of transplantation. RESULTS Graft survival at 3 years was 50% (18/36). Patient survival was 94% (34/36). The overall incidence of urinary tract infection was 56% (20/36). Complicated urinary tract infection was seen in 28% (10/36) and uncomplicated urinary tract infection in 47% (17/36) of the patients. The incidence of both complicated and uncomplicated urinary tract infection was lower in Group I. However, graft survival was lower in Group I patients. Overall graft survival was significantly lower in patients with vesicoureteral reflux compared with the rest of the group. CONCLUSIONS The incidence of urinary tract infection did not appear to be altered significantly whether the patients had bilateral nephrectomy or persistent vesicoureteral reflux. However, those patients who had ureteral reimplantation had fewer episodes of infection. Nephrectomy prior to transplantation should be performed selectively.

Bowel displacement for CT-guided tumor radiofrequency ablation: techniques and anatomic considerations.

PURPOSE To describe safety and efficacy of bowel displacement techniques and determine lesion characteristics that are likely to necessitate bowel displacement. PATIENTS AND METHODS A retrospective review of patients who underwent CT-guided renal tumor radiofrequency ablation (RFA) (January 2006-August 2008) was conducted. Techniques included hydrodissection, additional manual torquing of the RFA probe, and additional angioplasty balloon interposition. The goal was to displace bowel from the probe by at least 10 to 20 mm. Air-filled balloon interposition was intended as a thermal barrier. Pre- and postbowel displacement distances were measured by CT. Saline volumes were recorded. Multivariate stepwise regression analysis was used to determine the influence of laterality, renal location, and morphology of renal lesions on their proximity to the colon and use of bowel displacement techniques. RESULTS RFA was performed on 57 consecutive patients. Eleven (19%) patients had bowel displacement attempts. Median pre-RFA lesion edge to colon distance for nondisplaced vs displaced was 43 mm (range 10-100 mm) vs 6 mm (range 0-16 mm), respectively (P < 0.05). Two variables were significant for bowel displacement (F-ratio = 4.681, P = 0.006): Tumor position within the kidney in the craniocaudal plane (P = 0.014) and anterior-posterior plane (P = 0.007). Lower pole and posterior lesions tended to be closer to the colon and more likely to necessitate bowel displacement. Orientation in the medial-lateral plane (P = 0.77) and exophytic nature of the lesion (P = 0.83) were not significant features. Hydrostatic bowel displacement was always the first-line technique and was completely and partly successful in 8 (73%) and 1 (9%) attempts, respectively. Partial success was augmented by probe torquing (distance increased from 1 mm to 16 mm and then to 23 mm with torquing). Mean saline injection: 105 mL (range 55-440 mL). There were two complete failures (18%) in which bowel was displaced only by 0 to 2 mm despite injection of 280 to 440 mL. Balloon interposition was attempted in these two cases. Five minor complications occurred in the nondisplaced cohort. No complications occurred in the bowel displacement cohort. CONCLUSION Lower pole, posterior renal lesions are more likely to necessitate bowel displacement. Bowel displacement techniques are effective and safe in displacing bowel.