Gary C. Bellman

Tubeless Percutaneous Renal Surgery

PURPOSE We challenge the requirement for routine placement of a nephrostomy tube following percutaneous renal surgery. MATERIALS AND METHODS A total of 50 patients underwent tubeless percutaneous renal procedures consisting of nephrolithotripsy, endopyelotomy, and stone extraction plus endopyelotomy performed during the same setting. In the initial 30 patients a Double-J* stent and a Councill nephrostomy tube were placed at the end of the procedure. The Councill catheter was removed 2 to 3 hours postoperatively. The subsequent 20 patients received only a Double-J stent with no Councill catheter. This study group was compared to a control group of 50 age, sex and procedure matched patients who had previously undergone standard percutaneous renal procedures with routine placement of postoperative nephrostomy tubes. The incidence of complications, analgesia requirements, length of hospitalization, interval to return to normal activities and cost of treatment were compared between the 2 groups. RESULTS All 50 tubeless percutaneous procedures were performed successfully without significant complications. In the initial 15 patients postoperative renal ultrasound demonstrated no urinoma. Hospitalization was 0.6 days for the study group and 4.6 days for the controls (p = 0.0001). Average parenteral or intramuscular analgesia requirements were 11.58 and 36.06 mg. morphine sulfate, respectively (p = 0.0001), with patients requiring oral analgesia for 5.9 and 11.7 days, respectively (p = 0.0001). Patients in the study group returned to normal activities within 17.85 days versus 26.6 days for the controls (p = 0.0004). The costs of the procedures were

Holmium:YAG lithotripsy yields smaller fragments than lithoclast, pulsed dye laser or electrohydraulic lithotripsy

1,638 and

Laparoscopic linear cutting stapler failure

3,750 (129% greater), respectively, for a cost saving of

Use of fibrin glue in percutaneous nephrolithotomy.

2,112 per case. CONCLUSIONS Tubeless percutaneous renal surgery is a safe procedure and offers numerous advantages over routine placement of a nephrostomy tube. The hospitalization, analgesia requirements, return to normal activities as well as cost are significantly less with this new technique.

Laparoscopic evaluation of indeterminate renal cysts: long-term follow-up.

PURPOSE The mechanism of lithotripsy differs among electrohydraulic lithotripsy, mechanical lithotripsy, pulsed dye lasers and holmium:YAG lithotripsy. It is postulated that fragment size from each of these lithotrites might also differ. This study tests the hypothesis that holmium:YAG lithotripsy yields the smallest fragments among these lithotrites. MATERIALS AND METHODS We tested 3F electrohydraulic lithotripsy, 2 mm. mechanical lithotripsy, 320 microns pulsed dye lasers and 365 microns. holmium:YAG fiber on stones composed of calcium hydrogen phosphate dihydrate, calcium oxalate monohydrate, cystine, magnesium ammonium phosphate and uric acid. Fragments were dessicated and sorted by size. Fragment size distribution was compared among lithotrites for each composition. RESULTS Holmium:YAG fragments were significantly smaller on average than fragments from the other lithotrites for all compositions. There were no holmium:YAG fragments greater than 4 mm., whereas there were for the other lithotrites. Holmium:YAG had significantly greater weight of fragments less than 1 mm. compared to the other lithotrites. CONCLUSIONS Holmium:YAG yields smaller fragments compared to electrohydraulic lithotripsy, mechanical lithotripsy or pulsed dye lasers. These findings imply that fragments from holmium:YAG lithotripsy are more likely to pass without problem compared to the other lithotrites. Furthermore, the significant difference in fragment size adds evidence that holmium:YAG lithotripsy involves vaporization.

Radiation protection during percutaneous nephrolithotomy: a new urologic surgery radiation shield.

OBJECTIVES To characterize the frequency and nature of problems with linear cutting staplers to help prevent complications in the future. These devices are often used during laparoscopic urologic procedures. METHODS We retrospectively reviewed the experience with laparoscopic linear cutting staplers at two institutions routinely performing urologic laparoscopy and analyzed the difficulties with any staplers. Data from the Food and Drug Administration Center for Devices and Radiological Health were also examined to determine the prevalence and types of reported problems. RESULTS In performing approximately 460 laparoscopic cases, we encountered 5 problems (1%) with endovascular gastrointestinal anastomosis staplers. Fifty-five additional cases in 50 patients were documented in the Food and Drug Administration database. Of the 55 patients, 15 (27%) required open conversion to manage the problem, 8 (15%) received blood transfusions, and 2 (4%) died postoperatively. Twenty-two events occurred during 19 laparoscopic donor nephrectomies (35%) without associated graft dysfunction, damage, or loss. All phases of instrument use were subject to problems; however, abnormal firing of the stapler and improper staple formation were the most common and morbid aspects of device malfunction. CONCLUSIONS Despite the general reliability of linear cutting staplers, difficulties were encountered in every step of use. Most situations were successfully managed by prompt identification and appropriate intracorporeal maneuvers. Nevertheless, significant morbidity may occur, and conversion to an open operation should be considered. Many potential problems can be avoided by surgeon and staff education, and one should be aware of the alternative methods of tissue ligation currently available.

Laparoscopic management of indeterminate renal cysts

OBJECTIVES To report our experience with the use of fibrin glue during tubeless percutaneous nephrolithotomy. We addressed the safety of this approach and evaluated its use for any clinical benefit with respect to length of hospital stay, bleeding, analgesic usage, and urinary extravasation. METHODS This was a retrospective review of 43 patients who underwent tubeless percutaneous nephrolithotomy. In 20 consecutive patients (one bilateral), percutaneous tracts were injected with 2 to 3 mL of Tissel Vapor Heated sealant at the conclusion of the procedure. The fibrin glue was instilled during simultaneous removal of the percutaneous sheath. These 20 patients were compared with a control group (23 consecutive patients) in which fibrin glue was not used. The length of hospitalization, hematocrit drop, analgesic use, stone burden, operative times, postoperative complications, and any noted computed tomography scan findings were compared. RESULTS Postoperatively, the average length of hospital stay was less in the experimental than in the control group by 0.71 day (P <0.05). Differences in hematocrit drop between the experimental (6.8%) and control (5.6%) groups were not statistically significant. The total analgesic use was less in the experimental group, but the difference was not statistically significant. No statistical difference was found between the operative times for both groups. Postoperative fevers and wound seroma were noted in the experimental group. No abscesses or any significant changes along the percutaneous tracts were seen on postoperative computed tomography scans. In the control group, no procedure-related complications were noted. CONCLUSIONS The use of fibrin glue is safe in percutaneous nephrolithotomy procedures and additional prospective randomized studies are needed to evaluate for any clinical benefit.

URINARY IL-6 IS ELEVATED IN PATIENTS WITH UROLITHIASIS

PURPOSE We present our long-term follow-up of patients who have undergone laparoscopic evaluation for their indeterminate renal cysts, specifically reporting those patients who were found to have cystic renal-cell carcinoma (RCC) and assessing the safety and efficacy of the procedure. PATIENTS AND METHODS Fifty-seven patients with indeterminate renal cysts (28 Bosniak category II and 29 Bosniak category III) underwent laparoscopic evaluation between July 1993 and July 2000. A transperitoneal laparoscopic localization and aspiration of the cyst, cytologic analysis, and biopsy of the cyst wall and base were performed. A total of 11 patients were found to have cystic RCC. Patients with malignancy have been followed for a mean of 40 months (range 6-70 months), and five patients had 5 years or more of follow-up. RESULTS Eleven patients (19% of the total) were found to have cystic RCC. Three of these patients had Bosniak category II cysts, and eight had category III cysts. All tumors were low grade (I or II), and the stages were T1-2, Nx-0, M0. There has been no evidence of laparoscopic port site or renal fossa tumor recurrence, local recurrence, or metastatic disease to date in these patients. There is no cancer-specific mortality. CONCLUSIONS Long-term follow-up indicates that laparoscopic evaluation of indeterminate renal cysts is not associated with an increased risk of port site or retroperitoneal or peritoneal recurrence of RCC. It may save a patient from undergoing open surgery and should be considered as a diagnostic option for patients with indeterminate renal cysts.

Management of Rectal Injuries Sustained During Laparoscopic Radical Prostatectomy

BACKGROUND AND PURPOSE As endourology becomes an important part of the practice of urology, the use of fluoroscopic guidance has increased the exposure of urologists to the possibly deleterious effects of radiation. There is a need for a method of radiation protection for percutaneous nephrolithotomy (PCNL), as the exposure from radiation scatter may be significant, depending on the difficulty of establishing access. PATIENTS AND METHODS We ascertained the effectiveness of a newly modified radiation shield during PCNL. Exposure readings were taken using a thermoluminescent dose monitor placed different distances from the radiation source during six PCNLs. We compared the exposure readings with and without the shield. RESULTS The shield was able to reduce the radiation by an average of 96.1% at a distance of 25 cm and 71.2% at a distance of 50 cm from the source. CONCLUSION The shield can be used as one step toward the goal of reducing surgeon radiation exposure. Other methods, such as dose-minimizing imaging protocols and adaptation of equipment optimized to reduce exposure, are also important measures in creating a safe environment for both the urologist and the patient.

Special considerations in endopyelotomy in a horseshoe kidney

OBJECTIVES We present our follow-up of patients with indeterminate renal cysts who were initially evaluated laparoscopically. We specifically address those patients discovered to have cystic renal cell carcinoma by laparoscopy and the incidence of tract seeding, local recurrence, and distant metastases. METHODS Between July 1993 and September 1997, 35 patients with indeterminate renal cysts were evaluated laparoscopically. Under laparoscopic visualization, the cyst was located and aspirated, the fluid was sent for cytology, and the floor of the cyst was biopsied. The tissue was then evaluated immediately by one of our genitourinary pathologists, and an intraoperative decision was made. Four patients were found to have cystic renal cell carcinoma and underwent partial or radical nephrectomy in the same setting. An additional patient had a delayed partial nephrectomy 10 days after laparoscopy as a result of change in the final pathology reading. The patients with malignancy were followed with chest x-ray, liver function tests, abdominal computed tomography (CT) scans, and physical examination every 3 months for the first year and then every 6 months thereafter. The average follow-up was 20.2 months (range 8 to 30). RESULTS Of the 35 patients evaluated in this manner, 5 (14%) were found to have cystic renal cell carcinoma. There has been no evidence of local recurrence or metastatic disease to date. Physical examinations, chest x-rays, liver function tests, and abdominal CT scans all remain negative. CONCLUSIONS Initial laparoscopic evaluation of complex cysts can save the patient from undergoing needless open surgery. Laparoscopic biopsy of cystic renal cell carcinoma followed by open surgery does not seem to increase the incidence of peritoneal seeding, tract recurrence, or distant metastases. Although the preliminary results are very encouraging, long-term follow-up is clearly necessary.