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Retroperitoneal Laparoscopic Adrenalectomy for Functioning Adrenal Tumors: Comparison With Conventional Transperitoneal Laparoscopic Adrenalectomy

PURPOSE We attempted to confirm the possibility and feasibility of laparoscopic adrenalectomy via the retroperitoneal approach, and to compare results of the transperitoneal and retroperitoneal approaches. MATERIALS AND METHODS Three men and 8 women (mean age 39.6 years) with functioning adrenocortical tumors (primary aldosteronism in 5 and Cushings syndrome in 6) underwent laparoscopic adrenalectomy via the retroperitoneal approach using a balloon dissection technique and a newly developed ultrasonic aspirator. Results were compared to those of 27 cases of transperitoneal laparoscopic adrenalectomy. RESULTS Although the retroperitoneal approach was successful in all 5 patients with primary aldosteronism, it succeeded in only 2 of the 6 cases of Cushings syndrome. In 3 Cushings syndrome cases the retroperitoneal approach was changed to the transperitoneal laparoscopic approach due to difficulty in exploration. Open laparotomy was required in 1 case of left Cushings syndrome because of an inadvertent pancreatic injury. Subcutaneous emphysema developed in 6 patients without hypercapnia or prolonged postoperative symptoms. Mean operative time and blood loss, and time to oral intake and ambulation were 248.3 minutes, 151.4 ml., and 1.55 and 2 days, respectively. There was no difference between retroperitoneal and conventional transperitoneal laparoscopic adrenalectomy in regard to these factors or to convalescence. CONCLUSIONS Retroperitoneal laparoscopic adrenalectomy is feasible for primary aldosteronism. However, Cushings syndrome is presently a much more difficult indication than primary aldosteronism for this new operative technique.

Experience with 17 Cases of Laparoscopic Adrenalectomy: Use of Ultrasonic Aspirator and Argon Beam Coagulator

Between January 17, 1992 and July 31, 1993, 11 patients with primary aldosteronism, 3 with Cushings syndrome and 3 with a nonfunctioning adrenal tumor underwent laparoscopic adrenalectomy at our university hospital. In every patient adrenal tumor was removed successfully with adjacent normal adrenal tissue. The initial 10 operations were performed without use of an ultrasonic aspirator or argon beam coagulator, and the subsequent 7 procedures were done with those items. There was no difference between the groups in intraoperative blood loss or operative time. However, the tumors in the former group were significantly smaller than those of the latter group (mean 6.70 gm. versus 13.43 gm., respectively, p < 0.05, t test). For right tumors the argon beam coagulator was useful to resect or coagulate the liver, since adrenal tumors were sometimes tightly attached to the liver and upward retraction sometimes caused liver laceration. In obese patients or those with Cushings syndrome the ultrasonic aspirator was useful to remove retroperitoneal fat surrounding the adrenal tumor without injury to the small vessels. The mean hospital stay for these 17 patients (11.63 days) was significantly shorter than that of 16 patients with corresponding adrenal tumors undergoing open removal during the last 5 years (17.32 days, p < 0.05 t test). In conclusion, laparoscopic adrenalectomy is feasible for the surgical treatment of primary aldosteronism, Cushings syndrome and nonfunctioning adrenal tumors. The ultrasonic aspirator and argon beam coagulator may be useful for laparoscopic adrenalectomy.

Changes in urinary excretion of endothelin-1-like immunoreactivity before and after unilateral nephrectomy in humans. Comparison with other urinary parameters and unilateral adrenalectomy.

To assess the value of endothelin-1 (ET-1) as a parameter of renal functional overload and the process of hyperfiltration, urinary excretion of ET-1-like immunoreactivity (U-ET-1) and urinary excretion of other parameters [beta 2-microglobulin (beta 2-MG), N-acetyl-beta-D-glucosaminidase (NAG), albumin (Alb) and 24-hour creatinine clearance (Ccr24)] were measured before, 1, 2 and 7 days after unilateral nephrectomy in 15 patients with unilateral renal lesions (renal cell cancer, renal pelvic cancer, ureteral cancer and renal tuberculosis) and after unilateral adrenalectomy in 5 patients with adrenal lesions. In the nephrectomy group (NX), Ccr24 significantly decreased at 1 and 2 days after the operation, but the other 4 parameters significantly increased after the operation as compared to preoperative values. In the adrenalectomy group (ADX), neither Ccr24 nor ET-1/Cr showed any change after the operation, but the other 3 parameters (beta 2-MG/Cr, NAG/Cr and Alb/Cr) significantly increased. Comparing the NX and ADX groups, both ET-1/Cr and beta 2-MG/Cr in NX were significantly higher than in ADX after the operation. On the other hand, neither NAG/Cr nor Alb/Cr in NX differed from values in ADX. Comparing ET-1/Cr and other parameters, only beta 2-MG showed a positive significant correlation. These results suggest that U-ET-1 may be an indicator of functional overload of the kidney.

Changes in urinary excretion of endothelin-1-like immunoreactivity in patients with testicular cancer receiving high-dose cisplatin therapy.

To assess the value of endothelin-1 (ET-1) in estimating renal injury in patients receiving high doses of cisplatin, urinary excretion of ET-1-like immunoreactivity (U-ET-1), beta 2-microglobulin (U-beta 2-MG), and N-acetyl-beta-d-glucosaminidase (NAG) were measured before, 1 week after, and 2 weeks after the administration of cisplatin in eight patients with testicular cancer (mean age, 33.3 years). Levels of U-ET-1/creatinine (Cr) during and 1 week after cisplatin treatment were significantly higher than before cisplatin treatment. There were no differences in U-ET-1/Cr levels during, 1 week after, and 2 weeks after cisplatin treatment. The level of U-beta 2-MG/Cr during cisplatin treatment was significantly higher than levels before, 1 week after, and 2 weeks after treatment. However, there were no differences in U-beta 2-MG/Cr levels before, 1 week after, and 2 weeks after cisplatin treatment. The level of U-NAG/Cr during cisplatin treatment was higher than levels before, 1 week after, and 2 weeks after treatment; U-NAG/Cr during cisplatin treatment was higher than levels before, 1 week after, and 2 weeks after treatment; U-NAG/Cr gradually decreased after cisplatin treatment. Among the three parameters, only U-ET-1/Cr maintained a higher level after cisplatin treatment. The U-beta 2-MG/Cr level returned most rapidly to normal after cisplatin treatment. Although U-ET-1/Cr did not show any significant correlation with U-NAG/Cr (r = 0.282, P = NS), it showed a significant correlation with U-beta 2-MG/Cr (r = 0.454, P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Application of flexible renoureteroscope for antegrade urethroscopy in the treatment of congenital anterior urethral valve

Antegrade urethroscopy was performed through a cystostomy using a 10.8-fr caliber flexible renoureteroscope in 4 children (aged 2 years and 8 months, 2 months, 14 years and 1 month) with anterior urethral valve. The anatomy of the valves as well as their destruction after transurethral resection (TUR) were well visualized by antegrade urethroscopy. This technique was helpful in performing TUR-valve, after which the findings of voiding cystourethrography in every case and the findings of uroflowmetry in the elder 2 cases showed remarkable improvement. This technique is relatively simple to perform and is thought to be one of the best methods to treat anterior urethral valve. This technique is also applicable to other lower urinary tract lesions in children.

Balloon Dilatation for Entire Urethral Stricture

Two patients with entire urethral stricture were treated with balloon dilatation of the whole urethra using a torpedo-type dilatation balloon with satisfactory results. Postdilatation urethrograms revealed that the lumen of the urethra was of satisfactory width in both cases, and the patients are now voiding normally. There has been no complication requiring therapy. These successful results suggest that this technique is a good alternative treatment for entire urethral stricture, and can replace conventional dilatation.

Spontaneous hemorrhage of an adrenal cortical adenoma causing Cushing's syndrome

We report the case of a spontaneously ruptured adrenal adenoma which caused Cushings syndrome. The 34-year-old female patient had severe left-side back pain and anemia. Computerized tomography disclosed a retroperitoneal hemorrhage and a 4-cm mass on the left which was considered to be an adrenal tumor. An operation was successfully performed, and the patient is well 12 months after surgery.

Bladder Neck Suspension Using Percutaneous Bladder Neck Stabilization to the Pubic Bone with a Bone-Anchor Suture Fixation System:A New Extraperitoneal Laparoscopic Approach

A 39-year-old woman with type 1 genuine stress urinary incontinence was treated using a novel extraperitoneal laparoscopic bladder neck suspension procedure with a bone-anchor suture fixation system. Operative time and blood loss were 2.5 and 50 g, respectively. The patient showed a remarkable improvement on chain cystography and in subjective and objective well-being with no complications, even 12 months after surgery. Extraperitoneal laparoscopic bladder neck suspension using the bone-anchor suture fixation system is an easy and feasible procedure.

Incidence of Pouch Stones and Risk Factors for Urolithiasis in Patients with Continent Urinary Diversion or Neobladder Using Intestine

Urinary risk factors and inhibiting factors for urolithiasis, such as oxalate, calcium, phosphate, uric acid, citrate, and magnesium, were examined in 12 patients receiving continent urinary diversion, neobladder, or augmentation cystoplasty using intestine. These data were compared with the incidence of pouch stone formation. Ten (83.3%) of 12 patients had at least one risk factor, and 5 (41.7%) of 12 had two or more risk factors. Pouch stone developed in 4 (80%) of 5 patients with two or more risk factors, and in none of 7 patients with one or zero risk factors. The incidence of pouch stone in the former group was significantly higher than in the latter group. These results suggest that urinary reservoir operations should not be performed in patients with two or more risk factors for urolithiasis.

Endoscopic renal biopsy in pediatric patients: comparison of retroperitoneoscopy-assisted and retroperitoneoscopic methods.

Accessible online at: www.karger.com/journals/nef Dear Sir, Laparoscopic surgery including retroperitoneoscopy has been widely used in various urological disorders because of its advantage of being less invasive than open surgery [1– 3]. We have already reported our experience with laparoscopic renal biopsy via the retroperitoneal approach [4]. In this paper, retroperitoneoscopy-assisted renal biopsy (ASSIST) and retroperitoneoscopic renal biopsy (RETRO) were reported and compared. Eleven pediatric patients with the nephrotic syndrome or hematoproteinuria were included. The inclusion criteria were difficulties with needle renal biopsy because of poor detection of the kidneys by ultrasonography. Six (cases 1–6) underwent RETRO, and the other 5 (cases 7–11) underwent ASSIST. The patient’s age was between 2 and 15 years (mean: 6.17 years for RETRO and 4.4 years for ASSIST; table 1). The backgrounds of the two groups were comparable. Regarding RETRO, the method was similar to Gaur’s retroperitoneoscopic approach [5]. After full induction of a general anesthesia with endotracheal intubation, a 2-cm transverse skin incision was made at two-finger breadths below the tip of the 12th rib, and a small retroperitoneal space was created by blunt finger dissection. A dissecting balloon was inserted into the retroperitoneal space and was fully inflated. After removal of the dissection balloon, a 10-mm trocar was inserted by the initial wound, and CO2 insufflation with a pressure of not more than 8 mm Hg was begun. Then, a second trocar was inserted under endoscopic monitoring about 3 cm below the first trocar port. The lower pole of the kidney was easily identified, and renal biopsy was performed by a single stroke of a laparoscopic cup forceps through the second trocar port. Hemostasis was obtained using the Argon-Beam-Coagulator (Kobayashi Medical, Osaka Japan). For ASSIST, retroperitoneal space was dissected by the same procedure as for RETRO. Then, retractors for open surgery were inserted to widen the wound space, and a 0 or 12° urethrocystoscope was inserted into