Inderbir S. Gill

Access Technique for Retroperitoneoscopy

PURPOSE The access technique for retroperitoneoscopy is not well established, and differs from transperitoneal laparoscopic access in 3 key aspects: 1) location and technique of primary trocar placement, 2) optimal positioning of the balloon dilator and 3) technique for safe placement of secondary ports. Our method of obtaining retroperitoneoscopic access addresses these issues. MATERIALS AND METHODS A total of 37 patients underwent retroperitoneoscopic surgery of the kidney and upper ureter. RESULTS Our technique facilitates balloon placement within Gerotas fascia, minimizes peritoneal injury and optimizes port placement during retroperitoneoscopic surgery. CONCLUSIONS Although our success rate for placing the balloon within Gerotas fascia has improved, additional experience is required to achieve subfascial balloon placement more consistently.

LAPAROSCOPIC LYMPHOCELECTOMY: A MULTI-INSTITUTIONAL ANALYSIS

PURPOSE Because symptomatic lymphoceles are infrequent, single center studies generally report small numbers of patients. We report a multi-institutional experience with and long-term outcome following laparoscopic lymphocelectomy in 81 patients. MATERIALS AND METHODS Data were obtained from 9 institutions at which at least 5 cases of laparoscopic lymphocelectomy had been performed. Baseline patient demographics, operative time and blood loss, special operative adjunct techniques, postoperative course, convalescence, complications and lymphocele recurrence data were collected and analyzed. RESULTS A total of 56 men and 25 women with a mean age of 41 years were included in the study. Lymphocele formed after renal transplantation in 78 patients (96%) and after pelvic lymph node dissection in 3 (4%). Average operating time was 123 minutes with a mean blood loss of 43 ml. Omentopexy was performed in 11 cases (13.6%). No intraoperative stenting of the transplant ureter was performed. Intraoperative complications consisted of laryngospasm, bladder injury, inferior epigastric artery injury and mild renal capsule hematoma in 1 patient each. Conversion to open surgery was required for repair of bladder injury in 1, repair of preexisting hernia in 1, unusually thickened lymphocele wall in 1 and inaccessible lymphocele location in 4 cases. Mean time to ambulation and resumption of regular diet was 1 day, and mean hospital stay was 1.5 days. Postoperative complications included trocar site hernia in 1 and urinary retention in 2. Convalescence averaged 2.5 weeks. During a mean followup of 27 months 5 patients (6%) had lymphocele recurrence. CONCLUSIONS Laparoscopic lymphocelectomy is safe, minimally invasive and effective. It is an excellent alternative to the conventional open surgical approach.

Analysis of early readmissions after combined pancreas-kidney transplantation

Combined pancreas-kidney transplantation (PKT) has become generally accepted as an effective treatment option, but controversy exists regarding the early morbidity rate of the procedure. To address this issue, we retrospectively analyzed all readmissions occurring in the first 3 months after PKT. Over a 5-year period, we performed 98 PKTs with bladder drainage. The mean recipient age was 36.6 years, with a mean pretransplant duration of diabetes of 23.5 years. All patients received quadruple immunosuppression with antilymphocyte induction therapy. The mean length of initial hospital stay was 20 days. One hundred forty-five readmissions occurred in 73 patients (74.5%), with the initial readmission occurring at a mean of 8.5 days after hospital dismissal and 28 days after PKT. Twenty-five patients (25.5%) had no readmissions, 35 (36%) had one readmission, 17 (17%) had two readmissions, and the remaining 21 patients (21.5%) had three or more readmissions in the first 3 months. The mean number of readmissions was 1.5 per patient. Forty-seven patients (48%) were readmitted within 1 week, and all but one initial readmission occurred within 1 month of hospital dismissal. Causes of readmission included rejection (51), infection (32), pancreas-specific morbidity (such as dehydration, hematuria, or pancreatitis; 50), and miscellaneous causes (12). Thirteen patients (13%) underwent reoperation during readmission. The mean length of hospital stay during readmission was 7.6 days. The mean total length of hospitalization in the first 3 months after PKT was 31 days. Over the span of 5 years, no changes have occurred either in the incidence, timing, causes, or duration of readmissions. The patient survival rate is 96%, the kidney graft survival rate is 90%, and the pancreas graft survival rate is 88% after a mean follow-up of 2.6 years. Mean rehabilitation time (return to work or normal activity) after PKT was 4.0 months. In conclusion, PKT is associated with a fixed morbidity characterized by early readmission (within 1 week) in nearly half of patients and pancreas-specific morbidity as the cause in 35% of readmissions. During evaluation, prospective candidates should be counseled regarding the unique morbidity of PKT. Successful management strategies must emphasize the intensity of early follow-up and recognize the propensity toward immunologic, metabolic, exocrine, and urologic side effects.

Strategies for transplantation of cadaveric kidneys with congenital fusion anomalies

PURPOSE The dire shortage of cadaveric kidneys has led to a gradual expansion of donor criteria in the transplant community. The use of kidneys with anatomical fusion anomalies is uncommon and has not been well defined in the literature. We evaluated the surgical strategies and postoperative outcomes of transplanting cadaveric kidneys with congenital fusion anomalies. MATERIALS AND METHODS Three cadaveric kidneys with congenital fusion anomalies were procured and transplanted between May 1994 and November 1999. None of the 3 donors had any significant urological history. All fusion anomalies were identified during the organ procurement process. RESULTS Anomalies included 1 L-shaped cross-fused ectopic and 2 horseshoe kidneys. All 3 kidneys were procured en bloc. One horseshoe kidney with a narrow isthmus was split and the 2 kidneys were transplanted into separate recipients, while the other horseshoe kidney was transplanted en bloc into a single recipient. The L-shaped kidney was transplanted en bloc into 1 patient. All transplants were successful with a serum creatinine of 1.1 to 1.9 mg/dl. CONCLUSIONS To our knowledge we present the initial case of transplantation of an L-shaped kidney. Cadaveric kidneys with congenital fusion anomalies may be transplanted successfully using various individual technical strategies based on the specific renal anatomy. As such, these kidneys may be used to maximize the increasingly inadequate donor pool.

Contemporary Technique of Radical Prostatectomy

Once considered an unpopular operation with significant morbidity, radical retropubic prostatectomy has evolved into a refined, anatomically precise operation with satisfactory oncologic and functional outcomes (1). Recently, laparoscopy has been incorporated into the urologic armamentarium as an alternative technique for the treatment of localized prostate cancer. Laparoscopic radical prostatectomy (LRP) aims to simulate the open retropubic approach. Furthermore, owing to its enhanced visualization and magnification, the laparoscopic approach has the potential to impact favorably on the morbidity and functional sequelae related to this intricate operation.

Laparoscopic pelvic lymphadenectomy: Transperitoneal approach

Laparoscopic pelvic lymph node dissection (PLND) is the most commonly performed laparoscopic procedure in urology today. Indications for laparoscopic PLND are being refined to selectively identify patients who are at high risk for lymphatic metastases. From a technical standpoint, the anatomic detail and number of lymph nodes retrieved by the laparoscopic approach are comparable to open PLND. Laparoscopic PLND is associated with a steep learning curve and increased operative time; however, the decreased postoperative discomfort, shortened hospital stay, rapid resumption of normal activities, and enhanced cosmesis are clear advantages over open PLND.

Nephron-Sparing Surgery: Laparoscopic Partial Nephrectomy

With the widespread use of contemporary imaging techniques, small renal tumors are now being diagnosed with increased frequency. As a result, the application of nephronsparing techniques has increased in contemporary patients with renal cancer. Partial nephrectomy allows excision of the renal tumor completely and remains the standard technique for nephron-sparing surgery.1 Open partial nephrectomy offers long-term oncological outcomes equivalent to that of radical nephrectomy and long-term preservation of renal function in selected patients with a small renal tumor.2 With increasing experience in laparoscopic reconstructive and oncological procedures, significant interest has centered worldwide on laparoscopic partial nephrectomy (LPN).3 LPN has emerged as a viable alternative to open partial nephrectomy while minimizing patient morbidity. The technique of LPN is now refined and standardized, duplicating established principles of open partial nephrectomy.4 Initially, LPN was limited to patients with a small, superficial, solitary, peripheral, exophytic tumor. Advances in laparoscopic skills and technology have allowed efficacious achievement of renal hilar vascular control, renal hypothermia, tumor excision, caliceal suture repair, and hemostatic parenchymal suture repair. As result, the indications for LPN have been expanded to include larger, central, hilar, and infiltrating tumors. The experience with laparoscopic partial nephrectomy in the Cleveland Clinic now exceeds 550 cases. In this chapter, the current technique for LPN is detailed, including technical tips, results, and complications.

Laparoscopic Approach to Urinary Stone Disease

Minimally invasive antegrade and retrograde techniques combined with extracorporeal Shockwave lithotripsy (SWL) have virtually eliminated open surgery for stone disease. Success rates for treating renal calculi with the above combination approach 100%. The availability of finer instruments with better optical resolution has made the endourological approach the standard of care today. Nevertheless, there exists a category of stones that fail endourologic therapy and thus are candidates for open surgical intervention.

Advantages and Future Perspectives

During the last two decades, urology has benefited tremendously from advancements in technology. In the same vein as other minimally invasive treatment modalities, such as extracorporeal shock-wave lithotripsy and advanced endourological procedures, laparoscopy has recently been established as an effective minimally invasive treatment alternative for a variety of urological disorders. Retroperitoneoscopy and extraperitoneal laparoscopy reflect the continued search for less invasive approaches and have been increasingly utilized as an important approach in the urologic laparoscopic armamentarium [1].