Ioannis Georgiopoulos

Unfavorable outcomes of laparoscopic pyeloplasty using barbed sutures: a multi-center experience

PurposeBarbed self-retaining sutures (SRS) have been introduced as an advance in suture technology, facilitating reconstructive laparoscopic surgery. We present the experience of three centers performing laparoscopic pyeloplasty with the use of SRS.MethodsPreoperative, intraoperative and follow-up data were collected for 6 patients undergoing pyeloplasty using the Quill SRS (Angiotech, Vancouver, CAN) in three centers. Standard laparoscopic pyeloplasty technique was used and a knot-less continuous anastomosis between the spatulated ureter and the renal pelvis was created.ResultsKnot-less uretero-pelvic anastomosis creation was feasible in all six cases. Peri-operative data were similar to standard pyeloplasty using conventional suture materials. A very high stricture recurrence rate (5/6 patients) was noted during follow-up. Further endourologic and open interventions were needed to address the recurrence of the strictures.ConclusionsKnotless intracorporeal laparoscopic suturing using SRS for the reconstruction of UPJ during laparoscopic pyeloplasty is associated with high rates of stricture recurrence at least in the initial cases of each surgeon. Until further investigations elucidate the cause of treatment failure, SRS should not be recommended for upper urinary tract reconstruction.

Assessing the use of haemostatic sealants in tubeless percutaneous renal access and their effect on renal drainage and histology: an experimental porcine study.

To evaluate the mid‐term effects of haemostatic sealant application during tubeless percutaneous nephrolithotomy (PCNL) on renal drainage and histology in an in vivo porcine study.

Drug-eluting metallic stents in urology.

Drugeluting metal stents (DESs) have been extensively used in coronary and vascular disease. This type of stents has been proven to provide significantly lower restenosis rates due to the reduction of neo-intimal hyperplasia in comparison to the traditionally used bare metal stents (BMSs). The latter stents have been evaluated for more than a decade in urological practice in an attempt to provide permanent relief of urethral or ureteral obstruction. Although the initial results were promising, long-term experience revealed significant complications, which are mainly attributed to stent-related hyperplastic reaction compromising stent patency. The favorable experience of vascular DESs led to the application of DESs in both the urethra and ureter of animal models. These experimental results demonstrated a reduction of hyperplastic reaction of DESs in comparison to BMSs. Nevertheless, clinical data are currently not available. Considering the fact that DESs are under continuous development, the use of DESs in urology holds promise for the future and seems to be an intriguing field.

Laparoscopic simple prostatectomy: A reasonable option for large prostatic adenomas

Aim of the Study: In this work, surgical technique followed by two academic departments on laparoscopic simple prostatectomy (LSP) of large prostatic adenomas is being described. Materials and Methods: The initial cumulative experience from 11 patients with lower urinary tract symptoms of benign prostatic hyperplasia origin subjected to LSP is being presented. Results: All cases had prostatic adenomas greater than 80 ml. Mean operation time was 99.5 min (values from 70 to 150 min) and mean blood loss was 205 ml (values from 100 to 300 ml). Blood transfusion was deemed necessary in one case. Bladder catheter was removed successfully on postoperative day 5 in all cases. No significant postoperative complication was noted. At a 3 months follow-up a significant decrease in International Prostate Symptom Score (IPSS) was evident in all patients (mean IPSS 27.7 vs. 15.3 preoperative vs. postoperative accordingly). Conclusions: According to our data and similarly to the rest of the LSP literature, laparoscopic excision of voluminous prostatic adenomas is a feasible and safe procedure. Nevertheless, further investigation including a larger number of patients and long-term follow-up is deemed necessary before making definite conclusions regarding the approach.

Modular training for percutaneous nephrolithotripsy: The safe way to go.

Abstract Objectives should be describe a modular training scheme (MTS) which aims to provide training in percutaneous nephrolithotripsy (PCNL) and ensure the safety of the patients. Subjects and methods: Two trainees with no experience in PCNL attended the MTS under the supervision of an experienced mentor. The MTS included five modules, comprising an initial animal laboratory course (using pigs), to acquire basic skills (Module 1), and Modules 2–5 included making the puncture, tract dilatation, single-stone and large-stone management in clinical cases, respectively. Each participant progressed from one module to the next under constant mentoring and evaluation by the mentor. When the trainees completed the MTS they proceeded to perform 60 PCNL procedures independently while the mentor performed 25 for comparison purposes. A global rating scale was used for the objective evaluation of the trainees. Peri-operative variables were recorded and statistically compared as appropriate. Statistical significance was defined as P < 0.05. Results: One pig and 16 patients, and two pigs and 22 patients, were necessary to complete the MTS by each subject. There were no significant differences among the characteristics of the independently performed operations. The duration of surgery and fluoroscopy achieved a plateau similar to those of the mentor after ≈ 30 patients. The decrease in haemoglobin level, stone-free and complication rates in the patients were similar among the two trainees and the mentor. The complication rate of the trainees and the mentor never exceeded 13.3%. Conclusion: The MTS successfully combined animal and stepwise clinical training based on a standardised technique and objective evaluation.

Laparoendoscopic single-site surgery in kidney surgery: clinical experience and future perspectives.

Laparoscopic surgery of the upper urinary tract has reduced the morbidity related to large abdominal incisions and has resulted in significant advantages over open surgery. Nevertheless, the pursuit for even more minimally invasive alternatives to laparoscopy has led to the concept of scarless surgery and the approach of laparoendoscopic single-site surgery (LESS). LESS is currently a feasible approach for the majority of kidney surgical procedures, and there is intense debate regarding its efficiency and advantages. In the present review of the literature, the current status of upper urinary LESS and its advantages and disadvantages, as well the technological and technical evolution, are presented.

The full metallic double-pigtail ureteral stent: Review of the clinical outcome and current status.

The full metallic double-J ureteral stent (MS) was introduced as a method for providing long-term drainage in malignant ureteral obstruction. Experimental evaluation of the MS revealed that its mechanical features allow efficient drainage in difficult cases, which could not be managed by the insertion of a standard polymeric double-J stent. Clinical experience with the MS showed controversial results. Careful patient selection results in efficient long-term management of malignant ureteral obstruction. The use of the MS should also be considered in selected benign cases. Major complications are uncommon and the minor complications should not hinder its use. Experience in pediatric patients is limited and warrants additional study. The cost-effectiveness of the MS seems to be appropriate for long-term treatment. Further investigation with comparative clinical trials would document the outcome more extensively and establish the indications as well as the selection criteria for the MS.

Laparoscopic radical prostatectomy.

Laparoscopic radical prostatectomy (LRP) is the standard of care for the management of localized and locally advanced prostatic cancer in numerous institutions worldwide. The extraperitoneal approach for LRP (Endoscopic Extraperitoneal Radical Prostatectomy- EERPE) has been also well established in everyday clinical practice. Both approaches have been refined in the course of time and have achieved oncological and functional results directly comparable to open radical prostatectomy (ORP) and Robot-assisted laparoscopic radical prostatectomy (RALP). The complication rates remain similar among the approaches with LRP and RALP having a favorable outcome in terms of blood loss and postoperative hospitalization. Long-term outcomes of LRP have been published in the recent years and reveal oncological efficacy comparable to the alternative approaches. LRP seems to have stood the test of time and currently provides a cost-effective approach to minimally invasive radical prostatectomy in institutions that do not have access to a robotic surgical system.

Direct effects of vardenafil on the ureter: in vitro investigation and potential clinical applications of intralumenal administration.

Local intralumenal administration of substances with beneficial effects over the ureter appears to be a very attractive route for the administration of drugs to the urinary system, avoiding systemic adverse reactions associated with per os administration. This work investigates whether vardenafil is a good candidate for local intralumenal ureteral administration. More precisely, we examined the effect of vardenafil on human ureter contractility and on the viability of cultured human urothelial cells (hUC) and bladder smooth muscle cells (hBSMC). Our study revealed that vardenafil induced a dose-depended relaxation of isolated human ureteral tissue. In addition, growth and cell viability of cultured hBSMC and hUC remained unaltered after vardenafil application. Based on the above, this selective phosphodiesterase type 5 inhibitor can be considered as a promising pharmacologic agent for local intralumenal administration in clinical conditions in which ureteral dilation might be beneficial.

Optical coherence tomography provides images similar to histology and allows the performance of extensive measurements of drug-eluting metal stents in animal ureters

Optical coherence tomography (OCT) images and histology images of metal stents (MSs) inserted in animal ureters were compared, and the reliability of an OCT-based automated method for the performance of quantitative evaluation of ureteral MSs was evaluated. A zotarolimus-eluting metal stent (ZES) and a bare metal stent (BMS) were inserted in each ureter of ten pigs and six rabbits. OCT was performed in unobstructed stented ureters. Histopathologic examination of the stented ureters embedded in glycol-methacrylate took place. Quadrants of OCT images were compared to their respective histologic images by employing two independent observers who delineated different layers in the quadrants of OCT images and correlated them to the respective histologic quadrants. Manual (integrated OCT device software) and automated measurements of the OCT images using an automated strut detection method were compared. The observers highly agreed on the delineation of urothelium from the lamina propria and the lamina propria from the muscle layer of the ureteral wall. The algorithm measurements were similar to the manual measurements, and the algorithm proved to be reliable in the evaluation of ureteral MSs. Significantly higher endothelial hyperplasia of the BMSs in comparison to the ZESs was also quantitatively demonstrated by the strut detection method. OCT proved to be a reliable method for the evaluation of ureteral MSs. OCT provided images of the stented ureteral lumen similar to light microscopy quality. Measurements of the stented ureter are reliably performed by the automated strut detection method.