James F. Donovan

Laparoscopic Varix Ligation

Varicocele, dilated veins in the pampiniform plexus, is frequently a contributing factor in male infertility. We performed outpatient laparoscopic varix ligation in 14 patients (5 bilaterally) with clinically evident varices and persistent oligospermia and/or asthenospermia. The spermatic artery was identified and preserved in all but 1 varix ligation. Mean interval to resumption of preoperative activity levels was 3.4 days. On average, patients consumed 8.4 tablets of acetaminophen (325 mg.) with codeine (30 mg.) during the recovery period. The procedure is effective and decreases postoperative morbidity.

Retroperitoneal and pelvic extraperitoneal laparoscopy : An international perspective

OBJECTIVES To assess technical preferences and current practice trends of retroperitoneal and pelvic extraperitoneal laparoscopy. METHODS A questionnaire survey of 36 selected urologic laparoscopic centers worldwide was performed. RESULTS Twenty-four centers (67%) responded. Overall, 3988 laparoscopic procedures were reported: transperitoneal approach (n = 2945) and retroperitoneal/extraperitoneal approach (n = 1043). Retroperitoneoscopic/extraperitoneoscopic procedures included adrenalectomy (n = 74), nephrectomy (n = 299), ureteral procedures (n = 166), pelvic lymph node dissection (n = 197), bladder neck suspension (n = 210), varix ligation (n = 91), and lumbar sympathectomy (n = 6). Mean number of total laparoscopic procedures performed in 1995 per center was 41 (range 5 to 86). Major complications occurred in 49 (4.7%) patients and included visceral complications in 26 (2.5%) patients and vascular complications in 23 (2.2%). Open conversion was performed in 69 (6.6%) patients, electively in 41 and emergently in 28 (visceral injuries, n = 16; vascular injuries, n = 1 2). Retroperitoneoscopy/extraperitoneoscopy is gaining in acceptance worldwide: in 1993, the mean estimated ratio of transperitoneal laparoscopic cases versus retroperitoneoscopic/ extraperitoneoscopic cases per center was 74:26; however, in 1996 the ratio was 49:51. CONCLUSIONS Retroperitoneoscopy and pelvic extraperitoneoscopy are important adjuncts to the laparoscopic armamentarium in urologic surgery. The overall major complication rate associated with retroperitoneoscopy/extraperitoneoscopy was 4.7%.

Laparoscopic Partial Nephrectomy: Initial Experience and Comparison to the Open Surgical Approach

During an 18-month period, 6 laparoscopic partial nephrectomies were attempted, 4 of which were successful. The surgical technique was modified and improved between cases aided by new laparoscopic instrumentation, such as the argon beam coagulator and the 7.5 MHz. ultrasonic sector scanning system. In a retrospective comparison between laparoscopic and open partial nephrectomy, estimated blood loss was 525 ml. for the former versus 708 ml. for the latter procedure. However, operating time was more than 2 hours longer with the laparoscopic approach. The major advantages of the laparoscopic procedure appear to be a more rapid return to full diet, less postoperative pain and less requirement for parenteral narcotics. Despite the small size of this series and limited followup data, convalescence may be shortened by 4 weeks after laparoscopic partial nephrectomy. Patients with benign diseases of the kidney, especially with a duplicated collecting system, who require partial nephrectomy may be considered candidates for the laparoscopic approach. The advantages to the patient, however, may be offset by the technical demands on the surgeon.

Comparison of motility stimulants for cryopreserved human semen.

Caffeine, pentoxifylline, 2-deoxyadenosine, cyclic adenosine monophosphate (cAMP), relaxin, adenosine, kallikrein, and calcium were compared for their ability to stimulate motility of cryopreserved sperm. Caffeine, pentoxifylline, and 2-deoxyadenosine significantly increased the percentage of motile sperm at 15, 30, 45, and 60 minutes after administration. Sperm velocity was significantly increased by caffeine at 0, 15, 30, and 45 minutes, and by pentoxifylline at 0, 45, and 60 minutes. Consistent stimulation was not observed for other chemicals. Caffeine, pentoxifylline, and 2-deoxyadenosine were then examined for their ability to provide motility stimulation after removal with washing. With the exception of caffeine, percent motility and velocity for stimulated and untreated sperm were similar after washing. A significant reduction in motility was observed at 48 hours after washing for caffeine. The percentage of hamster oocytes penetrated at 24 hours after washing was significantly reduced for caffeine, 2-deoxyadenosine, and pentoxifylline combined with 2-deoxyadenosine. Pentoxifylline-treated sperm showed no reduction in fertilizing capacity. These results indicate that, of the chemicals examined, pentoxifylline is superior for motility stimulation of cryopreserved sperm.

Small renal mass biopsy--how, what and when: report from an international consensus panel.

To discuss the use of renal mass biopsy (RMB) for small renal masses (SRMs), formulate technical aspects, outline potential pitfalls and provide recommendations for the practicing clinician. The meeting was conducted as an informal consensus process and no scoring system was used to measure the levels of agreement on the different topics. A moderated general discussion was used as the basis for consensus and arising issues were resolved at this point. A consensus was established and lack of agreement to topics or specific items was noted at this point. Recommended biopsy technique: at least two cores, sampling different tumour regions with ultrasonography being the preferred method of image guidance. Pathological interpretation: ‘non‐diagnostic samples’ should refer to insufficient material, inconclusive and normal renal parenchyma. For non‐diagnostic samples, a repeat biopsy is recommended. Fine‐needle aspiration may provide additional information but cannot substitute for core biopsy. Indications for RMB: biopsy is recommended in most cases except in patients with imaging or clinical characteristics indicative of pathology (syndromes, imaging characteristics) and cases whereby conservative management is not contemplated. RMB is recommended for active surveillance but not for watchful‐waiting candidates. We report the results of an international consensus meeting on the use of RMB for SRMs, defining the technique, pathological interpretation and indications.

The role of haptic feedback in laparoscopic training using the LapMentor II.

INTRODUCTION Laparoscopic surgery has become the standard of care for many surgical diseases. Haptic (tactile) feedback (HFB) is considered an important component of laparoscopic surgery. Virtual reality simulation (VRS) is an alternative method to teach surgical skills to surgeons in training. Newer VRS trainers such as the Simbionix Lap Mentor II provide significantly improved tactile feedback. However, VRSs are expensive and adding HFB software adds an estimated cost of

Survival of patients with small cell carcinoma of the prostate during 1973–2003: a population‐based study

30,000 to the commercial price. The HFB provided by the Lap Mentor II has not been validated by an independent party. We used the Simbionix Lap Mentor II in this study to demonstrate the effect of adding an HFB mechanism in the VRS trainer. MATERIALS AND METHODS The study was approved by the University of Cincinnati Institutional Review Board. Twenty laparoscopically novice medical students were enrolled. Each student was asked to perform three different tasks on the Lap Mentor II and repeat each one five times. The chosen tasks demanded significant amount of traction and counter traction. The first task was to pull leaking tubes enough and clip them. The second task was stretching a jelly plate enough to see its attachments to the floor and cut these attachments. In the third task, the trainee had to separate the gallbladder from its bed on the liver. The students were randomized into two groups to perform the tasks with and without HFB. We used accuracy, speed, and economy of movement as scales to compare the performance between the two groups. The participants also completed a simple questionnaire that highlighted age, sex, and experiences in videogame usage. RESULTS The two groups were comparable in age, sex, and videogame playing. No differences in the accuracy, the economy, and the speed of hand movement were noticed. In fact, adding HFB to the Lap Mentor II simulator did not contribute to any improvement in the performance of the trainees. Interestingly, we found that videogame expert players tend to have faster and more economic motion in their dominant hands. However, the performance accuracy was not significantly affected. CONCLUSION The presence of HFB has less effect than it thought to be on the performance of the novice trainees. This may suggest that better HFB is still needed. However, there may be visual compensation for the lack of haptics. Playing videogames has a positive impact on economy, and the speed of the dominant had motion without affecting its accuracy. Further research is needed to clarify the value of haptics to the expert surgeon and compare it to the new trainees.

Splenectomy Complicating Left Nephrectomy

Study Type – Therapy (inception cohort)

Laparoscopic Surgical Training: Effectiveness and Impact on Urological Surgical Practice Patterns

PURPOSE We attempted to clarify the details of incidental splenectomy complicating left nephrectomy. MATERIALS AND METHODS We reviewed the literature and operations involving splenectomy performed during left nephrectomy between 1984 and 1994 at our university. Factors reviewed included patient characteristics, renal pathology, mechanisms of injury, blood transfusions and postoperative complications. RESULTS Of the 418 left nephrectomies 18 (4.3%) resulted in splenectomy via a transperitoneal approach. Patients with a large or upper pole renal lesion, malignancy or advanced age are increasingly likely to undergo unanticipated splenectomy. CONCLUSIONS Our results, combined with recommendations from the Centers for Disease Control and Prevention, suggest that all patients older than 65 years undergoing left transperitoneal nephrectomy or those at increased risk for splenic injury should receive preoperative pneumococcal vaccination.

Results in the United States with Sperm Micro-Aspiration Retrieval Techniques and Assisted Reproductive Technologies

Urological interest in laparoscopic surgical techniques has dramatically increased during the last several years. However, the extent to which these methods are being used and the impact of training courses on clinical use are unclear. We assessed urologist practice patterns subsequent to a formal training course in urological laparoscopic surgery. On 5 dates between January and October 1991, a total of 163 urologists participated in a 2-day, university sponsored, laparoscopic surgery training seminar. Instruction consisted of 8 hours of didactic lectures including 2 live video cases, 4.5 hours of simulation and 4.5 hours in a live animal laboratory. Three months after the course the participants were mailed a questionnaire inquiring as to the interval laparoscopic surgery experience. Practice demographics, additional training, equipment availability, number of laparoscopic surgery candidates identified, percentage of overall surgical case load, patient inquiries, cases performed and complications were assessed by the questionnaire. Descriptive and correlative information was then derived from the data set. A total of 105 course participants (64%) responded to the questionnaire and 64 had engaged in some form of additional training following the course. During the 3 months since course completion respondents had identified an average of 4 candidates for laparoscopic surgery, which represented a mean of 2.5% of the total case load. Specific patient inquiries averaged less than 1 per physician within 3 months. During this same interval respondents had performed a total of 156 laparoscopic procedures (1.7 per urologist). Of the participants 45% had not performed their first case and 32% had performed more than 1 laparoscopic procedure. A total of 11 complications was reported (7.2%) and in 7 instances the surgeon was required to convert to an open approach. Veress needle placement was perceived as the most difficult aspect of the technique (22% of the respondents). Training subsequent to the course was the best predictor of clinical use. Of those who responded 88% believed that their future use of laparoscopy would increase. This survey suggests that subsequent to training, laparoscopic techniques are being rapidly and safely used by urologists. However, in the current state of development the impact of laparoscopic surgery on global urological practice patterns appears to be small.