James M. Cummings

COMPARISON BETWEEN STANDARD FLANK VERSUS LAPAROSCOPIC NEPHRECTOMY FOR BENIGN RENAL DISEASE

To evaluate the role of laparoscopic nephrectomy in the management of benign renal diseases, 12 patients undergoing laparoscopic nephrectomy were compared to 13 undergoing a classical flank nephrectomy. Both groups were similar in regard to patient age and indications for surgery. The underlying pathological conditions included vesicoureteral reflux, tuberculosis, hydronephrosis, hypertension and failed pyeloplasty. Overall, operative time ranged from 105 to 360 minutes (mean 145) for the laparoscopic group and 60 to 240 minutes (mean 156.6) for the open surgery group. Hospital stay and interval to return to regular preoperative activities were 2 to 6 days (mean 3.5) and 10 to 21 days (mean 16) for patients undergoing laparoscopic nephrectomy, which was significantly shorter than for those undergoing a flank procedure, 3 to 16 days (mean 8) and 35 to 84 days (mean 32.3), respectively. Pain medication requirements were also markedly decreased after laparoscopic nephrectomy. Of the patients in the laparoscopic group 2 experienced complications with only 1 requiring conversion to open nephrectomy. The laparoscopic technique is an effective as the flank approach for benign renal conditions, while providing a more rapid recuperation and superior cosmetic result.

Transurethral Collagen Injections in the Therapy of Post-Radical Prostatectomy Stress Incontinence

PURPOSE We report on our initial results with glutaraldehyde cross-linked collagen used as an injectable bulking agent for the therapy of post-radical prostatectomy stress incontinence. MATERIALS AND METHODS A total of 19 men underwent collagen injection for treatment of post-radical prostatectomy stress incontinence. RESULTS Of the 19 patients treated 11 had either a good (4) or improved (7) result, for an overall satisfaction rate of 58% with a followup of 3 to 15 months (mean 10.4). Failure correlated with presence of bladder neck contracture or scarring and severity of incontinence. CONCLUSIONS Injection of collagen for stress incontinence after radical prostatectomy has an acceptable short-term success rate, particularly in men with milder incontinence and lack of bladder neck scarring.

Leak Point Pressures in Women With Urinary Stress Incontinence: Correlation With Patient History

PURPOSE We examined the relationship between historical factors in women with urinary stress incontinence and the Valsalva leak point pressure. MATERIALS AND METHODS Valsalva leak point pressure measurements in 57 women with urinary stress incontinence were compared to findings in the history. RESULTS Valsalva leak point pressure was low in 83% of women with severe leakage and previous surgery. Interestingly, 47% of patients without predisposing factors had low Valsalva leak point pressures. CONCLUSIONS Women with severe leakage and previous bladder neck surgery are likely to have urethral dysfunction as demonstrated by Valsalva leak point pressure testing. A significant incidence of low Valsalva leak point pressures in patients without predisposing factors could account for many failures of routine suspension procedures.

Complications of Laparoscopic Urological Surgery: Experience at St. Louis University

A total of 221 patients underwent laparoscopic surgery at our institution. An outcome analysis with regard to type of procedure, success and complications was done. Overall, 216 of 221 procedures (97.7%) were performed as originally planned. One operation was converted to an open procedure. Complications producing morbidity occurred in 33 of 217 patients (15.2%). There was no associated mortality. Most complications occurred early in the participating surgeons experience. Of the complications 11 (5.0%) were considered major and included formation of symptomatic lymphoceles (4 patients), vascular injury (1), ureteral transection (1), bladder perforation (1), bowel obstruction (1), cecal perforation (1) and cerebrovascular accident (1). One patient had an idiopathic reaction to the inhalation anesthetic. Of the 11 major complications 9 occurred among 98 patients undergoing pelvic lymphadenectomy and 7 of these occurred among a subset of 15 patients undergoing an extended dissection. Adjuvant surgical intervention was necessary in 13 patients: celiotomy in 5, laparoscopic techniques in 4 and minor surgical procedures or percutaneous techniques in 4. Our experience suggests that urological laparoscopic surgery is safe and offers a shorter convalescence. However, the technique must be regarded as major surgery, associated with a steep learning curve.

Radical Perineal Prostatectomy without Pelvic Lymphadenectomy: Selection Criteria and Early Results

PURPOSE We evaluated the surgical efficacy of radical perineal prostatectomy and determined preoperative parameters to identify patients at low risk for nodal metastasis. MATERIALS AND METHODS Of 155 men evaluated for radical perineal prostatectomy, 74 were assigned to a low risk category (prostate specific antigen less than 10 ng./ml., Gleason score less than 7). Of the patients 40 underwent laparoscopic lymph node dissection and 34 did not. This group was compared to 81 patients who underwent surgical staging and did not fit the low risk criteria. RESULTS None of 74 patients in the low risk group had nodal metastasis, while metastasis was present in 5 of 81 (6.1%) who did not meet such parameters. Organ-confined disease was present in 71.6% of men with low risk criteria, which was a significantly different rate than the 51.9% found in the other 81 men. CONCLUSIONS Radical perineal prostatectomy confers adequate cancer control and can be performed without pelvic node dissection in select patients.

An Approach for Using Full Thickness Skin Grafts for Complex Penile Surgeries in Children

PURPOSE Many problems in pediatric urology derive from a paucity of penile skin resulting from prior surgical interventions. While hypospadias surgery is most often responsible for creating this problem, excessive circumcision also can leave a patient with too little skin to cover the penis. To our knowledge we describe the first series of pediatric patients in whom FTSGs were used in a variety of difficult circumstances where penile skin was lacking. MATERIALS AND METHODS We retrospectively studied a cohort of 11 children 2 to 13 years old who underwent urethral repair and adjunctive skin grafting due to circumcision injuries (4 patients), traumatic urethral injury (1) or congenital lymphangiectasis (1), or for congenital hypospadias with previous failed surgery (5). In our patients available penile skin was used to reconstruct the urethra, while full thickness inguinal skin grafts were fashioned to resurface the denuded penis following reconstruction. RESULTS All patients underwent successful reconstruction and grafting. There were no intraoperative complications. There was 100% take of the grafts. Average followup was 23 months (range 3 weeks to 8.6 years). One patient had slight chordee at 6 years postoperatively, and 1 had development of a urethrocutaneous fistula at 8.6 years. All patients reported normal caliber urinary streams. CONCLUSIONS Use of full thickness inguinal skin grafts to resurface the penis provided patients with an esthetically acceptable result, and where necessary allowed penile skin to be used for urethroplasty. This technique is useful and justifies consideration in appropriately selected patients.

Evaluation of Fluid Absorption During Laser Prostatectomy by Breath Ethanol Techniques

PURPOSE Laser prostatectomy has evolved as a less invasive method of relieving bladder outlet obstruction due to prostatic enlargement. The elimination of adenomatous tissue by laser induced coagulation necrosis theoretically avoids the sequelae of fluid absorption noted during traditional transurethral resection of the prostate. However, to our knowledge no accurate determination of fluid absorption during laser prostatectomy has been performed to date. MATERIALS AND METHODS A technique previously described to determine the amount of irrigant absorbed during transurethral resection of the prostate measures breath ethanol levels using a standard alcohol breath analyzer during the procedure after a predetermined amount of ethanol is added to the irrigant fluid. This method was used in 4 men undergoing laser prostatectomy. RESULTS All 4 subjects had ethanol levels of 0 throughout the operation, indicating that little or no irrigant fluid was absorbed. CONCLUSIONS We demonstrated in a quantitative manner that fluid absorption during laser prostatectomy is almost nil and patients are, indeed, at no risk for the transurethral resection syndrome.

Laser prostatectomy: Initial experience and urodynamic follow-up

OBJECTIVES An evolving technology for the treatment of bladder outlet obstruction due to benign prostatic hyperplasia (BPH) is the use of the side-firing neodymium: yttrium-aluminum-garnet (Nd:YAG) laser to achieve prostatic tissue ablation. The purpose of this study was to determine the short-term efficacy of this procedure in both an objective and subjective manner. METHODS We examined this technique by carefully evaluating our first 25 men undergoing the procedure. Each patient was subjected to careful symptom score analysis using the American Urological Association symptom index and multichannel urodynamics, including pressure-flow studies both preoperatively and at 3 months postoperatively. RESULTS At the 3-month follow-up, symptom scores improved from a preoperative mean of 11.4 to 7.2 and the mean maximum flow rate improved from 6.1 to 14.5 cc/s. These are both significant at P < 0.001. Statistically similar improvement was seen in detrusor pressure at opening and at maximum flow. Eighty percent of the men studied had at least a 50% reduction in symptom score and a 50% improvement in flow rate. CONCLUSIONS We conclude that laser prostatectomy is a promising minimally invasive treatment for bladder outlet obstruction secondary to BPH and deserves further evaluation at longer terms of follow-up.

Testicular seminoma in a long-term survivor of the prune belly syndrome.

Patients with the prune belly syndrome have cryptorchidism as a constant feature of the constellation of anomalies. Testes that do not spontaneously descend represent a well-known risk factor for the development of testicular cancer. In this paper, we present the second case of a primary testicular germ cell tumor in a long-term survivor with prune belly syndrome.

Development of a malignant peripheral nerve sheath tumor following treatment for testicular seminoma

A novel case is reported in which an S2 nerve root malignant peripheral nerve sheath tumor was diagnosed approximately 8 years after treatment for Stage I testicular seminoma. This patient underwent right orchiectomy and subsequent irradiation therapy to the periaortic region, including the sacrum. Postoperative radiation therapy likely played a role in the development of this second malignancy.