John C. Hulbert

Laparoscopic Ablation of Symptomatic Renal Cysts

We report a laparoscopic approach to the drainage and ablation of symptomatic simple renal cysts. Ten patients with chronic pain, 6 of whom failed primary aspiration, underwent laparoscopic cyst ablation: 6 had solitary renal cysts, 3 had multiple cysts and 1 had a peripelvic cyst. The approach was transabdominal in 9 patients and extraperitoneal in 1. Intraoperatively, cyst fluid was obtained for cytological examination, and cyst walls were excised and sent for pathological examination. When possible, the remaining inner cyst walls were fulgurated to prevent recurrence. Mean total operating room time was 2 hours 27 minutes and blood loss was minimal. The sole complication was a postoperative retroperitoneal hematoma, which was managed conservatively. Malignancy was diagnosed in 2 patients, each of whom had a negative preoperative aspiration. These patients subsequently underwent radical nephrectomy. All remaining patients were asymptomatic at a mean followup of 10 months. Laparoscopic ablation of renal cysts is a safe and effective alternative to open surgery in patients who have failed conservative measures. Preoperative and intraoperative evaluation for malignancy should be performed.

Percutaneous removal of renal and ureteral calculi: experience with 400 cases.

Percutaneous removal of renal and ureteral calculi was performed in 500 patients since 1979. Experience with our first 100 cases enabled us to accumulate a variety of techniques. We report our experience with the subsequent 400 cases. As judged by plain films of the kidneys, ureters and bladder, and renal tomograms without contrast medium we attained a status free of stones in 99 per cent of the patients with renal and 94.5 per cent with ureteral calculi. Intravenous-assisted local anesthesia was used in 94 per cent of the cases. There was no mortality and the incidence of complications was low. Most patients with renal and ureteral calculi can be managed successfully and safely by percutaneous methods with good patient tolerance and minimal convalescence.

Tuberous sclerosis complex renal disease.

Although not as common as other genetic renal diseases such as autosomal dominant polycystic kidney disease, patients with tuberous sclerosis complex frequently have significant renal involvement. Recent revelations in the cell biology of these renal disease manifestations as well as effective therapies for tuberous sclerosis complex-related renal issues have heralded hope of improved renal survival and improved quality of life for the TSC patient. This review specifically addresses some of the major renal manifestations of this disease.

Percutaneous techniques for the management of caliceal diverticula containing calculi

Most frequently caliceal diverticula are found incidentally on routine excretory urograms. Smaller diverticula are associated with a low incidence of complications but larger diverticula with a narrow communication to the main collecting system will predispose to calculous formation as a result of stasis of urine within the diverticulum. The techniques used and results achieved in 10 patients with such calculi who have been successfully managed percutaneously are discussed. Particular reference is made to techniques used specifically to obliterate the diverticula.

Long-Term Renal Fate and Prognosis After Staghorn Calculus Management

We analyzed retrospectively 177 consecutive staghorn calculus patients to determine risk factors for ultimate renal deterioration and renal cause specific death. Mean followup was 7.7 years. Overall rate of renal deterioration was 28%. Renal deterioration was associated more frequently among patients with solitary versus nonsolitary kidneys (77% versus 21%, p < 0.001), previous versus initial stones (39% versus 14%, p = 0.03), recurrent versus nonrecurrent calculi (39% versus 22%, p = 0.07), hypertension versus normotension (50% versus 22%, p = 0.006), complete versus partial staghorn calculi (34% versus 13%, p = 0.02), diversion versus no diversion (58% versus 19%, p < 0.001) and neurogenic bladder versus normal voiding (47% versus 21%, p = 0.006), as well as those who refused treatment versus treated patients (100% versus 28%, p < 0.001). No patient with complete clearance of fragments died of renal related causes compared to 3% of those without clearance of fragments and 67% of those who refused treatment (p < 0.001). Our study suggests that long-term renal preservation in the staghorn calculus patient may depend on normal blood pressure, staghorn size, absence of diversion or voiding dysfunction, and complete stone eradication.

Laparoscopic Retroperitoneal Lymphadenectomy: Multi-Institutional Analysis

Modified unilateral laparoscopic retroperitoneal lymph node dissection was attempted in 20 patients with nonseminomatous testicular cancer. The procedure was completed in 18 men at a median operative length of 6 hours. Median estimated blood loss was 250 cc and median number of lymph nodes removed was 14.5. Nodal disease spread was noted in 3 of 18 patients (17%). Most patients were hospitalized for 3 days or less and had returned to normal activity levels within 2 to 3 weeks. Antegrade ejaculation was preserved in all 20 patients. Significant complications occurred in 6 of 20 patients (30%), with bleeding being the most common adverse event encountered. In 2 patients an abdominal incision and completion of the procedure by open retroperitoneal lymph node dissection were required due to significant bleeding following injury to the gonadal vessels. With a median followup of 10 months (range 2 to 25), 2 men had pulmonary disease recurrence and none had abdominal recurrence. Laparoscopic retroperitoneal lymph node dissection can be completed successfully in patients with stage I testicular cancer and may be most appropriate in those with limited risk of metastatic disease spread. The morbidity may be largely attributed to a steep learning curve. The efficacy of laparoscopic retroperitoneal lymph node dissection compared with standard techniques and determination of its role in patients with testicular cancer will require longer followup in larger groups of patients.

ROLE AND LONG-TERM RESULTS OF LAPAROSCOPIC DECORTICATION IN SOLITARY CYSTIC AND AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE

PURPOSE Access to retroperitoneal structures via the laparoscope has become established for various conditions. This minimally invasive approach has distinct advantages over conventional open surgery. We document our experience with laparoscopic cyst decortication for diseases of the kidney, including simple and complex cysts, multiple cysts and autosomal dominant polycystic kidney disease. MATERIALS AND METHODS We retrospectively reviewed the records of 17 patients who underwent a total of 20 procedures. Cases were categorized as polycystic kidney disease and nonpolycystic kidney disease. Factors analyzed were estimated blood loss, length of surgical procedure, hospital stay and complications. Followup included radiographic studies (computerized tomography and/or renal sonography) and patient subjective pain relief, as determined by clinical records and telephone interview. RESULTS Nine and 11 procedures were done for nonpolycystic kidney disease and polycystic kidney disease, respectively. Of the 8 patients with polycystic kidney disease 3 underwent repeat procedures. Followup was 3 to 63 months (average 26). All patients with simple cysts who were treated for pain were pain-free at the latest followup. Of the 10 procedures 9 (90%) performed for pain relief in polycystic kidney disease successfully produced immediate pain relief. Pain-free status decreased with time with 7 of 8 (87.5%) pain-free after 6 months, and 5 of 7 (71.4%) at 1, 4 of 6 (66.7%) at 2 and 1 of 4 (25%) at 3 years. A repeat operation successfully relieved recurrent pain in 2 of 3 cases (66.7%). Of the 7 patients with polycystic kidney disease who underwent surgery for pain relief 5 (71%) are currently pain-free. CONCLUSIONS Laparoscopic renal cyst decortication is an effective minimally invasive treatment for painful simple cysts. It is also effective for short to intermediate pain relief in autosomal dominant polycystic kidney disease. Long-term followup suggests that a repeat procedure may be necessary to maintain adequate control of symptoms in polycystic kidney disease.

Percutaneous intrarenal marsupialization of a perirenal cystic collection - endocystolysis

We report a case of a recurrent perirenal cyst after 4 previous attempts to obliterate the cyst by more conventional means percutaneously and by open surgery. Endocystolysis, a technique for the internal marsupialization of a cyst into the renal collecting system, was used successfully to obliterate the cyst. This case and the technique of endocystolysis are described in detail.

Involvement of the Spleen by Renal Angiomyolipoma: Metastasis or Multicentricity?

Angiomyolipoma has been regarded as a benign renal neoplasm composed of adult fat cells, atypical blood vessels and smooth muscle. We report a case in which a renal angiomyolipoma showed clear evidence of involvement of the spleen and regional lymph nodes. The consensus in the literature suggests that this phenomenon is a manifestation of the multicentric nature of angiomyolipoma, rather than metastasis.

Intraureteral Metallic Self-Expanding Endoprosthesis (Wallstent) in the Treatment of Difficult Ureteral Strictures

Intractable and recurrent ureteral stricture presents a continuous challenge to the urologist. We report on 5 patients with severe ureteral stricture who were successfully treated with self-expanding metallic stents. Ureteral stricture occurred at ureteroileal anastomotic sites after neoplasm resection in 2 cases, multiple upper ureteral strictures were related to multiple surgical procedures for correction of bladder exstrophy in 1 and a ureteral kink developed in 1. Treatment with transluminal balloon dilation provided poor results but self-expanding metallic stents were used successfully with no major complications. In the last patient the stent and the overlying ureter were removed due to recurrent reflux; the gross and histological ureteral changes are discussed in detail. The technical approach is described, alternative therapeutic options are considered and pertinent literature is reviewed.