Kuang-Kuo Chen

Retroperitoneoscopy-assisted nephroureterectomy for the management of upper urinary urothelial cancer

SummaryTraditionally, transitional cell carcinoma of the upper urinary tract needs a flank incision to remove the kidney and a lower abdominal incision to remove the ureter and bladder cuff. We report the surgical techniques and the initial clinical experience of retroperitoneoscopy-assisted nephroureterectomy for the treatment of this disease. Seven patients (6 males and 1 female; mean age 64.3 years, range 47-75 years) with the pre-operative diagnosis of upper urinary tract tumour underwent retroperitoneoscopy-assisted nephroureterectomy. The operation was performed first by retroperito-neoscopic nephrectomy, dissection of the lower third ureter and bladder cuff excision were performed with the traditional open method. The whole specimen with intact urothelium was removed through the lower abdominal incisional wound. We have successfully applied this technique for six patients with urothelial tumours. In one case, this technique had to be converted to open nephroureterectomy due to severe perirenal adhe...

Direct needle insufflation for pneumoretroperitoneum: anatomic confirmation and clinical experience

OBJECTIVESnThe feasibility and safety of direct needle insufflation to create pneumoretroperitoneum was assessed by an imaging study and clinical experience.nnnMETHODSnA total of 10 patients without previous retroperitoneal surgery or diseases received computed tomography scans of the retroperitoneum 2 cm above the iliac crest. Distances between quadratus lumborum and colon (Q-C distance) were measured in the supine and lateral positions. Changes of Q-C distance were calculated when the patient was changed from the supine to the lateral position. Operative charts on 38 retroperitoneoscopic procedures were collected prospectively to assess complications related to direct needle insufflation, which was performed by inserting a 14 G Veress needle blindly along the posterior axillary line 2 cm above the iliac crest.nnnRESULTSnQ-C distance increased from 8.7 to 27.3 mm (left side) and 4.6 to 18.1 mm (right side) when the patient was changed from the supine to the lateral position, both P values < 0.05. An average distance of 23 mm between colon and quadratus lumborum was found when patients were lying laterally. The misplacement of a Veress needle was encountered in 1 patient, in which a prefascia insufflation resulted in conversion of the endoscopic procedure. Needle puncture caused no visceral or great vessel injury.nnnCONCLUSIONSnSignificant anterior movement of the colon was found when patients were changed from the supine to the lateral position. It provided a window for inserting the Veress needle blindly into the retroperitoneum. The high success rate (97%) and low complication rate of direct needle insufflation were found in actual clinical applications. We considered needle insufflation a safe and effective method of establishing a pneumoretroperitoneum for any retroperitoneoscopic procedure.

Laparoscopic ligation of bilateral spermatic varices under epidural anesthesia

Feasibility and safety of laparoscopic ligation of bilateral internal spermatic varices under epidural anesthesia were assessed in 11 patients. Another 11 patients undergoing the same procedure under ventilation-assisted anesthesia served as controls. Patients in both groups belonged to the American Society of Anesthesia functional class I. Arterial blood analyses were obtained (1) in the horizontal supine position; (2) in the 15 degrees Trendelenburg position; (3) at 15 min after carbon dioxide pneumoperitoneum insufflation, and (4) at 15 min after desufflation in the supine position. In the epidural anesthesia group arterial blood parameters and respiratory rate remained stable in the Trendelenburg position. After intraperitoneal insufflation of carbon dioxide for 15 min, the arterial carbon dioxide level increased from 40.1 +/- 2.2 to 42.1 +/- 2.6 mm Hg, the respiratory rate increased from 17.0 +/- 1.4 to 20.6 +/- 1.2/min, the blood pH value decreased from 7.386 +/- 0.027 to 7.355 +/- 0.034, all values showing statistically significant differences. These changes returned to the preinsufflation level 15 min after release of the pneumoperitoneum. The above-mentioned parameters remained unchanged under the pneumoperitoneum by assisted ventilation in the control group. The mean time of surgery was similar in both groups: 82 and 90 min for the groups having general and epidural anesthesia, respectively. All laparoscopic procedures were accomplished successfully under general anesthesia. However, failure to ligate the internal spermatic varices occurred in 3 patients under epidural anesthesia, mainly due to patient intolerance to abdominal distension. The operation was continued under intubated general anesthesia for relaxing the abdominal muscle to provide an adequate working space. In 8 patients being successfully operated under epidural anesthesia, 5 experienced mild but tolerable abdominal distension; 2 complained of shoulder pain intraoperatively. Although laparoscopic ligation of internal spermatic varices could be accomplished in some patients under epidural anesthesia, it carried a high failure rate, more intraoperative morbidity, and significant arterial blood gas alterations. Routine ventilation-assisted anesthesia is suggested for therapeutic laparoscopy even for an easy procedure such as the ligation of the internal spermatic varices.

Adrenal cortical carcinoma with tumor thrombus invasion of inferior vena cava

A case of adrenal cortical carcinoma with inferior vena cava (IVC) involvement is presented. Ultrasonography, computed tomography, and venacavography all presumptively showed a large mass over the upper pole of the left kidney with tumor thrombus in the IVC. However, aortography demonstrated that this mass was receiving its blood supply from the left inferior phrenic artery, aorta, and left renal artery. Radical surgery, including resection of the tumor and its adjacent organs (kidney, distal pancreas, spleen) and the tumor thrombus in the IVC, with the aid of cardiopulmonary bypass, was performed. We emphasize that adrenal cortical carcinoma can have tumor thrombi invading the IVC, and in such cases we suggest radical surgical removal of the tumor and the thrombus.

Is Renal Function at the Tumor Side a Prognostic Factor in Ureteral Transitional Cell Carcinoma

OBJECTIVESnTo evaluate whether the ipsilateral renal function on the tumor side is a prognostic factor in transitional cell carcinoma (TCC) of the ureter.nnnPATIENTS AND METHODSnWe retrospectively reviewed 129 consecutive patients with ureteral TCC between September 1973 and July 1993 at our hospital. There were 98 males and 31 females aged from 31 to 84 years (mean 64.9). Of them, 126 patients who received intravenous pyelography (IVP) were divided into 3 groups according to their radiological findings (group 1: nonvisualization of kidney at tumor side; group 2: hydronephrosis or hydroureter; group 3: no obstruction). Eighty patients receiving radionuclide (131I-hippuran) renal function test (RRFT) with available effective renal plasma flow (ERPF) were divided into 2 groups using ipsilateral ERPF 50 ml/min as a cutoff value (group 1: < 50 ml/min; group 2: > or = 50 ml/min). The mean survival of each group was estimated by the Kaplan-Meier method.nnnRESULTSnFor patients receiving IVP, the mean survivals were 61.7, 99.7 and 83.8 months for groups 1, 2, and 3, respectively, and the differences between each 2 of the 3 groups were statistically significant (p < 0.05). For patients having RRFT, the mean survivals were 65.8 months for group 1 and 89.2 months for group 2 patients, and the difference between them was statistically significant (p < 0.05). When renal function, tumor number, grade, stage and type of treatment were analyzed using a multivariate method, only tumor stage was statistically significant as a prognostic factor.nnnCONCLUSIONnIpsilateral renal function at the tumor side is not a good prognostic factor for patients with ureteral TCC. However, when the stage of tumor is not available, renal function at the tumor side may provide an implication of the patients prognosis.

Inadvertent puncture of the kidney by a trocar during retroperitoneo-scopic ureterolithotomy

SummaryWe report a case of inadvertent renal injury caused by a correctly placed trocar during retroperi-toneoscopic ureterolithotomy. Tight adhesions between the kidney and posterior abdominal wall, caused by a pre-placed percutaneous nephrostomy tube, hindered the development of the working space using a dissecting balloon. The renal bleeding caused by the trocar puncture required open laparotomy for repair and the post-operative course was uneventful. This case highlighted the importance of direct visual surveillance during trocar placement and awareness of the difficulty of developing the retroperitoneal space in patients with a history of a percutaneous nephrostomy tube.