Mathew Oommen

Ureteropelvic Junction Obstruction Secondary to Crossing Vessels-To Transpose or Not? The Robotic Experience

PURPOSE We compared the surgical outcomes of robot assisted laparoscopic dismembered pyeloplasty in patients presenting with anterior crossing vessels with and without transposition of the crossing vessel. MATERIALS AND METHODS A total of 107 patients with ureteropelvic junction obstruction underwent robot assisted laparoscopic dismembered pyeloplasty. Evaluation of surgical success was based on validated pain scores, diuretic renography and imaging results, including excretory urography, computerized tomography or ultrasound. RESULTS Anterior crossing vessels were identified in 48 patients (44.9%) and vessels were transposed in 18 (37.5%) (group 1). No transposition was performed in 30 patients (62.5%) (group 2). Mean radiological followup was 52.9 weeks in group 1 and 65.3 weeks in group 2 (p = 0.181). Mean pain score on a scale of 10 was 0.82 in group 1 and 0.74 in group 2 (p = 0.917). A Whitaker test performed in 3 patients with persistent pain was negative. Preoperatively mean differential function on the affected side was 35.1% in group 1 and 36.9% in group 2 (p = 0.133). Half-time was calculated as a mean of 46.3 minutes in group 1 and 49.4 minutes in group 2 (p = 0.541). In groups 1 and 2 mean postoperative differential function improved to 41.1% and 40.9%, and mean half-time improved to 7.43 and 8.03 minutes, respectively (p = 0.491). A comparison of preoperative and postoperative differential function, and half-time in each group showed a statistically significant difference. The radiographic and symptomatic success rate was 100% with no open conversion and recurrence. CONCLUSIONS Comparison of robot assisted laparoscopic dismembered pyeloplasty outcomes revealed similar success rates in terms of the change in symptoms and renal function in patients with or without anterior crossing vessel transposition. Transposition of crossing vessel should only be performed when the anatomical relation dictates and it should be an intraoperative decision.

Laparoscopic Adrenalectomy for Large Adrenal Masses: Pushing the Envelope

PURPOSE To determine the role of laparoscopy for large adrenal tumors in terms of outcomes, pathology, operative time, and morbidity. PATIENTS AND METHODS A retrospective review of 24 patients who underwent laparoscopic adrenalectomy was performed to record the size of the lesions, surgical techniques used, operative times, estimated blood loss, duration of hospital stay, need for blood transfusion, conversion to open surgery, and complications. The laparoscopic adrenalectomy patients were divided into two groups based on tumor size: <8 cm (n = 16, group 1) and >or=8 cm (n = 8, group 2). RESULTS Mean tumor size was 5.6 cm for group 1 and 12.1 cm for group 2. Mean operative times were 143.12 and 188.75 minutes for groups 1 and 2, respectively. Mean estimated blood loss was 89.69 mL for group 1 and 334.38 mL for group 2. Operative time and blood loss were significantly higher in group 2. Pathologic examination revealed eight adrenal cortical adenomas, five myolipomas, four pheochromocytomas, four cysts/pseudocysts, and three adrenocortical hyperplasias. No significant difference was found between groups concerning transfusion rates, duration of hospital stay, and conversion to open surgery. CONCLUSION Laparoscopic adrenalectomy is a feasible procedure for large masses but results in longer operative times and higher total blood loss when compared with results for masses smaller than 8 cm. Our findings suggest, however, that laparoscopic adrenalectomy for masses larger than 8 cm can produce comparable results concerning hospital stay, conversion to open surgery rate, and pathologic outcome in comparison with results for adrenal masses smaller than 8 cm.

In Vitro Comparison of a Disposable Flexible Ureteroscope and Conventional Flexible Ureteroscopes

PURPOSE We compared and evaluated the objective characteristics (deflection characteristics, field of view and flow rate) of a disposable flexible ureteroscope and 6 established, commercially available flexible ureteroscopes. MATERIAL AND METHODS Six commonly used ureteroscopes, including Olympus URF-P3, Storz(R) 11278AU and 11274AAU, ACMI DUR-8 Elite and DUR-8, and Wolf 7331.001 (Richard Wolf Medical Instruments, Vernon Hills, Illinois), were compared with the recently introduced SemiFlex Scope disposable flexible ureteroscope. Specifications and purchase costs were acquired from each manufacturer. The disposable ureteroscope consisted of a reusable eyepiece and a semiflexible shaft with a 3.3Fr working channel. Active tip deflection was measured with and without the 3Fr basket, the 365 mum laser fiber and the 3Fr forceps. The flow rate and field of view of each scope were evaluated. RESULTS Active tip deflection (down/up) was highest in the disposable ureteroscope at 300/265 degrees. Although deflection was decreased by inserting the different endoscopic tools in all ureteroscopes, the disposable ureteroscope had the highest loss in flexion characteristics (35.7% down and 39.3% up). The flow rate, measured at 25 ml per minute in the disposable ureteroscope, was significantly lower than that of other ureteroscopes. The disposable ureteroscope had a 72-degree field of view, comparable to the optical characteristics of the other scopes. Compared to the other 6 flexible ureteroscopes the purchase price of the disposable scope was significantly lower and no further maintenance/repair expenses were required. CONCLUSIONS The disposable flexible ureteroscope has acceptable active tip deflection, field of view and flow rate compared to those of other flexible ureteroscopes on the market. Further evaluation of surgical outcomes will help delineate the definitive usefulness of the disposable flexible ureteroscope.

Transumbilical single‐port laparoscopic partial nephrectomy in a pig model

Study Type – Therapy (case series)
Level of Evidence 4

Robot-Assisted Laparoscopic Radical Prostatectomy in Patients with Previous Abdominal Surgery: A Novel Laparoscopic Adhesiolysis Technique

PURPOSE We evaluated the feasibility and outcomes of performing a novel laparoscopic adhesiolysis technique before robot-assisted laparoscopic radical prostatectomy (RALRP) in patients with previous abdominal surgery. PATIENTS AND METHODS A total of 18 men with incision scars from previous abdominal surgeries underwent RALRP. A 12-mm trocar was placed at the lateral lower quadrant away from the incision site, and a teaching laparoscope was introduced into the peritoneal cavity. Meticulous adhesiolysis was performed through a single trocar to subsequently allow safe placement of additional robotic trocars. Age, type of previous surgery, total operative time, console time, anastomosis time, estimated blood loss, transfusion rate, complications, and conversion rate were recorded. RESULTS All patients had multiple abdominal surgeries. Mean operative time was 297 minutes, mean console time was 194 minutes, and mean estimated blood loss was 241 mL. No access-related complication and no conversion to open surgery occurred. CONCLUSION This novel laparoscopic technique of adhesiolysis with a teaching laparoscope through a single trocar facilitates safe placement of trocars and accomplishment of RALRP in patients with previous abdominal surgery.

Ureteroenteric Anastomotic Stricture: Novel Use of a Cutting Balloon Dilator

INTRODUCTION Management of ureteroenteric strictures presents a significant challenge because of its intraabdominal location and morbidity associated with open surgical management. The peripheral cutting balloon microsurgical dilatation device (PCBD), approved by The United States Food and Drug Administration (USFDA) for use in coronary angioplasty, features a 2-cm noncompliant balloon with four microsurgical blades mounted longitudinally on its outer surface. We evaluated the feasibility and outcome of this cutting balloon dilator in the treatment of ureteroenteric anastomotic strictures. MATERIALS AND METHODS Three patients with a 1-cm or less ureteroenteric stricture underwent a transluminal incision under fluoroscopic guidance. Percutaneous access was obtained and a guidewire was introduced into the renal pelvis and ureter in antegrade fashion and passed through the stricture. The exact length of the strictured segment was measured. The PCBD was deployed over the guidewire and the balloon was inflated at the stricture site. The maximum diameter of the inflated balloon was 8 mm. Approximately 30 seconds later, the balloon was deflated and the enlarged passage from the ureter to the ileal loop was verified under fluoroscopy. A ureteral stent was placed and removed at 6 weeks after the procedure. RESULTS Postoperative computed tomography scans at 12 months revealed improved hydronephrosis. All patients were asymptomatic postoperatively. One patient had a solitary kidney and creatinine level decreased significantly following the procedure. CONCLUSION Dilatation and incision with PCBD is a novel approach for the treatment of the short ureteroenteric anastomotic strictures. Long-term data need to be obtained to establish the efficacy of this technique.

NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES) PARTIAL NEPHRECTOMY

In this issue we initiate the first “Video of the Month” selection by the AUA Audio-Visual Committee which will integrate articles published in an issue of The Journal of Urology® with videos from the 2009/2008 AUA Annual Meetings available in the AUA/BI DVD Library at (http://www.auanet.org/content/products/dvds.cfm#aua-bi-dvd). A commentary is provided to highlight the important viewpoints presented by the video as it relates to the articles. We hope readers will take advantage of this fast growing visual medium of education.

Posterior reconstruction before anastomosis improves the anastomosis time during robot-assisted radical prostatectomy.

Posterior reconstruction prior to anastomosis decreased anastomotic time for robotic surgeons in training.

Bladder Preservation Approaches

As more and more patients are living longer, they bring with them a host of chronic conditions. Often times, these comorbidities may prevent patients from being optimal candidates for the standard treatment for invasive or high-grade bladder cancer. This chapter briefly looks at some therapeutic surgical options for patients who are not ideal candidates for a prolonged radical cystectomy with concomitant reconstruction of the urinary tract.