Matthew L. Steinway

A Pfannenstiel Single-site Nephrectomy and Nephroureterectomy: A Practical Application of Laparoendoscopic Single-site Surgery

OBJECTIVES To present the initial clinical experience with laparoendoscopic single-site (LESS) radical nephrectomy and nephroureterectomy performed completely through a Pfannenstiel incision. METHODS Two patients underwent a single-site nephrectomy and nephroureterectomy for the diagnosis of an enhancing renal parenchymal mass and a renal pelvic mass, respectively. In both cases, a 7.5-cm Pfannenstiel incision was made and GelPort was inserted. Trocars were placed through the access port, and nephrectomy was performed using standard and bariatric length laparoscopic instruments. Distal ureter was resected through the Pfannenstiel incision for nephroureterectomy. No additional ports were used as both procedures were completed via the Pfannenstiel approach. RESULTS The procedures were completed in 187 and 409 minutes, respectively, without complication. Blood loss was estimated at 50 and 200 mL, respectively. Postoperatively, the patients required minimal analgesia. Patients were discharged on postoperative days 2 and 4, respectively. CONCLUSIONS LESS nephrectomy and nephroureterectomy using only a Pfannenstiel incision are technically feasible and reproducible in human beings if performed by surgeons with standard laparoscopic skills. Using standard and bariatric length laparoscopic instruments, the procedures were performed without complication, with minimal blood loss and minimal variance from standard laparoscopic techniques. We anticipate that this approach can be incorporated by the urologist adept at laparoscopic surgery and provides a practical application of LESS surgery for extirpative procedures.

Renal artery pseudoaneurysm from blunt abdominal trauma.

A 19-year-old male was involved in a high-speed motor vehicle accident. He sustained multiple traumatic injuries including skeletal fractures, a pulmonary contusion, grade 1 splenic injury, grade 3 right renal laceration and grade 4 left renal laceration with partial ureteropelvic junction disruption. He underwent open reduction/internal fixation of the left tibia/fibula fracture and a left indwelling ureteral stent was placed. The remaining injuries were treated nonoperatively and he was discharged home on hospital day 8. The patient was rehospitalized 8 days later with a left leg surgical wound infection. On readmission hematocrit decreased from 30.3 to 16.7. He received a transfusion of 4 units of packed red blood cells and computerized tomography of the abdomen/pelvis revealed a 4.8 cm left renal artery pseudoaneurysm (part A of figure). Subselective embolization of a large lobar branch pseudoaneurysm was performed using a 3Fr Renegade® Microcatheter and deployment of multiple 0.018-inch platinum microcoils within as well as proximal and distal to the lesion (part B of figure). A more proximal 1 cm wide mouth pseudoaneurysm in the main renal artery was also identified (part C of figure). Covered stent placement was considered but eventually dismissed secondary to patient age as well as the risk of stent fibrosis and stenosis. The wide mouth of the pseudoaneurysm did not make it amenable to coiling or n-butyl cyanoacrylate application and simple nephrectomy was subsequently performed.

Laparoendoscopic single-site (LESS) nephrectomy through a Pfannenstiel incision: porcine model.

PURPOSE AND OBJECTIVE Laparoscopic nephrectomy has become a standard of care for localized renal tumors. Several groups have demonstrated single-incision laparoscopic nephrectomy performed completely through the extraction site, including transumbilical, paramedian, and transvaginal incisions. The Pfannenstiel incision is a commonly used extraction site after laparoscopic radical nephrectomy. The advantages of this incision include improved cosmesis as well as decreased pain. We investigated the feasibility of performing a single-incision laparoscopic nephrectomy through a Pfannenstiel incision in a porcine model, because this is the extraction site of choice at our institution. MATERIALS AND METHODS Bilateral laparoscopic nephrectomies were performed in five acute female swine through a GelPort inserted into a 4- to 6-cm incision comparable to the human Pfannenstiel incision. RESULTS Nine of 10 attempted nephrectomies were completed successfully. One nephrectomy was aborted because of a renal capsule laceration from a retraction injury. Mean operative time was 70.6 minutes (range 49-120 min). Mean estimated blood loss was 29.4 mL (range 5-100 mL). CONCLUSIONS Laparoscopic nephrectomy through a single Pfannenstiel incision is technically feasible in the porcine model. We anticipate incorporating this approach in humans, because we commonly use the Pfannenstiel incision as an extraction site.

Paratesticular Serous Papillary Borderline Tumor

A 37-year-old male presented with a 2-year history of progressive left scrotal swelling. Ultrasound showed an enlarged left testicle with heterogeneous echogenicity. Serum a-fetoprotein (AFP) and b-human chorionic gonadotropin were negative. There was no evidence of metastatic disease on computerized tomography. Left radical inguinal orchiectomy was performed. Pathological examination of the specimen revealed a 6.0 5.0 5.0 cm multicystic mass surrounded by a dense, pink/white, rubbery capsule involving the epididymis but without invasion of the tunica albuginea. The cystic lining was thick and rubbery, with focal hemorrhage and multiple shaggy papillary excrescences (fig. 1). The cysts were 0.2 to 5.0 cm and filled with thick, brown/ maroon, mucinous fluid and tan/pink, gelatinous material. Histological sections revealed predominantly serous cells with focal endometrioid differentiation (fig. 2). The cells were immunoreactive to estrogen receptor (ER), cytokeratin (CK) 7 and Wilms tumor suppressor gene (WT-1) with negative staining for