Paramjit S. Chandhoke

Complications of Laparoscopic Pelvic Lymph Node Dissection

Intraoperative and postoperative complications were assessed in the first 372 patients undergoing laparoscopic pelvic lymph node dissection at 8 medical centers. In 16 patients laparoscopic node dissection could not be completed due to patient body habitus or technical difficulties. Of these aborted procedures 14 occurred during the initial 8 dissections at each institution. A total of 55 complications (15%) occurred: 14 were noted in the intraoperative and 41 in the postoperative period. Of these patients 13 required open surgical intervention for the treatment of a complication. Complications included vascular injury (11 patients), viscus injury (8), genitourinary problems (10), functional/mechanical bowel obstruction (7), lower extremity deep venous thrombosis (5), infection/wound problem (5), lymphedema (5), anesthetic complications (2) and obturator nerve palsy (2). Based on our experience, there is a significant learning curve associated with performing laparoscopic pelvic node dissection. However, with experience and adherence to laparoscopic surgical principles, the risk of complications may be minimized.

Laparoscopic partial nephrectomy in the pig model.

In an effort to further evaluate the potential application of laparoscopy to urologic surgery, we explored the feasibility of using this minimally invasive approach for performing a partial nephrectomy. Nine female pigs underwent laparoscopic partial nephrectomy (LPN) utilizing a plastic cable tie (15 mm. x 4 mm. x 1 mm.) to achieve renal ischemia and an Argon Beam Coagulator probe (ABC) (Birtcher Medical Systems) to fulgurate the transected surface. Six weeks after LPN, 6 pigs underwent creatinine clearance, renin level, arteriography, BP samples and were then killed. The renal remnants were weighed and sectioned for histological studies. These studies revealed excellent function of the renal remnant, no AV fistula, and no evidence of renovascular hypertension. LPN is a feasible, repeatable procedure in the pig. Control of the renal hilum, transient parenchymal compression with a plastic cable, and use of the argon beam coagulator are key elements in performing this procedure.

Transperitoneal nephrectomy for benign disease of the kidney: a comparison of laparoscopic and open surgical techniques.

OBJECTIVEnThe objective of this study was to compare the results of laparoscopic nephrectomy for benign disease to open surgical nephrectomy for benign disease.nnnMETHODSnTwenty consecutive patients undergoing laparoscopic nephrectomy for benign disease were compared with 23 patients undergoing open surgical nephrectomy for benign disease and with 29 patients undergoing a donor nephrectomy. Data were collected in the following areas: patient age, anesthetic risk, operative time, estimated blood loss, postoperative time to resume oral intake, parenteral analgesics, oral analgesics, hospital stay, complications, and convalescence. Information was obtained through chart review, telephone interviews, and mailed questionnaires.nnnRESULTSnCompared with open surgical nephrectomy, laparoscopic nephrectomy resulted in a statistically significant longer operative time; however, it afforded a statistically significant decrease in postoperative ileus (open group), hospital stay (both groups), oral analgesics (donor group), and convalescence (both groups). The incidence of complications was 15 percent in the laparoscopic group and 0 percent in the two open surgical groups; the majority of complications occurred during the initial seven laparoscopic procedures.nnnCONCLUSIONSnLaparoscopic nephrectomy is a more time-consuming procedure than open surgical nephrectomy. Also, early in ones experience with this technique, the complication rate is higher than with open surgery. However, despite the newness of the technique, it results in significant benefits to the patient: decreased postoperative pain, shorter hospitalization, and more rapid convalescence.

Optimal Therapy for the Distal Ureteral Stone: Extracorporeal Shock Wave Lithotripsy Versus Ureteroscopy

Extracorporeal shock wave lithotripsy (ESWL not equal to) is the optimal therapy for renal calculi less than 2 cm. in diameter and for proximal ureteral calculi. Controversy continues over the initial approach to distal ureteral calculi (that is below the bony pelvis): in situ ESWL versus ureteroscopy. Since February 1990, 76 distal ureteral calculi were treated at our institution using either in situ ESWL (Dornier HM3 ESWL with a Stryker frame modification in 27 patients or Siemens Lithostar electromagnetic ESWL in 22) or ureteroscopy (27 patients). Patient age and stone size were similar among the groups. All ESWL treatments were performed with the patient under intravenous sedation and on an outpatient basis. Stone-free rates were 96% for the HM3 device, 84% for the Lithostar and 100% for ureteroscopy. Retreatment was required in 3 Lithostar cases (14%) and 1 HM3 case (4%). When compared to ESWL ureteroscopy for distal ureteral stones was more time-consuming, entailed routine placement of a ureteral stent, often required general anesthesia, more often led to hospitalization and doubled the convalescence period. From a cost standpoint, ESWL on an HM3 unit was a few hundred dollars more expensive than ureteroscopy. In summary, we believe that in situ ESWL provides optimal first line therapy for distal ureteral calculi, while ureteroscopy is better reserved as a salvage procedure should ESWL fail.

Staging Pelvic Lymphadenectomy for Prostate Cancer: A Comparison of Laparoscopic and Open Techniques

The operative morbidity and convalescence of our initial 30 patients who underwent laparoscopic pelvic lymph node dissections were compared to those of 16 patients who underwent open surgical pelvic lymph node dissections performed at our institution for staging purposes between 1990 and 1992. The average time for laparoscopic pelvic lymph node dissection (199.4 minutes) was nearly twice that of surgical pelvic lymph node dissection (102.4 minutes). However, the blood loss in the former group was significantly less. Oral intake occurred after a mean of 0.63 days in the laparoscopic pelvic lymph node dissection group compared to 2.87 days in the surgical group. Also, laparoscopic pelvic lymph node dissection was superior to surgical pelvic lymph node dissection in terms of average postoperative analgesic use (1.55 versus 47 mg. morphine sulfate), average hospital stay (1.7 versus 5.37 days), average return to normal daily activities (4.94 versus 42.9 days) and interval to full recovery (10.8 versus 65.5 days). However, the incidence of significant complications in the laparoscopic pelvic lymph node dissection group was 13%, with no complications seen in the surgical group. Interestingly, all significant problems in the bilateral laparoscopic pelvic lymph node dissection patients were confined to our initial 12 patients, indicating the steepness of the laparoscopic learning curve.

Long-term comparison of renal function in patients with solitary kidneys and/or moderate renal insufficiency undergoing extracorporeal shock wave lithotripsy or percutaneous nephrolithotomy.

We compared the long-term effects of extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy monotherapy on renal function in 31 patients with a solitary kidney and/or chronic renal insufficiency who were all more than 2 years after treatment (mean 41.5 months). The change in the reciprocal of serum creatinine was used as an index to estimate changes in the glomerular filtration rate. A change of 20% or greater in the glomerular filtration rate was considered a clinically significant deterioration of renal function. The rate of deterioration of renal function in patients with a solitary kidney and creatinine of less than 2 mg./dl. was 22% for ESWL and 29% for percutaneous nephrolithotomy, respectively. All patients with a creatinine between 2 and 3 mg./dl. demonstrated long-term improvement of renal function regardless of the treatment modality. All 4 patients with creatinine greater than 3 mg./dl. undergoing ESWL had short-term improvement but eventual long-term deterioration of renal function. Indeed, 3 of these patients required dialysis within 2 years from the treatment dates. One patient with creatinine greater than 3 mg./dl. who underwent percutaneous nephrolithotomy demonstrated stabilization of the renal function after treatment. From our data, no convincing evidence could be found to suggest that ESWL results in long-term deterioration of renal function in patients with chronic renal insufficiency or a solitary kidney. We conclude that the choice between ESWL and percutaneous nephrolithotomy should be based on the stone composition, stone location and stone burden, rather than on the preexisting renal function or presence of a solitary kidney.

Percutaneous Stone Removal with the Patient in a Flank Position

We report a case of percutaneous removal of a staghorn calculus that was accomplished in a morbidly obese patient while he was in a full flank position. In this position, the stone could be successfully accessed and fragmented without compromising the pulmonary status of the patient.

Laparoscopic Repair of Vesicoureteral Reflux Utilizing the Lich-Gregoir Technique in the Pig Model

To date, laparoscopic urological surgery has largely been limited to diagnostic or ablative procedures. Herein we report our experience with laparoscopic reconstructive surgery to perform an extravesical ureteral reimplantation. Seven anesthetized pigs with iatrogenic ureteral reflux underwent a laparoscopic extravesical ureteral reimplantation. The newly created ureteral tunnel varied from 2 to 4 cm. In 3 pigs, the tunnel was created with tacking staples, while in the other 4 pigs, the tunnel was created with intracorporeal suturing techniques using a 3-zero polyglyconate running suture. The procedure required an average of 132 minutes. There was one anesthetic death. There were no urinary tract infections. At 3 to 8 weeks after reimplantation, the cystograms were repeated on 5 pigs. One of 2 stapled reimplant pigs still had reflux; 1 of 3 sewn reimplant pigs had reflux. At 6 months following the reimplantation, only 1 pig had residual grade I reflux and this was a sutured reimplantation. None of the stapled reimplantations exhibited any residual reflux on the surgical side; however, in 1 animal a submucosal staple was noted at the time of harvest.

Effect of Stent Duration on Ureteral Healing Following Endoureterotomy in an Animal Model

Ureteral strictures were created in 18 minipigs. Six weeks after stricture inducement, endourologic incision with a balloon cutting device was performed and a 7 F internal polyurethane stent was placed. After this step, 14 pigs remained in the study and were randomized into three different groups depending upon the time when the stent was removed: 1, 3 or 6 weeks. Twelve weeks after stricture incision, the pigs were killed, the status of the incised ureteral segment was evaluated histologically, and a healing score was determined. There were no statistically significant overall differences among the mean values of the overall healing score throughout the three different groups. However, when the one-week and the six-week groups (p < .05) were compared with respect to strictures requiring more than one incision due to stricture length greater than 2 centimeters, a more favorable outcome occurred in the 1 week group. Based on these findings it may be reasonable to remove ureteral stents as early as 1 week after endoureterotomy and endopyelotomy.

Laparoscopic Stapled Bladder Closure: Laboratory and Clinical Experience

We report our experience with closure of the bladder during laparoscopic nephroureterectomy by using a gastrointestinal anastomosis type stapling device designed to deliver 6, 3 cm. rows of 3.5 mm. titanium staples via a 12 mm. trocar. We initially used this stapling device to secure a cuff of bladder in 8 female pigs undergoing laparoscopic nephroureterectomy. Followup in these animals was completed 2 to 6 months postoperatively. Then, 3 patients underwent laparoscopic ureterectomy using the laparoscopic stapler to transect and secure the ureter along with a cuff of bladder. In neither the laboratory nor the clinical situation were any complications encountered due to the transvesical staples (for example extravasation, stone formation, urinary tract infection or abscess formation). Our preliminary results indicate that titanium staples may be an effective method to provide rapid and secure closure of the bladder in patients undergoing either laparoscopic nephroureterectomy or laparoscopic ureterectomy.