Paulos Yohannes

Management of malignant extrinsic compression of the ureter by simultaneous placement of two ipsilateral ureteral stents.

BACKGROUND AND PURPOSE Extrinsic ureteral obstruction caused by various malignancies often necessitates urinary diversion. The use of single ureteral stents as a form of urinary diversion results in a high failure rate, while the use of two ipsilateral stents has shown promising results. We report our experience using the latter technique. PATIENTS AND METHODS Between 1996 and 2001, four male and three female patients with a mean age of 65 years (range 37-95 years) who had extrinsic compression of the ureters underwent single stent management to relieve obstruction. Ureteral obstruction was secondary to prostate cancer (N = 3), cervical cancer (2), non-Hodgkins lymphoma (1), and transitional-cell cancer of the bladder and ureter (1). After failure of such management, two 7F stents or a combination of 8F/6F double-J ureteral stents were placed. The stents were changed every 4 to 6 months. Follow-up included serial renal ultrasound scans and serum creatinine measurements. RESULTS Ureteral stricture length ranged from 2 to 4 cm. Insertion of two double-J ureteral stents in a single ureter was successful in all cases. During the mean follow-up of 16 months (range 1-38 months), the ureteral stents were tolerated by all patients, without significant discomfort. Marked improvement of hydronephrosis and alleviation of flank pain was noted in all patients. Three patients have died at 1 to 3 months. Renal function improved, with a mean decline in the serum creatinine concentration from 3.2 mg/dL to 1.48 mg/dL in the five patients tested. CONCLUSION Simultaneous placement of two double-J ureteral stents for the management of ureteral obstruction secondary to a malignancy is a safe and effective technique.

Current trends in the management of posterior urethral valves in the pediatric population

P urethral valves (PUVs) are the most common congenital abnormalities causing bilateral renal obstruction. The widespread use of prenatal ultrasonography has contributed to an increase in the incidence and awareness of PUVs. The treatment of children with this anomaly has also evolved as radiographic imaging techniques and our understanding of the pathophysiology of obstructive uropathy has improved. Today, patients with PUVs who develop end-stage renal disease have the hope of undergoing renal transplantation; patients with PUVs represent 1% of those awaiting transplantation.1 Urodynamic investigation has allowed us to treat incontinence secondary to associated bladder dysfunction effectively, and the development of smaller endoscopic instruments and newer valve ablation devices have helped minimize perioperative morbidity. The mortality rate associated with PUVs has declined from 50% in the past few decades to less than 5%.2 Renal hemodialysis, excellent broadspectrum antibiotics, and improvements in neonatal intensive care units have contributed equally to the decline in mortality. According to Walker and Padron,3 mortality from PUVs usually occurs in newborns with severe bilateral renal dysplasia and pulmonary hypoplasia who were stillborn or died shortly after birth, neonates who died of sepsis or electrolyte imbalances, or older children and adolescents who eventually had renal failure. Despite these advances, 24% to 45% of patients will have renal insufficiency during childhood.4–7 Unfortunately, prenatal diagnosis of PUVs has not improved this rate. PUVS are encountered most commonly in males; however, anecdotal cases have been reported in females. Urethral valves have a wide range of clinical and anatomic presentations. Although most patients are diagnosed in the prenatal and neonatal period, published reports regarding patients presenting in adolescence and the second decade of life lends credence to the idea that PUVs may be a spectrum of disease as suggested by Hendren8 in 1971. The incidence is estimated to be between 1:3000 and 1:8000.1–8 Everyone agrees that to salvage renal function and maximize growth in infants with PUVs, obstruction of the urinary tract should be relieved at the earliest gestational age possible. Some believe that prenatal intervention is warranted if pulmonary hypoplasia or postnatal pulmonary insufficiency is to be avoided. Although controversial, prenatal intervention is technically difficult, and the ethical dilemma associated with it precludes its use in many surgical centers worldwide. PUVs can be associated with hypospadias, ureteropelvic junction stenosis, imperforate anus, dysgenetic kidneys, double urethra, solitary kidney, crossed renal ectopia, congenital heart disease, and arguably, prune belly syndrome. Three types of valves were described by Young and associates9 in 1919. Type I valves originate distal to the verumontanum on the floor of the posterior urethra. The valve cusps diverge distally in an anterolateral orientation and fuse anteriorly in the midline. Type II valves are folds of tissue that run between the bladder neck and the verumontanum. Type III valves are located just distal to the verumontanum; they are often characterized by a diaphragm-like appearance with an opening located posteriorly. Type I valves remain the most common type, and type III valves are very rare. The true incidence of type II valves is not known because most of these patients are asymptomatic, and some investigators doubt their existence. Dewan10 has advocated the presence of a common congenital posterior urethral obstruction morphology and termed this entity congenital obstructive posterior urethral membrane. This clinical observation sugFrom the Division of Urology, Department of Surgery, Creighton University, Omaha, Nebraska; Division of Pediatric Urology, New York Hospital-Cornell, New York, New York; and Divison of Pediatric Urology, Schneider Children’s Hospital, Long Island Jewish Medical Center, New Hyde Park, New York Reprint requests: Paulos Yohannes, M.D., Division of Urology, Department of Surgery, Creighton University, 601 North 30th Street, Suite 3822, Omaha, NE 68131 Submitted: October 22, 2001, accepted (with revisions): February 5, 2002 REVIEW CME ARTICLE

Tail stent versus re-entry tube: a randomized comparison after percutaneous stone extraction.

OBJECTIVES To evaluate the efficacy of a 7F tail stent with an 18F Councill nephrostomy tube and compare it to a 24F re-entry Malecot nephrostomy tube after percutaneous nephrolithotomy. METHODS Forty patients were prospectively randomized to receive either a 24F re-entry Malecot nephrostomy tube (group A, n = 20) or a 7F tail stent with an 18F Councill nephrostomy tube (group B, n = 20) for postoperative drainage. Patients were evaluated with an analogue scale questionnaire 15 days after percutaneous nephrolithotomy at the routine office follow-up visit asking them to rate the flank pain on a 0 to 10 scale, urinary urgency on a 0 to 10 scale, and quality of life, while the external drainage tubes were still in place. RESULTS The mean length of stay was 4.5 and 3.5 days for groups A and B, respectively. Flank urine leakage was present in all patients in group A for a period of 6 to 12 hours, and no patient in group B had any significant flank drainage. A statistically significant reduction of flank pain in favor of group B was observed (P = 0.0002). We did not observe any statistically significant difference when evaluating the urgency (P = 0.1) and quality-of-life scores (P = 0.09) between the two groups, even though a trend was noted toward amelioration in favor of group B patients. CONCLUSIONS The results of the present study suggest that the 7F tail stent is certainly better tolerated by the patients after percutaneous nephrolithotomy compared with the standard 24F re-entry Malecot nephrostomy tube.

Laparoscopy-Assisted Robotic Radical Cystoprostatectomy with Ileal Conduit Urinary Diversion for Muscle-Invasive Bladder Cancer: Initial Two Cases

BACKGROUND AND PURPOSE The use of the da Vinci robot is being investigated in the discipline of urologic surgery. We describe our experience with its use during radical cystoprostatectomy in two patients with organ-confined bladder cancer. PATIENTS AND METHODS Laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion was performed using the da Vinci robot. Both patients were informed about this new approach, and informed consent was obtained. RESULTS There were no intraoperative or postoperative complications. The operative time was 10 and 12 hours. A clear liquid diet was started on the third postoperative day. Final histopathology examination in both patients revealed T(3a)N(0)M(0) transitional-cell carcinoma. The hospital stay was 6 days. Both patients returned to normal activity within 2 weeks. CONCLUSION Robot-assisted laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion for muscle-invasive bladder cancer is feasible.

Laparoscopic Radical Excision of Urachal Sinus

Persistent urachus is a rare congenital anomaly. Various types of remnants have been described including cyst, alternating sinus, patent urachus, diverticulum, and sinus. The most common presenting symptom of urachal sinus is umbilical discharge. Radical excision of the remnant, with or without a bladder cuff, is essential to prevent future malignant degeneration or recurrence of the remnant. Although open surgical excision has been the treatment of choice for many years, the laparoscopic approach has become an attractive alternative because of its association with less postoperative pain, better cosmesis, and rapid convalescence. Laparoscopic radical excision of a urachal sinus was performed in a 16-year-old female patient who presented with umbilical discharge.

Rapid communication: pure robot-assisted laparoscopic ureteral reimplantation for ureteral stricture disease: case report.

BACKGROUND AND PURPOSE The role of the da Vinci robot is slowly being defined in minimally invasive urologic surgery. We report its use in the management of ureteral stricture disease. CASE REPORT A 42-year-old man with recurrent kidney stone disease was found to have a left distal-ureteral stricture. After failure of endoscopic treatment, a robot-assisted laparoscopic ureteral reimplantation was performed. The total operative time was 210 minutes. The estimated blood loss was <50 mL. There were no intraoperative or postoperative complications. Total analgesic use was 30 mg of morphine. The hospital stay was 5 days. CONCLUSION Pure robot-assisted laparoscopic ureteral reimplantation is a safe and feasible approach to the management of ureteral stricture disease.

Rapid Communication: Laparoscopic Anderson-Hynes Dismembered Pyeloplasty Using the da Vinci™ Robot: Technical Considerations

PURPOSE To present our initial experience with laparoscopic pyeloplasty utilizing the da Vinci robot for upper tract reconstruction. CASE REPORT A four-port transperitoneal approach was used in a 73-year-old man. The ureteropelvic (UPJ) obstruction was identified with a crossing vessel. After dismemberment of the UPJ, the renal pelvis was trimmed and reconstructed using the da Vinci robot. The total operative time was 5 hours; the time spent for reconstruction was 45 minutes. Blood loss was <150 mL. The postoperative analgesic requirement was 8 mg of morphine and 25 mg of hydrocodone. There were no intraoperative or postoperative complications. CONCLUSION The da Vinci robot can serve as a vital surgical tool during pyeloplasty with extensive reconstruction.

Retroperitoneoscopic radiofrequency ablation of a solid renal mass.

PURPOSE To report a new technique for radiofrequency (RF) ablation of a solid renal mass. PATIENT AND METHODS An 83-year-old man with a history of chronic renal insufficiency was found to have solid mass in the right kidney. Retroperitoneoscopic localization of the renal mass was accomplished using intraoperative ultrasonography. The lesion was treated with a 14-gauge RITA Starburst XL probe (Rita Medical Systems, Inc., Mountain View, CA). RESULTS The total treatment time included two cycles of 5.5 minutes. There were no intraoperative complications. Tissue desiccation was noted during treatment. A CT scan 48 hours after ablation showed a decrease in the density of the lesion suggestive of coagulation necrosis. The postoperative hospital course was uneventful. CONCLUSION The retroperitoneal laparoscopic technique is a feasible approach to performing RF ablation of a solid renal mass. It facilitates direct insertion of the RF probe, allows viewing and avoidance of adjacent structures such as bowel, and permits better staging by enabling biopsy of perirenal fatty tissue.

Management of Ureteral Stricture Disease during Laparoscopic Ureteroneocystostomy

BACKGROUND AND PURPOSE Laparoscopic surgery has many applications in urology. The surgical management of obliterative ureteral stricture disease using laparoscopy has not been widely reported. We recently implemented this technique in an adult patient with an obliterative ureteral stricture. METHODS A transperitoneal refluxing right ureteral reimplantation was performed using the Endostitch device. Placement of the new ureteral orifice in the bladder was monitored by simultaneous cystoscopy and laparoscopy. The anastomosis was performed without tension, torsion, or angulation and was stented for 4 weeks. RESULTS The operative time was 233 minutes. The blood loss was minimal. There were no intraoperative complications, and the postoperative hospital course was uneventful. CONCLUSION Laparoscopic ureteral reimplantation is a safe and feasible technique. Cystoscopic determination of the neoureteral orifice is helpful. The Endostitch device is a useful adjunct in this procedure.

Reconstruction of rabbit urethra with Surgisis® small intestinal submucosa

PURPOSE To evaluate the efficacy of Surgisis, porcine small intestinal submucosa, in the reconstruction of iatrogenic urethral defects in rabbits. MATERIALS AND METHODS Eight male white rabbits were enrolled in this protocol. A 2.5-cm segment of urethra was excised. One control consisted of a normal urethra. The other rabbits underwent urethroplasty with Surgisis and 6-0 Vicryl running suture. An 8F feeding tube was left in place to divert urine for 2 weeks after surgery. Retrograde urethrograms were performed to assess the patency of the urethras and to rule out fistula formation prior to sacrifice of the animals. The sacrifice protocol began with the control and a urethroplasty animal 6 weeks after surgery. The other rabbits were euthanized at 2-week intervals thereafter. RESULTS Surgisis promoted epithelial regeneration in all cases. One animal developed a wound infection; this was associated with a small fistula at the proximal end of the anastomosis. Good cosmetic and functional results were documented. Retrograde urethrograms showed no stricture formation at the site of the anastomosis in six rabbits. The histopathologic examination showed complete regeneration of all urethral layers, almost indistinguishable from the normal urethra. CONCLUSION Surgisis is an excellent material for urethral reconstruction in rabbits. It promotes regeneration of all the components of the host urethral layers and is biodegradable.