Premal J. Desai

Bilateral laparoscopic nephrectomy for significantly enlarged polycystic kidneys: a technique to optimize outcome in the largest of specimens

To present our experience with bilateral laparoscopic nephrectomy (BLN) for symptomatic autosomal‐dominant polycystic kidney disease (ADPKD), as surgical management of massively enlarged polycystic kidneys can be a daunting task.

Outcomes of laparoscopic radical nephrectomy in the setting of vena caval and renal vein thrombus: Seven-year experience

PURPOSE We present our experience with laparoscopic radical nephrectomy for T(3b) disease focusing on thrombus within the vena cava. PATIENTS AND METHODS A total of 14 patients with T(3b) disease were identified from a retrospective laparoscopic renal cancer database from 2000 to 2007. Patient demographics, clinical stage, preoperative imaging, intraoperative parameters, final pathology, and postoperative course were analyzed. In patients with a large tumor thrombus, the infraumbilical extraction excision was performed early and a gel port was placed. This was used when laparoscopic milking or determination of the distal extent of the tumor thrombus was difficult. RESULTS Preoperative imaging identified T(3b) disease in all but four patients. Four patients had caval involvement seen on imaging, with one extending well above 2 to 3 cm above the renal vein. Of the 14 patients, procedures in 13 were completed laparoscopically. There was one conversion early in the experience because of a positive frozen section of the renal vein; however, additional vein and caval margins were negative. There was one complication-a pulmonary embolism 5 days postoperatively, managed with anticoagulation, with no disease recurrence 4 years later. CONCLUSION In patients with T(3b) disease, laparoscopy is feasible and safe. Using advanced laparoscopic techniques to milk the tumor thrombus into the proximal renal vein with laparoscopic vascular instruments is critical to success in a purely laparoscopic thrombectomy. Placement of a gel port in the extraction incision early in the procedure may aid in hand-milking of the tumor thrombus into the renal vein in cases of extensive inferior vena cava involvement.

Utility of the Endovascular Stapler for Right-Sided Laparoscopic Donor Nephrectomy: A 7-Year Experience at Mayo Clinic

BACKGROUND Management of the renal vasculature during right laparoscopic donor nephrectomy (LDN) to maximize vessel length has been controversial. The endovascular gastrointestinal anastomosis (GIA) stapler has been used for renal vascular control for our donors since the inception of our LDN program. We evaluated and compared the outcomes of right and left LDNs using a single method for hilar control. STUDY DESIGN A retrospective review was performed of the first 400 LDNs and respective recipients at our institution. Patient demographics, perioperative variables, graft function, and complications were analyzed. RESULTS Four hundred LDNs were performed between 1999 and 2007. Forty-one were on the right. There were no statistically significant differences between the donor groups or their respective recipients. There were 4 (1%) stapler malfunctions, all occurring on the left side; 2 of these procedures were converted to open to obtain hemostasis. There were nearly equal rates of vascular complications, 4.9% and 4.7%, in the right and left groups, respectively. The overall immediate graft failure rate was 2.3%. Right and left recipient creatinine levels up to 24 months demonstrated no statistically significant differences. CONCLUSIONS We propose that the endovascular GIA stapler for left and right laparoscopic donor nephrectomy is safe for the donor. It standardizes the process, minimizes the need for additional maneuvers in securing the renal hilum, and produces similar outcomes for the recipient. The transplant team also plays an equally large role in favorable graft outcomes.

Does a history of previous surgery or radiation to the prostate affect outcomes of robot―assisted radical prostatectomy?

To evaluate retrospectively whether or not previous treatment to the prostate alters the perioperative outcomes from robot‐assisted radical prostatectomy (RARP) after the initial ‘learning curve’, as there are conflicting data on outcomes of RP in patients with previous treatment to the prostate.

Ureteroarterial Fistula Following Laser Endopyelotomy

uratio A 29-year-old female underwent robot assisted pyeloplasty with subsequent failure 5 weeks after surgery. Six weeks after stent placement for acute obstruction ureteroscopy revealed a short stricture at the anastomotic site. The decision was made to perform laser endopyelotomy under direct vision rather than using a cutting endopyelotomy balloon because we were already visualizing the stricture. No pulsations were identified and no bleeding was encountered. The patient resumed vigorous exercise and went hiking 2 weeks after surgery. Within 24 hours she had gross hematuria. Computerized tomography only confirmed blood within the collecting system and the bleeding ceased with bed rest. Ureteroscopy revealed pinpoint pulsatile bleeding coming from the previous endopyelotomy site. A ret-