Raymond R. Rackley

Single-Port Laparoscopic Surgery in Urology: Initial Experience

OBJECTIVES To present our initial experience with single-port laparoscopic urologic surgery using the Uni-X Single Port Access Laparoscopic System, a single port, multichannel cannula, with specially designed curved laparoscopic instrumentation. METHODS We performed single-port laparoscopic surgery in 10 patients, including renal cryotherapy in 4, wedge kidney biopsy in 1, radical nephrectomy in 1, and abdominal sacrocolpopexy in 4. For the transperitoneal approach, the multichannel port was inserted transumbilically, and for retroperitoneoscopy, the port was inserted at the tip of the 12th rib. Data were collected prospectively into our institutional review board-approved data registry. RESULTS Since September 25, 2007, a total of 10 patients have undergone single-port laparoscopic surgery for various upper abdominal and pelvic pathologic findings. All cases were completed successfully, without conversion to a standard laparoscopic approach. The total operative time for the various kidney procedures was 2.5 hours (range 2 to 3.2) and was 2.5 hours (range 2 to 3) for sacrocolpopexy. The mean blood loss was 100 mL for the renal procedures and 90 mL for sacrocolpopexy. The hospital stay was 2.8 days (range 1 to 8) for the kidney procedures and 2 days for sacrocolpopexy. One complication occurred in a patient with baseline congestive heart failure who underwent cryoablation and required oxygen mask ventilation postoperatively that delayed her hospital discharge for 1 week. The same patient, who was anemic preoperatively, was transfused with 3 U of packed red blood cells, although the postoperative computed tomography scan revealed a small perinephric hematoma. CONCLUSIONS Single-port laparoscopic renal cryotherapy, wedge kidney biopsy, radical nephrectomy, and abdominal sacrocolpopexy are safe and feasible. Additional experience and continued investigation are warranted.

Pelvic floor reconstruction

Herniation, including cystocele, rectocele and enterocystocele may be treated with prefabricated repair patches. The repair patches include a natural or synthetic biocompatible material having a shape adapted to support herniated tissue. The patch also contains a plurality of apertures positioned in the central plane of the patch which may permit ingrowth and may also be an attachment site for pexing sutures. The patch may be covered with coating to decrease the possibility of infection, and/or increase biocompatibility. The coating may also include one or more drugs, for example, an antibiotic, an immunosuppressant, and/or an anticoagulant.

THE IMPACT OF ADJUVANT NEPHRECTOMY ON MULTIMODALITY TREATMENT OF METASTATIC RENAL CELL CARCINOMA

Multimodality treatment of metastatic renal cell carcinoma with biological response modifiers and cytoreductive surgery has produced durable responses. The timing and impact of cytoreductive surgery on the success of immunotherapy require further study. We reviewed the treatment of 62 patients with metastatic renal cell carcinoma and primary tumors in place who qualified for multimodality treatment comprising adjuvant nephrectomy and biological response modifier protocols at our institution between 1987 and 1992. Of the patients 37 were scheduled to undergo initial adjuvant nephrectomy followed by biological response modifier therapy. A total of 25 patients underwent initial biological response modifier therapy with planned delayed adjuvant nephrectomy if a response to treatment was demonstrated. Of the 37 patients undergoing initial adjuvant nephrectomy, 8 (22%) were unable to enter induction of immunotherapy because of perioperative complications (1), medical contraindications (2), tumor progression (4) or death (1). Three patients in the initial adjuvant nephrectomy group (8%) had a partial response and the median survival in this group was 12 months (range 1 to 57). In the initial biological response modifier group 3 patients (12%) with an objective response (2 complete and 1 partial) to biological response modifier therapy underwent nephrectomy. The median survival for the initial biological response modifier group was 14 months (range 1 to 48). These results add to our understanding of the impact of adjuvant nephrectomy on patients with metastatic renal cell carcinoma considered for immunotherapy protocols.

COLLAGEN INJECTION THERAPY FOR POST-PROSTATECTOMY INCONTINENCE

PURPOSE Post-prostatectomy incontinence has an incidence of 5 to 12% and greatly affects quality of life. Since the approval of glutaraldehyde cross-linked collagen there is a renewed interest in injectable urethral bulking agents. We investigated the long-term efficacy and prognostic criteria for transurethral collagen injection therapy for men with post-prostatectomy incontinence. MATERIALS AND METHODS From November 1993 to May 1995, 62 men with post-prostatectomy incontinence (54 after radical prostatectomy and 8 after transurethral resection of the prostate) were treated with collagen via a transurethral approach. Median followup was 29.0 months from the date of the last injection procedure. RESULTS Social continence was defined as dry or minimal leakage requiring at most 1 pad daily with activity. Of 62 patients 38.7% achieved social continence and 8.1% became totally dry. The success rate was 35.2 for radical prostatectomy versus 62.5% for transurethral prostatic resection patients. Of the patients who achieved social continence with at least 1-year followup 23 (60.9%) remained so with no further treatment. At 2-year followup 21 patients (42.8%) maintained social continence. The success rate was 27.3% for those who wore a penile clamp or condom catheter before treatment (3 of 11 patients), and only 21.4% for those who underwent transurethral incision of a bladder neck contracture (3 of 14). A median of 4 injection procedures and 20.0 ml. collagen were required to achieve social continence. CONCLUSIONS Transurethral collagen injection therapy is a reasonable treatment option for post-prostatectomy incontinence in select patients in whom more conservative therapy has failed. However, patients who have required a penile clamp, experienced continuous leakage or undergone transurethral incision of a bladder neck contracture are unlikely to respond well to this treatment.

NOTES Transvaginal Nephrectomy: First Human Experience

OBJECTIVES To present the operative outcomes of the first natural orifice translumenal endoscopic surgery (NOTES) transvaginal nephrectomy. METHODS A 57-year-old woman with hypertension, right-sided flank pain, and radiographic evidence of an atrophic right kidney consented for NOTES transvaginal nephrectomy. Pneumoperitoneum was achieved with a Veress needle inserted deep in the umbilicus. Under direct vision, a colpotomy was made and a transvaginal port positioned. Using standard and articulating operating instruments inserted transvaginally, the kidney was mobilized and the renal hilum was controlled with an endovascular stapler. The kidney was placed in a laparoscopic retrieval bag and extracted through the vaginal incision. Salient demographic and operative data were obtained. RESULTS NOTES transvaginal nephrectomy was successfully completed, with all the operative steps performed transvaginally. Dense pelvic adhesions from a prior hysterectomy necessitated the use of a 5-mm umbilical port during vaginal port placement and for retraction of the ascending colon during division of the renal hilum. No intraoperative complications occurred. Operative time was 307 minutes, with 124 minutes dedicated to vaginal port placement and 183 minutes dedicated to adhesiolysis and nephrectomy. The duration of hospitalization was 23 hours. The visual analog pain scale score was 1 of 10 on postoperative day 2. CONCLUSIONS Our experience shows that NOTES transvaginal nephrectomy is technically feasible. Access to the peritoneal cavity should be performed under visual guidance and after insufflation through the umbilicus. Additional experience is needed to better define patient selection criteria and indications for NOTES transvaginal urologic surgery.

The efficacy of urethrolysis without re-suspension for iatrogenic urethral obstruction.

PURPOSE Urethral obstruction following surgical correction of stress urinary incontinence is not uncommon and urethrolysis is typically used to relieve symptoms. Whether one should resuspend the bladder neck concurrent with urethrolysis is controversial. We evaluate the efficacy of urethrolysis without re-suspension for the treatment of iatrogenic urethral obstruction. MATERIALS AND METHODS From April 1994 to January 1998, 31 women 29 to 78 years old (mean age 60) underwent transvaginal urethrolysis without concomitant re-suspension. The incident procedure was transvaginal urethropexy in 15 patients (48%), retropubic urethropexy in 5 (16%) and pubovaginal sling in 11 (36%). The most common presenting complaints were urinary retention, feeling of incomplete emptying or straining to void in 22 patients (71%) and irritative voiding symptoms in 17 (55%). Mean time from index procedure to urethrolysis was 14 months (range 2 to 36) and mean followup was 7 (range 1 to 27). RESULTS After urethrolysis 26 of 31 patients (84%) voided well or had significant improvement in symptoms. Of the 26 improved patients 6 had stress incontinence. Of these 6 patients 4 responded to periurethral collagen injection and are now dry. When individual variables were analyzed, none was found to be predictive of a successful outcome. CONCLUSIONS Transvaginal urethrolysis without concomitant re-suspension is an effective treatment for iatrogenic urethral obstruction. While 19% of patients may have recurrent incontinence, the majority can be treated with outpatient collagen injections. Overall 77% of patients voided well without incontinence, 7% voided well but with some incontinence and 16% remained obstructed after urethrolysis.

Urodynamic findings in postprostatectomy incontinence

Due to the large variability in the reported contribution of bladder dysfunction to postprostatectomy incontinence and the impact this dysfunction may have on the outcome of selected treatment, we retrospectively reviewed the videourodynamic findings of bladder and sphincteric function in patients with postprostatectomy incontinence. The contributions of bladder and sphincteric causes of incontinence are determined. Ninety‐two patients had multichannel videourdynamic testing performed as part of a comprehensive evaluation for incontinence at least 1 year after prostatectomy. Using a 6‐French double‐lumen catheter in the bladder and a 10‐French catheter in the rectum, all pressures were recorded continuously while in the upright position. Valsalva leak point pressures (VLPP) were measured in the absence of a bladder contraction at a 150‐ml volume and at 50‐ml increments thereafter until maximum functional capacity was reached. Bladder compliance and bladder capacity were determined and the presence of detrusor instability (DI) was documented. Sixty‐five patients (71%) presented after radical prostatectomy (RP) and 27 patients (29%) after transurethral resection of the prostate (TURP). The predominant urodynamic finding was sphincteric incompetence as VLPP were obtained in 85 patients (92%) and ranged from 12 to 120 cm water. DI was a common finding, occurring in 34 patients (37%), and classified as follows: a) phasic instability in 22/34, b) tonic instability in 3/34, and c) mixed phasic and tonic instability in 9/34. However, we found DI to be the sole cause of incontinence in only 3/92 patients (3.3%). There was no statistically significant difference in the incidence of sphincteric incompetence after RP or TURP; however, TURP patients had a higher incidence of DI, which was statistically significant (P = 0.019). There was no correlation of incontinence severity and VLPP when comparing preoperative pad usage to VLPP ⩽70 or ⩾71 cm water. Although bladder dysfunction may be contributing problem in patients with postprostatectomy incontinence, it is rarely the only mechanism for this disorder. VLPP does not correlate with incontinence severity. Although sphincteric incompetence is the most common mechanism contributing to incontinence after prostatectomy, bladder dysfunction may coexist or be an isolated cause of postprostatectomy incontinence. Therefore, urodynamic studies are important to illustrate the exact cause(s) of incontinence in each individual patient after prostatectomy. Neurol. Urodynam. 17:493–498, 1998.

Constitutive expression of the Wilms tumor suppressor gene (WT1) in renal cell carcinoma

The expression of the Wilms tumor suppressor gene WT1 is largely restricted to elements of the developing urogenital system. In the fetal kidney, WT1 transcripts are present at low levels in the condensing mesenchyme and at much higher levels in differentiating glomerular epithelium and are not detected in other mesenchymal‐derived epithelial structures such as the proximal and distal tubules. However, WT1 expression is observed in tubule‐like elements found in some Wilms tumors. As renal cell carcinoma (RCC) of the clear cell type is one of the most prevalent adult tumors of the kidney, and is thought to originate from the epithelial cells of the proximal tubules, we studied WT1 expression in RCCs. Despite the absence of WT1 in normal primary epithelial cells derived from proximal tubules, RCC tumors and tumor‐derived cell lines expressed WT1 RNA. Immunocytochemical analyses of tumor cryosections showed widespread expression throughout the poorly differentiated epithelial components of the tumor. Immunoblots of RCC samples detected a normal size WT1 protein and reciprocal antibody immunoprecipitations of RCC cell extracts indicated that WT1 interacts with p53 as has been demonstrated for normal human fetal kidney. The aberrant expression of functional WT1 in RCC may represent a reversion to a more de‐differentiated phenotype and may contribute to the tumorigenic phenotype by inappropriately activating or repressing genes involved in growth regulation. Int. J. Cancer 78:182–188, 1998.© 1998 Wiley‐Liss, Inc.

Management of iatrogenic foreign bodies of the bladder and urethra following pelvic floor surgery

Literature regarding the management of iatrogenic foreign body in the bladder and urethra following female pelvic reconstructive surgery, especially mesh erosion, are sparse. We present our recent experience with the removal of iatrogenic foreign bodies from the bladder and urethra and propose a treatment algorithm.

Collagen Injection Therapy for Female Intrinsic Sphincteric Deficiency

PURPOSE Since glutaraldehyde cross-linked collagen was approved for use, studies have reported success or improved rates of 63 to 86%. Long-term efficacy with strictly defined outcome criteria has not been reported. We report our experience with collagen injection therapy for female patients with intrinsic sphincteric deficiency to establish efficacy, duration of response and clinical predictors of success. MATERIALS AND METHODS A total of 96 women underwent collagen injection via a periurethral approach with local anesthesia. In all patients history, physical examination and video urodynamics documented intrinsic sphincteric deficiency without urethral hypermobility. Continence success was defined as dry or socially continent (minimal leakage requiring 1 or no pad daily even with strenuous activity). Median followup was 14.0 months. RESULTS Of 94 patients 67.0% achieved continence, 38.3% became dry and 28.7% became socially continent. Of 35 patients who achieved continence with at least 1 year of followup 6 had regression. Therefore, 82.9% of those successfully treated remained so at 1 year and none had de novo detrusor instability. An average of 2.1 procedures and 11.9 ml. collagen were required to achieve continence. The 31 patients not achieving success underwent an average of 3.2 procedures with 16.1 ml. collagen. No major complications have occurred to date. CONCLUSIONS Collagen injection achieves a reasonable rate of continence and good durability at 1 year of followup in female patients with intrinsic sphincteric deficiency and no urethral hypermobility.