Reinhard Peschel

LAPAROSCOPIC SURGERY FOR PHEOCHROMOCYTOMA: ADRENALECTOMY, PARTIAL RESECTION, EXCISION OF PARAGANGLIOMAS

PURPOSE Surgical treatment of pheochromocytoma includes adrenalectomy, adrenal sparing surgery and excision of extraadrenal paragangliomas. We report our experience using laparoscopy for these procedures. MATERIALS AND METHODS Between June 1992 and November 1997, 19 patients underwent laparoscopic surgery for pheochromocytoma. Of the patients 14 had solitary tumors, and 4 presented with bilateral pheochromocytomas and 1 or 2 additional paragangliomas. In 1 patient a recurrent pheochromocytoma was found in the contralateral adrenal following previous right adrenalectomy. One patient each had myocardiopathy, amaurosis and stroke secondary to severe hypertension. Two patients were pregnant. RESULTS All solitary tumors were treated with laparoscopic adrenalectomy. Laparoscopic adrenal sparing surgery (4 cases, 2 bilateral) and bilateral adrenalectomy (1) were performed for multiple familial pheochromocytoma, and all paragangliomas were excised simultaneously. The pregnant patients underwent surgery at 16 and 20 weeks of gestation, respectively. All procedures were completed as planned. The rate of minor intraoperative and postoperative complications was 11% and 16%, respectively, and there were no major complications. In all patients the catecholamine levels returned to normal and no residual tumors were found at followup. None of the patients undergoing partial resection required steroid replacement therapy. CONCLUSIONS In experienced hands, laparoscopic surgery for solitary and multiple pheochromocytoma and paraganglioma is feasible and safe, and does not increase the specific risks associated with pheochromocytoma surgery.

Laparoscopic nephron sparing surgery for small renal cell carcinoma.

PURPOSE In recent years the detection rate for small renal tumors has increased due to the widespread use of advanced diagnostic imaging techniques, which in turn has increased the need for nephron sparing surgery. We investigate whether laparoscopic surgery is a suitable approach to partial resection of small renal tumors. MATERIALS AND METHODS Between June 1994 and October 1996, 7 patients underwent laparoscopic wedge resection of the kidney for renal tumors up to 2 cm. in diameter. Hemostasis was achieved mainly by bipolar coagulation. In addition, the resection surface was cauterized with an argon beam coagulator and then sealed with fibrin glue. In 1 procedure a novel ultrasonic dissector was tested. RESULTS All procedures could be completed as planned. The only intraoperative complication was a pneumothorax that resolved spontaneously within 2 days. There were no postoperative complications. Histological examination yielded stage pT1 grade I renal cell carcinoma in 3, stage pT1 grade II in 2 and multilocular cysts in 2 cases. All patients had negative surgical margins. Postoperatively, renal function as assessed by serum creatinine was unchanged. Neither local recurrences nor metastases were observed during a followup of 7 to 35 months. CONCLUSIONS Our results indicate that laparoscopic partial nephrectomy is feasible for small renal cell carcinoma, and is associated with low morbidity and a low complication rate.

Laparoscopic Surgery for Stage T1 Renal Cell Carcinoma: Radical Nephrectomy and Wedge Resection

Objectives: Renal cell carcinoma (RCC) is likely to become one of the most important indications for laparoscopic surgery. We herein report our experience.Methods: From April 1994 until April 1999, 98 patients presenting with RCC were treated laparoscopically by either radical nephrectomy (RN; n = 73) or wedge resection (WR; n = 25). The mean age was 62.3 years. The mean tumour diameters were 3.8 cm (RN) and 1.9 cm (WR). All tumours were clinical stage T1 lesions. The transperitoneal approach was used for RN in all patients. For WR either the transperitoneal or the retroperitoneal approach was used. In 15 patients, the adrenal gland was removed simultaneously. The specimen was entrapped in an organ bag and removed intact through a small muscle–splitting incision in the lower abdominal wall.Results: RN: The mean operating time was 142 (range 86–230) min, the mean blood loss was 170 (range 0–1,500) ml, and the mean postoperative hospital stay was 7.4 (range 3–32) days. Minor complications occurred in 4.0% of the patients, while major complications were seen in 8.0% of them. WR: The mean operating time was 163.5 (range 90–300) min, the mean blood loss was 287 (range 20–800) ml, and the postoperative hospital stay was 8.0 (range 3–8) days. Minor complications: 4%, major complications: 8%. Histology revealed RCC stage T1 in 77 patients, stage T3a in 7, and stage T3b in 3 patients, oncocytoma in 2 patients, angiomyolipoma in 2, renal adenoma in 1, renal metastasis in 1, multilocular cysts in 4, and renal abscess in 1 patient. Over mean follow–up periods of 13.3 and 22.2 months for RN and WR, respectively, neither local recurrences nor metastases have been observed among patients with histologically confirmed RCC.Conclusions: Laparoscopic surgery for clinical stage T1 RCC is safe and efficient. Excellent tumour control can be achieved. However, longer follow–up periods will be necessary to confirm these results.

A comparison of Laparoscopic pyeloplasty performed with the daVinci robotic system versus standard Laparoscopic techniques: Initial clinical results

PURPOSE Laparoscopic pyeloplasty is an accepted therapy for primary ureteropelvic junction obstruction (UPJO), however difficulty associated with intracorporeal suturing has limited widespread clinical application. We report our initial experience of laparoscopic pyeloplasty performed with the daVinci robotic system matched to procedures performed with standard laparoscopic techniques. PATIENTS AND METHODS From June 2001 until August 2001, six patients underwent definitive management of primary UPJO using the daVinci robotic system. In four patients an Anderson-Hynes pyeloplasty was performed, while in two patients Fengerplasty was performed. Using demographic and preoperative information, each patient in the daVinci-assisted group was matched to a corresponding patient with primary UPJO undergoing laparoscopic pyeloplasty with standard techniques between November 1999 and June 2001. Perioperative results and follow-up data were subsequently compared. RESULTS Treatment groups were identical with regard to surgical procedure, gender, and side of UPJO. The length of hospitalization was 4 days for all patients, regardless of treatment group. Estimated blood loss was <50 cc in all cases. For Anderson-Hynes pyeloplasty, the mean overall operative and suturing times were 140 and 70 min using the daVinci system and 235 and 120 min using standard techniques, respectively. For the Fengerplasty, the mean overall operative and suturing times were 78 and 13 minutes using the daVinci system and 100 and 28 minutes using standard techniques, respectively. No complications were observed and there were no open conversions. CONCLUSION Anderson-Hynes pyeloplasty and Fengerplasty are feasible using either conventional laparoscopic techniques or the daVinci robotic system. In this initial pilot study, procedures performed with the daVinci robotic system resulted in overall decreased operative time, however factors responsible for the decreased operative time remain to be defined. Long-term prospective follow-up of procedures performed with or without the daVinci robotic system for surgeons with limited experience in laparoscopic management of UPJO is warranted to delineate the true efficacy of the device.

Anderson-Hynes dismembered pyeloplasty performed using the da Vinci robotic system

INTRODUCTION To evaluate and describe the use of the da Vinci robotic system in performing laparoscopic Anderson-Hynes pyeloplasty. TECHNICAL CONSIDERATIONS Between June 2001 and February 2002, 9 patients underwent laparoscopic Anderson-Hynes pyeloplasty with the da Vinci telerobotic surgical system. The diagnosis was based on the presenting symptoms and radiologic imaging findings. The technique for da Vinci-assisted Anderson-Hynes pyeloplasty followed the same steps as for conventional laparoscopy. Three transperitoneal laparoscopic ports were required for the robotic system, and a fourth laparoscopic port was used by the assistant for retraction, suction, and introduction of suture. The operative time, suturing time, perioperative complications, and success rates were prospectively evaluated. The mean operative time was 138.8 minutes (range 80 to 215), and the mean suturing time was 62.4 minutes (range 40 to 115). No intraoperative complications or open conversions were required. The estimated blood loss was less than 50 mL in all cases. The mean length of hospitalization was 4.7 days (range 4 to 11). Postoperatively, 1 (11.1%) of 9 patients required open exploration to repair a defect in the renal pelvis. At a mean follow-up of 4.1 months (range less than 1 to 8), all procedures were successful on the basis of the subjective and radiographic data. CONCLUSIONS All aspects of laparoscopic Anderson-Hynes pyeloplasty were performed using the da Vinci robotic system. da Vinci-assisted procedures resulted in favorable overall operative times, suturing times, perioperative complications, and available success rates, but additional clinical experience is required. Ongoing clinical application of robotic technology in a controlled scientific manner is needed to gauge the effectiveness of this method completely.

Extracorporeal shock wave lithotripsy versus ureteroscopy for distal ureteral calculi: a prospective randomized study.

PURPOSE We performed a prospective randomized study to determine appropriate first line treatment for distal ureteral stones. MATERIAL AND METHODS Between January 1996 and October 1997, 80 patients with distal ureteral stones (40 smaller than 5 mm. and 40 larger than 5 mm.) were randomized and treated with extracorporeal shock wave lithotripsy or ureteroscopy with a 9.5 or 6.5F semirigid ureteroscope. RESULTS Ureteroscopy was significantly better in terms of operative time, fluoroscopy time and time to achieve a stone-free state. The smaller the stones, the greater the difference between the 2 treatment modalities. CONCLUSIONS For distal ureteral stones we recommend ureteroscopy as first line treatment.

New Onset Hypertension After Extracorporeal Shock Wave Lithotripsy: Age Related Incidence and Prediction by Intrarenal Resistive Index

PURPOSE In a recent study we found an increased resistive index immediately after extracorporeal shock wave lithotripsy (ESWL) in patients older than 60 years, which suggests renovascular disturbance. The present 26-month followup study was undertaken to investigate the relevance of elevated resistive index levels and the incidence of new onset hypertension. MATERIALS AND METHODS Of the initial 76 patients 57, including 20 of the 23 at risk patients 60 or greater years, group 3), were followed for more than 26 +/- 6 months after ESWL. Followup included 2 resistive index measurements by Doppler ultrasound of the treated and the contralateral kidney, at least 2 blood pressure measurements 1 week apart and excretory urography as well as determination of plasma renin activity in 9 patients. RESULTS With 1 exception, elevated resistive index levels and hypertension were observed exclusively in patients older than 60 years. In these patients the resistive index ranged between 0.65 and 0.86 (mean plus or minus standard deviation 0.74 +/- 0.05, normal less than 0.7). This increase in resistive index was statistically significant (p < 0.0001). Compared to the levels obtained immediately after ESWL, the resistive index continued to increase in all 9 patients older than 60 years who had hypertension (45%), whereas in the normotensive patients the resistive index was either stable or decreased. There was a strong positive correlation (0.903) between pathological resistive index levels and blood pressure. CONCLUSIONS Patients older than 60 years are at risk for disturbances of renal perfusion as assessed by the resistive index, and 45% of these patients have new onset hypertension within 26 months of treatment.

Laparoscopic and retroperitoneoscopic repair of ureteropelvic junction obstruction

OBJECTIVES The aim of this study was to evaluate laparoscopic and retroperitoneoscopic pyeloplasty and to compare the efficacy of dismembered and nondismembered techniques. METHODS Since May 1993, a modified laparoscopic transperitoneal (14 patients) and a retroperitoneoscopic approach (3 patients) have been used for the management of ureteropelvic junction obstruction. In 7 patients aberrant vessels were encountered; 1 patient had a horseshoe kidney. Surgical repair was achieved by dismembered pyeloplasty (8 patients), nondismembered Fenger-plasty (longitudinal incision, transverse closure; 3 patients), transaction and reanastomosis of the renal pelvis (1 patient), ureterolysis and displacement of crossing vessels (4 patients). RESULTS In 1 patient dismembered pyeloplasty could not be scheduled because of cardiovascular problems. A minimal transient lesion of the sympathetic nerve was observed postoperatively in 1 patient and pulmonary embolism in another. The operative time in dismembered pyeloplasty was between 240 and 360 minutes (mean, 280); the results were good in all patients. Equally good results were obtained with nondismembered Fenger-plasty, and the operating time was shorter (120 to 180 minutes). Ureterolysis was found to have a failure rate of 50%. CONCLUSIONS Laparoscopic dismembered pyeloplasty yielded good results but it is too complicated to become a standard procedure. Nondismembered Fenger-plasty, which also showed good results, is more suitable for laparoscopy and retroperitoneoscopy. The indications for this technique should be defined more precisely as more experience is being collected. The results of ureterolysis when used as a single measure were poor, and, therefore, this technique should be abandoned.

LAPAROSCOPIC RETROPERITONEAL LYMPH NODE DISSECTION FOR CLINICAL STAGE I NONSEMINOMATOUS TESTICULAR CARCINOMA: LONG-TERM OUTCOME

PURPOSE We report the long-term oncological efficacy and morbidity of laparoscopic retroperitoneal lymph node dissection for testicular carcinoma. MATERIALS AND METHODS From August 1992 to September 1999, 73 consecutive patients underwent laparoscopic retroperitoneal lymph node dissection with modified unilateral template dissection. All lumbar vessels within the template were routinely transected in the initial 29 cases only. Patients with positive lymph nodes received 2 cycles of chemotherapy. RESULTS Operative time ranged from 150 to 630 minutes (mean 221) in our most recent 28 cases. All but 2 operations were completed as planned for a conversion rate of 2.7%. Minor intraoperative complications developed in only 6.8% of cases. In our last 44 patients there was no major and only 1 minor (2.3%) postoperative complication. Mean postoperative hospitalization was 3.3 days. Ejaculation was preserved in all patients. Lymph nodes were positive in 19 cases (26%). Mean followup in 47 patients with pathological stage I disease was 43.3 months (range 7 to 84). We noted 1 retroperitoneal recurrence due to false-negative histological findings but there were no other relapses. At a mean followup of 42.7 months (range 6 to 86) 17 patients with pathological stage II carcinoma treated with 2 cycles of adjuvant chemotherapy were also free of disease. CONCLUSIONS In our hands laparoscopic retroperitoneal lymph node dissection has not only proved its surgical efficiency, but also its oncological efficacy. Patient satisfaction is high. During long-term followup of more than 3 years not a single recurrence developed due to surgical failure.

Robotic Anderson-Hynes pyeloplasty: 5-year experience of one centre.

To present our 5‐year experience with robotically assisted laparoscopic pyeloplasty (RALP), as LP has been shown to have similar success rates as open surgery, but standard LP requires high operative skills and a correspondingly long period of training, limiting its widespread availability, and RALP is easier and quicker to learn due to facilitated intracorporeal suturing.