Richard Neururer

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.

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.

Laparoscopic retroperitoneal lymph node dissection: description of the nerve-sparing technique.

INTRODUCTION Laparoscopic retroperitoneal lymph node dissection (RPLND) is associated with a more favorable postoperative recovery and decreased morbidity compared with open RPLND. To date, laparoscopic RPLND is used as a diagnostic tool for patients with clinical Stage I nonseminomatous germ cell tumor and as a diagnostic and therapeutic tool for patients with low-volume Stage II nonseminomatous germ cell tumor after chemotherapy. In an effort to further expand the therapeutic implications for laparoscopic RPLND, we describe a nerve-sparing technique for laparoscopic RPLND. TECHNICAL CONSIDERATIONS In all cases, a four-port transperitoneal approach was used to perform a unilateral nerve-sparing technique. Laparoscopic nerve-sparing RPLND requires complete exposure of the retroperitoneum, similar to the standard procedure. A stepwise surgical approach is required for prospective identification of the sympathetic trunk and postganglionic nerve fibers. Identification and division of the lumbar veins is required for complete mobilization of the vena cava to facilitate dissection of the postganglionic nerves on the right side as they course dorsal to the vena cava. Meticulous dissection was required for preservation of the postganglionic nerves in the interaortocaval and para-aortic regions. CONCLUSIONS Laparoscopic nerve-sparing RPLND is technically feasible. Performance of laparoscopic nerve-sparing RPLND decreases the potential morbidity associated with the standard laparoscopic technique further and may help expand the therapeutic potential for this minimally invasive procedure.

Laparoscopic radical nephrectomy in the elderly.

Authors from Innsbruck present their work in laparoscopic radical nephrectomy in elderly patients. They evaluated the outcome of this technique in patients over 75 years old and compared the results with a similar number of patients aged less than 75 years who had the same procedure. Despite more comorbid conditions in the older group the final outcome was equally as good as in the younger patients.

Plain abdominal radiography with transabdominal native tissue harmonic imaging ultrasonography vs unenhanced computed tomography in renal colic

In the first paper in this section, the authors from Austria compare plain film plus transabdominal native‐tissue harmonic ultrasonography with unenhanced CT for the diagnosis of urinary calculi in patients with acute flank pain. In this prospective study, they found that CT is the most accurate method of diagnosis, but that the other method of diagnosis compared favourably, with excellent results.

Laparoscopic varicocele ligation in children and adolescents using isosulphan blue: a prospective randomized trial

To evaluate, in a randomized prospective trial in children and adolescents, the feasibility of isosulphan blue‐based lymphatic vessel preservation during laparoscopic varicocelectomy and its impact on the complication rate, as the operative management of varicoceles remains controversial.

Haemostatic sealants in nephron-sparing surgery: what surgeons need to know

Surgical haemostatic agents have been increasingly applied for the control of bleeding, and have excellent potential in laparoscopy. Several factors are important when evaluating the use of sealants. We present a brief overview of the history, composition and mechanism of action of sealants, together with a report on experimental studies and clinical experience with haemostatic sealants. We searched for reports on haemostatic agents and their use in renal parenchymal haemostasis; 15 animal models studies and 11 papers on clinical experience were included. The development of haemostatic agents and instruments is allowing the wider diffusion of challenging procedures. Several experimental animal studies have shown the efficacy and safety of sealants for haemostasis during nephron‐sparing surgery. Clinical studies confirm the effectiveness of synthetic or fibrin glue, in particular during laparoscopic surgery. Sealants are effective and safe topical agents to control bleeding during nephron‐sparing surgery. They should not be viewed as an alternative, but as complementary agents to be used to improve surgical outcomes. Further prospective studies are necessary to validate their role in relation to other haemostatic support techniques.

Value of 3-Dimensional Transrectal/ Transvaginal Sonography in Diagnosis of Distal Ureteral Calculi

In a prospective study, the feasibility of 3‐dimensional (3D) transrectal/transvaginal sonography in comparison with transabdominal sonography and intravenous urography (IVU) in identifying distal ureteral calculi was evaluated.

Multimodal evaluation of renal perfusional changes due to extracorporeal shock wave lithotripsy

To examine the effect of extracorporeal shock wave lithotripsy (ESWL) on renal perfusion before and after treatment, by assessing renal resistive index (RI) using colour Doppler ultrasonography (CDUS), magnetic resonance perfusion imaging (MRPI), radionuclide renography and big‐endothelin‐1 values (Big‐ET‐1).