Richard Vanlangendonck

Renal hypothermia achieved by retrograde endoscopic cold saline perfusion: technique and initial clinical application

We describe the technique and initial clinical results with application of a novel method to achieve renal parenchymal hypothermia using retrograde ureteral access. A 38-year-old man was scheduled to undergo an open right partial nephrectomy for renal cell carcinoma. Before the open procedure, a ureteral access sheath was advanced to the ureteropelvic junction under fluoroscopic guidance; through the access sheath, a 7.1F pigtail catheter was also advanced. After clamping the renal artery and vein, ice-cold saline (-1.7 degrees C) was circulated through the access sheath and drained via the 7.1F pigtail catheter; renal cortical and medullary parenchymal temperatures were measured using thermocouples. This technique of intrarenal cooling achieved a renal cortical temperature of 24 degrees C and a medullary temperature of 21 degrees C. The endoscopic procedure required an additional 35 minutes of operation time to complete. Histopathologic investigation of the specimen revealed no associated damage to the ureteral urothelium from access sheath placement or to the collecting system urothelium from exposure to ice-cold saline irrigation. Retrograde endoscopic renal hypothermia is feasible and effective. The technique requires no novel equipment or special surgical skills. This method can be applied to patients undergoing open or laparoscopic complex renal ablative and reconstructive procedures that require renal hypothermia.

Modified renal morcellation for renal cell carcinoma: laboratory experience and early clinical application

OBJECTIVES To present our modified technique to expedite the entrapment and morcellation process. Standard renal morcellation is typically performed using a 12-mm incision, with the specimen entrapped within a durable LapSac. Because the LapSac does not have a deployment mechanism, its application is technically demanding and time consuming. The recent elimination of the electrical morcellator has also made the morcellation process time consuming and tedious. METHODS Using an in vitro porcine kidney morcellation model, we compared traditional morcellation (n = 10) with our modified morcellation technique (n = 10). The modified morcellation technique incorporated an EndoCatch entrapment sac and used standard manual morcellation through a 3-cm incision. The 3-cm incision allowed for extracorporeal morcellation, because the specimen could be seen through the abdominal wall defect. Subsequently, we performed 11 laparoscopic radical/total nephrectomies for renal masses using the modified morcellation technique through a 3-cm incision. RESULTS In this in vitro model, renal specimen morcellation with the standard technique required a mean of 9.4 minutes (16.5 g/min) and modified morcellation required 3.24 minutes (51.24 g/min; P <0.0001). The mean fragment size with standard and modified morcellation was 1.47 and 4.46 g, respectively (P <0.0001). EndoCatch entrapment sack integrity was confirmed in all 10 cases (100%). Clinically, 12 patients underwent modified morcellation of radical nephrectomy specimens. All specimens were renal cell carcinoma, with a mean specimen weight of 724 g. The mean entrapment time was 2 minutes, 40 seconds, and the mean morcellation time was 11 minutes. EndoCatch entrapment sack integrity was confirmed in all cases. At a mean follow-up of 8 months, no trocar site or local recurrences have developed. CONCLUSIONS Preliminary laboratory and clinical data have demonstrated that the modified morcellation technique is safe and expeditious. The larger fragments that result from the modified technique may facilitate tumor staging. The technique must be performed with great care to prevent sack perforation. Prospective randomized comparison of the modified and standard morcellation techniques and long-term follow-up are required before routine application of this technique.

Recurrent Pelvic Floor Defects After Abdominal Sacral Colpopexy

PURPOSE The incidence of site specific pelvic organ prolapse defects following sacral colpopexy is not clearly reported. We evaluated site specific pelvic organ defects after colpopexy and determined its impact on patient satisfaction. MATERIALS AND METHODS A total of 40 women with vault prolapse underwent abdominal sacral colpopexy, culdeplasty and paravaginal repair. Followup consisted of pelvic examination and satisfaction assessment every 6 months. The Baden-Walker classification was used and prolapse halfway to the introitus (grade II) or greater was considered significant prolapse. Surgical failure was identified as grade III prolapse or greater. Satisfaction was assessed on a scale of 1 to 3 with 3 being highly satisfied and according to whether patients perceived a successful outcome. RESULTS A total of 40 patients with an average age of 66.5 years (range 48 to 81) had an average followup of 25.5 months (range 18 to 42). Of the 40 patients 22 (55%) did not have significant prolapse, including 14 with no prolapse, and 8 with grade I cystocele and/or rectocele. Of the 40 patients 18 (45%) had recurrent significant prolapse, including cystocele in 8 (grades II and III in 4 each), rectocele in 6 (grades II and III in 2 and 4, respectively), and grade II cystocele and rectocele in 3. There was 1 case of recurrent vault prolapse. Eight of 40 cases (20%) were considered surgical failures. Patients without prolapse were highly satisfied (average score 2.95) and 100% considered surgery to have been successful. The recurrent prolapse group was less satisfied (mean score 2.5) and 66.7% considered the surgery successful. CONCLUSIONS Recurrent pelvic organ prolapse is not an uncommon finding after colpopexy and it may adversely affect patient satisfaction.

Impact of a Double-Pigtail Stent on Ureteral Peristalsis in the Porcine Model: Initial Studies Using a Novel Implantable Magnetic Sensor

BACKGROUND AND PURPOSE The effect of stents on ureteral peristalsis in vivo is not entirely clear. We sought to develop a minimally invasive method for its study. MATERIALS AND METHODS In female domestic pigs, electrical potentials from the ureter were measured by bipolar steel-wire electromyography electrodes delivered laparoscopically. Mechanical movement was measured by giant magneto resistive sensors mounted on custom-made aluminum strips. After baseline values were obtained, the animals were randomized to receive silicone or polyurethane stents, and ureteral peristalsis was measured for 8 hours acutely and for 4 hours 1 week later. RESULTS Implantation of the devices took an average of 30 minutes. A consistent correlation was found between laparoscopically observed peristaltic waves and the peristalsis detected by the two measuring devices. The devices themselves did not affect peristalsis. Stent insertion increased peristaltic activity initially but later reduced or stopped it. There was no difference in the effects of the two types of stents. CONCLUSIONS The new technique permits close monitoring of ureteral peristalsis in vivo. Smaller stents appear to have less immediate effect than larger ones, but all type of stents tested eventually caused aperistalsis.

Laparoscopic cecostomy tube placement in an Indiana pouch.

A cecostomy tube is normally placed in an Indiana pouch for drainage and irrigation in the postoperative period. A clinical dilemma occurs when the cecostomy tube fails or is dislodged in the early postoperative period. We present the laparoscopic replacement of a cecostomy tube in the immediate postoperative period.