Sakti Das

Retroperitoneal and pelvic extraperitoneal laparoscopy : An international perspective

OBJECTIVES To assess technical preferences and current practice trends of retroperitoneal and pelvic extraperitoneal laparoscopy. METHODS A questionnaire survey of 36 selected urologic laparoscopic centers worldwide was performed. RESULTS Twenty-four centers (67%) responded. Overall, 3988 laparoscopic procedures were reported: transperitoneal approach (n = 2945) and retroperitoneal/extraperitoneal approach (n = 1043). Retroperitoneoscopic/extraperitoneoscopic procedures included adrenalectomy (n = 74), nephrectomy (n = 299), ureteral procedures (n = 166), pelvic lymph node dissection (n = 197), bladder neck suspension (n = 210), varix ligation (n = 91), and lumbar sympathectomy (n = 6). Mean number of total laparoscopic procedures performed in 1995 per center was 41 (range 5 to 86). Major complications occurred in 49 (4.7%) patients and included visceral complications in 26 (2.5%) patients and vascular complications in 23 (2.2%). Open conversion was performed in 69 (6.6%) patients, electively in 41 and emergently in 28 (visceral injuries, n = 16; vascular injuries, n = 1 2). Retroperitoneoscopy/extraperitoneoscopy is gaining in acceptance worldwide: in 1993, the mean estimated ratio of transperitoneal laparoscopic cases versus retroperitoneoscopic/ extraperitoneoscopic cases per center was 74:26; however, in 1996 the ratio was 49:51. CONCLUSIONS Retroperitoneoscopy and pelvic extraperitoneoscopy are important adjuncts to the laparoscopic armamentarium in urologic surgery. The overall major complication rate associated with retroperitoneoscopy/extraperitoneoscopy was 4.7%.

Survey of neuromuscular injuries to the patient and surgeon during urologic laparoscopic surgery

OBJECTIVES Laparoscopy may be complicated by neuromuscular injuries, both to the patient and to the surgeon. We used a survey to estimate the incidence of these injuries during urologic laparoscopic surgery, to assess risk factors for these injuries, and to determine preventive measures. METHODS A survey of neuromuscular injuries associated with laparoscopy submitted to 18 institutions in the United States was completed by 18 attending urologists from 15 institutions. RESULTS From among a total of 1651 procedures, there were 46 neuromuscular injuries in 45 patients (2.7%), including abdominal wall neuralgia (14), extremity sensory deficit (12), extremity motor deficit (8), clinical rhabdomyolysis (6), shoulder contusion (4), and back spasm (2). Neuromuscular injuries were twice as common with upper retroperitoneal as with pelvic laparoscopy (3. 1% versus 1.5%). Among patients with neuromuscular injuries, those with rhabdomyolysis were heavier (means 91 versus 80 kg) and underwent longer procedures (means 379 versus 300 minutes), and those with motor deficits were older (means 51 versus 42 years of age). Of the surgeons, 28% and 17% reported frequent neck and shoulder pain, respectively. CONCLUSIONS Although not common, neuromuscular injuries during laparoscopy do contribute to morbidity. Abdominal wall neuralgias, injuries to peripheral nerves, and joint or back injuries likely occur no more frequently than during open surgery, but risk of rhabdomyolysis may be increased. Positioning in a partial rather than full flank position may reduce the incidence of some injuries. Measures to reduce neuromuscular strain on the surgeon during laparoscopy should be considered.

Balanitis xerotica obliterans--a review.

Balanitis xerotica obliterans (BXO) is a scarcely known disease, wrongly considered rare. With a high degree of suspicion and histologic examination, the condition will prove to be much more frequent than one generally believes. The etiology of the condition is unknown at present. Many cases of BXO occurring after circumcision may be cases of secondary phimosis due to BXO not being recognized at the time of surgery. Most of the cases of BXO are seen in the third to fifth decades of life, even though they may occur at the extremes of age. Biopsy of the lesions is not essential in all cases and is indicated to differentiate from penile cancer and in atypical cases. Early diagnosis and treatment of BXO are very important in preventing the urological complications of the diseases such as urethral stricture. Treatment of BXO depends on the anatomic location of the lesions and their extent and severity, together with the rapidity of progression of the disease process. The treatment may vary from topical corticosteroids, laser vaporization in early cases to meatoplasty and urethroplasty in extensive cases. Topical pharmacotherapy is useful in the early stages to reduce the initial symptoms and slow down the progression, but is not effective in all cases and is not the curative treatment of disease. Meatal stenosis, phimosis, scar adhesions, fissures, erosions of glans and prepuce and involvement of the urethra are indications for surgical treatment. Surgery seems to be the only treatment that can relieve the symptoms of advanced disease. Modified circumcision, with total removal of inner preputial layer, definitively relieves phimosis without any recurrence. Meatotomy will not prevent the recurrence of meatal stenosis. Excision of the scleroatrophic tract and grafting of the glans base, coronal sulcus, and the end of the shaft give a complete relief of pain during erection and intercourse in circumcised patients with balanopreputial adhesions and restore the elasticity of the skin of penile shaft. These procedures have been shown to yield excellent functional results during a follow-up period of up to 4 years. BXO involving anterior urethra can be treated by 2-stage urethroplasty or substitution urethroplasty. The complete excision of the stricture and flap urethroplasty seems to be better than a 2-stage procedure. However, at the present time, it is not possible to say that surgery can completely resolve this chronic and progressive disease. Despite many reports in the literature of cases of BXO associated with squamous cell carcinoma, the etiologic relationship between the two conditions is uncertain.

Duplication of the male urethra.

Our experience with 4 male subjects with accessory urethras is reported. The anatomic types, clinical presentations and treatment modalities of urethral duplication are discussed. Our scrutiny of all cases reviewed in the literature led us to classify patients into 3 types, depending upon the anatomic and embryologic features. Type 1 is a complete accessory urethra arising from a separate or confluent opening within the bladder and extending to an external orifice. Type 2 includes accessory urethras that arise from the primary urethra and may or may not extend to a distal orifice. Type 3 is the most unusual anomaly, in which 1 of the duplicated urethras arises from the bladder or proximal urethra and opens onto the perineum.

Pediatric renal trauma

OBJECTIVES To review the pediatric renal trauma cases during the past 10 years to determine the appropriate indications for imaging and operative intervention. METHODS We searched the medical records from 1989 to 1999 and identified 61 patients aged up to 18 years old with objective data on renal trauma grade by either computed tomography or operative exploration and analyzed the data. RESULTS Of the 61 cases, 46 were blunt and 15 were penetrating injuries. Thirty-two (70%) of 46 patients with blunt injuries and all 15 patients (100%) with penetrating injuries sustained significant grade 2-5 injuries. The 14 grade 1 blunt injuries included 4 (29%) with gross hematuria, 7 (50%) with microscopic hematuria, and 3 (21%) with normal urinalyses. The 32 grade 2-5 blunt injuries included 20 (63%) with gross hematuria, 8 (25%) with microscopic hematuria, and 4 (13%) with normal urinalyses. The 15 grade 2-5 penetrating injuries included 9 (60%) with gross hematuria, 2 (13%) with microscopic hematuria, and 4 (27%) with normal urinalyses. Five of the blunt (11%) and 13 of the penetrating (87%) injuries were managed with renal operative intervention, including 12 repairs of lacerations or vessel injuries and 6 nephrectomies. CONCLUSIONS Renal injuries of significant grade were encountered that presented with microscopic hematuria, as well as with normal urinalysis findings. Therefore, the decision for renal imaging for the diagnosis and grading of renal injuries should not be based on urinalysis alone in isolation from clinical status, history, and mechanism of injury. Although the vast majority of renal injuries do not require surgical intervention, their accurate grading prompts treatment with surveillance, bed rest, and close in-hospital monitoring.

Extraperitoneal Laparoscopy-Assisted Percutaneous Nephrolithotomy in a Left Pelvic Kidney

Treatment of urolithiasis within a pelvic kidney presents a technical challenge. We report an extraperitoneal laparoscopy-assisted percutaneous approach to access the lower-pole calix of a pelvic kidney for percutaneous nephrolithotomy.

Laparoscopic antegrade continence enema (Malone) procedure: description and illustration of technique.

The antegrade continence enema (ACE Malone) procedure has improved the lives of many patients who struggle with intractable forms of constipation. We describe a laparoscopic approach to this technique and review the literature.

Hand‐assisted laparoscopic vs the open (flank incision) approach to radical nephrectomy

To compare the outcome in contemporaneous groups of patients undergoing hand‐assisted laparoscopic radical nephrectomy (HALRN) or open (flank) radical nephrectomy (ORN), as many series worldwide have confirmed the feasibility and advantages of LRN in managing renal cell carcinoma (RCC).

Ureteral Ectopia into Cystic Seminal Vesicle with Ipsilateral Renal Dysgenesis and Monorchia

A case of ureteral ectopia into a cystic seminal vesicle with ipsilateral renal dysgenesis is presented. Related embryologic events, clinical manifestations, diagnosis and management are discussed. Associated ipsilateral absence of the testes with this syndrome has not been reported previously.

Transurethral Ureteroscopy and Stone Manipulation Under Direct Vision

Transurethral ureteroscopy of the terminal ureter, using a pediatric cystoscope, aided in basket removal of an obstructing calculus under direct visual control after unsuccessful attempts at closed manipulation.