Sero Andonian

Laparoendoscopic Single-Site Pfannenstiel Versus Standard Laparoscopic Donor Nephrectomy

OBJECTIVESnTo compare laparoendoscopic single-site (LESS) Pfannenstiel donor nephrectomy with a contemporary series of standard laparoscopic (SL) donor nephrectomies.nnnMETHODSnThe initial 6 LESS donor nephrectomies were compared with a case-matched 6 SL donor nephrectomies within the same time period (June 2008 till March 2009). Patient characteristics (sex, age, body mass index, graft volume, and vascular anatomy), perioperative data (operative time, warm ischemia time [WIT], and estimated blood loss), and postoperative information (complications, length of stay, visual analog scale [VAS], and total morphine requirements) were collected prospectively and analyzed retrospectively.nnnRESULTSnIn the LESS group, there were no conversions to SL or open. There was no significant difference between the two groups in terms of baseline characteristics (age, body mass index, allograft volume). However, SL group included more right-sided patients (three compared with one) and more venous anomalies (retrorenal veins in two patients and multiple veins in another). There was no significant difference between SL and LESS in terms of operative time (117 vs. 142 minutes), WIT (5 minutes in both groups), estimated blood loss (150 vs. 100 mL), median length of stay (2 days in both), and total morphine equivalents (42 vs. 83 mg). None of the patients received transfusions perioperatively. A patient in the SL group developed a wound infection requiring packing and antibiotics. There were no perioperative complications in the LESS group. Although VAS scores were lower in the LESS versus SL group at each of post-operative day (POD) #2 (1.5 vs. 4) and discharge (0 vs. 2), this did not reach statistical significance.nnnCONCLUSIONSnIn this small retrospective series, SL was associated with more complex renal anatomy. However, there was no difference between the two groups in terms of WIT, narcotic requirements, and VAS scores. Therefore, the advantages of LESS may only be cosmesis. To verify these results, both procedures need to be compared prospectively in a randomized fashion.

Laparoendoscopic Single-site Pfannenstiel Donor Nephrectomy

OBJECTIVESnTo describe laparoendoscopic single site (LESS) donor nephrectomy procedure through a Pfannenstiel incision. Laparoscopic donor nephrectomy has become the standard approach in harvesting kidneys from live donors. This is usually performed through 3 ports placed in a triangular manner in addition to the Pfannenstiel incision where the kidney is removed.nnnMETHODSnThrough a 5 cm Pfannenstiel incision, three 5 mm ports were placed in a triangular manner. A 5 mm flexible-tip laparoscope was used to perform laparoscopic donor nephrectomy. Before ligating the renal hilum, the superior midline trocar was exchanged for a 12-mm trocar to allow for an Endo-GIA stapler. After the kidney was placed in the entrapment sac, the anterior rectus fascia between the 2 midline ports was incised and the kidney was removed. After closure of the fascial defects, the Pfannenstiel incision was closed in a subcuticular manner.nnnRESULTSnLESS Pfannenstiel donor nephrectomy was successfully performed in 6 patients without standard laparoscopic or open conversion. No additional needlescopic instruments were used. The median age was 46 years with median body mass index of 28.3 kg/m(2). The median operative time was 142 minutes with a median warm ischemia time of 5 minutes. Median hospital stay was 2 days and the median pain score at discharge was 0. None of the patients received transfusions perioperatively and none had peri-operative complications.nnnCONCLUSIONSnLESS Pfannenstiel donor nephrectomy offers the benefits of improved cosmesis over the standard laparoscopic donor nephrectomy. Prospective randomized trials are needed to compare the postoperative pain levels in between these 2 techniques.

Use of the Valveless Trocar System Reduces Carbon Dioxide Absorption During Laparoscopy When Compared With Standard Trocars

OBJECTIVESnTo prospectively compare a novel type of valveless trocar that creates a curtain of pressurized carbon dioxide [CO(2)] gas (which maintains pneumoperitoneum at a lower gas flow rate) with standard trocars; to quantify the volume of CO(2) used; and to characterize CO(2) elimination during laparoscopic renal surgery.nnnMETHODSnA total of 51 patients undergoing laparoscopic renal surgery by a single surgeon were prospectively evaluated using either the valveless trocar (n = 26) or standard trocars (n = 25). Patient demographics, operative time, volume of CO(2) gas consumed, CO(2) elimination, perioperative parameters, and postoperative complications were recorded and analyzed.nnnRESULTSnBoth patient cohorts were comparable in their preoperative demographics, including body mass index, the number of patients with chronic obstructive pulmonary disease, and smoking history. Mean operative time was lower in the valveless trocar cohort (124.1 minutes) compared with the conventional trocar group (145.6 minutes), P = .047. Use of the valveless trocar was associated with a lower volume of intraoperative CO(2) consumed (120.0 ± 82.8 vs 300.6 ± 191.5; P < .001) and reduced CO(2) elimination compared with standard trocar use after the first 16 minutes of insufflation (P < .05). Minimal complications occurred, including 2 cases of subcutaneous emphysema in the valveless trocar group, and 1 case of respiratory acidosis in the conventional trocar group.nnnCONCLUSIONSnUse of a valveless trocar significantly reduced CO(2) consumption during transperitoneal laparoscopy. The valveless trocar also demonstrated significantly reduced CO(2) elimination and absorption when compared with the standard trocar.

A New Valve-Less Trocar for Urologic Laparoscopy: Initial Evaluation

INTRODUCTIONnLaparoscopic trocars typically maintain pneumoperitoneum using trap door valves and silicone seals. However, valves and seals hinder passage of instruments, cause lens smudging, trap specimens and needles being removed from the abdominal cavity, and lose their seal with repeated instrument exchange.nnnAIMnThe aim of the present study was to evaluate the feasibility of a newly designed valve-less trocar.nnnMETHODSnThe valve-less trocar system creates a curtain of forced gas to maintain pneumoperitoneum. A separate unit filters smoke and recirculates captured escaping gas. The valve-less trocar was trialed in consecutive laparoscopic renal procedures of a single surgeon. Perioperative parameters and outcomes were collected and analyzed. The systems safety, advantages, and disadvantages were evaluated. Insufflation gas usage, elimination, and absorption were also measured.nnnRESULTSnTwenty-five patients underwent laparoscopic renal procedures using the valve-less trocar system. The procedures included laparoscopic partial, radical, and donor nephrectomy. The mean patient age was 58.26 years. The mean operative time was 125 minutes and the mean drop in Hb for the cohort was 2.34 g/dL (range 0.4-5.4). Two patients developed subcutaneous emphysema and of the two patients, one developed clinically insignificant pneumomediastinum postoperatively. There were no postoperative complications. The surgeon noted that the use of a valve-less trocar decreased smudging of laparoscopes, expeditiously evacuated smoke during cauterization leading to improved visualization, maintained pneumoperitoneum even while suctioning, and resulted in easy extraction of specimens and needles. It was noted that insufflation gas consumption was low and CO(2) elimination was not impaired.nnnCONCLUSIONnUse of a valve-less trocar is safe. Decreased laparoscope smudging may translate into decreased operative times and reduced gas consumption may equate to cost savings. Additionally, its use brings several advantages and convenience to the operating surgeon. However, the system should be compared with conventional trocars prospectively to demonstrate clinical and economic benefit.

Pfannenstiel laparoendoscopic single‐site (LESS) vs conventional multiport laparoscopic live donor nephrectomy: a prospective randomized controlled trial

To present outcomes of a randomized, patient‐blinded controlled trial on Pfannenstiel laparoendoscopic single‐site (LESS) vs conventional multiport laparoscopic live donor nephrectomy.

Long-Term Follow-Up for Salvage Laparoscopic Pyeloplasty After Failed Open Pyeloplasty

OBJECTIVESnTo report our long-term experience with salvage laparoscopic pyeloplasty after a failed open procedure. Laparoscopic repair of a primary ureteropelvic junction obstruction (UPJO) is associated with very high long-term success. However, there are limited data on patients who have failed previous open pyeloplasty. We have determined that salvage laparoscopic pyeloplasty is an excellent option for these patients.nnnMETHODSnWe queried our laparoscopic pyeloplasty database of 367 patients from July 1994 to May 2007 for patients who had undergone prior open pyeloplasty. We analyzed demographic data, perioperative course, complications, and follow-up studies on identified subjects. We assessed clinical status by verbal pain scale and diagnostic studies. Radiologic follow-up consisted of diuretic renal scan, intravenous pyelography, or both.nnnRESULTSnWe identified 9 patients (2.5%) who underwent salvage laparoscopic pyeloplasty for persistent obstruction after open pyeloplasty. The mean age of our cohort was 30.5 years (range, 19-50 years). Mean operative time was 204 minutes (range, 80-264 minutes), estimated blood loss was 105 mL (range, 20-300 mL), and mean length of stay was 2.1 days (range, 2-3 days). No intraoperative or postoperative complications were reported. All patients reported relief of symptoms in the immediate postoperative period. At a median follow-up of 66 months (range, 12-119 months), 8 of 9 patients (89%) had clinical and radiologic resolution of UPJO with stable renal function, pain free status, and a patent ureteropelvic junction. The remaining patient failed laparoscopic repair within the first year with evidence of persistent obstruction, necessitating endopyelotomy.nnnCONCLUSIONSnOur findings support the use of salvage laparoscopic pyeloplasty as an excellent option for patients who failed previous open pyeloplasty. This approach provides durable long-term outcomes.

Laparoscopic Partial Nephrectomy : an Update on Contemporary Issues

Laparoscopic partial nephrectomy (LPN) is a technically challenging procedure with up to 5-year follow-up data. In this article, incidence of renal cell carcinoma, indications, and contraindications for LPN are presented. In addition, LPN for benign diseases such as atrophic renal segments associated with duplicated collecting systems and calyceal diverticula associated with recurrent UTIs are presented. Hilar clamping, ischemic time, positive margins, and port-site metastasis, in addition to complications and survival outcomes, are discussed. The advantages of lower cost, decreased postoperative pain, and early recovery have to be balanced with prolonged warm ischemia. Its long-term outcomes in terms of renal insufficiency or hemodialysis requirements have not been defined completely. Randomized clinical trials comparing open partial nephrectomy (OPN) versus LPN are needed.

Habib Laparoscopic Bipolar Radiofrequency Device: A Novel Way of Creating an Avascular Resection Margin in Laparoscopic Partial Nephrectomy

INTRODUCTIONnHemostasis during the laparoscopic partial nephrectomy (LPN) is a challenge. Usually, the renal hilum is clamped to minimize blood loss. However, prolonged ischemia leads to irreversible damage. Therefore, new technology is needed to minimize blood loss while performing LPN without hilar clamping. The Habib 4x Laparoscopic device (Angio Dynamics, Queensbury, NY) is a four-pronged bipolar radiofrequency probe that is proven to reduce blood loss in laparoscopic liver resections without hilar clamping. The aim of this pilot study was to evaluate this new technology in LPN.nnnMETHODSnThree patients, with exophytic renal lesions (1.1-4 cm), underwent LPN without hilar clamping, using the Habib Laparoscopic device to create an avascular resection margin.nnnRESULTSnMean operative time was 150.3 minutes, mean estimated blood loss was 100 cc, and none of the patients required transfusions. There was no significant difference between the mean pre- and postoperative serum creatinine levels (P > 0.05). All 3 resected masses were renal-cell carcinomas. Intraoperative frozen sections demonstrated negative margins in all cases. However, in the second case, with a renal lesion of 4 cm, the permanent section analysis on margins was read as focally positive. There were no complications. On follow-up imaging of up to 12 months, there were no recurrences.nnnCONCLUSIONSnThe Habib 4x Laparoscopic device permits the resection of exophytic renal lesions without the need for hilar clamping. However, a cautery artifact can cause difficulty in interpreting the frozen-section analysis of resection margins. Therefore, its use should be restricted to lesions of less than 2 cm.

Aetiology of non‐diagnostic renal fine‐needle aspiration cytologies in a contemporary series

To determine the aetiology of non‐diagnostic renal fine‐needle aspiration cytologies (FNACs) in a contemporary series.

Lasers in percutaneous renal procedures

IntroductionSince the invention of lasers in 1960, they have been increasingly used in medicine. In this review paper, the types of lasers used in urology, in addition to their applications to percutaneous renal surgery will be reviewed. Specifically, use of lasers in the percutaneous management of renal stones, upper tract transitional cell carcinoma and stricture will be reviewed.Materials and methodsPubmed was searched for citations since 1966. The following terms were used: “lasers”, “calculi”, “endopyelotomy”, and “transitional cell carcinoma”.ResultsDue to its minimal depth of penetration, holmium laser has proven to be safe and efficacious. It is currently the primary energy source for flexible instrumentation, and also has demonstrated efficacy in percutaneous lithotripsy (faster than ultrasonic lithotripsy and safer than electrohydraulic lithotripsy). Holmium laser been used for antegrade endopyelotomy and percutaneous resection of upper tract transitional cell carcinoma.ConclusionsHolmium laser is safer than other lasers and has become the gold standard for laser lithotripsy for flexible instrumentation. It has been used successfully in the percutaneous management of renal stones, ureteropelvic junction obstruction, and upper tract transitional cell carcinoma. Holmium laser is an alternative energy source to conventional lithotripters and electrocautery for endopyelotomy and resection of upper tract transitional cell carcinoma.