Steven G. Docimo

The Results of Surgical Therapy for Cryptorchidism: A Literature Review and Analysis

PURPOSE The literature was reviewed to consolidate the diverse success rates reported for orchiopexy. MATERIALS AND METHODS A total of 64 articles pertaining to 8,425 undescended testicles was reviewed and found to contain evaluable data. Success was defined as scrotal position and lack of atrophy. RESULTS Success rates by anatomical testicular position were 74% for abdominal, 82% for peeping and 87% for canalicular testes, and 92% for those located beyond the external ring. Success rates by procedure were 89% for inguinal, 67% for Fowler-Stephens, 77% for staged Fowler-Stephens, 81% for transabdominal, 73% for 2-stage and 84% for microvascular orchiopexy. CONCLUSIONS The significant failure rate for proximal testes suggests that efforts to improve orchiopexy should continue.

The "mini-perc" technique: a less invasive alternative to percutaneous nephrolithotomy.

Abstract The disadvantages of standard percutaneous nephrolithotomy (PCNL) as compared with ureteroscopy or extracorporeal shock-wave lithotripsy include increased blood loss, greater pain, and longer hospital stay. A 13-Fr “mini-perc” technique using a ureteroscopy sheath for PCNL was developed in an attempt to address these drawbacks. Nine “mini-percs” have been performed in patients aged 40–73 years with stone burdens of ≤ 2 cm2. On average, patients had 1.4 stones with a cross-sectional area of 1.5 cm2. The mean total procedure time, estimated blood loss, and hematocrit decrease were 176 min, 83 ml, and 6.6%, respectively. On average, patients used 14 mg of parenteral morphine and stayed 1.7 days in the hospital. There was no procedure-related complication or transfusion. Eight of nine kidneys (89%) were stone-free on early follow-up at a mean of 3.8 weeks. As compared with standard PCNL, the “mini-perc” technique has similar early success rates in selected patients and may offer advantages with respect to hemorrhage, postoperative pain, and shortened hospital stays.

High Failure Rate of Indwelling Ureteral Stents in Patients with Extrinsic Obstruction: Experience at 2 Institutions

The indwelling ureteral stent commonly is used to bypass 2 types of obstruction: 1) intrinsic obstruction usually due to stones or ureteropelvic junction abnormalities or 2) extrinsic compression, for example by retroperitoneal tumor. To determine the success of this intervention at 2 institutions the medical records of all patients undergoing cystoscopic placement of a stent for ureteral obstruction were reviewed. Procedures were classified by several parameters, including the type and location of the ureteral obstruction, indications for stent placement and success of the procedure. Stent failure was defined arbitrarily as clinical occlusion of the stent within 30 days of placement. X-rays were reviewed as available to measure stricture length and location in patients with extrinsic obstruction. Of the procedures at Brigham and Womens Hospital in Boston, where silicone stents are used almost exclusively, 23 perforated indwelling stents placed for intrinsic obstruction were uniformly successful. In contrast, of 24 stents placed for extrinsic obstruction 11 failed (p less than 0.0005). At Beth Israel Hospital, where polyurethane stents are used most commonly, all 21 perforated indwelling stents placed for intrinsic obstruction were successful, while 9 of 22 stents placed for extrinsic obstruction failed (5 within the first 24 hours of placement, p less than 0.0005). The only parameter that seemed to be a predictor of stent failure was luminal size, and this only in silicone catheters. The reasons for this surprising failure rate of internal stents in the face of extrinsic obstruction are not known but may be related to previous studies that describe a relationship among ureteral peristalsis, venting side holes and flow rate.(ABSTRACT TRUNCATED AT 250 WORDS)

A multi-institutional analysis of laparoscopic orchidopexy

Objective To combine and analyse the results from centres with a large experience of laparoscopy for the impalpable testis with small series, to determine the expected success rate for laparoscopic orchidopexy.

An Analysis of Clinical Outcomes Using Color Doppler Testicular Ultrasound for Testicular Torsion

Objectives. To delineate the clinical outcomes of color Doppler ultrasound (US) in the equivocal torsion patient. Methods. From 1992 to 1997, 130 patients (<23 years old) from 2 institutions underwent US imaging using a 7.5-mHz linear transducer to evaluate an acute scrotum equivocal, or of low suspicion, for torsion. The US reports and hospital charts of these patients were retrospectively reviewed. Results. After clinical and radiologic evaluation, torsion was excluded in 110 patients without surgical exploration. In 3 patients, intermittent testicular torsion was diagnosed and in 17 patients, emergent exploration was performed for US diagnosis of testicular torsion. Twenty-five patients (22.7%) were subsequently lost to follow-up. Follow-up of 85 patients with US negative for torsion (mean length of follow-up = 466.9 days) revealed no testicular atrophy in 83. Two patients underwent delayed orchiectomy/contralateral orchiopexy for missed testicular torsion. Of 17 patients with US positive for torsion, 9 underwent orchiectomy for a necrotic torsed testis, 7 viable torsed testes were found, and 1 torsed appendix testis was found. Therefore, color Doppler US for the equivocal acute scrotum yielded a 1% false-positive rate, sensitivity of 88.9%, and specificity of 98.8%. Conclusion. When faced with ruling out testicular torsion, it is necessary to integrate the multiple pieces of patient data, knowing that each piece of data may have inaccuracies. With this in mind, this analysis of outcomes verifies that color Doppler US is an excellent adjunctive study in the clinically real situation in which the clinical evaluation is equivocal or low suspicion.

Laparoscopic bladder augmentation using stomach

We present a case of bladder augmentation with stomach, via a laparoscopic approach. The patient was a 17-year-old girl with sacral agenesis and a poorly compliant bladder. A wedge of stomach, based on the right gastroepiploic pedicle, was obtained using a stapled technique. The bladder was opened and the gastric segment was sutured in place. A needle suspension was also carried out. Three months later, the patient was dry and catheterizing every 4 hours. Laparoscopic bladder augmentation is technically feasible and, in the properly selected patient, may be the preferred technique for creation of a compliant high-volume urinary reservoir.

Telesurgical mentoring : Initial clinical experience

AbstractBackground: Minimally invasive surgical techniques yield significant individual, economic, and social benefits when performed by experienced surgeons. Unfortunately, many of these techniques, such as laparoscopy, are associated with steep learning curves, and the incidence of complications has clearly been shown to be inversely related to experience. The initial high complication rate and the dearth of experienced endoscopic surgeons have raised concerns over training, granting of hospital privileges, and most importantly patient safety. The goal of this study was to employ current telecommunications technology in a system for the mentoring of relatively inexperienced surgeons. Therefore, we created a telesurgical system that would allow an endoscopic specialist at a central site to offer guidance and assistance to a surgeon during a laparoscopic procedure. Methods: We developed a system that connected a central site and an operative site, a distance of approximately 3.5 miles, via a single T1 (1.54 Mbs) point-to-point communications link. The system provided real-time video display from either the laparoscope or an externally mounted camera located in the operating room, full duplex audio, telestration over live video, control of a robotic arm that manipulated the laparoscope, and access to electrocautery for tissue cutting or hemostasis. Results: Seven patients underwent laparoscopic procedures using the telesurgical consultation system over the communications link. In all cases, the primary surgeon had limited experience with the laparoscopic approach but still had the basic skills required to obtain intraperitoneal access. All seven cases were completed successfully without complications. Conclusion: These initial studies have demonstrated the feasibility, effectiveness, and safety of telementoring. Telesurgical applications have the potential to greatly improve surgical education, credentialing, and patient care by offering patients and their surgeons global access to surgical specialists.

Laparoscopic assisted reconstructive surgery.

PURPOSE We describe the use of laparoscopy to assist in performing complex pediatric reconstructive cases with the goals of improved cosmesis, and limited postoperative morbidity and adhesion formation. MATERIALS AND METHODS Eight patients a mean age of 13.4 years underwent 8 laparoscopic assisted reconstructive procedures at our institution from June 1995 to February 1998. The group consisted of 5 patients with spina bifida, 1 with sacral agenesis, 1 with classic bladder exstrophy and 1 with bladder dysfunction secondary to posterior urethral valves. Information was obtained via personal communication and review of the hospital records. RESULTS Eight successful laparoscopic assisted procedures were performed, including bladder augmentation and an appendiceal Mitrofanoff procedure in 4 cases as well as tapered ileal Mitrofanoff and Malone antegrade continence enema procedures in 1, and bladder augmentation, appendiceal Mitrofanoff and antegrade continence enema procedure, gastrocystoplasty removal, ileal augmentation and an appendiceal Mitrofanoff procedure, and an antegrade continence enema procedure in 1 each. The laparoscopic component of these operations included extensive mobilization of the right colon in all patients and complete appendiceal harvesting in 2. Reconstruction was then completed through a Pfannenstiel incision in 4 patients, previous low midline scar in 2 and a small midline incision in 2. Drains were placed via existing trocar sites and open incisions were carried through other sites whenever possible. Continent stomas were matured through a trocar site in all 8 cases. Final cosmesis was excellent. Operative time was comparable to that of similar open procedures and intraoperative blood loss was minimal. CONCLUSIONS Laparoscopy may be used as a successful adjunct in complex pediatric reconstructive procedures to minimize disfiguring and morbid upper abdominal incisions, and decrease the risk of future adhesions.

Endourological Management of Pediatric Stone Disease: Present Status

PURPOSE The incidence of nephrolithiasis in the pediatric population has been steadily increasing. The miniaturization of endoscopic instruments and improvement in imaging modalities have facilitated safe and effective endourological treatment in this patient population. We reviewed the current status of pediatric stone disease management. MATERIALS AND METHODS A comprehensive literature review was performed using MEDLINE/PubMed to evaluate the indications, techniques, complications and efficacy of endourological stone management in children. RESULTS In the 1980s shock wave lithotripsy revolutionized stone management in children, becoming the procedure of choice for treating upper tract calculi less than 1.5 cm. Percutaneous nephrolithotomy has replaced open surgical techniques for the treatment of stone burdens greater than 1.5 cm with efficacy and complication rates mirroring those in the adult population. However, at an increasing number of centers ureteroscopy is now being performed in cases that previously would have been treated with shock wave lithotripsy or percutaneous nephrolithotomy. Results from recent retrospective series demonstrate that stone-free rates and complication rates with ureteroscopy are comparable to percutaneous nephrolithotomy and shock wave lithotripsy. Although concerns remain with all endoscopic techniques in children regarding damage to the urinary tract and renal development, neither short-term nor long-term adverse effects have been consistently reported. CONCLUSIONS Shock wave lithotripsy, percutaneous nephrolithotomy and ureteroscopy are highly effective endourological techniques to treat stone disease in the pediatric population. A lack of prospective randomized trials comparing treatment modalities coupled with a vast disparity in the access to resources worldwide continues to individualize rather than standardize stone treatment in children.

Telementoring of laparoscopic procedures

AbstractBackground: To assess the feasibility of telementoring, a clinical telepresence system was developed. Methods: Telementoring was attempted in 14 advanced and 9 basic urologic laparoscopic procedures. The remote surgeon located in a control room (>1,000 feet from operating room) supervised an inexperienced surgeon. Mentoring was accomplished with real-time video images, two-way audio communication, a robotic arm used to control the videoendoscope, and a telestrator. The patient outcome, complications, and operative time were assessed and compared to patients undergoing matched procedures in which the experienced surgeon was working side by side with the primary surgeon. Results: The overall telementoring success rate was 95.6% (22/23 cases) with no increase in complications. Telementoring of a laparoscopic radical nephrectomy failed secondary to improper positioning of the robotic arm. Operative times compared between telementored and traditionally mentored procedures were not statistically different for basic procedures but were longer for advanced cases. Conclusions: Telementoring of laparoscopic procedures is safe and feasible. Further clinical studies are needed prior to implementing telementoring in surgical training.