Thomas Oliver Henkel

Laparoscopic nephrectomy: The experience of the laparoscopy working group of the German Urologic Association

PURPOSEnThe centers of the laparoscopy working group of the German Urologic Association collected data to prove the efficacy, safety and reproducibility of laparoscopic nephrectomy.nnnMATERIALS AND METHODSnAt 14 centers 482 laparoscopic nephrectomies have been performed until December 1996 via a transperitoneal approach in 344 (71%) and a retroperitoneal approach in 138 (29%). All 482 laparoscopic nephrectomies were performed by a total of 20 surgeons with an average of 24 procedures per surgeon (range 4 to 105). The indications for nephrectomy were benign renal pathology in 444 patients (92%), including renovascular disease in 28%, hydronephrosis in 20%, reflux nephropathy in 15%, chronic pyelonephritis in 12%, end stage nephrolithiasis in 11%, renal dysplasia in 4% and renal tuberculosis in 1%. Of the remaining 38 patients (8%) laparoscopic radical nephrectomy was performed for renal cell carcinoma in 5% and for upper tract transitional cell carcinoma in 3%.nnnRESULTSnOperating time depended mainly on the pathology of the kidney (that is small dysplastic organ versus large hydronephrosis) and the learning curve of the surgeon. However, the average operating time did not vary significantly among the different centers (maximum 277.6 and minimum 81.9 minutes). Intraoperative or perioperative complications were noted in 29 patients (6.0%), including bleeding in 22 (4.6%), bowel injury in 3, hypercarbia in 2 and pleura lesion in 1 and pulmonary embolism in 1. The conversion rate was 10.3% (bleeding, bowel injury, difficult dissection), including 4 patients with renal tuberculosis, 2 with xanthogranulomatous nephritis, and 1 each following renal trauma and embolization. The re-intervention rate was 3.4% due to bleeding in 6 cases, abscess formation in 3, intestinal stenosis in 2 and a pancreatic fistula and port hernia in 1. Mean hospital stay was 5.4 days.nnnCONCLUSIONSnLaparoscopic nephrectomy has become a well established procedure in those urology departments focusing on laparoscopy. The indications and results are reproducible at these centers. However, for patients with severe perinephritis (that is renal tuberculosis, xanthogranulomatous nephritis, posttraumatic atrophy) a higher likelihood of open conversion must be considered.

RETROPERITONEOSCOPY: EXPERIENCE WITH 200 CASES

PURPOSEnA retroperitoneal access is commonly used for open urological procedures. Since the introduction of the balloon dissecting technique by Gaur this anatomical route has also been used for laparoscopic surgery. We present our experience with retroperitoneoscopy in 200 cases.nnnMATERIALS AND METHODSnFrom December 1992 to October 1997 a total of 200 retroperitoneoscopic procedures were performed in 197 patients 4 to 82 years old, comprising 78 nephrectomies, 50 renal cyst resections, 14 nephropexies, 11 ureterolyses, 8 retroperitoneal lymph node dissections, 8 renal biopsies, 6 adrenalectomies, 6 heminephrectomies, 6 pyeloplasties, 5 ureterolithotomies, 6 ureterocutaneostomies and 2 others. Of the patients 38 (19%) and 22 (11%) had undergone previous abdominal surgery, and kidney and ureter operations, respectively. Dissection of the retroperitoneal space was enabled by the use of a balloon catheter in 14, balloon trocar system in 93 and finger dissection technique in 93 cases.nnnRESULTSnWe classified 76 procedures (38%) as simple (renal biopsy, renal cyst resections, ureterocutaneostomy), 102 (51%) as difficult (adrenalectomy, nephrectomy, nephropexy) and 22 (11%) as very difficult (pyeloplasty, heminephrectomy, lymphadenectomy). There was a significant learning curve during the first 50 cases reflected by longer operating time, and higher complication, conversion to open surgery and open reintervention rates (14, 10 and 6%, respectively). In addition to the learning curve, mean operating time depended on the difficulty of the procedure, averaging 45 to 100 minutes for a simple, 95 to 185 for a difficult and 185 to 240 for a very difficult retroperitoneoscopy. In the last 50 cases the complication, conversion and reintervention rates (2, 4 and 2%, respectively) were acceptable for routine clinical application.nnnCONCLUSIONSnAfter experience with more than 200 cases of retroperitoneoscopy the access technique has been significantly simplified. The procedure is standardized, safe and reproducible.

Nephrectomy: A Comparative Study between the Transperitoneal and Retroperitoneal Laparoscopic versus the Open Approach

Objectives: Different techniques have been introduced to perform laparoscopic nephrectomy using either the transperitoneal or the retroperitoneal route. However, to date only few data exist comparing the results and morbidity of these procedures as well as with the standard technique of open nephrectomy. Material and Methods: This paper compares the clinical results of 18 transperitoneal laparoscopic nephrectomies (TLN) for benign renal disease with 17 retroperitoneal laparoscopic nephrectomies (RLN) and 19 consecutive open nephrectomies (Nx). All groups were comparable in terms of indication. The analysis of clinical data included operative time, morbidity, length of analgesic use and postoperative hospital stay. Results: The mean operative time for benign disease was 206.5 for TLN, 211.2 for RLN and 117 min for open nephrectomy. Analgesic medication requirement per patient was 2 days for TLN, 1 day for RLN and 4 days for Nx while the postoperative hospital stay averaged 7 days for TLN, 6 days for RLN and 10 days for Nx. The time of convalescence was 21 days after RLN, 24 days after TLN versus 40 days after open nephrectomy. Conclusions: Our results demonstrate an overall clear advantage of a laparoscopic approach when compared to open surgery and also reveals distinct benefits of a retroperitoneal approach.

Laparoscopic Retroperitoneal Lymph Node Dissection for Nonseminomatous Germ Cell Tumors: Indications and Limitations

PURPOSEnWe describe our experience with laparoscopic retroperitoneal lymph node dissection in 26 patients with nonseminomatous germ cell tumors: 17 had stage I disease with no clinical (computerized tomography, ultrasound or tumor markers) evidence of metastases and 9 (2 with stage IIb and 7 with stage IIc disease) had residual tumor after chemotherapy but with negative tumor markers. Laparoscopic dissection was performed to assess more fully pathological status of the relevant retroperitoneal lymph nodes in both groups.nnnMATERIALS AND METHODSnThe patient was positioned and trocars were introduced at sites similar to that used for transperitoneal laparoscopic nephrectomy (flank position with 3, 10 mm. and 2, 5 mm. ports). After the white line of Toldt was incised and the colon was reflected anteromedially, the retroperitoneal space was exposed. The landmarks of lymph node dissection were then isolated, including the ureter, aorta, inferior vena cava and both renal veins. Lymph node dissection was performed identical to that for open surgery, with a modified template including the paracaval, interaortocaval, upper preaortic and right common iliac nodes for right tumors, and para-aortic and upper preaortic nodes for left tumors. Lymph node chains were retrieved with a small organ bag.nnnRESULTSnThe procedure was completed successfully in 16 of 17 patients with stage I disease (mean duration 268 minutes for the left and 312 minutes for the right sides). No intraoperative complications were encountered. One patient had delayed ureteral stenosis requiring operative repair, 1 had a pulmonary embolism with an uneventful outcome and 1 who underwent laparoscopic retroperitoneal lymph node dissection on the right side later had retrograde ejaculation. Embryonal carcinoma was found in 1 of the 17 patients. Average postoperative hospital stay was 4.5 days for patients without complications or conversion to an open procedure. After a median followup of 27 months no patient had regional relapse but 2 had pulmonary metastases that were treated successfully with 3 cycles of platinum based chemotherapy. Laparoscopic dissection was significantly more difficult in patients with stage II tumors after chemotherapy. Only in 2 patients with stage IIb disease was laparoscopic lymphadenectomy successful. In 5 of the 7 patients with stage IIc cancer portions of the dissection had to be done after conversion to an open (conventional) operation via a small incision (suprainguinal or pararectal). In 1 patient the laparoscopic approach was completely abandoned and converted to an open operation via a standard midline incision. In all 9 cases histopathological examination revealed complete necrosis. No patient has evidence of disease.nnnCONCLUSIONSnOur preliminary experience suggests that a modified laparoscopic retroperitoneal lymph node dissection is feasible for stage I tumors. However, it cannot be recommended after previous chemotherapy (stages IIb and IIc disease).

The technique of transperitoneal laparoscopic nephrectomy, adrenalectomy and nephroureterectomy

In the traditional kidney position three trocars are inserted after creation of a pneumoperitoneum: 10 mm periumbilical (port I), 10/12 mm subcostal (port II) and 12/10 mm above the iliac spine (port III) in the mamillary line. After laterocolic incision the colon is dissected away from the lateral wall. Thereafter two 5-mm trocars (ports IV, V) are inserted into the lateral abdominal wall parallel to parts II and III. Following clipping and dissection of the ovarian (spermatic) vein, the ureter is isolated and incised. Then the cranial part of the ureter is used as a retractor exposing the renal hilum for dissection of the renal vessels. The main renal artery and vein are dissected separately by use of an endoscopic stapling device (Endo-GIA, white magazine). Finally, the kidney including Gerotas fascia is isolated from the adrenal and the upper peritoneum. Entrapment of the organ is performed with a specially designed bag (Lap-sac). The neck of the bag is brought out onto the surface of the abdomen (via port II/III) allowing digital morcellation with index finger inside the bag and removal of the organ in several pieces. We have applied this technique for 17 procedures in the upper retroperitoneum: 9 transperitoneal laparoscopic nephrectomies (TLN) for benign disease (5 hydronephrosis, 3 renovascular disease, 1 chronic pyelonephritis), 3 radical TLN including adrenalectomy for renal cell carcinoma (T2G2), 1 adrenalectomy for a cortical adrenaloma, 1 nephroureterectomy, 1 diagnostic ureterolysis and 2 modified retroperitoneal lymphadenectomies for stage I testicular cancer. The mean operation time was 4 h (2-5), the mean postoperative hospital stay 6 days (4-12).(ABSTRACT TRUNCATED AT 250 WORDS)

Retroperitoneal laparoscopic nephrectomy and other procedures in the upper retroperitoneum using a balloon dissection technique.

This article describes a hydraulic balloon dissection technique. The retroperitoneum is developed via a small lumbodorsal incision between the edges of the musculus latissimus dorsi and musculus obliquus externus and then after visualization of its correct position the balloon catheter is filled with 500-1,200 ml of warm normal saline (according to patient size). The device consists of the finger of a surgeons glove ligated around the end of a rigid bladder catheter. The balloon insufflation is maintained for 5 min to guarantee adequate hemostasis. Recently, we have replaced the balloon catheter by a balloon trocar sheath allowing direct endoscopic control of the hydraulic dissection. After retrieval of the balloon the CO2 insufflator is connected to the first trocar. All secondary trocars are placed under endoscopic control. The hydraulic dissection techniques also enable optimal creation of an effective pneumoperitoneum in children. Until now, we have used this technique for twelve procedures in the upper retroperitoneum including five nephrectomies, two nephroureterectomies, one tumor nephrectomy, one nephropexy, one renal cyst marsupialization and two renal biopsies. Up to now we have encountered no major complications. Three of the nephrectomized patients had undergone multiple previous abdominal surgical interventions. The retroperitoneal approach allows the surgeon to apply similar dissecting techniques as used in respective open procedures. It has become the routine approach for laparoscopic procedures in benign renal disease. This procedure can be performed even in cases with previous abdominal surgery.

The Clinical Introduction of a Third Generation Lithotriptor: Modulith SL 20

The Modulith SL 20* was designed as a third generation lithotriptor with outstanding disintegrative efficacy in vitro, and equipped with a combined fluoroscopic and ultrasound localization system integrated in a multifunctional table. Its introduction to clinical extracorporeal shock wave lithotripsy took place in 3 phases. In phase 1 (49 patients) only in line ultrasound localization was possible. The many caliceal stones were adequately disintegrated with restricted generator voltage. In phase 2 (81 patients) fluoroscopic localization with the virtual focus of an adapted x-ray C-arm unit enabled in situ lithotripsy of ureteral stones in 33% of all patients. Phase 3 (549 patients) was characterized by additionally increasing the generator voltage to 20 kv. This development of the lithotriptor by improving the localization system and shock wave energy resulted in the possibility for successful disintegration of stones in the entire upper urinary tract (including the complete ureter), decreased treatment time (52 to 39 minutes) and an improved efficiency quotient (0.45 to 0.67). During phase 3 auxiliary measures were performed before lithotripsy in 24% of the cases. After 1.8% of the treatments minor or moderate perirenal fluid collection or bleeding was detected by routine followup sonography. A 91% stone-free rate was achieved with only 9.3% curative auxiliary measures after extracorporeal shock wave lithotripsy, including a 23% retreatment rate. Thus, the Modulith device had a high efficacy quotient compared with other lithotriptors.

Interstitial Laser Coagulation in Benign Prostatic Hyperplasia: A Critical Evaluation after 2 Years of Follow-Up

Since 1993 we have prospectively followed a cumulative cohort of males with benign prostatic hyperplasia and symptomatic bladder outlet obstruction who underwent interstitial laser coagulation (ILC) of the prostate. We evaluated the safety and efficacy of ILC with respect to relief of symptoms and bladder outlet obstruction. In addition to the critical evaluation of our clinical results, the perineal and transurethral approaches were investigated as they may make a substantial impact on the overall success rate, including prostate size, number of sticks per prostate volume and type of application. A total of 59 patients were treated with the Nd-YAG laser (mediLas fibertom) between April 1993 and December 1996. At the time of reevaluation, 47 patients had completed a follow-up of up to 24 months. A perineal approach was used in 34%, transurethral in 23%, and a combined approach in 43% of the patients, depending on the preoperative volume of the prostate. 75% were high-risk patients in accordance with the ASA score (ASA III). The efficacy of treatment was assessed 6, 12, 24 and 52 weeks postoperatively in accordance with the International Prostate Symptom Score (IPS/quality of life), cystomanometric studies, peak urinary flow rate, residual volume and volume reduction of the prostate. Reduction of prostatic volume and sticks used per prostate volume were correlated to the overall success rate. A significant improvement in all voiding parameters (flow rate, residual volume), including the symptom score, was observed. Pdet decreased from an average of 90 cm H2O preoperatively to 42 cm H2O postoperatively after 24 weeks and the mean reduction in prostate volume was 14 cm3. Interestingly, it was noted that the overall success rate was not size-related. A distinct positive correlation was found in the number of sticks performed and the improvement in objective and subjective parameters. In view of the low morbidity outcome, especially in high-risk patients, we proclaim Nd-YAG interstitial laser coagulation of the prostate to be an effective and safe alternative method of treatment for symptomatic benign prostatic hyperplasia.

Retroperitoneoscopic surgery — technique, indications and first experience

SummaryAlthough retroperitoneoscopic procedures were already being performed in the late seventies, it was the balloon-dissecting technique introduced by Gaur, together with the progressive experience in trans-peritoneal laparoscopic procedures in the upper retroperitoneum, that initiated the clinical breakthrough of retroperitoneoscopy. We modified the balloon-dissecting technique into a hydraulic, video-optically controlled balloon dissection of the retroperitoneal space. This technique permitted successful, extensive laparoscopic surgery on the kidney and ureter. We summarize the history of retroperitoneoscopy, the different methods of gaining access to the retroperitoneum and the types of surgery made possible by this new approach, along with our experience in our first 41 cases.

Extracorporeal shock-wave lithotripsy and endoscopy: combined therapy for problematic bile duct stones

SummaryEndoscopic treatment of bile duct stones is currently successful in 86% of patients. We prospectively studied the efficacy and complication rate of extracorporeal shock-wave lithotripsy (ESWL) of problematic bile duct stones combined with endoscopy. When stone removal was not possible, patients were subjected to ESWL, Fragmented stones were removed endoscopically. During 1 year, 220 patients presenting with choledocholithiasis were diagnosed and 188 were successfully treated endoscopically. In all, 3 subjects received alternative treatmenl and the remaining 29 (13%) constituted our study group: 19 (65%) were women and the mean age was 76.7 years. Overall, 22 (76%) were high-risk patients; 23 (79%) were jaundiced and 9 (31%) had cholangitis at admission. The most frequent indication for ESWL was stone size. Stone fragmentation was achieved in 80% of cases. Complications were mild and were managed conservatively. No patient died. Complete stone clearance was possible in 23 (80%) cases. The association of ESWL and endoscopy enhanced the success rate of endoscopic stone clearance from 86% to 96%. During the same period, open surgery was performed in 4 cases for residual common bile duct (CBD) stones and in 32 cases in association with simultaneous cholecystectomy.